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.

 

Reminder: The Attestation Deadline for the Medicare EHR Incentive Program is 2 Days Away!

Providers Must Attest to 2015 EHR Incentive Program Requirements by March 11, 2016 at 11:59 PM EST

The attestation deadline for the Medicare Electronic Health Record (EHR) Incentive Program is only 2 days away!

Eligible professionals, eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program must attest using the Medicare & Medicaid EHR Incentive Program Registration and Attestation System no later thanFriday, March 11, 2016 at 11:59 p.m. ET.

Medicaid EHR Incentive Program participants should refer to their respective states for attestation information and deadlines. Certain Medicaid eligible professionals may use the Registration and Attestation System as an alternate attestation method to avoid the Medicare payment adjustment (80 FR 62900 through 62901).

To attest to the EHR Incentive Programs in 2015:

• Eligible Professionals may select an EHR reporting period of any continuous 90 days from January 1, 2015 (the start of the 2015 calendar year) through December 31, 2015.


• Eligible Hospitals/CAHs may select an EHR reporting period of any continuous 90 days from October 1, 2014 (the start of the federal fiscal year) through December 31, 2015.

Attestation Resources

For assistance with attestation, please review the following CMS resources:

• Preparing to Participate in the EHR Incentive Programs Fact Sheet


• Attestation Worksheet and User Guide for Eligible Professionals


• Attestation Worksheet and User Guide for Eligible Hospitals and CAHs

For More Information

Visit the Registration and Attestation page on the CMS EHR Incentive Programs website.

For attestation questions, please contact the EHR Information Center Help Desk at (888) 734-6433/ TTY: (888) 734-6563 and select option 1. The hours of operation are Monday to Friday between 8:30 a.m. and 7:30 p.m. EST

Reminder: The Attestation Deadline for the Medicare EHR Incentive Program is 3 Days Away!

Providers Must Attest to 2015 EHR Incentive Program Requirements by March 11, 2016 at 11:59 PM EST

The attestation deadline for the Medicare Electronic Health Record (EHR) Incentive Program is only 3 days away!

Eligible professionals, eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program must attest using the Medicare & Medicaid EHR Incentive Program Registration and Attestation System no later than Friday, March 11, 2016 at 11:59 p.m. ET.

Medicaid EHR Incentive Program participants should refer to their respective states for attestation information and deadlines. Certain Medicaid eligible professionals may use the Registration and Attestation System as an alternate attestation method to avoid the Medicare payment adjustment (80 FR 62900 through 62901).

To attest to the EHR Incentive Programs in 2015:

• Eligible Professionals may select an EHR reporting period of any continuous 90 days from January 1, 2015 (the start of the 2015 calendar year) through December 31, 2015.


• Eligible Hospitals/CAHs may select an EHR reporting period of any continuous 90 days from October 1, 2014 (the start of the federal fiscal year) through December 31, 2015.

Attestation Resources

For assistance with attestation, please review the following CMS resources:

• Preparing to Participate in the EHR Incentive Programs Fact Sheet


• Attestation Worksheet and User Guide for Eligible Professionals


• Attestation Worksheet and User Guide for Eligible Hospitals and CAHs

For More Information

Visit the Registration and Attestation page on the CMS EHR Incentive Programs website.

For attestation questions, please contact the EHR Information Center Help Desk at (888) 734-6433/ TTY: (888) 734-6563 and select option 1. The hours of operation are Monday to Friday between 8:30 a.m. and 7:30 p.m. EST

CMS Extends Attestation Deadline for EHR Incentive Programs

CMS Extends the Attestation Deadline for the EHR Incentive Programs to March 11, 2016

The Centers for Medicare & Medicaid Services (CMS) extended the attestation deadline for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs toFriday, March 11, 2016 at 11:59 p.m. ET, from the original deadline of Monday, February 29.

Eligible professionals, eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program can attest through the CMS Registration and Attestation System. Providers participating in the Medicaid EHR Incentive Program should refer to their respective states for attestation information and deadlines. Certain Medicaid eligible professionals may use the Registration and Attestation System as an alternate attestation method to avoid the Medicare payment adjustment (80 FR 62900 through 62901).

