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Type: Intent/Governance affecting more than 1 eCQM
Resolution: Answered
Priority: Moderate
Component/s: Guidance
Labels:
- Policy

Contact Phone:
253-389-3154
Institution/Name:
McKesson
Solution:

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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

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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

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?

Thanks so much,
Maggie

Maggie Lohnes, RN
Quality Strategy
Enterprise Intelligence
Email: maggie.lohnes@mckesson.com
Direct: (253) 389-3154

CLIP OF GUIDANCE FOR ELIGIBLE PROFESSIONALS RE: USE OF EXCEPTION RULE – highlighted is the type of language we need for Eligible Hospitals

My practice does not typically collect information on any of the core, alternate core, and additional clinical quality measures (CQMs) listed in the Stage 1 final rule on the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. Do I need to report on CQMs for which I do not have any data?
EPs are not excluded from reporting clinical quality measures, but zero is an acceptable value for the CQM denominator. If there were no patients who met the denominator population for a CQM, then the EP would report a zero for the denominator and a zero for the numerator. [[For the core measures, if the EP reports a zero for the core measure denominator, then the EP must report results for up to three alternate core measures (potentially reporting on all 6 core/alternate core measures). For the menu-set measures, we expect the EP to report on measures which do not have a denominator of zero.]] If none of the measures in the menu set applies to the EP, then the EP must report on three of such measures, reporting a denominator of zero, and then attest that the remainder of the menu-set measures have a value of zero in the denominator.
As we stated in the Stage 1 final rule (75 FR 44409-10): "The expectation is that the EHR will automatically report on each core clinical quality measure, and when one or more of the core measures has a denominator of zero then the alternate core measure(s) will be reported. If all six of the clinical quality measures in Table 7 have zeros for the denominators (this would imply that the EPs patient population is not addressed by these measures), then the EP is still required to report on three additional clinical measures of their choosing from Table 6 in this Stage 1 final rule. In regard to the three additional clinical quality measures, if the EP reports zero values, then for the remaining clinical quality measures in Table 6 (other than the core and alternate core measures) the EP will have to attest that all of the other clinical quality measures calculated by the certified EHR technology have a value of zero in the denominator, if the EP is to be exempt from reporting any of the additional clinical quality measures (other than the core and alternate core measures) in Table 6."

RELATED INFORMATION RE: ELIGIBLE HOSPITAL MEASURES:

After consideration of the public comments received and for the reasons discussed
earlier, we are finalizing the following policy on case threshold exemptions for eligible hospitals
and CAHs in all stages of meaningful use beginning in FY 2014. However, eligible hospitals
and CAHs that are demonstrating meaningful use for the first time must submit their CQMs
through attestation and will not be able to qualify for this exemption. The burden of submitting
the aggregate population and sample size counts in order to qualify for the exemption would be
at least equal to the effort required to obtain and attest to the calculated CQM data.

Eligible hospitals and CAHs that have 5 or fewer discharges per quarter in the same
quarter as their reporting period in FY 2014, or 20 or fewer discharges per full FY reporting
period beginning in FY 2015, for which data is being electronically submitted (Medicare and
non-Medicare combined) as defined by the CQM’s denominator population are exempted from
reporting the CQM.
For example, if the CQM's denominator population is ischemic stroke
patients greater than or equal to 18 years of age, then the threshold would be 5 or fewer ischemic
stroke patients aged 18 years or older discharged from the hospital in the quarter for which data
is being submitted (the hospital's FY 2014 3-month quarter reporting period). To be eligible for
the exemption, hospitals must submit their aggregate population and sample size counts for
Medicare and non-Medicare discharges for the CQM for the reporting period no later than the
2-month submission period of October 1 through November 30 immediately following the
reporting period (please see section II.B.1. of this final rule for a description of reporting and
submission periods). Hospitals will report this information in the same manner as for the
Hospital IQR Program (76 FR 51639 through 51641). Please refer to the QualityNet website

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