EHs and CAHs have the option of attesting or ereporting CQMs in 2015 through 2017
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1 CMS-3310-FC & CMS-3311-FC: MU Stage 3 Proposed Reporting on Clinical Quality Measures Using Certified EHR Technology Requirements for Eligible Hospitals & Critical Access Hospitals Key Takeaways EHs and CAHs have the option of attesting or ereporting CQMs in 2015 through 2017 Medicare Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) can meet the clinical quality measurement (CQM) reporting requirement for Meaningful Use (MU) by either attesting or ereporting CQMs in 2015, 2016, and Attestation Reporting Periods Vary Year to Year Depending on EH Meaningful Use Status EHs and CAHs choosing attestation must attest to 16 of 29 ecqms from 3 of the 6 National Quality Strategy Domains in years 2015, 2016, and Reporting periods and submission dates vary year to year Attestation reporting period for CQMs is any continuous 90-day period within calendar year Returning MU EHs and CAHs must attest for a full calendar year worth of CQMs data in First Year MU EHs and CAHs can attest on any continuous 90 day period in Returning MU EHs and CAHs must attest for a full calendar year worth of CQMs data in CQM data will be attested to on a quarterly basis. ereporting Option: # of CQMs and Reporting Periods Vary Year to Year 2015 EHs and CAHs that choose ereporting in 2015 must submit 16 of 29 ecqms electronically for 1 quarter of CY2015 by February 29 th, 2016 Page 1
2 2016 EHs and CAHs that choose ereporting in 2016 must submit 4 of 29 ecqms for 1 quarter of CY2016 by February 28 th, For 2016, ereporting of 4 ecqms is REQUIRED to avoid the FY18 IQR Payment Determination Adjustment even if EHs attest CQMs for Meaningful Use CQM reporting requirements will be published in the CY2017 IPPS Final Rule Mandatory ereporting of CQMs in 2018 All EHs and CAHs must electronically report CQMs in 2018 unless they attest to a hardship. States will continue to define requirements for Medicaid Medicaid EH and CAH ecqm reporting timelines and submission requirements will continue to be determined by each of the states. Details specific for Medicare Eligible Hospitals and Critical Access Hospitals 2015 CQM Attestation Option Requirements EHs and CAHs may select any continuous 90-day period from October 1, 2014 through December 31, 2015, to report CQMs via attestation using the EHR Incentive Program registration and attestation system. EHs and CAHs may meet the CQM component of Meaningful Use by attesting to collecting data on 16 of the 29 available ecqms found in the Meaningful Use Stage 2 menu using 2014 Certified EHR Technology (CEHRT.) Selected ecqms must come from a minimum of 3 of the 6 National Quality Domains. EHs and CAHs must submit CQM data via the EHR Incentive Program registration and attestation system no later than February 29 th, CQM ereporting Option Requirements As highlighted in the FY15 IPPS Final Rule, Second Year Stage 1 and Stage 2 EHs and CAHs may also meet the CQM component of MU by: o Electronically collecting data on 16 CQMs of the 29 available CQMs found in the MU Stage 2 Final Rule menu. Page 2
3 o o o o Selected ecqms must come from a minimum of 3 of the 6 National Quality Domains. EHs must submit one quarter of CQM data to CMS Quarter 1: January 1st -March 30th, 2015 Quarter 2: April 1st-June 30th, 2015 Quarter 3: July 1st-September 30th, 2015 Quarter 4: October 1st-December 31st, 2015 Using 2014 CEHRT and the latest Measure Specifications (May 2015 Annual Update) If errors are found in a specification, EHs must utilize the latest correct specification for the ecqm Submit patient level data using reporting standard QRDA I to QualityNet by Submission Deadline for 2015: February 29th, EHs successfully reporting and meeting all other MU and Inpatient Quality Reporting Program (IQR) requirements will meet the CQM reporting requirement for both programs with one successful electronic submission. For this option, EH s CQM data will be publically reported via HospitalCompare.gov. Defined CQM sets and the published electronic specifications for CQMs that are in use for all CMS aligned programs are currently posted on the ecqm Library page: CQM Attestation Option Requirements EHs and CAHs choosing to attest must capture and report CQM data for January 1, 2016 through December 31, 2016 to report CQMs via attestation using the EHR Incentive Program registration and attestation system. EHs and CAHs may meet the CQM component of Meaningful Use by attesting to collecting data on 16 of the 29 available ecqms found in the Meaningful Use Stage 2 menu using 2014 Certified EHR Technology (CEHRT.) Selected ecqms must come from a minimum of 3 of the 6 National Quality Domains. EHs and CAHs must submit CQM data via the EHR Incentive Program registration and attestation system no later than February 29 th, Attestation of CQMs for the MU program in 2016 will not meet CQM electronic reporting requirements for the Hospital IQR program in reporting year 2016/payment year Page 3
