CMS2 - Followup Timeframe

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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 measure explicitly requires the follow-up to occur within 2 days following the positive screen. Therefore, the positive depression screen on 1/1/25 and an intervention performed a day later would meet the numerator if 1) it was authored by 1/3/25, AND 2) the 1/1/25 depression screen was also the "most recent” (done last) during the measurement period.

      The guidance noting the following is the expectation; however the logic as written looks at the author date time for the intervention and cannot differentiate to exclude when the intervention is performed and authored during a different encounter, as opposed to the provider authoring the documentation from a visit 2 days later: "The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician or provider’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record.” (Guidance section) .

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      Thank you for inquiring about the Preventive Care and Screening: Screening for Depression and Follow-Up Plan eCQM. The measure explicitly requires the follow-up to occur within 2 days following the positive screen. Therefore, the positive depression screen on 1/1/25 and an intervention performed a day later would meet the numerator if 1) it was authored by 1/3/25, AND 2) the 1/1/25 depression screen was also the "most recent” (done last) during the measurement period. The guidance noting the following is the expectation; however the logic as written looks at the author date time for the intervention and cannot differentiate to exclude when the intervention is performed and authored during a different encounter, as opposed to the provider authoring the documentation from a visit 2 days later: "The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician or provider’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record.” (Guidance section) .
    • CMS0002v15
    • CMS0002v14

      Need guidance in interpreting the timing for Followup for the positive screening in below scenarios.

      Note: In below scenarios, given that all the codes are valid taken from vsac, and providers are in shared EHR, questions are mostly on the timeframe for the followups. Thank you

      Scenario1: Adult patient

      1/1/2025 8:00AM - 8:30AM: Provider A:  Qualifying encounter +Positive Screening

      1/14/2025 8:00AM - 8:30AM: Provider A:  Qualifying encounter  + Intervention, Performed": "Follow Up for Adolescent Depression"

       

      Question1: Would this meet numerator? even though followup is not done on same day as Positive screening, it is done on another qualifying encounter, which is within 14days from screening. Would the qualifying encounter on 1/14/2025 with screening done within14days prior(1/1/2025)  and followup on same day as qualifying enc(1/14/2025) meet numerator?

      What is the outcome for Provider A?

      --------

      Scenario2: Adult patient

      1/1/2025 8:00AM - 8:30AM: Provider A:  Qualifying encounter +Positive Screening

      1/14/2025 8:00AM - 8:30AM: Provider B:  Qualifying encounter 

      1/16/2025 8:00AM - 8:30AM: Provider B: Medication, Order: Adult Depression Medications.

      Question2: Would this followup meet numerator? As 1/14/2025 will be  another qualifying encounter, which is within 14days from screening and followup order is done within 2days from that encounter.

      What is the outcome for Provider A?

      What is the outcome for Provider B?

      --------

      Scenario3: Adult patient

      1/1/2025 8:00AM - 8:30AM: Provider A:  Qualifying encounter +Positive Screening

      1/10/2025 8:00AM - 8:30AM: Provider B:  Qualifying encounter 

      1/14/2025 8:00AM - 8:30AM: Provider C: Qualifying encounter  + Medication, Active: Adult Depression Medications.

      2/20/2025 8:00AM - 8:30AM: Provider D:  Qualifying encounter 

      Question3: Would this followup meet numerator? As 1/14/2025 will be  another qualifying encounter, which is within 14days from screening and followup order is done within 2days from that encounter.

      What is the outcome for Provider A?

      What is the outcome for Provider B?

      What is the outcome for Provider C?

      What is the outcome for Provider D? there is no screening in past14days from this visit, neither the followup

      ----------

      Question4: Based on below guidance, is it right ot understand that If screening is done on an encounter, followup is expected to be on same day? Only if screening is done alone, then any encounter within 14days from that screening will qualify for numerator if they have a followup on that day?

      Please provide general guidance on how to interpret this which we could use for any scenario. Thank you

      ==============

      Guidance from Measure Specifications mention this: 

      The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter

      ------------------------------

      Most Recent Adult Depression Screening Positive and Follow Up Provided

      from
      "Most Recent Adult Depression Screening" LastAdultScreen,
      "Follow Up Intervention for Positive Adult Depression Screening" FollowUpPositiveAdultScreen,
      "Qualifying Encounter During Measurement Period" QualifyingEncounter
      where Global."NormalizeInterval" ( LastAdultScreen.relevantDatetime, LastAdultScreen.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod
      and LastAdultScreen.result ~ "Depression screening positive (finding)"
      and ( start of Global."NormalizeInterval" ( FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod ) during QualifyingEncounter.relevantPeriod
      or FollowUpPositiveAdultScreen.authorDatetime 2 days or less on or after day of end of QualifyingEncounter.relevantPeriod
      )
      and Coalesce(start of Global."NormalizeInterval"(FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod), FollowUpPositiveAdultScreen.authorDatetime) during "Measurement Period"

       

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Priyanka Murthy
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              Updated:
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