Uploaded image for project: 'eCQM Issue Tracker'
  1. eCQM Issue Tracker
  2. CQM-7209

CMS2v12 and CMS2v13 - Screening for Depression and Follow-up Plan of Care

XMLWordPrintable

    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • Debra M Barnhart
    • 4175767605
    • Mercy Health ACO, LLC
    • Hide
      ONC or the measure steward responsible for the guidance for the logic used by EHR vendors for eCQM reporting may need to modify the guidance to account for these scenarios described above.

      Thank you for your inquiry regarding CMS2v12 and CMS2v13 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Please note that the measure is not prescriptive in the specific “validated depression screening tool” being used and therefore provides no hierarchy for acceptance of one tool over another. The measure only requires the most recent, and since both are most recent, the intent is that if the most recent includes both a negative and positive screening, the patient is only in the numerator if the positive result also includes documentation of an intervention following the positive screen. We will include this as a clarification in a future logic update for the measure specification.
      Show
      ONC or the measure steward responsible for the guidance for the logic used by EHR vendors for eCQM reporting may need to modify the guidance to account for these scenarios described above. Thank you for your inquiry regarding CMS2v12 and CMS2v13 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Please note that the measure is not prescriptive in the specific “validated depression screening tool” being used and therefore provides no hierarchy for acceptance of one tool over another. The measure only requires the most recent, and since both are most recent, the intent is that if the most recent includes both a negative and positive screening, the patient is only in the numerator if the positive result also includes documentation of an intervention following the positive screen. We will include this as a clarification in a future logic update for the measure specification.
    • CMS0002v14
    • CMS0002v13
    • Hide
      Missing logic to account for depression screens documented using a combination template for documenting a PHQ2/9 which results in a PHQ 2 score and a PHQ 9 score with the same file time and date stamp. We have discovered reporting errors related to this issue.
      Show
      Missing logic to account for depression screens documented using a combination template for documenting a PHQ2/9 which results in a PHQ 2 score and a PHQ 9 score with the same file time and date stamp. We have discovered reporting errors related to this issue.

      Our physicians and providers document PHQ 9 using a PHQ2/9 combination template.  We have discovered reporting errors related to the PHQ 2/9.  The PHQ 2/9 includes a total score for both the PHQ2 and the PHQ9.  A PHQ 2/9 combination template is when a score for the PHQ 2 is totaled after the responses to the first two questions are documented and a total PHQ 9 score is displayed after the remaining 7 question responses are documented.  When the patient’s responses are entered into the EHR the time stamp file time for the PHQ 2 and the PHQ 9 score totals are the same. A patient may have a negative PHQ 2 score and a positive PHQ9 score or a positive PHQ2 score and a negative PHQ 9 score. The CMS infrastructure looks to the first score associated with the PHQ2 and ignores the PHQ 9 score. According to our EHR  vendor, CMS has not provided the infrastructure (logic) to account for this scenario when the score is negative and the clinicians assessment is positive (or the reverse) or when a PHQ 2/9 is documented. The CMS infrastructure (logic) does not consider scenarios where both mappings (PHQ 2 and PHQ 9) are present and the file time and date stamp are the same.  Physicians and other eligible providers review the outcome (score) of the screening tool and clinically assess the patient for signs and symptoms of depression.  The eligible provider documents their clinical assessment – depression screening is negative or depression screening is positive.  When the PHQ 2/9 is used it is possible for the PHQ 2 score total to be positive or negative.  The eligible providers clinical assessment for depression may not match the score. Our EHR vendor has said that they are not able to modify code to address these scenarios and that the change must come from CMS.

      We are unable to reliably submit eCQMs for quality reporting until guidance is given on this scenario.

            AIR EC eCQM Team AIR EC eCQM Team
            DebraBarnhart Debra Barnhart
            Votes:
            0 Vote for this issue
            Watchers:
            5 Start watching this issue

              Created:
              Updated:
              Resolved:
              Solution Posted On: