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Featured Questions
Are new participants that attest only to the Medicaid EHR
Incentive Program in 2017 required to attest to ...- In the 2017 OPPS/ASC final rule, we stated that time and
cost limitation concer... (more)
- In the 2017 OPPS/ASC final rule, we stated that time and
cost limitation concerns related to the 2015 Edition upgrades made it
unfeasible for new participants to attest to the Stage 3 objectives and
measures in 2017 in the EHR Incentive Program Registration and Attestation
System.
We finalized that are all new EPs and eligible hospitals
seeking to avoid the 2018 payment adjustment or any new participating CAH in
2017 seeking to avoid the 2017 payment adjustment would have to attest to
Modified Stage 2 objectives and measures. This requirement is for those
who attest to CMS through the EHR Incentive Program Registration and
Attestation system. In the final rule we stated that this change would apply to
Medicaid providers who usually attest to their State. However, we clarify
further that this provision is only applicable to Medicaid providers who are
dual-eligible and attest to CMS through the EHR Incentive Program Registration
and Attestation system.
(FAQ18257)
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What is the policy for measure calculation for actions
outside of the EHR reporting period for the Medicar...- In the 2017 OPPS/ASC final rule we final... (more)
- In the 2017 OPPS/ASC final rule we finalized changes for meaningful use measures (unless otherwise specified), actions included in the numerator must occur within the EHR reporting period if that period is a full calendar year, or if it is less than a full calendar year, within the calendar year in which the EHR reporting period occurs. Meaning that all actions in the numerator must occur between January 1st and December 31st for all calendar years beginning in 2017.
The following objectives and measures fall under this policy in 2017 for Modified Stage 2: - Protect Patient Health Information: (Security Risk Analysis),
- Health Information Exchange,
- Patient Specific Education,
- Patient Electronic Access (measure 2 - VDT)
- Secure Messaging (EPs only for Modified Stage 2), and
- Public Health Reporting
The following objectives and measures fall under this policy
for Stage 3: - Protect Patient Health Information (Security Risk Analysis),
- Patient Electronic Access to Health Information (measure 2-Patient Specific Educational
Resources),
- Coordination of Care Through Patient Engagement (measure 1 – VDT and measure 2-
Secure Messaging)
- Health Information Exchange (measure 1 – Send a Summary of Care), and
- Public Health Reporting.
For more information specific to the Security Risk Assessment, see FAQ # 13649. Please note that beginning in 2017, the security risk assessment must be conducted within the calendar year in which the EHR reporting period occurs.
For more information specific to numerator calculations for actions outside the EHR reporting period for the Medicare and Medicaid EHR Incentive Programs prior to 2017, see FAQ # 8231.
(FAQ18261)
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What is the definition of "new patient" for billing evaluation and management (E/M) services?- Interpret the phrase... (more)
- Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. The AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf). You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.
(FAQ1969)
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What are cross-cutting measures in Physician Quality Reporting System (PQRS) and how do face-to-face encoun...- Cross-cutting measures are any measures that are broadly ... (more)
-
Cross-cutting measures are any measures that are broadly applicable across multiple clinical settings and eligible professionals (EPs) or group practices within a variety of specialties. The requirement of reporting cross-cutting measures was introduced to the Physician Quality Reporting System PQRS) program beginning in 2015 and remains a requirement for 2016 PQRS. The requirement of reporting a cross-cutting measure is triggered if an EP or a group practice bills a face-to-face encounter. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP or group practice billed for services that are associated with face-to-face encounters under the Physician Fee Schedule (PFS). This includes general office visits, outpatient visits, and surgical procedure codes; however, CMS does not consider telehealth visits as a face-to-face encounter. If an EP or group practice bills a service defined as a face-to-face encounter, CMS will analyze claims-based data to determine if a cross-cutting measure may have been applicable. If at least 15 cross-cutting measure denominator eligible encounters are found for an EP or group practice, then CMS maintains that the cross-cutting measure was applicable for that EP to report. If less than 15 cross-cutting measure denominator eligible encounters occur, then the cross-cutting measure requirement would not be applicable. For more information on cross-cutting measures and face-to-face encounters navigate to the topics on the CMS.gov PQRS Measures Codes web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html and scroll down to view and click the hyperlinks for cross-cutting measures and/or face-to-face encounters. The claims- and registry-based Measure-Applicability Validation (MAV) materials contain more information about this topic and can be located for the specific PQRS program year on the PQRS Web site on the Analysis and Payment web page found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html Please contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via e-mail at [email protected] should you have questions regarding this topic.
(FAQ12168)
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What physician shared patient data sets are available?- ... (more)
- The
physician referral data linked below was provided as a response to a Freedom of
Information Act (FOIA) request. These files represent the number of encounters
a single beneficiary has had across physicians at intervals of 30, 60, 90 and
180 days. For more details about the file contents for years 2009 - 2015,
please see the Technical Requirements document: http://downloads.cms.gov/foia/Physician_Shared_Patient_Patterns_Technical_Requirements.pdf.
Note: The files range in size from 1-7 gigabytes. Special statistical
software is needed for analysis. These files will not fully open in a text
editor or Microsoft Excel.
