Submitting CQMs in 2013 for EHR Incentive Programs

Learn More About Submitting Quality Data for the EHR Incentive Programs for 2013

The following is correspondence from CMS.
Providers must report clinical quality measures (CQMs) to CMS to demonstrate meaningful use under the EHR Incentive Programs.

For the 2013 reporting year, there are two options for reporting CQMs for the Medicare EHR Incentive Program: through the CMS Attestation System OR through electronic reporting pilots.

Attestation
When you are ready to submit CQM data through the Attestation System, you should:

1. Log in to the CMS Registration and Attestation system
2. Enter your data for the meaningful use core and menu objectives
3. Report your CQM data directly from your certified EHR technology into the Attestation System:
   • Eligible professionals must report a total of six CQMs
     • Three core or alternate core measures (only report an alternate core measure if one of the core denominators is zero)
     • Three additional measures from a list of 38
   • Eligible hospitals must report a total of 15 CQMs
     • Two measures that target emergency department throughput processes
     • Seven measures that address the care of patients with stroke
     • Six measures that address the care of patients with venous thromboembolism
   • If you are attesting to CQM data for the EHR Incentive Programs you may submit a zero result for a CQM if the zero is the accurate calculation from your EHR

Electronic Reporting Pilots
Eligible professionals and eligible hospitals also have the option to submit CQMs through electronic reporting, or eReporting, pilots:

• For eligible professionals: Through the PQRS-Medicare EHR Incentive Pilot
• For eligible hospitals: Through the QualityNet portal

Providers participating in the Medicaid EHR Incentive Program will need to attest through their state’s internet-based portal.

Exclusions
Some CQMs cannot be met during the reporting period chosen by the provider and so exclusions are available for those CQMs. For example, many CQMs for EPs require a minimum of two visits for a patient to meet the denominator criteria. Exclusions do not count against a provider’s attestation requirements.

2014 CQM Reporting Changes
Beginning in 2014, all providers must report CQMs based on new requirements outlined in the Stage 2 final rule, regardless of what stage they are in.  For more information on these requirements, such as the number of CQMs and how to select which ones to report, visit the 2014 CQMs webpage.