We have providers seeing patients at ECFs and they don't have CEHRT and aren't integrated into the system. In this case, even though the services are billed, they might not be reportable for eCQMs—not because of the CPT codes, but due to data capture limitations.

So, since our ECFs aren't using CEHRT, any encounters that happen there—like those billed with CPT codes 99304-99318—can't be included in the MSSP ACO's eCQM reporting, because eCQMs must be generated from CEHRT to meet CMS requirements.

So, the way I understand this is that these encounters are essentially excluded by default, not due to CMS measure specifications, but because we can't generate valid eCQMs from non-CEHRT data and since our ECF population accounts for significantly less than 25% of our total ACO population, we have more flexibility in meeting the 75% data completeness threshold for eCQM reporting.

With that being said, CMS requires that ACOs report on 100% of denominator-eligible ** patients across all payers and provide numerator responses for at least 75% of those instances. However, if ECF encounters are not CEHRT-enabled and represent a minority of our total patient volume, we can likely meet the threshold by focusing on all our other patients. Can the ECF data, while technically part of the denominator, be excluded operationally due to lack of CEHRT? I read that CMS allows for this when it's a small portion of the population and not due to cherry-picking. I also read to stay compliant, we would need to document the reason for data gaps (e.g., lack of CEHRT at ECFs), maximize data capture from all CEHRT-enabled sites, which we are currently doing, and by selecting eCQMs that are less dependent on ECF encounters, which we have also done.

Is this all accurate? Can we exclude this very small portion of the population on the QRDA and work towards implementing CEHRT in 2026?