(FAQ7977)
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Who can enter medication orders in order to meet the measure for the computerized provider order entry (CPO...- As mentioned in 80 FR 62798, a medical staff person who is a credentialed medical assistant or is credentialed to and pe... (more)
- As mentioned in 80 FR 62798, a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant may enter orders. We maintain our position that medical staff must have at least a certain level of medical training in order to execute the related CDS for a CPOE order entry. We defer to the provider to determine the proper credentialing, training, and duties of the medical staff entering the orders as long as they fit within the guidelines we have proscribed. We believe that interns who have completed their medical training and are working toward appropriate licensure would fit within this definition. We maintain our position that, in general, scribes are not included as medical staff that may enter orders for purposes of the CPOE objective. However, we note that this policy is not specific to a job title but to the appropriate medical training, knowledge, and experience. For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10134
Date Updated: 05/12/2016
(FAQ2851)
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What is the difference between a legacy provider identifier (LPI) and a National Provider Identifier (NPI)?...- LPIs are any of a known set of identifie... (more)
- LPIs are any of a known set of identifiers used by either states or the federal government to identify service providers prior to the arrival of National Provider Identifiers (NPIs). LPIs can be state-specific provider IDs, Medicare Provider Identification Number (PIN), Medicare Unique Physician Identification Number (UPIN), Online Survey Certification and Reporting (OSCAR) IDs, Medicare National Supplier Clearinghouse (NSC) numbers, other Medicare IDs of unknown type, as well as other commercial numbering systems. NPIs are a unique, 10-digit, sequentially assigned national identification number that are mandated by HIPAA to be used by health care providers, health plans, and health care clearinghouses in all administrative and financial HIPAA transactions. NPIs are routinely assigned only to medical providers. There are many non-medical providers serving Medicaid enrollees (e.g. home care services and transportation) that do not usually receive NPIs. So, all Medicaid providers have some types of LPIs, but not all Medicaid providers have NPIs. CMS began collecting NPIs in MSIS data in Fiscal 2009, although reporting was not complete for medical providers initially. NPIs have been captured in MAX to the extent they are available, beginning with 2009 data.
(FAQ6115)
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How does Medicare pay for services delivered by non-participating providers?- For services and procedures performed by... (more)
- For services and procedures performed by non-participating fee-for service providers (i.e., those providers who opt out of Medicare assignment), the total Medicare allowed amounts for servicers and procedures are slightly lower (5% lower) compared to Medicare allowed amounts for participating providers. However, while participating providers can only charge Medicare beneficiaries a coinsurance amount up to 20% of the Medicare allowed amount, non-participating providers can charge beneficiaries the 20% coinsurance plus an additional amount up to a total of 115% of their reduced allowed amount (this is referred to as the limiting charge portion).
(FAQ9920)
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What steps does a provider have to take to determine if there is a specialized registry available for them,...- The eligible professional (EP) is not required to make an exhaustive search of all potential registries. Instead, they ... (more)
- The eligible professional (EP) is not required to make an exhaustive search of all potential registries. Instead, they must do a few steps to meet due diligence in determining if there is a registry available for them, or if they meet the exclusion criteria.
1 – An EP should check with their State* to determine if there is an available specialized registry maintained by a public health agency.
2 – An EP should check with any specialty society with which they are affiliated to determine if the society maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider’s EHR reporting period.
If the EP determines no registries are available, they may exclude from the measure.
For EPs: The provider may meet the specialized registry measure up to 2 times. This can be done through reporting to:
Two registries maintained by a public health agency
Two registries maintained by one or more specialty societies
One registry maintained by a public health agency and one maintained by a specialty society
One registry maintained by a public health agency and one exclusion
One registry maintained by a specialty society and one exclusion
Two exclusions
PLEASE NOTE: In 2015, providers may also simply claim an alternate exclusion for a measure as defined in FAQ 12985.
*If you report to an entity other than a State as your reporting jurisdiction (such as a county) you may elect to check with them.
Created 12/11/2015
Updated 02/25/2016
(FAQ13657)
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What can count as a specialized registry?- A submission to a specialized
registry may count if the receiving entity meets the following requirements:
The recei... (more)
- A submission to a specialized
registry may count if the receiving entity meets the following requirements:
The receiving entity must declare that they are ready to accept
data as a specialized registry and be using the data to improve population
health outcomes. Until such time as a centralized repository is available
to search for registries, most public health agencies and clinical data
registries are declaring readiness via a public online posting.
Registries should make this information publically available for potential
registrants.
The receiving entity must also be able to receive electronic
data generated from CEHRT. The electronic file can be sent to the
receiving entity through any appropriately secure mechanism including, but not
limited to, a secure upload function on a web portal, sFTP, or Direct. Manual
data entry into a web portal would not qualify for submission to a specialized
registry.font-family:
The receiving entity should have a registration of intent
process, a process to take the provider through test and validation and a
process to move into production. The receiving entity should be able
to provide appropriate documentation for the sending provider or their current
status in Active Engagement.
For qualified clinical data registries, reporting to a QCDR may count for the
public health specialized registry measure as long as the submission to the
registry is not only for the purposes of meeting CQM requirements for PQRS or
the EHR Incentive Programs; In other words, the submission may count if
the registry is also using the data for a public health purpose. Many
QCDRs use the data for a public health purpose beyond CQM reporting to
CMS. A submission to such a registry would meet the requirement for the
measure if the submission data is derived from CEHRT and transmitted
electronically.
Created 12/11/2015
Updated 02/25/2016
(FAQ13653)
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In order to receive payments under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Progr...- In... (more)
- In order to receive Medicare EHR incentive payments, EPs, eligible hospitals, and critical access hospitals must have an enrollment record in PECOS with an APPROVED status. Medicaid EPs do not have to be in PECOS. It is possible to receive payment for Medicare claims and not be in approved status. We encourage all providers to verify their status as soon as possible.
