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Payment Year 2 (Stage 1 Meaningful Use)


To meet Stage 1 Meaningful Use (MU) requirements, Eligible Professionals (EPs) must attest to meeting MU criteria that consist of Core measures; Menu measures; and Clinical Quality Measures (CQMs).  Each measure requires a unique response.  Some responses can be yes/no attestations while others involve numeric entries such as a numerator and denominator.  The following guidelines apply to Stage 1 MU attestations in 2013.

Reporting period:  the reporting period for the first year of Stage 1 MU is 90-days in the current calendar year.   (Note the distinction between the patient volume reporting period which is based on 90-days of data from the prior calendar year.)

Stage 1 Meaningful Use Supporting Documentation:  EPs must upload EHR screenshots and other supporting documentation with Protected Health Information redacted (i.e., HIPAA protected information) at the time of attestation in order for the payment request to be processed.  For further guidance, refer to the Stage 1 Meaningful Use Supporting Documentation webpage.

Core Measures:  EPs must meet 13 (of 13) Core measures. If exclusion is claimed on a measure (that offers exclusion), the measure is considered met. 

Check the CMS Meaningful Use webpage to learn more about the Stage 1 MU requirements for EPs and download specification sheets for each MU measure.

If the EP practices in more than one site/location that has certified EHR technology (CEHRT), the Core measure numerators and denominators need to include the patient records from all CEHRTs and any records maintained in paper or noncertified EHR.  For further guidance on calculating numerators and denominators from multiple locations, refer to CMS FAQ 3609.

Menu Measures:  EPs must meet 5 (of 10) Menu measures.  At least one must be a Public Health measure.  If the State of New Hampshire is unable to accept data for a Public Health measure, EPs will receive exclusion and the measure will be considered met.  Check the CMS Meaningful Use webpage to learn more about the Stage 1 MU requirements for EPs and download specification sheets for each MU measure.

EPs who do not have the same Menu objectives implemented across each of their practice locations equipped with CEHRT may attest to the five Menu objectives that represent the greatest number of their patient encounters. For measures that require a percentage threshold, they can limit the denominator to the location or locations that pursued that menu objective. (Medicare and Medicaid EHR Incentive Program – Stage 2 – Final Rule p. 53981)

Clinical Quality Measures (CQMs):  in 2013, EPs may choose from two options based on their edition of CEHRT.  For further guidance, refer to the Certified Health IT Product List.

2011 Edition:

  • 3 (of 3) Core CQMs;
  • 0-3 Alternate Core CQMs.  (An Alternate Core CQM must be reported as a substitute for each Core CQM that had a denominator of 0.);
  • 3 (of 38) Additional CQMs that relate to the EP’s practice.  It is acceptable to use the value of zero (0) as a denominator if this value was produced by CEHRT.

Combination of 2011 and 2014 Edition or 2014 Edition:

  • 2 Core CQMs;
  • 1 mandatory Alternate Core CQM plus 0-2 Alternate Core CQMs.  (An Alternate Core CQM must be reported as a substitute for each Core CQM that was reported with a denominator of 0.);
  • 3 (of 27) Additional CQMs that relate to the EP’s practice.  It is acceptable to use the value of zero (0) as a denominator if this value was produced by certified EHR technology.

EPs having greater than 50% of their clinical activity at one site can include only CQM data from the site where they see greater than 50% of their patients. For further guidance, refer to the CMS Clinical Quality Measures webpage.

Rules

  • EPs that work at multiple practice locations: at least 50 percent of their total patient encounters must take place at a location(s) where certified EHR technology is available.  (These EPs would base all MU measures only on those encounters that occurred at locations with CEHRT.)  For the purpose of calculating the 50 percent threshold, all encounters (and not just Medicaid and/or Needy Individual encounters) should be considered in this calculation.
  • MU measures may not be applicable to every clinical practice.  For example, dentists do not typically perform immunizations.  In these cases, providers would not have any eligible patients or actions for the measure denominator and could attest to an exclusion (i.e., be excluded from having to meet that measure).  Claiming an exclusion (i.e., providing a ‘yes’ response to an exclusion) for a specific measure qualifies as submission of that measure.
  • Measure results do not round up.  For example, a numerator of 199 and a denominator of 1,000 is 19%. 
  • Measures that require a result greater than a given percentage must be more than that given percentage to pass.  For example, in a measure requiring a result of greater than 80%, a result of 80.1% will pass, but a result of 80.0% will not pass.
  • There are two types of percentage-based denominators reported for MU measures.  The first is when the denominator equals all patients seen or admitted during the EHR reporting period.  In this instance, the denominator is all patients regardless of whether their records are maintained using certified EHR technology. The second is based on actions or subsets of patients seen or admitted during the EHR reporting period.  In this instance, the denominator only includes patients, or actions taken on behalf of those patients, whose records are maintained using certified EHR technology.
 
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