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Type: EC eCQMs - Eligible Clinicians
Resolution: Answered
Priority: Moderate
Component/s: None
Labels:
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Solution:

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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 this measure is patient-based, which means that we do not determine outcomes at each encounter but rather look at the patient’s care experience over the course of the measurement period (calendar year). Depression screening is required once per measurement period, not at all encounters. However, the most recent is used to determine the outcome if screened more than once.

• Scenario 1: The version 14 specification requires that the follow-up take place during the timeframe of the qualifying encounter to 2 days afterward to be considered for numerator compliance. Assuming no other encounters occurred during the measurement period for scenario 1, the most recent screen would be completed during the family medicine encounter (considered the qualifying encounter). If follow-up actions were documented within the timeframe of the qualifying encounter to two days following, the patient would meet the numerator.

• Scenario 2: In this case, the screening from the 3/2 can be used (since it is within 14 days of the 3/4 qualifying visit); however, the follow-up would not qualify under the v.14 specification since it occurs before the qualifying visit period. For the measurement period, this would not be numerator-compliant. 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 this measure is patient-based, which means that we do not determine outcomes at each encounter but rather look at the patient’s care experience over the course of the measurement period (calendar year). Depression screening is required once per measurement period, not at all encounters. However, the most recent is used to determine the outcome if screened more than once. • Scenario 1: The version 14 specification requires that the follow-up take place during the timeframe of the qualifying encounter to 2 days afterward to be considered for numerator compliance. Assuming no other encounters occurred during the measurement period for scenario 1, the most recent screen would be completed during the family medicine encounter (considered the qualifying encounter). If follow-up actions were documented within the timeframe of the qualifying encounter to two days following, the patient would meet the numerator. • Scenario 2: In this case, the screening from the 3/2 can be used (since it is within 14 days of the 3/4 qualifying visit); however, the follow-up would not qualify under the v.14 specification since it occurs before the qualifying visit period. For the measurement period, this would not be numerator-compliant. 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.
2025 Performance Period EC eCQMs:

CMS0002v14
Impact:

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Measure description states: Percentage of patients aged 12 years and older 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 depression screening 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.

Clarification requested regarding the 14-day lookback period when patient seen multiple times with an eligible visit during the 14-day period.

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Measure description states: Percentage of patients aged 12 years and older 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 depression screening 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. Clarification requested regarding the 14-day lookback period when patient seen multiple times with an eligible visit during the 14-day period.

Are organizations required to utilize any depression screening that occurred within 14-days of an eligible visit to evaluate numerator criteria? Is the intent of the measure that organizations use one depression screening to evaluate multiple visits for numerator criteria?

SCENARIO 1:

Patient seen by Family Medicine provider for an eligible visit on 3/25/2025 with a depression screening occurring and documented at that visit. Screen was positive and provider ordered medication. Using this eligible encounter, the patient would meet numerator criteria for a positive depression screen with appropriate follow-up.

Patient seen later that same day (3/25/2025) with OB/GYN provider for an eligible visit. No screening was performed at this visit and depression care needs were not addressed. Since the screening from the Family Medicine visit earlier that day was within the 14-day lookback period, are we required to utilize the same, earlier depression screening done at the Family Medicine appointment to evaluate the OB/GYN visit for numerator compliance? If yes, the patient would not meet numerator criteria for a positive depression screen with appropriate follow-up.

SCENARIO 2:

Patient seen for non-eligible visit with Psychiatry provider on 3/2/2025 with a depression screening occurring and documented that visit. Screen was positive and provider ordered medication. Since this is not an eligible encounter, this visit/screening would not be used to determine numerator criteria.

Patient seen for eligible visit on 3/4/2025 with Cardiology provider. No depression screening occurred at this visit, and depression care needs were not addressed. Since the screening from the Psychiatry visit on 3/4/2025 is within the 14-day lookback period, are we required to utilize the same, earlier depression screening done on 3/2/2025 to evaluate the 3/4/2025 visit for numerator compliance? If yes, the patient would not meet numerator criteria for a positive depression screen with appropriate follow-up.

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