There are three ways to verify that you have an enrollment record in PECOS: 1. Check the Ordering Referring Report on the CMS website. If you are on that report, you have a current enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll/, click on "Ordering Referring Report" on the left. Use Internet-based PECOS to look for your PECOS enrollment record. If no record is displayed, you do not have an enrollment record in PECOS. Go to Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in PECOS. Click on "Medicare Fee-For-Service Contact Information" under "Downloads. If you are not in PECOS, the best way to submit your application is through internet-based PECOS. For more information go to: For more information go to: http://www.cms.gov/EHRIncentivePrograms
FAQ10154
Updated 5/12/2016
(FAQ2887)
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If an applicable manufacturer or applicable group purchasing organization (GPO) provides a payment or trans...- No. A payment or transfer of value as described above would not be subject to reporting under Open Payments for any cove... (more)
- No. A payment or transfer of value as described above would not be subject to reporting under Open Payments for any covered recipient physician speakers or faculty. As explained in the Calendar Year 2015 Physician Fee Schedule Final Rule, when an applicable manufacturer or GPO provides funding to a continuing education provider, but does not: 1) select or pay the covered recipient speaker directly, or (2) provide the continuing education provider with a distinct, identifiable set of covered recipients to be considered as speakers for the continuing education program, CMS will consider those payments to be excluded from reporting under § 403.904(i)(1) [revised as § 403.904(h)(i)]. This approach is consistent with our discussion in the preamble to the final rule, where we explained that if an applicable manufacturer conveys ”full discretion” to the continuing education provider, those payments are outside the scope of the rule (79 Fed. Reg. 67759). We continued by saying “[t]his is the case even if the applicable manufacturer or applicable GPO learns the identity of the covered recipient during the reporting year or by the end of the second quarter of the following reporting year.”(79 Fed. Reg. 67760).
(FAQ8165)
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For 2015, how should a provider report on the public health reporting objective if they had not planned to ...- ... (more)
- We do not intend to inadvertently penalize providers for their inability to meet measures that were not required under the previous stages of meaningful use. Nor did we intend to require providers to engage in new activities during 2015, which may not be feasible after the publication of the final rule in order to successfully demonstrate meaningful use in 2015.
In the final rule at 80 FR 62788, we discuss our final policy to allow for alternate exclusions and specifications for certain objectives and measures where there is not a Stage 1 measure equivalent to the Modified Stage 2 (2015 through 2017) measure or where a menu measure is now a requirement. This includes the public health reporting objective as follows.
First, EPs scheduled to be in Stage 1 may attest to only 1 public health measure instead of 2 and eligible hospitals or CAHs may attest to only 2 public health measures instead of 3. Second, we will allow providers to claim an alternate exclusion for a measure if they did not intend to attest to the equivalent prior menu objective consistent with our policy for other objectives and measures as described at 80 FR 62788. Strong We will allow Alternate Exclusions for the Public Health Reporting Objective in 2015 as follows strong EPs scheduled to be in Stage 1: Must attest to at least 1 measure from the Public Health Reporting Objective Measures 1-3
• May claim an Alternate Exclusion for Measure 1, Measure 2 or Measure 3.
• An Alternate Exclusion may only be claimed for up to two measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure described in 495.22 (e)(10)(i)(C).
EPs scheduled to be in Stage 2: Must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3
• May claim an Alternate Exclusion for Measure 2 or Measure 3 (Syndromic Surveillance Measure or Specialized Registry Reporting Measure) or both
Eligible hospitals/CAHs scheduled to be in Stage 1: Must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-4
• May claim an Alternate Exclusion for Measure 1, Measure 2, Measure 3 or Measure 4
• An Alternate Exclusion may only be claimed for up to three measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure described in 495.22 (e)(10)(ii)(C).Eligible hospitals/CAHs scheduled to be in Stage 2: Must attest to at least 3 measures from the Public Health Reporting Objective Measures 1-4
• May claim an Alternate Exclusion for Measure 3 (Specialized Registry Reporting Measure)
Created 10/19/2015
Updated 10/20/2015
Updated 10/21/2015
Updated 11/20/2015
(FAQ12985)
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If I submit a hardship exception application, does that mean that I cannot attest for 2015 EHR reporting pe...- No. Submission of a hardship exception application does not prevent a provider from attesting and receiving an incentiv... (more)
- No. Submission of a hardship exception application does not prevent a provider from attesting and receiving an incentive payment if meaningful use requirements are met.
Attestation for 2015 EHR reporting periods is currently open. We urge providers to try to attest by the March 11, 2016 attestation deadline. If they successfully attest, they will avoid the payment adjustment in 2017 and may also be eligible to receive an EHR Incentive payment.
However if a provider cannot attest for a 2015 reporting period or believes their attestation may be unsuccessful, the provider can apply for a hardship exception to avoid the payment adjustment in 2017. The application will not prevent a provider from earning an incentive if their attestation is in fact successful. The deadline to submit a hardship exception application is for both eligible professionals and eligible hospitals are July 1, 2016. Providers may find the application and instructions at: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.html
https://questions.cms.gov/faq.php?id=5005&faqId=14357
Created 02/18/2016
Updated 02/26/2016
(FAQ14357)
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Will the Centers for Medicare & Medicaid Services (CMS) conduct audits as part of the Medicare and Medi...- Any provider attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program pot... (more)
- Any provider attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program potentially can be subject to an audit. Here's what you need to know to make sure you're prepared: Overview of the CMS EHR Incentive Programs Audits• All providers attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses. Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.• CMS, and its contractors, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers.• States, and their contractors, will perform audits on Medicaid providers.• CMS and states will also manage appeals processes. Preparing for an Audit• To ensure you are prepared for a potential audit, save the electronic or paper documentation that supports your attestation. Also save the documentation that supports the values you entered in the Attestation Module for Clinical Quality Measures (CQMs). Hospitals should also maintain documentation that supports their payment calculations.• Upon audit, the documentation will be used to validate that the provider accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate. Details of the Audits• There are numerous pre-payment edit checks built into the EHR Incentive Programs' systems to detect inaccuracies in eligibility, reporting, and payment. • Post-payment audits will also be completed during the course of the EHR Incentive Programs.•;Medicare audit notification will come from Figliozzi and Company, or the EHR Meaningful Use Audit Team• If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped. • CMS has an appeals process for eligible professionals, eligible hospitals, and critical access hospitals that participate in the Medicare EHR Incentive Program.• States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.What information should an eligible professional, eligible hospital, or critical access hospital participating in the Medicare or Medicaid Electronic Health Record (EHR) Incentive Programs maintain in case of an audit? An audit may include a review of any of the documentation needed to support the information that was entered in the attestation. The level of the audit review may depend on a number of factors, and it is not possible to include an all-inclusive list of supporting documents.& The primary documentation that will be requested in all reviews is the source document(s) that the provider used when completing the attestation. This document should provide a summary of the data that supports the information entered during attestation. Ideally, this would be a report from the certified EHR system, but other documentation may be used if a report is not available or the information entered differs from the report.This summary document will be the starting point of most reviews and should include, at minimum:• The numerators and denominators for the measures• The time period the report covers • Evidence to support that it was generated for that eligible professional, eligible hospital, or critical access hospital. Although the summary document is the primary review step, there could be additional and more detailed reviews of any of the measures, including review of medical records and patient records. The provider should be able to provide documentation to support each measure to which he or she attested, including any exclusions claimed by the provider. A few examples of additional support are as follows:• Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support – Proof that the functionality is available, enabled, and active in the system for the duration of the EHR reporting period.• Electronic Exchange of Clinical Information – Screenshots from the EHR system or other documentation that document a test exchange of key clinical information (successful or unsuccessful) with another provider of care. Alternately, a letter or email from the receiving provider confirming the exchange, including specific information such as the date of the exchange, name of providers, and whether the test was successful.• Protect Electronic Health Information – Proof that a security risk analysis of the certified EHR technology was performed prior to the end of the reporting period (e.g., report which documents the procedures performed during the analysis and the results). • Drug Formulary Checks – Proof that the functionality is available, enabled, and active in the system for the duration of the EHR reporting period.• Immunization Registries Data Submission, Reportable Lab Results to Public Health Agencies, and Syndromic Surveillance Data Submission– Screenshots from the EHR system or other documentation that document a test submission to the registry or public health agency (successful or unsuccessful). Alternately, a letter or email from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data, including the date of the submission, name of parties involved, and whether the test was successful • Exclusions – Documentation to support each exclusion to a measure claimed by the provider. For Medicare eligible professionals and for hospitals that are eligible for both Medicare and Medicaid EHR incentive payments - When a provider is selected for an audit, they will receive an initial request letter from the audit contractor. The request letter will be sent electronically by the audit contractor from a CMS email address and will include the audit contractor’s contact information. The email address provided during registration for the EHR Incentive Program will be used for the initial request letter.The initial review process will be conducted at the audit contractor’s location, using the information received as a result of the initial request letter. Additional information might be needed during or after this initial review process, and in some cases an on-site review at the provider’s location could follow. A demonstration of the EHR system could be requested during the on-site review. A secure communication process has been established by the contractor, which will assist the provider to send any information that could be considered sensitive. Any questions pertaining to the information request should be directed to the audit contractor. States will have separate audit processes for their Medicaid EHR Incentive Program. For more information about these audit processes, please contact your State Medicaid Agency.
Updated on 11/19/2013
(FAQ7711)
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How can a provider meet the “Protect Electronic Health Information” core objective in the Electronic He...- To meet the “Protect Electronic Health Information” core objective for Stage 1, eligible professionals (EP), eligibl... (more)
- To meet the “Protect Electronic Health Information” core objective for Stage 1, eligible professionals (EP), eligible hospitals or critical access hospitals (CAH) must conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process.
In Stage 2, in addition to meeting the same security risk analysis requirements as Stage 1, EPs and hospitals will also need to address the encryption and security of data stored in the certified EHR technology (CEHRT).
These steps may be completed outside or the EHR reporting period time frame but must take place no earlier than the start of the EHR reporting year and no later than the provider attestation date. For example, a EP who is reporting Meaningful Use for a 90-day EHR reporting period may complete the appropriate security risk analysis requirements outside of this 90-day period as long as it is completed no earlier than January 1st of the EHR reporting year and no later than the date the provider submits their attestation for that EHR reporting period.
This meaningful use objective complements but does not impose new or expanded requirements on the HIPAA Security Rule. In accordance with the requirements under (45 CFR 164.308(a)(1)(ii)), providers are required to conduct an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI). Once the risk analysis is completed, providers must take any additional “reasonable and appropriate” steps to reduce identified risks to reasonable and appropriate levels.
Please note that a security risk analysis or review needs to be conducted during each EHR reporting year for Stage 1 and Stage 2 of meaningful use to ensure the privacy and security of their patients’ protected health information.
For more information about completing a security risk analysis, please see the following resources: Security Risk Assessment Tip Sheet:
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/SecurityRiskAssessment_FactSheet_Updated20131122.pdf
https://www.cms.gov/Regulations-and-
Health Information Privacy and Security: A 10 Step Plan: http://www.healthit.gov/providers-professionals/ehr-privacy-security/10-step-plan"
Created 10/6/2014
Updated 11/5/2014
Archived 12/15/15
(FAQ10754)
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Who pays the difference between what the provider charges and Medicare pays?- The provider has an agreement with Medic... (more)
- The provider has an agreement with Medicare to accept Medicare’s payment and the difference is not paid by Medicare or any other entity, including the beneficiary.
