I have logged issues previously with CMS2 - specifically related to the relatively recent change that added to the population screened those with existing depression and who are currently under treatment, as this now conflates screening results with reassessment results. This has been acknowledged with CMS2v14 having a known issue - and a published workaround to satisfy it... In essence, patients currently being treated for depression who do not get a new prescription for a medication, or a new referral for counseling or treatment are at risk of failing the measure. The "solution" for 2025 is to create a click-box mapped to a particular SNOMED code signifying ongoing treatment.

CMS2v15 was supposed to improve this burdensome workaround - and it may do so with these two updates. First, an antidepressant on the active med list will be considered as a satisfier, and a new prescription or med order is not required. Secondly, a follow-up may include education about self-care, nutrition, exercise, etc.

Unfortunately, it attempting to remedy this known issue, this "clarification" will make things significantly worse... paraphrasing... "if multiple depression screenings are done on the same day, the measure has no concept of hierarchy and will consider both screeners as equally valid... and thus if one screener is positive and the other is negative, the patient will be considered to be screened as positive for depression, and a follow-up is necessary to meet the measure numerator requirements.

Much or more likely most depression screening is done by primary care clinicians, and within primary care, it is not unusual to SCREEN initially with a PHQ-2, and where the PHQ-2 is positive, reflex to the PHQ-9. And while this is not a requirement, I believe that most clinicians would not diagnose depression simply on the basis of a PHQ-2 score... as it is only a screening tool. On the other hand, one could (along with other information) use the results of a PHQ-9 to diagnose and quantify depression as mild, moderate, or severe.

Unless I am misreading the 2026 specs, CMS2v15 is clarifying that if clinicians are foolish enough to use a common practice and do the right thing for patients (reflexing a positive PHQ-2 to administration of a PHQ-9), they risk having lower scores for this measure. Why... if the measure defines itself as not recognizing the hierarchy of PHQ-2 to PHQ-9, then a positive PHQ-2 followed by a negative PHQ-9 is by definition misinterpreted as positive - and this patient now fails the depression screening measure unless this patient without depression is either prescribed an antidepressant, referred to a psychiatrist, or counseled by the primary care doctor for a condition the patient doesn't have.

Further, I would ask the expert panel that considers updates to this measure to keep this in mind.
1. If the goal of this measure is to screen patients who may need attention or treatment of depression - please reconsider adding an exclusion of an active problem of depression. There are plenty of clinical protocols for re-assessing patients with an active problem of depression who are on medication, receiving counseling, or utilizing self-care tactics. Including these individuals as people who need re-screening IMO only adds to the burden of documenting a follow-up.
2. Please also consider that within the US, the majority of patients with depression have mild depression and are managed by a primary care physician, and many without medication. Thus, many (perhaps a majority of) patients who screen positive will not be referred or started on medication, and thus without creating a click-box which is mapped to a SNOMED code in the value set, these patients will be seen as measure fails.
3. This issue then compounds itself because of the requirement to annually screen all patients... Thus, each patient with mild depression who is treated by their PCP without medication risks becoming a measure fail every time a subsequent PHQ-9 is administered. Specifically... if the PCP went to the trouble of duplicatively documenting counseling or guided self-treatment in a special form mapped to relevant SNOMED codes - this would only work for the measure year until a subsequent PHQ-9 was done... and unless the special form was clicked correctly, the patient correctly identified and efficiently and effectively managed for mild depression is seen by the measure as a measure fail.

Thank you.