[CQM-7123] CMS 2 Depression Screening and Follow Up Exclusions Created: 07/17/24  Updated: 08/01/24  Resolved: 08/01/24

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

Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs Priority: Moderate
Reporter: Renee Martinez Assignee: Mathematica EC eCQM Team (Inactive)
Resolution: Answered Votes: 0
Labels: None

Contact Name: Eugenia Renee Martinez
Contact Email: renee.martinez@crmcwy.org
Contact Phone: 3076337442
Solution: Thank you for your inquiry on CMS2v13: Preventive Care and Screening: Screening for Depression and Follow-Up Plan.

If the patient declines follow-up, the patient will not meet the Numerator. The ‘Denominator Exception’ only applies if the patient declines the depression screening, NOT the follow-up plan. The patient still can meet the Numerator, if the patient is screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if the screening is positive, a follow-up plan is documented on the date of, or up to two days after the date of the qualifying encounter.

The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, the documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter. This measure does not evaluate if the patient received treatment. Thus, if the patient refuses treatment for their depression, but a follow-up plan has been documented, the patient would meet the Numerator.
Solution Posted On:
2024 Performance Period EC eCQMs:
CMS0002v13

 Description   

A few of my providers have asked if a patient tests positive for depression but declines any follow up intervention, would they be excluded from the measure? I reviewed the specifications and was not able to find if declining follow up would be an exclusion or if they would just not meet the measure.



 Comments   
Comment by Mathematica EC eCQM Team (Inactive) [ 07/26/24 ]

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) [ 07/19/24 ]

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

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