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  1. eCQM Issue Tracker
  2. CQM-7675

CMS2v14 Preventative Care and Screening for Depression and Follow-up Plan

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Icon: Moderate Moderate
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    • Jennifer A Chamberland
    • 207-441-0552
    • MaineGeneral Medical Center
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      Thank you for inquiring about the Preventive Care and Screening: Screening for Depression and Follow-Up Plan (v14) eCQM. It is not entirely clear as to your interpretation of “document properly” or “did not document it properly”. Please note that if you report as a group, then the most recent depression screening is used to report on the measure. If that most recent depression screening was negative (no depression based on the results from a normalized and validated screening tool), then it would meet the numerator criteria. However, if that most recent screening is positive for depression, then there must be a documented follow-up within two calendar days of the qualifying encounter to be in the numerator. If there is no documented follow-up, or that follow-up is documented before the encounter relevant period or greater than two calendar days after the qualifying encounter, then the patient would fail to meet the numerator criteria.
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      Thank you for inquiring about the Preventive Care and Screening: Screening for Depression and Follow-Up Plan (v14) eCQM. It is not entirely clear as to your interpretation of “document properly” or “did not document it properly”. Please note that if you report as a group, then the most recent depression screening is used to report on the measure. If that most recent depression screening was negative (no depression based on the results from a normalized and validated screening tool), then it would meet the numerator criteria. However, if that most recent screening is positive for depression, then there must be a documented follow-up within two calendar days of the qualifying encounter to be in the numerator. If there is no documented follow-up, or that follow-up is documented before the encounter relevant period or greater than two calendar days after the qualifying encounter, then the patient would fail to meet the numerator criteria.
    • CMS0002v14
    • CMS0002v13
    • Impacting performance across the organization

      We have to write our own internal tracking report for Depression Screening to monitor performance and want to make sure our logic is accurate. Right now we are giving credit for the 'most" recent Depression Screen documented. We report to MIPS as a group across Primary Care and Medical Specialties who all use the same EMR. If a patient is seen in Primary Care and they do a depression screen and document properly they will get credit of 'met' for that patient. However if then the patient sees a Behavioral Health clinician in another practice after the Primary Care visit and they document a depression screen but did not document it properly we now consider that patient not met even though they had one that was done already once in the calendar year. Is that correct logic that if there is more than one screening done during the calendar year that the most recent is what should be considered for numerator or should we give credit for the patient if they had at least one and it was documented correctly. 

            AIR EC eCQM Team AIR EC eCQM Team
            jechamberland Jennifer A Chamberland
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