CQM Case Number Threshold Exemption

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[CQM Issue Tracker] Additional guidance re: EH MU CQM exemption rule across system hospitals


Can you direct me to guidance regarding the use of the CQM exemption rule? Scenario is multi-hospital system that would like to choose the same 16 Eligible Hospital MU Stage 2 CQMs to report for each of their hospitals, with each hospital attesting separately. If any of the hospitals do not have discharge volumes to meet one or more of the 16 measures chosen by the system office, may they to invoke the exemption rule rather than select other measures from the set?

It has been our interpretation for the intent of the regulation that a hospital should select measures from the set of 29 that meet their patient population, and only if they cannot find 16 measures among the full 29 can they invoke the exemption rule. Given the amount of work this entails for the provider, we would appreciate written documentation of that fact. We did find language related to EPs that provides clarity on this issue (clipped and highlighted via [[double brackets]] below), but could not find similar language regarding Eligible Hospitals.

Would you kindly direct me to written guidance regarding this question, or perhaps to someone who can dig into this for us?


The CQM case number threshold exemption for hospitals begins in FY2013 for all stages of meaningful use. The hospital must submit the number of cases discharged during the reporting period for the CQM(s) for which the hospital would like to involve the case number threshold exemption.

Here are some additional details:

CQM Issue Tracker - CQM-610


Additional Resources: