Cypress testing for § 170.315(c)(1) currently allows certification of the entire C1 without including a TIN. The criterion requires that health IT must “record all data necessary to successfully calculate selected clinical quality measures (CQMs)”. For QRDA III submissions under MIPS individual reporting, CMS defines an individual as “a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single TIN,” making TIN a required element.

ACOs reporting for MSSP will be aggregating data for multiple providers and TINs, resulting in QRDA I files being used for data exchange. QRDA I files containing only an NPI are non-deterministic, since a provider may practice within multiple TINs. Since HL7 QRDA specifications are permissive to cover both Hospital and EC reporting cases, and CMS Implementation Guides do not apply to QRDA I files for the purposes of EC eCQM data exchange, there needs to be stronger validation from Cypress to support the end-to-end workflow for group reporting of EC eCQMs. Without TIN, a receiving vendor for QRDA I cannot reliably attribute providers or perform accurate calculations, creating a real-world gap in reporting accuracy and interoperability.

We request that Cypress be updated so that C1 certification fails for EC eCQMs when a TIN is missing, with a clear error message indicating that the TIN is required.