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  2. CQM-6524

CMS 2v12 Depression Screening and Follow-Up

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Julie Davis
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      Thank you for your inquiry regarding CMS2v12-Preventative Care and Screening: Screening for Depression and Follow-Up Plan.
      Per the guidance in the measure specification, "The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter". Therefore, based on the information provided in the scenario, the second screening would qualify as the most recent and should be the one counted toward the measure.

      Numerator
      ( "Patient Age 12 to 16 Years at Start of Measurement Period"
          and ( "Has Most Recent Adolescent Screening Negative"
              or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"
          )
      )
        or ( "Patient Age 17 Years at Start of Measurement Period"
            and ( "Has Most Recent Adolescent Screening Negative"
                or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"
                or "Has Most Recent Adult Screening Negative"
                or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"
            )
        )
        or ( "Patient Age 18 Years or Older at Start of Measurement Period"
            and ( "Has Most Recent Adult Screening Negative"
                or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"
            )
        )
      ​......

      Has Most Recent Adolescent Screening Negative
      ( "Most Recent Adolescent Depression Screening" AdolescentScreen
          where AdolescentScreen.result ~ "Depression screening negative (finding)"
      ) is not null
       
      Has Most Recent Adult Screening Negative
      ( "Most Recent Adult Depression Screening" AdultScreen
          where AdultScreen.result ~ "Depression screening negative (finding)"
      ) is not null

      Secondly, you wrote, "Our vendor states that following the logic, the denominator exclusion (the refusal) occurs first the pt is excluded and the logic does not continue on to the next screening." Please note that patient refusal of screening is captured as a denominator exception, not an exclusion, and prevents the clinician from being penalized for not performing the quality action. However, in this scenario, since there was a screening performed after the refusal the second screening would be used.

      Denominator Exceptions
      ( exists "Medical or Patient Reason for Not Screening Adolescent for Depression"
          and not "Has Adolescent Depression Screening"
      )
        or ( exists "Medical or Patient Reason for Not Screening Adult for Depression"
            and not "Has Adult Depression Screening"
        )

      Show
      Thank you for your inquiry regarding CMS2v12-Preventative Care and Screening: Screening for Depression and Follow-Up Plan. Per the guidance in the measure specification, "The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter". Therefore, based on the information provided in the scenario, the second screening would qualify as the most recent and should be the one counted toward the measure. Numerator ( "Patient Age 12 to 16 Years at Start of Measurement Period"     and ( "Has Most Recent Adolescent Screening Negative"         or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"     ) )   or ( "Patient Age 17 Years at Start of Measurement Period"       and ( "Has Most Recent Adolescent Screening Negative"           or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"           or "Has Most Recent Adult Screening Negative"           or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"       )   )   or ( "Patient Age 18 Years or Older at Start of Measurement Period"       and ( "Has Most Recent Adult Screening Negative"           or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"       )   ) ​...... Has Most Recent Adolescent Screening Negative ( "Most Recent Adolescent Depression Screening" AdolescentScreen     where AdolescentScreen.result ~ "Depression screening negative (finding)" ) is not null   Has Most Recent Adult Screening Negative ( "Most Recent Adult Depression Screening" AdultScreen     where AdultScreen.result ~ "Depression screening negative (finding)" ) is not null Secondly, you wrote, "Our vendor states that following the logic, the denominator exclusion (the refusal) occurs first the pt is excluded and the logic does not continue on to the next screening." Please note that patient refusal of screening is captured as a denominator exception, not an exclusion, and prevents the clinician from being penalized for not performing the quality action. However, in this scenario, since there was a screening performed after the refusal the second screening would be used. Denominator Exceptions ( exists "Medical or Patient Reason for Not Screening Adolescent for Depression"     and not "Has Adolescent Depression Screening" )   or ( exists "Medical or Patient Reason for Not Screening Adult for Depression"       and not "Has Adult Depression Screening"   )
    • CMS0002v12
    • Multiple depression screenings on the same day/encounter visit with different outcomes.

      A patient has two depression screens completed on the same qualifying encounter.

      The first screen was a PHQ-2, patient "Declines to be asked" resulting in a Denominator Exception.

      The second screen was completed 3 minutes later using an Edinburgh Postnatal Depression Scale with a score of 1, resulting in a negative screen and MET numerator outcome. 

      Our vendor states that following the logic, the denominator exclusion (the refusal) occurs first the pt is excluded and the logic does not continue on to the next screening. 

      When there are two different responses on the same day resulting in different outcomes, can you confirm which depression screen would be considered to determine the outcome?  Thank you.

            edave Mathematica EC eCQM Team
            Jadavis Julie A. Davis
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