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

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 the measure’s Guidance section and logic denote that the most recent depression screening completed during a qualifying encounter (or within 14 days prior) is used to assess measure compliance. This is a patient-based measure, and while the screening is only required once, if multiple screenings are completed, only the most recent (the last one during the measurement period) is used. When multiple providers using the same EHR report on the measure, the most recent of all depression screenings during the measurement period—regardless of which provider performed it—is used for measure reporting. The measure is not reported separately based on individual provider actions, but only overall, for the patient. Therefore, to meet the measure’s explicit intent, you must track all screenings during the measurement period to identify the most recent (which is the one done last during the measurement period).

Guidance:
"The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter."

Numerator Logic:
• Numerator
o
 ( "Patient Age 12 to 16 Years at Start of Measurement Period"
 and ( "Has Most Recent Adolescent Screening Negative"
 or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"
 )
 )
 or ( "Patient Age 17 Years at Start of Measurement Period"
 and ( "Has Most Recent Adolescent Screening Negative"
 or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"
 or "Has Most Recent Adult Screening Negative"
 or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"
 )
 )
 or ( "Patient Age 18 Years or Older at Start of Measurement Period"
 and ( "Has Most Recent Adult Screening Negative"
 or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"
 )
 )

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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 the measure’s Guidance section and logic denote that the most recent depression screening completed during a qualifying encounter (or within 14 days prior) is used to assess measure compliance. This is a patient-based measure, and while the screening is only required once, if multiple screenings are completed, only the most recent (the last one during the measurement period) is used. When multiple providers using the same EHR report on the measure, the most recent of all depression screenings during the measurement period—regardless of which provider performed it—is used for measure reporting. The measure is not reported separately based on individual provider actions, but only overall, for the patient. Therefore, to meet the measure’s explicit intent, you must track all screenings during the measurement period to identify the most recent (which is the one done last during the measurement period). Guidance: "The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter." Numerator Logic: • Numerator o  ( "Patient Age 12 to 16 Years at Start of Measurement Period"  and ( "Has Most Recent Adolescent Screening Negative"  or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"  )  )  or ( "Patient Age 17 Years at Start of Measurement Period"  and ( "Has Most Recent Adolescent Screening Negative"  or exists "Most Recent Adolescent Depression Screening Positive and Follow Up Provided"  or "Has Most Recent Adult Screening Negative"  or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"  )  )  or ( "Patient Age 18 Years or Older at Start of Measurement Period"  and ( "Has Most Recent Adult Screening Negative"  or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided"  )  )
2025 Performance Period EC eCQMs:

CMS0002v14
Impact:
A provider has expressed concern regarding how this measure is currently impacting their performance metrics.

The core of the issue lies in the interpretation of the measure's specifications. According to the provider, the CMS guidelines state that a depression screening is required only once per measurement period, not necessarily at every encounter. In a specific instance, Provider 'A' conducted a depression screening on January 27, 2025, and documented a negative result.

However, the same patient was subsequently seen by Provider 'B' several months later. Provider 'B' also performed a depression screening, which yielded a positive result, but did not document any follow-up. As a result, this later encounter is now counting against Provider 'A'. The provider's understanding is that "CMS guidelines state that it only needs to be submitted and tracked once per performance period. So once we've successfully tracked this information, there's no further need for the EHR to continue tracking it on a patient."

Your guidance on this matter would be greatly appreciated.

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