Guidance on Public Health Reporting Requirements for the EHR Incentive Programs

cms-twitter-200The Centers for Medicare & Medicaid Services (CMS) has published frequently asked questions (FAQs) about the public health reporting objective for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. These include three new FAQs about when providers can register their intent to report to a registry, what a provider should do in 2016 if they did not previously intend to report to a public health reporting measure, and the alternate exclusions available for public health reporting in 2016. Review these FAQs below to learn more.

FAQ #14393 (New): Can a provider register their intent after the first 60 days of the reporting period in order to meet the measures if a registry becomes available after that date?

If a registry declares readiness at any point in the calendar year after the initial 60 days, a provider may still register their intent to report with that registry to meet the measure under Active Engagement Option 1. However, a provider who could report to that registry may still exclude for that calendar year if they had already planned to exclude based on the registry not being ready to allow for registrations of intent within the first 60 days of the reporting period.

FAQ #14397 (New): What should a provider do in 2016 if they did not previously intend to report to a public health reporting measure that was previously a menu measure in Stage 2 and they do not have the necessary software in CEHRT or the interface the registry requires available in their health IT systems? What if the software is potentially available but there is a significant cost to connect to the interface?

In the 2015 EHR Incentive Programs Final Rule, we stated that we did not intend for providers to be inadvertently penalized for changes to their systems or reporting made necessary by the provisions of that regulation. This included alternate exclusions for providers for certain measures in 2016, which might require the acquisition of additional technologies they did not previously have for measures they did not previously intend to include in their activities for meaningful use (80 FR 62945). Therefore, in order that providers are not held accountable to obtain and implement new or additional systems, we will allow providers to claim an alternate exclusion from certain public health reporting measures in 2016 if they did not previously intend to report to the Stage 2 menu measure…read the full FAQ.

FAQ #14401 (New): For 2016, what alternate exclusions are available for the public health reporting objective? Is there an alternate exclusion available to accommodate the changes to how the measures are counted?

We do not intend to inadvertently penalize providers for changes to their systems or reporting made necessary by the provisions of the 2015 EHR Incentive Programs Final Rule. This includes alternate exclusions for providers for certain measures in 2016, which might require the acquisition of additional technologies they did not previously have or did not previously intend to include in their activities for meaningful use (80 FR 62945). For 2016, EPs scheduled to be in Stage 1 or Stage 2 must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3 and eligible hospitals or CAHs scheduled to be in Stage 1 or Stage 2 must attest to at least 3 public health measures from the Public Health Reporting Objective Measures 1-4…read the full FAQ.

FAQ #13657 (Updated): What steps does a provider have to take to determine if there is a specialized registry available for them, or if they should instead claim an exclusion? Read the full FAQ.

FAQ #14117 (Updated): What steps do eligible hospitals and Critical Access Hospitals need to take to meet the specialized registry objective? Is it different from EPs? Read the full FAQ.

FAQ #13653 (Updated): What can count as a specialized registry? Read the full FAQ.

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