Review 2016 CQM Requirements for Eligible Professionals and Hospitals

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To participate successfully in the Medicare & Medicaid EHR Incentive Programs, eligible professionals, eligible hospitals, and critical access hospitals (CAHs) must submit clinical quality measures (CQMs).

2016 CQM Requirements for Eligible Professionals (EPs)

EPs must report 9 out of a possible 64 measures. At least 3 of those must cover the National Quality Strategy domains, which include:

• Patient and Family Engagement


• Patient Safety


• Care Coordination


• Population/Public Health


• Efficient Use of Healthcare Resources


• Clinical Process/Effectiveness

EPs have several options for reporting their CQMs:

1. Medicare EHR Incentive Program Reporting Options:

• Option 1: Attest to CQMs through the EHR Registration & Attestation System


• Option 2: eReport to CQMs through the Physician Quality Reporting System (PQRS) Portal

1. Options that align with Other Quality Programs:

• Option 3: Report individual CQMs through the PQRS Portal


• Option 4: Report group CQMs through the PQRS Portal


• Option 5: Report group CQMs through Pioneer ACO participation or Comprehensive Primary Care Initiative participation

1. Medicaid EHR Incentive Program Reporting Options:

• Option 6: Attest to CQMs through their State Medicaid Portal

2016 CQM Requirements for Dually Eligible Hospitals and Critical Access Hospitals (CAHs)

Dually Eligible hospitals and CAHs participating in the EHR Incentive Programs have two options for reporting CQMs:

• Option 1: Attest to 16 of 29 possible CQMs through the EHR Registration & Attestation System


• Option 2: eReport 4 CQMs through Hospital Inpatient Quality Reporting (IQR) through QualityNet Secure Portal

Note: The CQM reporting options for EPs and hospitals in 2016 are the same as the options that were available in 2015. Medicaid-only hospitals report their CQMs via their state's portal.