4 CQM ereporting Option Requirements and ereporting Mandates for the CMS IQR Program in reporting year 2016/Payment Year 2018 As highlighted in the FY16 IPPS Final Rule, Second Year Stage 1 and Stage 2 EHs and CAHs may also meet the CQM component of MU by: o Electronically collecting data on 4 CQMs of the 29 available CQMs found in the MU Stage 2 Final Rule menu. o EHs must submit one quarter of CQM data to CMS Either Quarter 3 (July 1st-September 30th, 2016) or Quarter 4 (October 1st-December 31st, 2016) o Using 2014 CEHRT or 2015 CEHRT) and the latest Measure Specifications (May 2015 Annual Update) If errors are found in a specification, EHs must utilize the latest correct specification for the ecqm o Submit patient level data using reporting standard QRDA I to QualityNet by Submission Deadline for 2016: February 28th, For the IQR program in 2016 Reporting Year/Payment Year 2018, electronic submission of 4 ecqms is required for eligible hospitals to avoid the 2018 IQR payment adjustment. o Six previously adopted measures (ED-1, ED-2, PC-01, STK-04, VTE-5, and VTE-6) must still be submitted via chart-abstraction to the IQR program regardless of whether they are also submitted as ecqms. For CY2016, EH s CQM data will NOT be publically reported via HospitalCompare.gov as CMS conducts data validity testing on ereported CQMs. Defined CQM sets and the published electronic specifications for CQMs that are in use for all CMS aligned programs are currently posted on the ecqm Library page: Page 4
5 2017 CQM Attestation Option Requirements for Medicare and Medicaid Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) EHs and CAHs have the option to attest 16 out of 29 CQMs in 3 of the 6 NQS Domains in 2017 CMS will require a CQM reporting period of 1 full calendar year which consists of 4 quarterly data reporting periods for EHs that attest. o January 1, 2017-March 30, 2017 (Submission Deadline: May 31, 2017) o April 1, 2017-June 30, 2017 (Submission Deadline, August 31, 2017) o July 1, 2017-September 30, 2017 (Submission Deadline, November 30, 2017) o October 1, 2017-December 31, 2017 (Submission Deadline, February 28 th, 2018) First time Medicaid EHs will have a CQM reporting period of any continuous 90 days in CY2017. That reporting period does not need to align with the EHs 90-day MU EHR Measure and Objective Reporting Period. CQM ereporting Option Requirements Medicare EHs have the option of ereporting ecqms in ereporting submission criteria, reporting periods, and submission deadlines will be published in the CY2017 IPPS Final Rule (will be published in August, 2016.) ereporting EHs and CAHs must use CEHRT and the latest version of ecqm specifications (May 2016 Annual Update.) ereporting EHs and CAHs must submit patient level data using reporting standard QRDA I to QualityNet Page 5
6 2018 Mandatory CQM ereporting Requirements Medicare EHs and CAHs are REQUIRED to ereport ecqms in 2018 or face the MU payment adjustment for failing to successfully meet MU reporting criteria. ereporting submission criteria, reporting periods, and submission deadlines will be published in the CY2018 IPPS Final Rule (will be published in August, 2017.) ereporting EHs and CAHs must use CEHRT and the latest version of ecqm specifications (May 2016 Annual Update.) ereporting EHs and CAHs must submit patient level data using reporting standard QRDA I to QualityNet Hardship Exemption: o Attestation in 2018 will be allowed for EHs facing circumstances which render them unable to electronically report (such as a data submission system failure, natural disaster, or certification issue outside the control of the provider) who may attest to CQMs if they also attest that electronically reporting was not feasible. Details specific for Medicare Eligible Hospitals and Critical Access Hospitals Medicaid EH Quality Reporting for Meaningful Use Individual states will determine how they will accept electronic reporting or attestation of CQM data State plans must be approved by CMS Page 6
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