Thank you for your inquiry on CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. If the patient declines follow-up, the patient will not meet the Numerator. The ‘Denominator Exception’ only applies if the patient declines the depression screening, NOT the follow-up plan. The patient still can meet the Numerator, if 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 the screening is positive, a follow-up plan is documented on the date of, or up to two days after the date of the qualifying encounter. The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, the documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter. This measure does not evaluate if the patient received treatment. Thus, if the patient refuses treatment for their depression, but a follow-up plan has been documented, the patient would meet the Numerator.