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  1. eCQM Issue Tracker
  2. CQM-7433

Depression Screening

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Nicole Martin
    • 5415800419
    • Umpqua Health Alliance
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      Thank you for your follow-up inquiry. Note the steps provided by our team explain what the EHR should be doing to calculate a patient's outcome for the measure during the defined measurement period.
       
      Any encounter (that meets the value set for encounter types) can be considered a qualifying encounter for the patient. From your provided encounters:
      • 6/15 is a qualifying encounter
      • 7/15 is a qualifying encounter
       
      Since the patient was diagnosed as bipolar during the 6/15 encounter, then it would be seen as BEFORE the 7/15 encounter, making the patient excluded from the measure’s denominator. The EHR programming will not look to see if there was screening or follow-up because it stops calculation when the patient is excluded.
       
      If there was only one qualifying encounter (patient was seen for the 6/15 encounter only and never again during the measurement period) with no screening and a new bipolar diagnosis, then the patient would NOT meet the exclusion criteria. This would be because the diagnosis occurred during the only qualifying encounter and not before.

      Please see v13 of the measure flow for reference here: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v13-eCQMFlow.pdf
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      Thank you for your follow-up inquiry. Note the steps provided by our team explain what the EHR should be doing to calculate a patient's outcome for the measure during the defined measurement period.   Any encounter (that meets the value set for encounter types) can be considered a qualifying encounter for the patient. From your provided encounters: • 6/15 is a qualifying encounter • 7/15 is a qualifying encounter   Since the patient was diagnosed as bipolar during the 6/15 encounter, then it would be seen as BEFORE the 7/15 encounter, making the patient excluded from the measure’s denominator. The EHR programming will not look to see if there was screening or follow-up because it stops calculation when the patient is excluded.   If there was only one qualifying encounter (patient was seen for the 6/15 encounter only and never again during the measurement period) with no screening and a new bipolar diagnosis, then the patient would NOT meet the exclusion criteria. This would be because the diagnosis occurred during the only qualifying encounter and not before. Please see v13 of the measure flow for reference here: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v13-eCQMFlow.pdf
    • CMS0002v14
    • CMS0002v13
    • if no screening is done during encounter, is patient excluded

      see also CQM-7396

      I am not certain you actually answered my question

      taking your example steps
      Example:
      1.    Look at all qualifying encounters during measurement period
          a) 6-15-23 (no screening) and 7-15-23 (screening done)

      2.    Determine if there was bipolar diagnosis prior to any of the qualifying encounters
          a) Bipolar was diagnosed during 6-15-23 visit (this is NOT prior to any qualifying encounter)

      3.    If yes, exclude (and STOP evaluation)
           a) I do not know what STOP evaluation means. 

      4.    If no, check to see if screened
           a) patient was not screened

      1.    If screened positive, was there follow-up… etc.

       ***********************************************

      Since patient did NOT have a diagnosis prior to qualifying encounter AND they were not screened, are they in the GAP?

      or are you saying that since the most recent ENCOUNTER (7-15-23) came AFTER the bipolar diagnosis, the patient is excluded?

      or is it that since the most recent SCREENING (7-15-23) came AFTER the bipolar diagnosis, the patient is excluded?

       

            AIR EC eCQM Team AIR EC eCQM Team
            nmartin Nicole Martin
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