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  1. eCQM Issue Tracker
  2. CQM-1355

Do 4 full-year plus 5 partial-year eCQMs submitted through EHR Direct satisfy the PQRS Program?

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    • Icon: Intent/Governance affecting more than 1 eCQM Intent/Governance affecting more than 1 eCQM
    • Resolution: Answered
    • Icon: Minor Minor
    • None
    • Tom Lee
    • Yes or no answer and explanation
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      EPs and group practices are responsible for satisfying all applicable PQRS reporting requirements, regardless of the status of their EHR system. Specifically, EPs and group practices reporting 2014 PQRS measures via direct EHR product or EHR data submission vendor are required to submit all (i.e., 100%) of their eligible patient data for the 9 measures across 3 domains on which they are reporting in order to meet the criteria for 2014 PQRS incentive eligibility and avoid the 2016 PQRS payment adjustment. For example: the Influenza Immunization Measure (CMS 147v2 NQF 0041) per the measure specification should only be reported for patients seen during the Flu season which is not the full 12 month reporting period but all the patients that were seen during the flu season should be submitted. If an EP’s or group practice’s certified EHR technology (CEHRT) system does not contain patient data for at least 9 measures covering at least 3 domains, then the EP or group practice must report the measures for which there is Medicare patient data. An EP or group practice must report on at least 1 measure for which there is Medicare patient data in order to meet the criteria for 2014 PQRS incentive eligibility and avoid the 2016 PQRS payment adjustment.


      EPs and group practices that submit less than one full year of data bear the risk that doing so may prevent EPs and group practices from meeting the measure criteria for PQRS and can impact their performance scores for the physician value-based payment modifier (VM).


      Please contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org for help with questions. They are available from 7:00 a.m. to 7:00 p.m. CST Monday through Friday.

      Please see the FAQ located here:
      https://questions.cms.gov/faq.php?id=5005&faqId=10018

      Show
      EPs and group practices are responsible for satisfying all applicable PQRS reporting requirements, regardless of the status of their EHR system. Specifically, EPs and group practices reporting 2014 PQRS measures via direct EHR product or EHR data submission vendor are required to submit all (i.e., 100%) of their eligible patient data for the 9 measures across 3 domains on which they are reporting in order to meet the criteria for 2014 PQRS incentive eligibility and avoid the 2016 PQRS payment adjustment. For example: the Influenza Immunization Measure (CMS 147v2 NQF 0041) per the measure specification should only be reported for patients seen during the Flu season which is not the full 12 month reporting period but all the patients that were seen during the flu season should be submitted. If an EP’s or group practice’s certified EHR technology (CEHRT) system does not contain patient data for at least 9 measures covering at least 3 domains, then the EP or group practice must report the measures for which there is Medicare patient data. An EP or group practice must report on at least 1 measure for which there is Medicare patient data in order to meet the criteria for 2014 PQRS incentive eligibility and avoid the 2016 PQRS payment adjustment. EPs and group practices that submit less than one full year of data bear the risk that doing so may prevent EPs and group practices from meeting the measure criteria for PQRS and can impact their performance scores for the physician value-based payment modifier (VM). Please contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org for help with questions. They are available from 7:00 a.m. to 7:00 p.m. CST Monday through Friday. Please see the FAQ located here: https://questions.cms.gov/faq.php?id=5005&faqId=10018
    • High - unable to report for the PQRS Program using the EHR Direct method.

      A provider organization is upgrading to 2014 CEHRT on Nov 1, and the CEHRT supports 9 of the eCQMs (June 2013 version suitable for 2014 PQRS reporting through the EHR Direct method). For 4 eCQMs, the client will have a full year of data for Jan 1 - Dec 31. However, for the other 5 eCQMs, the client will only have a partial year of data (Nov 1 - Dec 31 ) captured after the Nov 1 upgrade. The reason why is that not all the data elements required for those 5 eCQMs were captured by the previous version of the CEHRT.

      The question is whether reporting the 4 full-year eCQMs and 5 partial-year eCQMs for individual EPs (whose eCQMs contain Medicare patient data) will be sufficient to meet PQRS in accordance with the following passage in the "2014 PQRS: EHR Reporting Made Simple" guide published April 2, 2014:
      1. Using a direct EHR product that is Certified EHR Technology (CEHRT) or EHR data submission vendor that is CEHRT, report on at least 9 measures covering 3 National Quality Strategy (NQS) domains

      • If the EP’s CEHRT does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report the measures for which there is Medicare patient data. An EP must report on at least 1 measure for which there is Medicare patient data.

            julia.skapik Julia Skapik (Inactive)
            tomslee99 Tom Lee (Inactive)
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