(FAQ9264)
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If an eligible provider fails to meet meaningful use (MU) during a participation year in the Medicare Elect...- An Eligible Professional (EP), Eligible Hospital or Critical Access Hospital (CAH) that participates in the Medicare EHR... (more)
- An Eligible Professional (EP), Eligible Hospital or Critical Access Hospital (CAH) that participates in the Medicare EHR Incentive Program and does not meet MU for one participation year is highly encouraged to continue to attest and earn incentive payments for future participation years.
If a participating provider does not successfully attest for a given year, he/she will not be eligible to receive an incentive payment for that year. However, attesting and receiving an incentive payment for a future participation year is based on the provider’s ability to meet MU during that year and not based on success or failure in previous years.
When a provider continues to participate and submit attestation information in subsequent years, the progression through the stages of MU will continue to follow the CMS-established timeline of meeting the MU criteria of each stage for two program years, regardless of whether he/she demonstrates MU in each consecutive year.
For example, if an EP demonstrates the stage 1 criteria for the 1st payment year, but does not meet the stage 1 criteria in the 2nd payment year, the EP will receive an incentive payment for the 1st payment year but not receive the associated incentive payment for the 2nd year.
When the EP proceeds to attest for the 3rd payment year, he/she may be eligible to receive the associated incentive payment if MU is met. However, since the EP has completed the 1st and 2nd program years, the EP will be expected to demonstrate the stage 2 meaningful use criteria to receive payment in the 3rd year, even if he/she did not meet the stage 1 criteria in the 2nd year.
If a provider registers to participate in the EHR Incentive Program for the first year but chooses to withdraw their attestation, the provider may have the opportunity to start over and “repeat” their first year of participation in the Incentive Program if a CMS post payment or prepayment audit has not been initiated. If the provider withdraws their attestation during or after a CMS audit has been conducted, the provider forfeits the ability to reattest as a Year 1 participant and must attest as a Year 2 participant in the next year. Once the provider has withdrawn and the audit has been initiated, the progression along the EHR Incentive Program timeline has begun and the provider would need to meet MU along this schedule in order to earn the associated incentive payments.
Please see title=https://questions.cms.gov/reps/faq.php?faqId=7737" target=FAQ 7737 for information about the meaningful use progression in the Medicaid EHR Incentive Program.
For more information about the EHR Incentive Program timeline, please visit http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html To use the interactive “My EHR Participation Timeline” tool, please visit: http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Participation-Timeline.html
(FAQ9220)
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A number of measures for Meaningful Use objectives for eligible hospitals and critical access hospitals (CA...- There are two methods for calculating ED admissions for the denominators for measures associated with Meaningful Use obj... (more)
- There are two methods for calculating ED admissions for the denominators for measures associated with Meaningful Use objectives. Eligible hospitals and CAHs must select one of the methods below for calculating ED admissions to be applied consistently to all denominators for the measures. That is, eligible hospitals and CAHs must choose either the "Observation Services method" or the "All ED Visits method" to be used with all measures. Providers cannot calculate the denominator of some measures using the "Observation Services method," while using the "All ED Visits method" for the denominator of other measures. Before attesting, eligible hospitals and CAHs will have to indicate which method they used in the calculation of denominators (77 FR 53984).Observation Services method. When using this method, the denominator should include the following visits to the ED: The patients who are admitted to the inpatient department (Place of Service (POS) 21) either directly or through the emergency department.The patients who are initially presented to the emergency department (POS 23) and receive observation services. Patients who receive observation services under both POS 22 and POS 23 should be included in the denominator. Details on observation services can be found in the Medicare Benefit Policy Manual, Chapter 6, Section 20.6.All ED Visits method. An alternate method for computing admissions to the ED is to include all ED visits (POS 23 only) in the denominator for all measures requiring inclusion of ED admissions. All actions taken in the inpatient or emergency departments (POS 21 and 23) of the hospital would count for purposes of determining meaningful use. For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
5/12/2016
(FAQ2843)
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I have a Drug Enforcement Administration (DEA) Number. Do I need a National Provider Identifier (NPI) as well?- The NPI does not replace the function of the DEA Number, which is to identify the prescriber of a controlled or dangerou... (more)
- The NPI does not replace the function of the DEA Number, which is to identify the prescriber of a controlled or dangerous substance. The NPI was adopted to identify a health care provider as a health care provider in standard transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A health care provider who is a covered entity under HIPAA is required to obtain an NPI, and to use that NPI to identify itself as a health care provider in HIPAA standard transactions. Health care providers who are not covered entities under HIPAA, but who prescribe medications, order services for patients, refer patients to other providers, or who otherwise need to be identified in HIPAA standard transactions that are conducted by other health care providers, will need (but are not required) NPIs so that those other health care providers can use that number to identify them in the HIPAA standard transactions that they conduct. The definition for a HIPAA covered health care provider may be found at 45CFR 162.103.
(FAQ2091)
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While the denominator for measures used to calculate meaningful use in the Medicare and Medicaid Electronic...- The criteria for a numerator is not constrained to the EHR reporting period unless expressly stated in the numerator sta... (more)
- The criteria for a numerator is not constrained to the EHR reporting period unless expressly stated in the numerator statement for a given meaningful use measure. The numerator for the following meaningful use measures should include only actions that take place within the EHR reporting period: Preventive Care (Patient Reminders) and Secure Electronic Messaging.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 objectives or measure. For program year 2015 and subsequent years, the requirements have been defined in the final rule (80 FR 62792). For more information specific to the Security Risk Assessment in 2015 and subsequent years, see FAQ #13649 https://questions.cms.gov/faq.php? Created on 4/26/2013
Updated on 6/23/2014
Updated on 9/24/2015
Updated on 12/11/2015
Updated on 12/14/2015
(FAQ8231)
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Which Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and f...- The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transactions to indicate h... (more)
- The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transactions to indicate health care provider type, classification, and/or specialization. A healthcare provider must select a Healthcare Provider Taxonomy Code from this code set when applying for a National Provider Identifier (NPI). The code set is maintained by the National Uniform Claim Committee (NUCC) and is made available to the public by the Washington Publishing Company (WPC). Information on requesting changes to the code set is available from the NUCC (www.nucc.org/). Frequently Asked Questions and information on printing or downloading the code set is available from the WPC (www.wpc-edi.com ).
All covered health care providers are eligible for NPIs and may apply for them. Because they are health care providers, medical students, interns, residents, and fellows are eligible for NPIs. If they do not transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are not “covered” health care providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs. If they do, however, they would be covered health care providers and they must get NPIs.• A Healthcare Provider Taxonomy Code for classifying medical students, and interns and residents who are not yet licensed (based on state licensing requirements), is available for use: Student, Health Care (390200000X). The code is defined as follows: An individual who is enrolled in an organized health care education/training program leading to a degree, certification registration, and/or licensure to provide health care. Medical students, interns, and residents who are not licensed should select the Student, Health Care code when applying for NPIs.• Once licensed as an allopathic or osteopathic physician, the physician should update his/her data in the National Plan and Provider Enumeration System (NPPES) by submitting a change in the Healthcare Provider Taxonomy Code to reflect the change in status from medical student to physician. (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change).• If physicians who have been assigned NPIs become board-certified in other specialties or subspecialties, the physicians should update his/her data in the NPPES with these changes or additions in their specializations (i.e., they would indicate the changes or additions by changing their Healthcare Provider Taxonomy Codes). (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change.)
(FAQ1947)
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Are payments provided to a consulting firm or third party, whom in turn provide the payment (in whole or pa...- Yes, Open Payments requires reporting of both direct and indirect payments and other transfers of value provided by an a... (more)
- Yes, Open Payments requires reporting of both direct and indirect payments and other transfers of value provided by an applicable manufacturer or applicable group purchasing organization to a covered recipient. An indirect payment is a payment or transfer of value made by an applicable manufacturer, or an applicable group purchasing organization, to a covered recipient, or a physician owner or investor, through a third party, where the applicable manufacturer, or applicable group purchasing organization, requires, instructs, directs, or otherwise causes the third party to provide the payment or transfer of value, in whole or in part, to a covered recipient(s), or a physician owner or investor. Key words: Open Payments, Sunshine Act
(FAQ8155)
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The billing provider on a claim is an eligible professional (EP) but the performing provider type is not an...- In establishing an encounter for purposes of patient volume, please see the regulations at 495.306(e)(2)(i)-(ii) at 75 F... (more)
- In establishing an encounter for purposes of patient volume, please see the regulations at 495.306(e)(2)(i)-(ii) at 75 FR 44579. Furthermore, in estimating patient volume for any EP or hospital, we do not specify any requirements around billing, but rather we discuss patients. For example, if a physician’s assistant (PA) provides services, but they are billed through the supervising physician, it seems reasonable that a State has the discretion to consider the patient as part of the patient volume for both professionals. However, this policy would need to be applied consistently. In this scenario, using services provided by the PA but billed under the physician in the physician’s numerator (e.g., Medicaid encounters) also would increase the physician’s denominator (all encounters), because the State would need to adequately reflect the total universe of patients (both Medicaid and non-Medicaid) who the PA saw, but for whom the physician billed.In terms of meaningful use, because each eligible professional must demonstrate meaningful use of certified EHR technology him or herself, if the State cannot not distinguish between the physician’s claims and the PA’s individual claims, then this would not be an adequate audit methodology. To view the final rule, please visit: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10098
(FAQ2817)
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When reporting on the Summary of Care objective in the Electronic Health Records (EHR) Incentive Program, w...- A transition of care is defined as the movement of a patient from one setting of care (hospital, ambulatory, primary car... (more)
- A transition of care is defined as the movement of a patient from one setting of care (hospital, ambulatory, primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. To count toward the Summary of Care objective for providers sharing access to an EHR, the transition or referral may take place between providers with different billing identities such as a different National Provider Identifier (NPI) or hospital CMS Certification Number (CCN).For Measure 1 of the Summary of Care objective, include the transitions of care in which a summary of care document was provided to the recipient of the transition or referral by any means. For Measure 2 of the Summary of Care objective, include the transitions of care in which a summary of care document was transmitted electronically using a Certified EHR Technology (CEHRT) to the recipient, or via exchange facilitated by an organization that is an eHealth Exchange participant, or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. If the receiving provider already has access to the CEHRT of the initiating provider of the transition or referral, simply accessing the patient's health information does not count toward meeting this objective. However, if the initiating provider also sends a summary of care document, this transition can be included in the denominator and the numerator as long as it is counted consistently across the organization and across both measures If: For Measure 1, a summary of care document is also provided by any means. For Measure 2, a summary of care document is provided using the same technical standards used if the receiving provider did not have access to the CEHRT, To meet Measure 3 of the Summary of Care objective, providers may send a single summary of care document to a provider using a different EHR and EHR Vendor as part of the 10% threshold for measure #2, or, if providers do not exchange summary of care documents with recipients using a different CEHRT in common practice, they may retain documentation on their circumstances and attest "Yes" to meeting measure #3 if they have and are using a certified EHR which meets the standards required to send a CCDA (170.202) Added on 2/10/2014
Updated 4/10/2014
Updated 9/30/2015
(FAQ9690)
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When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Heal...- If a staff member of the eligible provider is appropriately credentialed and performs similar assistive services as a me... (more)
- If a staff member of the eligible provider is appropriately credentialed and performs similar assistive services as a medical assistant but carries a more specific title due to either specialization of their duties or to the specialty of the medical professional they assist, he or she can use the CPOE function of CEHRT and have it count towards the measure. This determination must be made by the eligible provider based on individual workflow and the duties performed by the staff member in question. Whether a staff member carries the title of medical assistant or another job title, he or she must be credentialed to perform the medical assistant services by an organization other than the employing organization. Also, each provider must evaluate his or her own ordering workflow, including the use of CPOE, to ensure compliance with all applicable federal, state, and local law and professional guidelines.
