Tuesday, February 7, 2012

Attesting to Meaningful Use Quality Measures

I was recently asked how eligible professionals should report the Meaningful Use Clinical Quality Measures if there are zero denominators (i.e. you do not have any hypertensives, adults, or patients with 2 or more visits in the measurement period)

Here's the answer as I understand the regulations and FAQs:

1.  Report on the 3 Core measures if you can, which include
*Hypertension: Blood Pressure Measurement
*Tobacco Use Assessment and Tobacco Cessation Intervention
*Adult Weight Screening and Follow-up

2.  If any of the 3 Core measures has a zero denominator, replace them one-for-one with one of the 3 alternate core measures.   If you can’t get to 3 non-zero denominators between the core and alternate core, report on all 6 (even if it means that you have to report 6 zero denominators)
*Weight Assessment and Counseling for Children and Adolescents
*Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
*Childhood Immunization Status

3.  Regardless of the above, you MUST report on 3 of the remaining 38 Additional Set measures.  If you are reporting any zero denominators from these Additional Set measures, you must attest that you have no other non-zero denominator measures.  Essentially, you have to confirm that you’re not running away from non-zero denominator measures.

In summary, the minimal requirement is for 6 measures (3 core or alternate core, 3 additional set).  You may have to report up to 9 measures if there are zero denominators involved.  If you can’t find 3 non-zero denominators among the core and alternate core, you have to report on all 6 (even if it means that you’re reporting 6 zero denominators).  In addition, you still have to report on 3 from the remaining 38 additional set measures.  If any of these 3 additional set measures is a zero denominator, you must confirm that you don’t have a non-zero denominator for any of the remaining 35 that you’re not reporting on.
Micky Tripathi posted a blog about this last summer that provides additional detail.

You'll find the FAQs that address the Clinical Quality Measures here.


T. Harkness said...

I would only add one additional comment regarding clinical quality measures (CQMs). The measures reported must be obtained via ONC certified electronic health records or reporting modules. In some cases, at least within the ambulatory practice ONC certified EHRs, vendors only certified on nine measures total - the three core measures, the three alternate core measures and three of the 38 available menu (or additional set) measures. You can see the measures on which your vendor certified by finding and selecting the EHR product on the ONC CHPL website (http://onc-chpl.force.com/ehrcert). If your EHR vendor or reporting module did not certify on all 38 available menu measures, you must report only on the certified measures even if there are zero patients that qualify for the menu CQMs. For example, if the eligible provider is a pediatrician but their EHR vendor only certified on menu measures (NQF 0031) Breast Cancer Screening, (NQF 0033) Chlamydia Screening for Women and (NQF 0034) Colorectal Cancer Screening, the eligible provider must report only on the certified measures even if they are not applicable to their practice unless they have access to a ONC certified reporting module that certified on additional menu clinical quality measures. Some FAQs that may be helpful can be found at https://questions.cms.hhs.gov/app/answers/detail/a_id/10465 (Answer ID 10465) and https://questions.cms.hhs.gov/app/answers/detail/a_id/10589/kw/clinical%20quality%20indicators/related/1 (Answer ID 10589).

Anonymous said...

T. Harkness your statement is incorrect.

See CMS FAQ 10649


T.Harkness said...

Thank you, Anonymous, for the correction and link for the CMS FAQ. CMS had issued a newer FAQ of which I was not aware. As long as the provider is using certified EHR technology, they can submit results for CQMs calculated by their certified EHR technology.