CMS Issues Updates on EHR Incentive Questions

Question: If my practice does not typically collect information on any of the core, alternate core, and additional clinical quality measures (CQMs) listed in the Final Rule on the Medicare and Medicaid EHR Incentive Programs, do I need to report on CQMs for which I do not have any data?

Answer: Eligible professionals (EP) are not excluded from reporting CQMs, but zero is an acceptable value for the CQM denominator. If there were no patients who met the denominator population for a CQM, then the EP would report a zero for the denominator and a zero for the numerator. Read the complete answer.

Question: Can eligible professionals use CQMs from the alternate core set to meet the requirement of reporting three additional measures for the Medicare and Medicaid EHR Incentive Programs?

Answer: No, if EPs report data on all three CQMs from the core set, they would not report on any from the alternate core set. The three additional CQMs must come from Table 6 of the final rule (75 FR 44398-44408), excluding those CQMs included in either the core set or the alternate core set. Read the complete answer.

Question: If one of the measures for the core set of CQMs for eligible professionals is not applicable for my patient population, am I excluded from reporting that measure for the Medicare or Medicaid EHR Incentive Programs?

Answer: An eligible professional (EP) is not excluded from reporting core clinical quality measures (CQMs). However, zero is an acceptable value to report for the denominator of a CQM if there is no patient population within the EHR to whom that CQM applies. Read the complete answer.

Question: If none of the core, alternate core, or additional clinical quality measures adopted for the Medicare and Medicaid EHR incentive programs apply, am I exempt from reporting on all CQMs?

Answer: In the event that none of the 44 clinical quality measures (CQMs) applies to an EP’s patient population, the EP is still required to report a zero for the denominators for all six of the core and alternate core CQMs. Read the complete answer.

Question: If the denominators for all three of the core CQM are zero, do I have to report on the additional CQMs for eligible professionals under the Medicare and Medicaid EHR Incentive Programs?

Answer: If the denominator value for all three of the core CQMs is zero, an EP must report a zero denominator for all such core measures, and then must also report on all 3 alternate core CQMs. Read the complete answer.

Question: For the Medicare and Medicaid EHR Incentive Programs, if the certified EHR technology possessed by an eligible professional generates zero denominators for all CQMs in the additional set that it can calculate, is the eligible professional 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. Read the complete answer.

Question: I am an eligible professional who has successfully attested for the Medicare EHR Incentive Program, so why haven’t I received my incentive payment yet?

Answer: For EPs, incentive payments for the Medicare EHR Incentive Program will be made approximately eight to ten weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year. Read the complete answer.

See more CMS Updated FAQs published on next pages.