Our records indicated that you called about whether an Eligible Hospital in its 2nd year or beyond is required to submit its clinical quality measures (CQMs) electronically for the entire fiscal year.
Our customer service representative (CSR) informed you that in 2014, all eligible hospitals or critical access hospitals are able to use a 3-month, or 90 day, reporting period, regardless of whether they are in their first year of participation or not. Eligible hospitals or critical access hospitals in their first year of participation can attest to their CQM results for any continuous 90-day reporting period. An eligible hospital or critical access hospital in its first year of meaningful use must attest by July 1, 2014 to avoid a payment adjustment in 2015. However, eligible hospital or critical access hospitals that are in their second year of participation or beyond, have the option to electronically report CQM data for a full federal fiscal year, or a three-month quarter within the federal fiscal year.
CMS is allowing this shortened period in 2014 only so that all eligible hospitals and critical access hospitals can upgrade to a 2014 edition of Certified EHR Technology and have adequate time to implement their new Certified EHR systems.
Please note that the same EHR reporting period must be used for meaningful use functional measures as with the CQMs. For example, if the EHR reporting period selected to calculate the meaningful use functional measures is January 1st through March 31st, then the CQM EHR reporting period used for CQM data submission must also be January 1st through March 31st (whether via attestation or electronic reporting).
When the new Final Rule was adopted (and published September 4, 2012), CMS expected to require that all Medicare-eligible providers beyond their first year of demonstrating meaningful use must electronically report their CQM data to CMS beginning in 2014. (Medicaid EPs and hospitals that are eligible only for the Medicaid EHR Incentive Program would electronically report their CQM data to their state.)
However, a change was announced in the FY 2014 IPPS/LTCH PPS final rule, indicating that eligible hospitals and critical access hospitals have the option to continue to report aggregate CQM data through the Attestation module of the Medicare and Medicaid EHR Incentive Program Registration & Attestation System for program year 2014. Please note, that the submission of aggregate CQM data via the Attestation module will not satisfy the reporting requirements for the Hospital IQR Program. The EHR Incentive Program website will be updated shortly to reflect this.
States may still require the submission of Quality Reporting Data Architecture III, or QRDA-III files in order to fulfill the CQM reporting requirements for the Medicaid EHR Incentive Program. Please contact your State Medicaid Agency for more information about the requirements of electronically submitting CQM data.
The tracking number for this inquiry is 311007. If you have further questions, please visit the CMS Medicare & Medicaid EHR Incentive Programs Website located at http://cms.gov/EHRIncentivePrograms/. You will find accurate and up-to-date information about the programs, including eligibility, payment amounts, requirements, upcoming events and more. Bookmark http://cms.gov/EHRIncentivePrograms/ and check back often to learn more about these programs, or contact the EHR Information Center at (888) 734-6433.
The Medicare and Medicaid EHR Incentive Programs listserv provides timely, authoritative information about the programs, including registration and attestation updates and details about the payment process. The listserv messages are another CMS resource to provide you with the latest news about the Incentive Programs. On average, two messages are sent per week. Information on how to join the listserv can be found at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/CMS_EHR_Listserv.html.
The EHR Information Center