[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:

  • Threshold for exemption from reporting a CQM during the relevant EHR reporting period:
    • 1st year of demonstrating MU (or all stages of MU in FY2014) 90-day EHR reporting period 5 or fewer discharges
    • 2nd year or beyond of demonstrating MU Full year EHR reporting period 20 or fewer discharges
    • Defined by the CQM’s denominator population •Applies on a CQM by CQM basis

  • Invoking case threshold exemption in FY 2013:
    • All 15 of CQMs from Stage 1 final rule required
    • Reduce the # of CQMs required by the # of CQMs for which the hospital does not meet the case threshold of discharges

  • Invoking case threshold exemption in FY 2014:
    • 16 CQMs covering at least 3 domains from a list of 29 CQMs required
    • Same process as in FY 2013, but in order to be exempted from reporting fewer than 16 CQMs, would need to qualify for case threshold exemption for more than 13 of the 29 CQMs.
    • If the CQMs for which the hospital can meet the case threshold of discharges do not cover at least 3 domains, the hospital would be exempt from the requirement to cover the remaining domains

CQM Issue Tracker - CQM-610


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