Thank you for your inquiry regarding CMS2v14. The measure does not specify the credentials or provider type of the individual who can or review the depression screening. Additionally, the measure logic does not explicitly capture who documents each component. For successful reporting and to receive ‘credit’ for this measure, a Merit-based Incentive Payment System (MIPS) eligible professional or clinician must document under a qualifying encounter code, as indicated by the “Qualifying Encounter During Measurement Period” definition and in the event of a positive screening, a MIPS eligible clinician would need to document the follow-up plan to meet the numerator requirements. In the scenario you provided, if a nurse practitioner (NP) documents the screening separately from the physician’s visit, the physician’s encounter alone will not meet the measure requirements.
For further information on MIPS eligible clinician types and requirements, please refer to the information located on the Quality Payment Program website:
https://qpp.cms.gov/mips/how-eligibility-is-determined#mips-eligible-clinician-types