CMS2 v15 (2026): Clarification of screening, qualifying encounter, and follow-up plan timing in pre-encounter MA workflows

XMLWordPrintable

    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Raymond Blair
    • 817-723-9548
    • Privia Medical Group, North Texas
    • Hide
      Thank you for inquiring about CMS2v15: Preventive Care and Screening: Screening for Depression and Follow-Up Plan.
      • Scenarios 1 & 5: These scenarios do not meet the numerator because, although the patients were screened within 14 days of the qualifying encounter, the follow-up referrals for a positive screen were placed before the qualifying encounters. Therefore, the timing does not meet the numerator criterion. We have documented these scenarios for consideration in future refinements to the measure.
      • Scenarios 2 & 3: These scenarios meet the numerator criteria, as the screen was completed within 14 days prior to the qualifying encounter and the follow-up occurred during or within 2 days following the qualifying encounter.
      • Scenario 4: The patient did not receive a timely screening (day 15), and thus does not meet the numerator. If the patient were screened in a timely manner (e.g., day 14), they would not meet the numerator since the referral was documented before the qualifying encounter.

      Show
      Thank you for inquiring about CMS2v15: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. • Scenarios 1 & 5: These scenarios do not meet the numerator because, although the patients were screened within 14 days of the qualifying encounter, the follow-up referrals for a positive screen were placed before the qualifying encounters. Therefore, the timing does not meet the numerator criterion. We have documented these scenarios for consideration in future refinements to the measure. • Scenarios 2 & 3: These scenarios meet the numerator criteria, as the screen was completed within 14 days prior to the qualifying encounter and the follow-up occurred during or within 2 days following the qualifying encounter. • Scenario 4: The patient did not receive a timely screening (day 15), and thus does not meet the numerator. If the patient were screened in a timely manner (e.g., day 14), they would not meet the numerator since the referral was documented before the qualifying encounter.
    • CMS0002v15
    • CMS0002v14
    • Hide
      We are finalizing internal eCQM workflows and educational materials for 2026 reporting. Ambiguity in CMS2 v15 timing logic (screening date, qualifying encounter, and follow-up plan documentation) risks incorrect guidance to clinical teams, potential measure failure, and audit exposure. We need authoritative confirmation before distributing materials as final.
      Show
      We are finalizing internal eCQM workflows and educational materials for 2026 reporting. Ambiguity in CMS2 v15 timing logic (screening date, qualifying encounter, and follow-up plan documentation) risks incorrect guidance to clinical teams, potential measure failure, and audit exposure. We need authoritative confirmation before distributing materials as final.

      This question applies specifically to the finalized CMS2 v15 eCQM for the 2026 performance year (January 1, 2026–December 31, 2026), not prior versions.

      We are requesting official clarification of CMS2 v15 (QDM) timing logic related to depression screening, qualifying encounters, and follow-up plan documentation when screenings are performed by medical assistants (MAs) prior to a provider encounter.

      Per our understanding of the CMS2 v15 specification:

      • The qualifying encounter is the anchor for measure evaluation.
      • A depression screening must occur on the date of the qualifying encounter or within 14 calendar days prior to the encounter.
      • If the most recent screening tied to the encounter is positive, a follow-up plan must be documented during the qualifying encounter or within 2 calendar days after the encounter.

      We would like confirmation of how the eCQM logic evaluates the following scenarios.

       

      Scenario 1:

      • Day 0 (Monday): MA administers PHQ-9 by telephone. Result is positive. No qualifying encounter occurs.
      • Day 2 (Wednesday): MA discusses the result with the provider and places a referral (follow-up plan) under delegated authority.
      • Day 14 (Monday): Patient has a qualifying provider encounter (E&M, AWV, telehealth, or telephone).

      Question:
      Does this scenario fail numerator criteria because the follow-up plan was authored prior to the qualifying encounter rather than during the encounter or within 2 calendar days after the encounter?

       

      Scenario 2: 

      • Day 0 (Monday): MA administers PHQ-9 by telephone. Result is positive.
      • Day 14 (Monday): Patient has a qualifying provider encounter. During that encounter, the provider reviews the positive screening and documents a follow-up plan.

      Question:
      Does this scenario meet numerator criteria under CMS2 v15?

      Scenario 3: 

      • Day 0 (Monday): MA administers PHQ-9 by telephone. Result is positive.
      • Day 14 (Monday): Patient has a qualifying provider encounter.
      • Day 16 (Wednesday): Provider documents a follow-up plan (within 2 calendar days after the encounter).

      Question:
      Does this scenario meet numerator criteria based on follow-up timing relative to the qualifying encounter?

       

      Scenario 4: 

      • Day 0 (Monday): MA administers PHQ-9 by telephone. Result is positive.
      • Day 2 (Wednesday): MA places a referral (follow-up plan).
      • Day 15 (Tuesday): Patient has a qualifying provider encounter.

      Question:
      Does this scenario fail because the screening occurred more than 14 calendar days prior to the qualifying encounter, regardless of the existence of a follow-up plan?

       

      Scenario 5: 

      • Day 0 (Monday): MA administers PHQ-9 by telephone. Result is positive.
      • Day 2 (Wednesday): MA places a referral (follow-up plan).
      • Day 14 (Monday): Patient has a qualifying provider encounter, but no new follow-up plan is documented during or after the encounter.

      Question:
      Does this scenario fail because the follow-up intervention was authored before the qualifying encounter rather than during the encounter or within 2 calendar days after the encounter?

       

      Additional Context:

      • Referrals placed by MAs are entered under delegated provider authority within the EHR.
      • This question is focused strictly on CMS2 v15 QDM logic and narrative guidance, not EHR workflow preference.
      • Our current interpretation is that Scenarios 2 and 3 meet numerator criteria, while Scenarios 1, 4, and 5 do not.
      • We are seeking confirmation that this interpretation aligns with CMS2 v15 logic and intent for 2026 reporting.
      • -Of course it wouldn't have to be an MA, it could be a paper PHQ9, RN, LVN, etc who performed the screening on day zero in any of these scenarios. 

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Raymond Blair
            Votes:
            0 Vote for this issue
            Watchers:
            3 Start watching this issue

              Created:
              Updated:
              Resolved:
              Solution Posted On: