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Meaningful Use FAQ Updates Clarify Reporting Period Rules

By Sara Heath

As meaningful use standards continue to evolve, the Centers for Medicare & Medicaid Services (CMS) has issued updates to their frequently asked questions list. Updating three questions for clarification, CMS addresses issues regarding numerator measures for transitions of care, group practice immunizations data, and whether measures reported after an EHR reporting period can count toward meaningful use.

CMS meaningful use standards clarified in frequently asked questions

The first updated question entails which transitions of care count toward the numerator of the measures. CMS first explains that a transition of care is defined by the movement of a patient from one care setting to another. In order to count toward the numerator of the measures, CMS says, the patient must be transferred from one setting of care to a completely separate setting. For example, the two settings should have different billing identities, National Provider Identifiers (NPIs), or hospital CMS Certification Numbers (CCNs).

The second question involves whether an eligible practitioner (EP) that is part of a group practice that submits to a public health agency may also attest to meeting meaningful use standards for immunizations.

If an eligible professional (EP) in the EHR Incentive Programs is part of a group practice that has achieved ongoing submission to a public health agency (PHA), but the EP himself/herself did not administer any immunizations to any of the populations for which data is collected by their jurisdiction's immunization registry during their EHR reporting period, can he/she attest to meeting the measure since they are part of the group practice that is submitting data to the registry?”

CMS states that if immunizations are not a part of that EP’s scope of practice, they may not attest to the measure and must claim exclusion. However, if the situation is simply that the EP did not administer any immunizations during a specific meaningful use reporting period they do not have to claim exclusion. Such EPs would have to ensure that they have done the proper registrations and testing and are reporting measures as soon as they do have data to report.

The final question regards whether data from outside the meaningful use period can be submitted to the numerator measures. CMS states that data for the numerator measure is  not required to be collected only during the EHR reporting period unless specifically stated as such for a specific measure, for example in Preventive Care and Secure Electronic Messaging.

CMS also states that if meaningful use measures are going to be collected from outside of the reporting period, it must be within a reasonable time frame.

“For all other meaningful use measures, the actions may reasonably fall outside the EHR reporting period timeframe but must take place no earlier than the start of the reporting year and no later than the date of attestation in order for the patients to be counted in the numerator, unless a longer look-back period is specifically indicated for the objective or measure,” CMS states.

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