The Centers for Medicare and Medicaid Services responded to two new frequently asked questions about the meaningful use incentive program, covering denominator issues and calculating clinical quality measures. The complete questions and answers are:
Question: For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, if the certified EHR technology possessed by an eligible professional (EP) generates zero denominators for all clinical quality measures (CQMs) in the additional set that it can calculate, is the EP responsible for determining whether they have zero denominators or data for any remaining CQMs in the additional set that their certified EHR technology is not capable of calculating?
Answer: No, the EP is not responsible for determining the status of CQMs that their certified EHR technology is not capable of calculating. The certification criterion for ambulatory CQMs sets a minimum threshold in order for the certification criterion to be met. An EHR technology must be certified to the 6 core CQMs (3 core and 3 alternate core CQMs in Table 7 of the final rule) and at least 3 CQMs from the additional set (Table 6 of the final rule). In the final rule, we stated that it was our expectation that EPs would seek out certified EHR technologies that include and were certified for CQMs relevant to their scope of practice. In later stages of meaningful use and the corresponding certification requirements, we will seek to address situations where an EP does not obtain certified EHR technology that would enable the EP to report on CQMs that are relevant to their practice.
Question: For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, if certified EHR technology possessed by an eligible professional (EP) includes the ability to calculate clinical quality measures (CQMs) from the additional set that are not indicated by the EHR developer or on the Certified Health Information Technology Product List (CHPL) as tested and certified by an ONC - Authorized Testing and Certification Body (ONC-ATCB), can the EP submit the results of those CQMs to CMS as part of their meaningful use attestation?
Answer: Yes, the EP can submit results for CQMs in the additional set (Table 6 of the final rule) calculated by certified EHR technology, even if those CQMs were not individually tested and certified by an ONC-ATCB. We expect to revisit CQM requirements in more detail for later stages of meaningful use as well as the corresponding certification requirements.
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