Clinical Quality Measures - CY 2016

In 2016 eligible hospitals (EHs) have the option of attesting eCQM data or electronically reporting eCQM data.

CQM Attestation Option Requirements

  • EHs and CAHs choosing to attest must capture and report CQM data for January 1, 2016 through December 31, 2016 to report CQMs via attestation using the EHR Incentive Program registration and attestation system.
  • EHs and CAHs may meet the CQM component of Meaningful Use by attesting to collecting data on 16 of the 29 available eCQMs found in the Meaningful Use Stage 2 menu using 2014 Certified EHR Technology (CEHRT.)
  • Selected eCQMs must come from a minimum of 3 of the 6 National Quality Domains.
  • EHs and CAHs must submit CQM data via the EHR Incentive Program registration and attestation system no later than February 29th, 2016.
  • Attestation of CQMs for the MU program in 2016 will not meet CQM electronic reporting requirements for the Hospital IQR program in reporting year 2016/payment year 2018.

CQM eReporting Option Requirements and eReporting Mandates for the CMS IQR Program in reporting year 2016/Payment Year 2018

  • As highlighted in the FY16 IPPS Final Rule, Second Year Stage 1 and Stage 2 EHs and CAHs may also meet the CQM component of MU by:
    • Electronically collecting data on 4 CQMs of the 29 available CQMs found in the MU Stage 2 Final Rule menu.
    • EHs must submit one quarter of CQM data to CMS
      • Either Quarter 3 (July 1st-September 30th, 2016) or Quarter 4 (October 1st-December 31st, 2016)
    • Using 2014 CEHRT or 2015 CEHRT) and the latest Measure Specifications (May 2015 Annual Update)
      • If errors are found in a specification, EHs must utilize the latest correct specification for the eCQM
    • Submit patient level data using reporting standard QRDA I to QualityNet https://cportal.qualitynet.org/QNet/pgm_select.jsp by
      • Submission Deadline for 2016: February 28th, 2017.
  • For the IQR program in 2016 Reporting Year/Payment Year 2018, electronic submission of 4 eCQMs is required for eligible hospitals to avoid the 2018 IQR payment adjustment.
    • Six previously adopted measures (ED-1, ED-2, PC-01, STK-04, VTE-5, and VTE-6) must still be submitted via chart-abstraction to the IQR program regardless of whether they are also submitted as eCQMs.