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  2. CQM-6923

CMS2v13 - Depression screening and follow-up

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      Thank you for your question on CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter. Per your example, if the patient was screen positive on 2/29/2024 and had an encounter that same day, or within the 14 calendar days prior to the encounter, then this encounter (Encounter 4) would be evaluated for numerator compliance. The patient would not meet the numerator because there was no follow-up plan documented on the date of or up to two days after the date of the qualifying encounter.

      Specific to the numerator compliance logic, this is captured in the ‘Most Recent Adult Depression Screening Positive and Follow Up Provided’ (or Most Recent Adolescent Depression Screening Positive and Follow Up Provided)- see below:

      Most Recent Adult Depression Screening Positive and Follow Up Provided
      from
        "Most Recent Adult Depression Screening" LastAdultScreen,
        "Follow Up Intervention for Positive Adult Depression Screening" FollowUpPositiveAdultScreen,
        "Qualifying Encounter During Measurement Period" QualifyingEncounter
        where Global."NormalizeInterval" ( LastAdultScreen.relevantDatetime, LastAdultScreen.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod
          and LastAdultScreen.result ~ "Depression screening positive (finding)"
          and ( start of Global."NormalizeInterval" ( FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod ) during QualifyingEncounter.relevantPeriod
              or FollowUpPositiveAdultScreen.authorDatetime 2 days or less on or after day of
              end of QualifyingEncounter.relevantPeriod
          )
          and Coalesce(start of Global."NormalizeInterval"(FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod), FollowUpPositiveAdultScreen.authorDatetime)during "Measurement Period"
      Show
      Thank you for your question on CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter. Per your example, if the patient was screen positive on 2/29/2024 and had an encounter that same day, or within the 14 calendar days prior to the encounter, then this encounter (Encounter 4) would be evaluated for numerator compliance. The patient would not meet the numerator because there was no follow-up plan documented on the date of or up to two days after the date of the qualifying encounter. Specific to the numerator compliance logic, this is captured in the ‘Most Recent Adult Depression Screening Positive and Follow Up Provided’ (or Most Recent Adolescent Depression Screening Positive and Follow Up Provided)- see below: Most Recent Adult Depression Screening Positive and Follow Up Provided from   "Most Recent Adult Depression Screening" LastAdultScreen,   "Follow Up Intervention for Positive Adult Depression Screening" FollowUpPositiveAdultScreen,   "Qualifying Encounter During Measurement Period" QualifyingEncounter   where Global."NormalizeInterval" ( LastAdultScreen.relevantDatetime, LastAdultScreen.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod     and LastAdultScreen.result ~ "Depression screening positive (finding)"     and ( start of Global."NormalizeInterval" ( FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod ) during QualifyingEncounter.relevantPeriod         or FollowUpPositiveAdultScreen.authorDatetime 2 days or less on or after day of         end of QualifyingEncounter.relevantPeriod     )     and Coalesce(start of Global."NormalizeInterval"(FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod), FollowUpPositiveAdultScreen.authorDatetime)during "Measurement Period"
    • CMS0002v13

      In the scenario below, which encounter will be used to assess numerator compliance? Can you confirm the logic behind numerator compliance?

      Is it based on the latest qualifying encounter and assessing for a positive depression screening and a follow-up plan documented OR is it based on the latest qualifying encounter WITH a positive depression screening and a follow-up plan documented? 

      1. January 9, 2024 - Encounter 1 – PHQ-9 Score = 10 and is positive for depression.  No follow-up plan is documented. 
      2. January 30, 2024 – Encounter 2 – PHQ-9 Score = 7
      3. February 16, 2024  - Encounter 3 – PHQ-9 Score = 12 and is positive for depression.  Follow-up plan is documented.
      4. February 29, 2024 – Encounter 4 – PHQ-9 Score = 11.  Patient already has a diagnosis of depression.  No additional follow-up plan is documented.

      Which encounter will be used to assess numerator compliance?

      • Encounter 1 (first encounter in 2024)
      • Encounter 3 (follow-up plan is documented)
      • Encounter 4 (most recent encounter in 2024)

            edave Mathematica EC eCQM Team
            joluna John Carlo
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