I reached out to CMS regarding this issue and they said to post it hear, as they no longe work with eCQMs.

We are a radiation oncology practice (not a hospital) and some of our patient - facing visits are no charge visits. We have instances where we've completed depression screenings, but they are not counting toward our measure, as the measure states it has to be on a billable visit. This unfairly sets our practice up to not meet a measure that we're actually meeting.

For example, a patient was seen at the beginning of the year by a physician, MIPS depression screening was completed, but the visit ended up being a no-charge visit. The same patient was seen one month later, for a billable visit, but screening was not completed, because our clinicians saw it was previously completed. The encounter date showing as not-met is the date for the second visit.

Is there any way this issue can be addressed and depression screening can count when completed, regardless of billable or non-billable?

Please note that since we are not a hospital, I am not familiar with the CSM codes below to select from. This is for 2025 reporting, so I'm choosing the first code available.