CMS 2 - Depression Screening and Follow-Up: Denominator Exception Clarification

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
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      Thank you for inquiring about the Preventive Care and Screening: Screening for Depression and Follow-Up Plan eCQM. The denominator exception intends to provide an allowance for providers unable to screen patients for depression (due to medical or patient reasons). It is not intended to be an exception for not providing an intervention when the patient has been screened positive. We are currently working to revise the measure flow to reflect this. Please follow the measure’s CQL logic when calculating the measure not the measure flow. The measure’s logic for the denominator exception is below and notes that the patient could not have had documentation of a depression screening within 14 days of a qualifying encounter during the measurement period in addition to documentation of an allowable exception. Therefore, based on the patient scenario you provided, the patient would neither meet the denominator exception (a depression screening was done during a qualifying encounter in the measurement period) nor the numerator criteria (no follow-up provided).
      Denominator Exceptions
       
      ( exists "Medical or Patient Reason for Not Screening Adolescent for Depression"
          and not "Has Adolescent Depression Screening"
      )
        or ( exists "Medical or Patient Reason for Not Screening Adult for Depression"
            and not "Has Adult Depression Screening"
        )
      Has Adult Depression Screening
       
      exists ( ["Assessment, Performed": "Adult depression screening assessment"] AdultScreening
          with "Qualifying Encounter During Measurement Period" QualifyingEncounter
            such that Global."NormalizeInterval" ( AdultScreening.relevantDatetime, AdultScreening.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod
              and AdultScreening.result is not null
      )
       

      Show
      Thank you for inquiring about the Preventive Care and Screening: Screening for Depression and Follow-Up Plan eCQM. The denominator exception intends to provide an allowance for providers unable to screen patients for depression (due to medical or patient reasons). It is not intended to be an exception for not providing an intervention when the patient has been screened positive. We are currently working to revise the measure flow to reflect this. Please follow the measure’s CQL logic when calculating the measure not the measure flow. The measure’s logic for the denominator exception is below and notes that the patient could not have had documentation of a depression screening within 14 days of a qualifying encounter during the measurement period in addition to documentation of an allowable exception. Therefore, based on the patient scenario you provided, the patient would neither meet the denominator exception (a depression screening was done during a qualifying encounter in the measurement period) nor the numerator criteria (no follow-up provided). Denominator Exceptions   ( exists "Medical or Patient Reason for Not Screening Adolescent for Depression"     and not "Has Adolescent Depression Screening" )   or ( exists "Medical or Patient Reason for Not Screening Adult for Depression"       and not "Has Adult Depression Screening"   ) Has Adult Depression Screening   exists ( ["Assessment, Performed": "Adult depression screening assessment"] AdultScreening     with "Qualifying Encounter During Measurement Period" QualifyingEncounter       such that Global."NormalizeInterval" ( AdultScreening.relevantDatetime, AdultScreening.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod         and AdultScreening.result is not null )  
    • CMS0002v14

      CMS 2 Depression Screening Exceptions

      We would like clarification on the following scenario:

      Patient has Medical Reason or Patient Reason for not screening for adult depression on 3/2/XXXX on an qualifying encounter.  On 4/2/XXXX, the patient has another qualifying encounter, has a positive screen, but didn’t have a follow-up.   

      At https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v14.html, it says, “( exists "Medical or Patient Reason for Not Screening Adult for Depression"

           and not "Has Adult Depression Screening"

       )”

      In this situation, the patient does have a depression screening, so it seems that we can’t use the denominator exception.

      On the eCQM Flow pdf at 2025 eCQM Flow – CMS2v14: Preventive Care and Screening: Screening for Depression and Follow-Up Plan, it say to move to the denominator exceptions evaluation if “Most recent depression screen is positive with a follow up documented on the date of or up to two days after the qualifying encounter “ is No.  In this situation, the answer would be No, so one would continue down the eCQM flow to assess for a Patient or Medial Reason.   And there is a Medical or Patient reason documented on 3/2/XXXX).   Using the eCQM flow, it seems the patient would be excepted. 

      Is the patient “Not Met” for numerator conditions because there was no follow-up documented or Excepted because they had a previous reason not screening?

       

      Thank you for the clarification. 

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Shari Black
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