MIPS 134: Preventive Care Screening: Screening for Depression and Follow-Up Plan (CMS2)

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Andrea Howard
    • 2814667590
    • McKesson
    • Hide
      Thank you for inquiring about CMS0002v15 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Given the use of a shared EMR and the fact that CMS0002v15 is a patient-based eCQM, all providers would have the same outcome. The measure requires only one depression screening to be completed annually, and if positive, an appropriate follow-up action be documented. If multiple screenings are completed during the measurement period, the most recent one (done last) is used. If you review the measure flow (available at https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2-v15.0.000-eCQM-Flow.pdf), you will note that the denominator exception only applies when there is no screening completed during the measurement period. Because a depression screening was performed during the June 2025 qualifying visit, the result was negative, and no other screens occurred in 2025, the patient would be included in the numerator for the measurement period. This outcome was validated in the eCQM logic validation tooling and applies to all providers using the shared EMR (i.e., Providers A through E in your example).
      Show
      Thank you for inquiring about CMS0002v15 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Given the use of a shared EMR and the fact that CMS0002v15 is a patient-based eCQM, all providers would have the same outcome. The measure requires only one depression screening to be completed annually, and if positive, an appropriate follow-up action be documented. If multiple screenings are completed during the measurement period, the most recent one (done last) is used. If you review the measure flow (available at https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2-v15.0.000-eCQM-Flow.pdf), you will note that the denominator exception only applies when there is no screening completed during the measurement period. Because a depression screening was performed during the June 2025 qualifying visit, the result was negative, and no other screens occurred in 2025, the patient would be included in the numerator for the measurement period. This outcome was validated in the eCQM logic validation tooling and applies to all providers using the shared EMR (i.e., Providers A through E in your example).
    • CMS0002v15
    • CMS0002v14
    • We need clarifying information on the below scenarios.

      Good afternoon,

      I am writing this question on behalf of Practice Insights QCDR regarding MIPS 134 Depression (MIPS eCQM version specification). 

      We understand that MIPS 134 is a patient-based measure where the intended Can you please clarify the measure performance calculation may differ for clinicians at the same practice, given the following scenario:

      The patient, Sammy Smith, is cared for by multiple physicians during the year at Apha Oncology Clinic.

      • Physician A sees Sammy for a qualifying E/M visit in Feb 2025 and does not complete a depression screen.
      • Physician B sees Sammy for a qualifying E/M visit in June 2025 and completes a depression screen.  The screen is negative.  Physician C also sees Sammy on the same day for a qualifying E/M visit and does not complete a depression screen because she sees in the EHR that one was completed earlier in the day by Physician B.
      • Physician D sees Sammy for a qualifying E/M visit in Sept 2025 and does not complete a depression screen because the patient’s medical record indicates that a depression screen was already completed by Physician B in June and the result was negative.
      • Physician E sees Sammy for a qualifying E/M visit in Nov 2025 and the patient refuses to complete a depression screen and this is recorded as a Denominator Exception. 

      For Individual Clinician MIPS Reporting:

      1. Which Physicians should receive numerator credit for MIPS 134?
      2. Does CMS expect the patient to be screened 5 times during 2025 because he was seen by 5 different physicians at Alpha Oncology Clinic OR can a completed depression screen be referenced for each of the physicians who have had a qualifying E/M with Sammy?
      3. Which physicians should have the patient qualify for a Denominator Exception due to the patient refusal to complete the depression screen?

      For the Group MIPS Reporting:

      1. Should Sammy be considered Numerator Met because the Depression Screen was completed in June 2025 OR should Sammy be considered a Denominator Exception because the most recent screening attempt resulted in a patient refusal?

      Thank you in advance for clarifying these scenarios.

      Andrea Howard

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Andrea Howard
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