Depression Screening Denominator Exception - future visits

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • William Nattrass
    • Piedmont Healthcare
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      Thank you for your inquiry regarding CMS2v15. As stated in the Guidance section of the specification, this measure assesses the most recent depression screening during a qualifying encounter (or within 14 calendar days prior to that encounter). In the scenario you described:
      • The January encounter, where Patient Refused was documented as a valid Denominator Exception, would be excluded from the performance rate calculation for that encounter, since the numerator criteria were not met and the exception was appropriately applied.
      • The February encounter, however, is treated as a separate, new qualifying encounter. Since the depression screening was performed and is the only, and most recent, screening during a qualifying encounter and during the measurement period and resulted in a positive finding, but no follow-up plan was documented during that same encounter, the measure would be scored as Not Met for that visit.
      Show
      Thank you for your inquiry regarding CMS2v15. As stated in the Guidance section of the specification, this measure assesses the most recent depression screening during a qualifying encounter (or within 14 calendar days prior to that encounter). In the scenario you described: • The January encounter, where Patient Refused was documented as a valid Denominator Exception, would be excluded from the performance rate calculation for that encounter, since the numerator criteria were not met and the exception was appropriately applied. • The February encounter, however, is treated as a separate, new qualifying encounter. Since the depression screening was performed and is the only, and most recent, screening during a qualifying encounter and during the measurement period and resulted in a positive finding, but no follow-up plan was documented during that same encounter, the measure would be scored as Not Met for that visit.
    • CMS0002v15
    • CMS0002v14
    • Clarification regarding Denominator Exceptions per encounter for MIPS eCQM report outcomes...

      Looking through other Jira's, I am seeing that for the most part, if either Patient Refused or Medical Reason Denominator Exceptions are used during an encounter, this would meet the "once per measurement period" requirement for reporting and no future screenings need to be performed ("no need to try to rescreen). Also, if a screening is done and is positive, the follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator.

      You also do not need to document the denominator exception to every qualifying encounter after it was documented earlier in that measurement period.

      Based off of all that I found - I just wanted to confirm the following example:

      1. If a patient is seen in January of the reporting period and Patient Refused is documented as the Denominator Exception, but is then seen again in February and a screening is done - showing Positive with NO Follow-up, would the patient then hit the denominator as NOT MET for the February encounter or does the Denominator Exception hold from January...

      Asking based off of what I read in another Jira 6726 - 

      Please note that denominator exception (i.e., medical exception) would remove the patient from the denominator of the performance rate only if the numerator criteria are not met.

       

            Assignee:
            AIR EC eCQM Team
            Reporter:
            William Nattrass
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