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  1. eCQM Issue Tracker
  2. CQM-7091

Depression Screening (CMS2v13) Denominator Exception

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Ramsey Abdallah
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      Thank you for your question about CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan.

      This measure is patient-based. Patient-based measures consider all of the care a patient receives during the measurement period. Depression screening is required once per measurement period, not at all encounters. In your example provided, the patient meets the denominator exception on June 1. This encounter would meet the "once per measurement period" requirement for reporting. Clinically, it is provider discretion that determines if the patient condition warrants continued effort to rescreen for depression; if they feel it is clinically justified. However, for the measure calculation, there is no need to try to rescreen and document that the patient refused depression screening on the June 20th encounter.
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      Thank you for your question about CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. This measure is patient-based. Patient-based measures consider all of the care a patient receives during the measurement period. Depression screening is required once per measurement period, not at all encounters. In your example provided, the patient meets the denominator exception on June 1. This encounter would meet the "once per measurement period" requirement for reporting. Clinically, it is provider discretion that determines if the patient condition warrants continued effort to rescreen for depression; if they feel it is clinically justified. However, for the measure calculation, there is no need to try to rescreen and document that the patient refused depression screening on the June 20th encounter.
    • Not measure related
    • Not measure related
    • Not measure related
    • Not measure related
    • Not measure related
    • CMS0002v13
    • Not measure related
    • Not measure related
    • Not measure related
    • Not measure related
    • The issue impacts both office workflow and patient experience. Having to repeatedly ask the question is an issue with patients.

      We have been reviewing our depression screening data for several weeks and noticed issues with our performance. Upon review, we identified an issue with the denominator exception. Our EHR does not account for denominator exception (patient reason or medical reason) if the patient has a subsequent visit. For example, if we documented that the patient refused screening on June 1, 2024, the EHR would remove the patient from the denominator. However, if the patient had a follow-up visit on June 20, the EHR vendor is arguing that the provider should be required to ask again and document if the patient refuses again. If an exception is not documented again, it lists the the patient as Unmet. Since the measure is patient specific and to respect the wishes of our patients, we do not attempt a screen at subsequent visits. We are seeking confirmation if the denominator exception entry is required for every single encounter a patient has in the performance period.

            edave Mathematica EC eCQM Team
            rabdallah1 Ramsey Abdallah (Inactive)
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