CMS-3310-FC & CMS-3311-FC: MU Stage 3
Proposed Reporting on Clinical Quality Measures Using
Certified EHR Technology Requirements for
Eligible Hospitals & Critical Access Hospitals 2015-2018
Key Takeaways
EHs and CAHs have the option of attesting or eReporting CQMs
in 2015 through 2017

Medicare Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) can meet the
clinical quality measurement (CQM) reporting requirement for Meaningful Use (MU)
by either attesting or eReporting CQMs in 2015, 2016, and 2017.
Attestation Reporting Periods Vary Year to Year Depending on
EH Meaningful Use Status

EHs and CAHs choosing attestation must attest to 16 of 29 eCQMs from 3 of the 6
National Quality Strategy Domains in years 2015, 2016, and 2017. Reporting periods
and submission dates vary year to year.
2015

Attestation reporting period for CQMs is any continuous 90-day period within calendar
year 2015.
2016


Returning MU EHs and CAHs must attest for a full calendar year worth of CQMs data
in 2016.
First Year MU EHs and CAHs can attest on any continuous 90 day period in
2016
2017

Returning MU EHs and CAHs must attest for a full calendar year worth of CQMs data
in 2014. CQM data will be attested to on a quarterly basis.
eReporting Option: # of CQMs and Reporting Periods Vary Year
to Year
2015

EHs and CAHs that choose eReporting in 2015 must submit 16 of 29 eCQMs
electronically for 1 quarter of CY2015 by February 29th, 2016
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2016


EHs and CAHs that choose eReporting in 2016 must submit 4 of 29 eCQMs for 1
quarter of CY2016 by February 28th, 2017.
For 2016, eReporting of 4 eCQMs is REQUIRED to avoid the FY18 IQR Payment
Determination Adjustment even if EHs attest CQMs for Meaningful Use.
2017

CQM reporting requirements will be published in the CY2017 IPPS Final
Rule
Mandatory eReporting of CQMs in 2018

All EHs and CAHs must electronically report CQMs in 2018 unless they attest to a
hardship.
States will continue to define requirements for Medicaid

Medicaid EH and CAH eCQM reporting timelines and submission requirements will
continue to be determined by each of the states.
Details specific for Medicare Eligible Hospitals and Critical Access
Hospitals
2015
CQM Attestation Option Requirements

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EHs and CAHs may select any continuous 90-day period from October 1, 2014 through
December 31, 2015, 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.
CQM eReporting Option Requirements

As highlighted in the FY15 IPPS Final Rule, Second Year Stage 1 and Stage 2 EHs and
CAHs may also meet the CQM component of MU by:
o Electronically collecting data on 16 CQMs of the 29 available CQMs found in the
MU Stage 2 Final Rule menu.
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o
o
o
o
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Selected eCQMs must come from a minimum of 3 of the 6 National Quality
Domains.
EHs must submit one quarter of CQM data to CMS
 Quarter 1: January 1st -March 30th, 2015
 Quarter 2: April 1st-June 30th, 2015
 Quarter 3: July 1st-September 30th, 2015
 Quarter 4: October 1st-December 31st, 2015
Using 2014 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 2015: February 29th, 2016.
EHs successfully reporting and meeting all other MU and Inpatient Quality Reporting
Program (IQR) requirements will meet the CQM reporting requirement for both programs
with one successful electronic submission.
For this option, EH’s CQM data will be publically reported via HospitalCompare.gov.
Defined CQM sets and the published electronic specifications for CQMs that are in use
for all CMS aligned programs are currently posted on the eCQM Library page:
http://www.cms.gov/RegulationsandGuidance/Legislation/EHRIncentivePrograms/eCQM_Library.html
2016
CQM Attestation Option Requirements

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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.
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CQM eReporting Option Requirements and eReporting Mandates
for the CMS IQR Program in reporting year 2016/Payment Year
2018

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
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:
o Electronically collecting data on 4 CQMs of the 29 available CQMs found in
the MU Stage 2 Final Rule menu.
o 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)
o 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
o 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.
o 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.
For CY2016, EH’s CQM data will NOT be publically reported via
HospitalCompare.gov as CMS conducts data validity testing on eReported CQMs.
Defined CQM sets and the published electronic specifications for CQMs that are in
use for all CMS aligned programs are currently posted on the eCQM Library page:
http://www.cms.gov/RegulationsandGuidance/Legislation/EHRIncentivePrograms/eCQM_Library.html
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2017
CQM Attestation Option Requirements for Medicare and Medicaid
Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs)



EHs and CAHs have the option to attest 16 out of 29 CQMs in 3 of the 6 NQS Domains
in 2017
CMS will require a CQM reporting period of 1 full calendar year which consists of 4
quarterly data reporting periods for EHs that attest.
o January 1, 2017-March 30, 2017 (Submission Deadline: May 31, 2017)
o April 1, 2017-June 30, 2017 (Submission Deadline, August 31, 2017)
o July 1, 2017-September 30, 2017 (Submission Deadline, November 30, 2017)
o October 1, 2017-December 31, 2017 (Submission Deadline, February 28th, 2018)
First time Medicaid EHs will have a CQM reporting period of any continuous 90 days in
CY2017. That reporting period does not need to align with the EHs 90-day MU EHR
Measure and Objective Reporting Period.
CQM eReporting Option Requirements

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

Medicare EHs have the option of eReporting eCQMs in 2017.
eReporting submission criteria, reporting periods, and submission deadlines will be
published in the CY2017 IPPS Final Rule (will be published in August, 2016.)
eReporting EHs and CAHs must use CEHRT and the latest version of eCQM
specifications (May 2016 Annual Update.)
eReporting EHs and CAHs must submit patient level data using reporting standard
QRDA I to QualityNet https://cportal.qualitynet.org/QNet/pgm_select.jsp
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2018
Mandatory CQM eReporting Requirements

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Medicare EHs and CAHs are REQUIRED to eReport eCQMs in 2018 or face the MU
payment adjustment for failing to successfully meet MU reporting criteria.
eReporting submission criteria, reporting periods, and submission deadlines will be
published in the CY2018 IPPS Final Rule (will be published in August, 2017.)
eReporting EHs and CAHs must use CEHRT and the latest version of eCQM
specifications (May 2016 Annual Update.)
eReporting EHs and CAHs must submit patient level data using reporting standard
QRDA I to QualityNet https://cportal.qualitynet.org/QNet/pgm_select.jsp
Hardship Exemption:
o Attestation in 2018 will be allowed for EHs facing circumstances which render
them unable to electronically report (such as a data submission system failure,
natural disaster, or certification issue outside the control of the provider) who may
attest to CQMs if they also attest that electronically reporting was not feasible.
Details specific for Medicare Eligible Hospitals and Critical Access
Hospitals
2015-2017 Medicaid EH Quality Reporting for Meaningful Use


Individual states will determine how they will accept electronic reporting or attestation of
CQM data
State plans must be approved by CMS
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