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  2. CQM-6882

2024 spec clarification

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    • Resolution: Answered
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    • Amanda Fredricksen
    • Mayo Clinic
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      Thank you for your inquiry on CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. In the scenarios that was provided, only the encounter on May 20th would count towards the numerator.

      To meet the numerator, the patient is screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.
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      Thank you for your inquiry on CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. In the scenarios that was provided, only the encounter on May 20th would count towards the numerator. To meet the numerator, the patient is screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.
    • CMS0002v13

      Beginning with the 2024 measurement year, patients with a history of depression will no longer be excluded from the measure denominator. At our organization, patients with existing depression are monitored more frequently (minimum of quarterly) than the minimum annual screening requirement the measure specification outlines. In many instances, this assessment and follow up occurs outside of a qualifying encounter. In the scenario below, the patient completes the depression screening tool 4 times during the measurement period but only once within the appropriate timeframe of a qualifying encounter. Would CMS expect that organizations would use the May 20th date to evaluate measure criteria against as this is the only screening that occurred during the qualifying encounter or within 14 calendar days prior to the encounter?

      • January 10th, 2024: Patient completes a depression screening via the patient portal. Provider may/may not change the patient’s care plan. No qualifying visit occurs the day of or 14 days after to this assessment.

      • May 20th, 2024: Patient completes the depression screening via the patient portal 2 days prior to a qualifying encounter with the provider. Provider addresses needs during the qualifying encounter.

      • August 15, 2024: Patient completes a depression screening via the patient portal. Provider may/may not change the patient’s care plan. No qualifying visit occurs the day of or 14 days after to this assessment.

      • November 29th, 2024: Patient completes a depression screening via the patient portal. Provider may/may not change the patient’s care plan. No qualifying visit occurs the day of or 14 days after to this assessment.

      • Patient has no other qualifying visits in the measurement year.

            edave Mathematica EC eCQM Team
            m076050 Amanda Fredricksen
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