To attest to the EHR Incentive Programs in 2015:

• Eligible Professionals may select an EHR reporting period of any continuous 90 days from January 1, 2015 (the start of the 2015 calendar year) through December 31, 2015.


• Eligible Hospitals/CAHs may select an EHR reporting period of any continuous 90 days from October 1, 2014 (the start of the federal fiscal year) through December 31, 2015.

Attestation Resources

For assistance with attestation, please review the following CMS resources:

• Preparing to Participate in the EHR Incentive Programs Fact Sheet


• Attestation Worksheet and User Guide for Eligible Professionals


• Attestation Worksheet and User Guide for Eligible Hospitals and CAHs


• Broadband Access Exclusions Tip Sheet


• Health Information Exchange Fact Sheet


• Public Health Reporting in 2015 for Eligible Professionals


• Public Health Reporting in 2015 for Eligible Hospitals/CAHs

For More Information

Visit the Registration and Attestation and the 2015 Program Requirements pages on theCMS EHR Incentive Programs website.

Stage 2 Attestation User Guides Now Available

Review Steps for Submitting Stage 2 Meaningful Use Data through the Attestation System

 

Are you preparing to submit Stage 2 meaningful use data for the Medicare EHR Incentive Program? If so, CMS has recently posted the following step-by-step guides to help navigate the CMS Attestation System:

• Stage 2 Attestation User Guide for Eligible Professionals


• Stage 2 Attestation User Guide for Eligible Hospitals and CAHs

These guides provide instructions and important information that you will need in order to successfully attest, as well as helpful tips and screenshots to walk you through the process.

Note: While all providers begin their registration through the CMS Registration & Attestation System, Medicaid eligible professionals and Medicaid-only eligible hospitals must attest through their State Medicaid Agency’s website. Please visit the Medicaid State Information pageto learn more.

 

Additional Stage 2 Resources

CMS has additional resources to help ensure your attestation will be successful:

• Stage 2 Attestation Worksheet for Eligible Professionals


• Stage 2 Attestation Worksheet for Eligible Hospitals and CAHs


• Stage 2 Meaningful Use Specification Sheet Table of Contents for Eligible Professionals


• Stage 2 Meaningful Use Specification Sheet Table of Contents for Eligible Hospitals and CAHs

For More Information

Visit the Registration and Attestation and Stage 2 pages for more information on how to successfully demonstrate meaningful use.

Reminder: EHR Hardship Exception Applications for Eligible Professionals

Eligible Professionals Must Submit Hardship Exception Applications by July 1, 2014

Are you a Medicare provider who was unable to successfully demonstrate meaningful use for 2013 due to circumstances beyond your control? CMS is accepting applications for hardship exceptions to avoid the upcoming Medicare payment adjustment for the 2013 reporting year.

 

Payment adjustments for the Medicare EHR Incentive Program will begin on January 1, 2015 for eligible professionals.

 

However, you can avoid the adjustment by completing a hardship exception application and providing supporting documentation that proves demonstrating meaningful use would be a significant hardship for you. CMS will review applications to determine whether or not you are granted a hardship exception.

 

CMS has posted hardship exception applications on the EHR website for:

• Eligible professionals


• Eligible professionals submitting multiple National Provider Identifiers (NPIs)

Applications for the 2015 payment adjustments are due July 1, 2014 for eligible professionals.  If approved, the exception is valid for one year.

 

New Hardship Exception Tipsheets

You can also avoid payment adjustments by successfully demonstrating meaningful use prior to the payment adjustment. Tipsheets are available on the CMS website that outline when eligible professionals must demonstrate meaningful use in order to avoid the payment adjustments.

 

Want more information about the EHR Incentive Programs?

Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

EHR Incentive Programs: Program Highlights to Date

Latest Success Data on Provider Participation in the EHR Incentive Programs

CMS has released February 2012 data that highlights program-to-date (since January 2011) participation and payment totals under  the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The February report documents continued growth in  registrations and payments, including:

• Over 211,500 eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) have registered for the Medicare and/or Medicaid EHR Incentive Programs since January 2011
  
  
  
  • Over 20,000 registered for the Medicare and/or Medicaid EHR Incentive Programs in the month of February
  
  
  
  


• Over 62,000 EPs, eligible hospitals, and CAHs have been paid for successfully participating in the Medicare and/or Medicaid EHR Incentive Programs


• Over $3.8 billion has been paid in Medicare and Medicaid EHR Incentive Program payments to EPs, eligible hospitals, and CAHs across the country
  
  
  
  • Over $738 million was paid in the month of February
  
  
  
  

Visit the Data and Reports page on the EHR website to review more of more data on continued acceleration in  registration and payment data.

Helpful Resources 

CMS has created several resources to help participants navigate the Medicare and Medicaid EHR Incentive Programs. A few key resources include:

• An Introduction to the Medicare EHR Incentive Program for Eligible Professionals- This interactive guide helps EPs navigate every aspect of the Medicare program and provides helpful resources and tips along the way. A Medicaid guide will be available later this spring. 


• Updated User Guides- CMS has updated the registration and attestation user guides, which walk EPs and eligible hospitals through CMS' registration and attestation system. There are five guides in total and all of them can be downloaded from the Educational Materials page of the EHR website. 


• Provider Testimonial Videos- These videos, which can be found on the CMS YouTube channel, highlight providers' experiences participating in the EHR Incentive Programs.

If you are considering registering for the programs, but have not done so yet, take a look at the CMS EHR website and use our eligibility tool to find out if you can participate. 

Remember: 2012 is the last year in which EPs can receive a full incentive payment in the Medicare EHR Incentive Program. Beginning in 2013, EPs will receive a smaller overall total payment. Remember to register early.

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

New Interactive Guide for EPs in the Medicare EHR Incentive Program

Take a Look at CMS’ New Medicare EHR Incentive Program Guide for Eligible Professionals (EPs)

CMS has created a new comprehensive tool, An Introduction to the Medicare EHR Incentive Program for Eligible Professionals, to help guide EPs through all of the phases of the Medicare EHR Incentive Program—from eligibility and registration to attestation and payment. Chapters provide information on:

• EHR Incentive Program basics


• How to participate (determining eligibility and registration)


• Meaningful use and choosing measures


• Attestation


• Helpful resources on the Medicare and Medicaid EHR Incentive Programs

The guide is interactive. Users can click on sections of the Table of Contents to learn more about specific areas of the program. Interactive tabs are also included at the bottom of each page where users can jump from chapter to chapter. Additionally, each section provides readers with user-friendly screen shots, charts, and links to the CMS website.

Note: If a user prefers a hard copy document, the guide can also be printed. Links are written out and hyperlinked throughout the guide.

The guide can be found on the Educational Materials section of the EHR website, along with several other helpful tools and resources for participants in the Medicare and Medicaid EHR Incentive Programs.

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs. 

New Attestation Resources Have Been Posted

CMS has developed attestation worksheets to help providers successfully attest to meeting meaningful use through the CMS web-based attestation system.

These attestation worksheets allow eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) to log additional data for core and menu measures that might not be obtained only through their certified electronic health record (EHR) system. In order to provide complete and accurate information for certain of these measures, EPs and hospitals may have to include information from paper-based patient records or from other areas. (Please note that clinical quality measures must be reported directly from certified EHR technology).

You can fill out the attestation worksheets electronically or manually, and then keep the worksheet on hand as you attest so your data is easily accessible.

You can find the worksheets by clicking the links below. Make sure to use the worksheet that pertains to you:

• 
  
  Attestation Worksheet for Eligible Professionals


• 
  
  Attestation Worksheet for Eligible Hospitals and Critical Access Hospitals

Updates to the Comprehensive EHR Incentive Program FAQs Document
CMS has also posted the latest FAQs document on the CMS website. This interactive document provides updated FAQs up to the end of April 2011. Each FAQ is sorted by topic to help you more easily review information about various aspects of the EHR Incentive Programs. CMS will continue to provide updates as new FAQs are added.

Want more information about the EHR Incentive Programs?
Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs