Good morning,

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

MIPS 134 Measure Instructions state:

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. The most recent screening submitted will be used for performance calculation. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The follow-up plan must be related to a positive depression screening, example: “Patient referred for psychiatric evaluation due to positive depression screening.”

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.