2018 EH CQM Reporting
August 8, 2018
New in 2018: For the Medicare Promoting Interoperability (PI) program (previously called the EHR Incentive Program), electronic submission of electronic clinical quality measures (eCQMs) is required for all eligible hospitals. Manual attestation is only an option available for eligible hospitals and critical access hospitals (CAHs) in specific circumstances when electronic reporting is not feasible. If your hospital needs to submit a manual attestation on the clinical quality measures, you will be required to complete a Hardship Exception application and provide proof of the hardship.
Below are the eligible hospital clinical quality measure (CQM) requirements for both the Medicare and Medicaid programs.
2018 Clinical Quality Measure Requirements
- For hospitals also reporting eCQMs via the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) program, the four eCQMs you report via the CMS IQR program will count for the Medicare PI program.*
- For hospitals not reporting eCQMs to the CMS IQR program but submitting their CQMs electronically for the Medicare PI program, you will need to report on four eCQMs. The reporting period is one self-selected calendar quarter of data.*
- For hospitals not reporting eCQM as part of the IQR program or electronically submitting CQMs for the Medicare PI program, you will need to report on all 16 CQMs. For manual submission of CQMs, the reporting period is a full year of data (calendar year 2018), unless it is your first year of participation in the program. Then the reporting period is 90 days.* If you are reporting manually, you will be required to complete a Hardship Exception application and provide proof of the hardship.
*Under the Medicaid PI program, states have the flexibility to determine the requirements and methods for reporting CQMs. Some states align their Medicaid CQM requirements with the Medicare requirements but not always. You will want to double check with your State Medicaid office to verify specific criteria on CQM reporting.
The Montana Medicaid PI program will accept the eCQM data submitted to CMS for the IQR or Medicare PI programs, which will be loaded directly from QualityNet into the Montana Medicaid PI State Level Registry (SLR).
Requirements for Electronic Submission of CQMs:
- Use of Quality Reporting Document Architecture (QRDA) Category I for CQM electronic submissions
- Electronic health record (EHR) technology certified to the 2014 or 2015 edition
- Required to have the EHR technology certified to all 16 available CQMs
- Use of eCQM specifications published in the 2017 eCQM annual update for calendar year 2018 reporting and any applicable addenda; available on the eCQI Resource Center website
CMS eCQM Resources:
- 2018 CMS Implementation Guide for QRDA I for Hospital Quality Reporting
- CMS Clinical Quality Measures Basics
Detailed information on the eligible hospital core elements (non-CQMs) for each program can be found on our blog post from April 16, 2018.
If you have any questions or run into issues with any of the Meaningful Use objectives and would like help, please use the “Leave a Reply” section below, or email Patty Kosednar directly with your questions or comments.