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  2. CQM-7647

CMS-2 Depression Screening and Follow Up

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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      Thank you for inquiring about the Preventive Care and Screening: Screening for Depression and Follow-Up Plan eCQM. Please note that with the patient scenario described, the 5/15 screening was within 11 days before the eligible encounter; however, since the follow-up did not occur the day of the encounter or up to 2 days later, this would not count toward numerator compliance. The specification indicates explicitly, “Patients 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 positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter”. We applaud the effort that your organization has put into ensuring that your patients with depression are being adequately managed. We will evaluate with a future annual update how to better align the follow-up timeframe with the screening not to penalize providers who take immediate action with a positive screen completed within 14 days of the encounter.
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      Thank you for inquiring about the Preventive Care and Screening: Screening for Depression and Follow-Up Plan eCQM. Please note that with the patient scenario described, the 5/15 screening was within 11 days before the eligible encounter; however, since the follow-up did not occur the day of the encounter or up to 2 days later, this would not count toward numerator compliance. The specification indicates explicitly, “Patients 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 positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter”. We applaud the effort that your organization has put into ensuring that your patients with depression are being adequately managed. We will evaluate with a future annual update how to better align the follow-up timeframe with the screening not to penalize providers who take immediate action with a positive screen completed within 14 days of the encounter.
    • CMS0002v14

      Our organization has a process in which patients with existing, active depression are engaged via the patient portal to complete a PHQ9 on a minimum of a quarterly basis to monitor their depression.  This monitoring process sometimes overlaps with an eligible encounter and clarification is being requested.

      SCENARIO

      January 15th - patient sent PHQ9 via patient portal for monitoring of existing, active depression diagnosis by the primary care provider.  No eligible encounter on or 14 days prior to the screening.  Screening is negative and patient needs addressed.

      May 15th - patient sent PHQ9 via patient portal for monitoring of existing, active depression by the primary care provider.  Screening is positive. Provider makes medication change on May 15th. 

      May 26th - Patient has an eligible encounter with a specialty provider.  Patient not screened for depression at visit because patient needs are being addressed via by primary care provider care management processes.  Specialty provider does not address PHQ9 completed on May 15th on the day of the eligible encounter or two days after the encounter because primary care  is actively managing the patient's needs.

      August 15th - patient sent PHQ9 via patient portal for monitoring of existing, active depression by the primary care provider.  No eligible encounter on or 14 days prior to the screening.  Patient screens negative and patient needs addressed.

      November 15th - patient sent PHQ9 via patient portal for monitoring of existing depression by primary care provider.  No eligible encounter on or 14 days prior to the screening.  Patient screens negative and patient needs addressed.

      Regarding the May 26th eligible visit, would the patient not be in the numerator if the specialty provider did not address the PHQ9 on or two days after the eligible visit?

      From a population health standpoint, significant resources are being used to actively manage patients with active depression diagnoses throughout the measurement year. What options do organizations have to report appropriate screenings and follow-up during the measurement year that may not be addressed by the specific provider at an eligible visit but is being managed by another provider?

            AIR EC eCQM Team AIR EC eCQM Team
            Shari Black Shari Black
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