[CQM-6393] Appropriate Flow Created: 09/05/23  Updated: 09/15/23  Resolved: 09/15/23

Status: Closed
Project: eCQM Issue Tracker
Component/s: None

Type: EC eCQMs - Eligible Clinicians Priority: Moderate
Reporter: Molly Holmstrom-Bolster (Inactive) Assignee: Mathematica EC eCQM Team (Inactive)
Resolution: Answered Votes: 0
Labels: None

Contact Name: Molly Holmstrom-Bolster
Contact Email: molly.holmstrom-bolster@uglhealth.org
Contact Phone: 9062319588
Institution/Name: Upper Great Lakes Family Health
Solution: ​Thank you for your inquiry on CMS2v12: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Patients who have ever been diagnosed with depression or with bipolar disorder at any time prior to the qualifying encounter would qualify for the Denominator Exclusion. Please work with EHR vendor to resolve your issue.
Solution Posted On:
2023 Performance Period EC eCQMs:
CMS0002v12

 Description   

We are working with our registry tool (Azara) to clear up a discrepancy.  

The timeline is as follows: 

3/15/23 - PHQ9 was positive, appropriate follow-up, patient was dx with depression

8/1/23 - pt had a repeat PHQ9 that was positive, but no follow-up was completed for various reasons

The patient is being listed as a fallout for the 8/1 appt, because "they were not diagnosed prior to the measurement period".  We think that this is not the intention of the measure, and rather either this is going off of the 3/15 visit, at which point the patient did have a positive PHQ-9 as well as a follow-up, or it's going off of the 8/1 visit at which point the patient had the exclusion of a depression dx.  The registry tool feels that the patient needed a follow-up at the 8/1 appt despite the positive dx 4.5 months prior. 

Please advise.  Thank you!

 

 

 



 Comments   
Comment by Mathematica EC eCQM Team (Inactive) [ 09/13/23 ]

We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience.

Comment by Mathematica EC eCQM Team (Inactive) [ 09/06/23 ]

Thank you for submitting your question. We will review your ticket and provide a response as soon as possible.

Generated at Sun Sep 21 15:34:36 UTC 2025 using Jira 10.3.9#10030009-sha1:eff8913ed2270ee44ab422c3609af4c4f36536d0.