[CQM Issue Tracker] Case Number Thresholds vs Zero Denominators


Our customers are preparing for Stage 2 and the 2014 CQM measure requirements, and there seems to be some general confusion over the aspects of case number thresholds and measure results with a zero denominator. We have previously entered CQM-610, specifically on the case number thresholds, which was responded to by Maria Michaels, as well as a new CMS FAQ created. (8400). (FYI, this JIRA issue has been entered per Maria Michaels request)

The specific clarifications needed now are around the following two questions:

1. If the patient volume/denominator population for a measure is 5 or less/quarter in 2014, or 20 or less/year in later years, are providers REQUIRED to claim a case number threshold? Or is it acceptable for them to report the measure results anyway?

2. There are times when a provider may expect that they will have patients in the denominator for the measure, based on doing some case mix analysis ahead of time, but especially due to the shorter reporting period of 3 months/quarter for 2014, they end up with a zero denominator. In that case, they may not have done the work to build out and collect an alternate measure by the time they realize this. Is it acceptable for them to report the zero denominator for that measure?


Response to #1: The case threshold exemption is not a requirement, so they can just report the measure results anyway and not use the exemption. The impetus for this policy was for the more specialized hospitals (such as children’s hospitals or cancer hospitals) that rarely, if ever, have patients that would fit the denominator criteria of some of the CQMs. However, we chose not to limit it to those specific types of hospitals but rather set the criteria for when it was allowable to use the exemption since other types of hospitals may find themselves able to use the exemption.

Response to #2: Yes, if they have zero patients that fit the denominator criteria during the reporting period they are using, they can report a zero denominator. (NOTE: They would still need to have CEHRT that is certified for each of the CQMs for which they report zero denominators).

CQM Issue Tracker - CQM-805


Additional Resources:

Case Number Thresholds vs Zero Denominators

Minimum Case Threshold-Zero Denominator Presentation