Created: 08/20/2013
(FAQ9058)
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Starting with 2016 Open Payments data collection and reporting to CMS in 2017, are payments provided by an ...- Yes, the payment is reportable if the applicable manufacturer determines that the payment meets the definition of an ind... (more)
- Yes, the payment is reportable if the applicable manufacturer determines that the payment meets the definition of an indirect payment, and the applicable manufacturer knows or can determine the identity of the covered recipient by the end of the second quarter of the following reporting year. An indirect payment is defined at 42 C.F.R. §403.902 as a payment or other transfer of value made by an applicable manufacturer to a covered recipient through a third party, where the applicable manufacturer requires, instructs, directs, or otherwise causes the third party to provide the payment or transfer of value, in whole or in part, to a covered recipient. In accordance with 42 C.F.R. §403.904(i)(1), indirect payments or other transfers of value do not have to be reported if the applicable manufacturer is unaware of the identity of the covered recipient during the reporting year or by the end of the second quarter of the following reporting year. Keywords: Open Payments, Sunshine Act, CME, Physician Fee Schedule
(FAQ11638)
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Is the physician the only person who can enter information in the electronic health record (EHR) in order t...- The Stage 3 Final Rule for the Medicare and Medicaid EHR incentive programs specifies that in order to meet the meaningf... (more)
- The Stage 3 Final Rule for the Medicare and Medicaid EHR incentive programs specifies that in order to meet the meaningful use objective for computerized provider order entry (CPOE), any licensed health care provider or a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant can enter orders in the medical record, per state, local and professional guidelines. The remaining meaningful use objectives do not specify any requirement for who must enter information.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10071
Date Updated: 05/12/2016
(FAQ2771)
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Who is eligible to receive an NPI?- The National Provider Identifier (NPI) was adopted and became effective May 23, 2007 as the standard unique health ident... (more)
- The National Provider Identifier (NPI) was adopted and became effective May 23, 2007 as the standard unique health identifier for health care providers to carry out a requirement in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for the adoption of such a standard. An entity who meets the definition of a “health care provider” – that is, any provider of medical or other health services, and any other person or organization that furnishes, bills, or is paid for health care in the normal course of business – is eligible to receive a provider ID, or NPI. Under HIPAA, a covered health care provider is any provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted. These covered health care providers must obtain an NPI and use this number in all HIPAA transactions, in accordance with the instructions in the adopted Implementation Guides/TR3 Reports. The NPI may also be used on paper claims, but HIPAA does not govern that method of submitting claims.
In general, health care providers include hospitals, nursing homes, ambulatory care facilities, durable medical equipment suppliers, clinical laboratories, pharmacies, and many other “institutional” type providers; physicians, dentists, psychologists, pharmacists, nurses, chiropractors and many other health care practitioners and professionals; group practices, health maintenance organizations, and others. For more information and white papers about health care providers, including atypical providers, visit the CMS website at: http://www.cms.hhs.gov/NationalProvIdentStand/.
(FAQ1849)
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If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the healt...- Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of ... (more)
- Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the internet (https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart) or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services' forms page (www.cms.hhs.gov/cmsforms) or may call the NPI Enumerator (1-800-465-3203) and request a form.
(FAQ1859)
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What is HETS and how do I get connected to use this system?- The HIPAA Eligibility Transaction System (HETS) is intended ... (more)
- The HIPAA Eligibility Transaction System (HETS) is intended to allow the release of eligibility data to Medicare providers or their authorized billing agents for the purpose of preparing an accurate Medicare claim, determining beneficiary liability, or determining eligibility for specific services. Such information may not be disclosed to anyone other than the provider, supplier, or beneficiary for whom a claim is filed. The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.The data included in a 271 response file is to be considered true and accurate only at the particular time of the transaction. The HETS 270/271 application provides access to Medicare Beneficiary eligibility data in a real-time environment. In real-time mode, the Trading Partner transmits a 270 request and remains connected while the receiver processes the transaction and returns a 271 response. Providers, Clearinghouses, and/or Third Party Vendors, herein referred to as “Trading Partners”, may initiate a real-time 270 eligibility request to query coverage information from Medicare on patients for whom services are scheduled or have already been delivered.
Please refer to the HETS 'How To Get Connected' page on the cms.gov website for additional information on how to obtain a connection to, and then apply for, HETS access. Please contact the Help Desk if you have any questions. Call: 1-866-324-7315 . You can also email the help desk at [email protected]. This email address is monitored Monday - Friday 7AM - 7PM ET. Emails are typically answered within 24-48 business hours.
(FAQ2151)
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Does CMS require updated physician (or non-physician practitioner) orders for lab, radiology services, or a...- CMS is not requiring the ordering provider to rewrite the or... (more)
- CMS is not requiring the ordering provider to rewrite the original order with the appropriate ICD-10 code for lab, radiology services, or any other services after ICD-10 implementation on October 1, 2015, including Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
Products and services that require a diagnosis code on the order will use ICD-9-CM codes if written prior to October 1, 2015. If the order is for a repetitive service that will continue to be delivered and billed after October 1, 2015, providers have the option to use the General Equivalence Mappings (GEMs) posted on the 2016
ICD-10-CM and GEMs web page to translate the ICD-9-CM codes on the
original order into ICD-10-CM diagnosis codes.
(FAQ12625)
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If an EP, eligible hospital or Critical Access Hospital (CAH) is unable to effectively plan for a reporting...- Yes, if a provider is unable to meet the requirements of meaningful use for an EHR reporting period in 2015 for reasons ... (more)
- Yes, if a provider is unable to meet the requirements of meaningful use for an EHR reporting period in 2015 for reasons related to the timing of the publication of the final rule, a provider may apply for a hardship exception.
For the hardship exception for the 2017 payment adjustment, CMS is required to use the categories defined for a hardship on the CMS website as of December 15, 2015. Through inquiries to CMS, providers have expressed that a primary concern related to the rule timing is in making any system changes, including to calculations or reports, in time to succeed in 2015. Therefore, the sub-category for issues related to the 2015
rulemaking timeline is included under the existing category for extreme and uncontrollable circumstances related to the implementation and use of CEHRT (Section 2.2d).
Providers who experienced an issue with their CEHRT related to the rule timing and any other provider for whom the timing of the rule caused a significant hardship should select sub-category 2.2d on the 2017 hardship exception application.
CMS does not require a provider or group of providers to submit documentation for this or any other hardship category selected and CMS will not be reviewing documentation supporting the application on a case-by-case basis. CMS will review the application to record the category selected and use the identifying information to approve the hardship exception for each provider listed on the application. Providers should retain documentation of their circumstances for their own records, but no such documentation is required for review by CMS.
(FAQ12845)
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How will the 2015 Physician Quality Reporting System (PQRS) payment adjustment apply to providers who do no...- Whether or not an eligible professional (EP) is deemed Medicare participating or... (more)
- Whether or not an eligible professional (EP) is deemed Medicare participating or non-participating (non-par), the PQRS payment adjustment will be applied to the allowed Medicare Physician Fee Schedule (MPFS) rate before the beneficiary co-insurance is assessed and independent of other claim adjustments
If the EP does not participate (non-par) in Medicare (i.e., does not accept Medicare's allowed charges as payment in full for all of his/her Medicare patients), and is subject to a payment adjustment due to his/her failure to meet the reporting criteria established under the PQRS during the 2013 program period, the negative 1.5% 2015 PQRS payment adjustment will be applied after the initial 5% reduction of the allowed MPFS for being a non-participating Medicare provider.
EPs, who choose not to accept assignment, may not charge the beneficiary more than the Medicare limiting charge for unassigned claims for Medicare services. Non-par, non-assigned EPs may choose to collect the entire amount up front from the beneficiary at the time of service. The maximum limiting charge is 115% of the MPFS amount. The beneficiary is not responsible for billed amounts in excess of the limiting charge for a covered service.
Example 1: Non-par EP is not subject to the PQRS payment adjustment In calendar year 2015, a non-par, non-assigned EP provides a particular service equal to $100.00 based on the 2015 MPFS. First, the 5% reduction is applied for being a non-par. The adjusted MPFS for this service is $95.00. If the non-par EP is not subject to the PQRS payment adjustment, the adjusted and allowed MPFS amount would remain at $95.00. Following are steps for illustration:
STEP 1: Apply Non-par adjustment (less 5%)
- Original amount for service based on 2015 MPFS: $100.00
- Calculate the 5% reduction for non-par status: $100.00 x 0.5 = $5.00
- Reduce the non-par MPFS allowed amount: $100.00 - $5.00 = $95.00
The adjusted non-par MPFS amount ($95.00) would then be used to calculate the non-par limiting charge (up to 115%) for that service. For this example, the maximum non-par limiting charge allowed for the service would be $109.25 as illustrated by the following:
STEP 2: Calculate the limiting charge allowed (up to the 115%)
- Limiting Charge Allowed: $95.00 x 1.15 = $109.25
Example 2: Non-par EP is subject to the PQRS payment adjustment In calendar year 2015, a non-par, non-assigned EP is subject to the PQRS payment adjustment. He/she provides a particular service equal to $100.00 based on the 2015 MPFS. First, the MPFS amount for that particular service is reduced by 5% for being non-par and the resultant adjusted MPFS for this service is now $95.00. Next, the fee is reduced by 1.5% for the PQRS payment adjustment. The following illustrates these steps:
STEP 1: Apply non-par adjustment (less 5%)
- Original MPFS Amount for service based on MPFS: $100.00
- 5% reduction for MPFS because of NON-PAR status: $100.00 x 0.5 = $5.00
- MPFS Allowed Amount: $100.00 - $5.00 = $95.00
STEP 2: Apply negative PQRS adjustment (less 1.5%)
- 1.5% reduction because of PQRS negative payment adjustment: $95.00 x 0.015 = $1.43
- Adjustment Total: $95.00 - $1.43 = $93.57
The negative 1.5% PQRS adjustment will be applied to the adjusted MPFS amount ($95.00). Thus, $93.57 would be the new non-par adjusted MPFS amount for the initial $100.00 service.
STEP 3: Calculate PQRS Limiting Charge (up to 115% of MPFS)
- Limiting Charge Allowed (115%): $93.57 x 1.15 = $107.61
The non-par adjusted MPFS amount ($93.57) would be used when calculating the PQRS limiting charge; which, for this example would be $107.61 for the service.
These examples are for informational purposes only and are not intended to take the place of the Remittance Advice.
Additional information is available in the Medicare Learning Network (MLN) Fact Sheet 8667. If you have any specific questions about how to code a claim for the PQRS payment adjustment, please contact your Medicare Administrative Contractor (MAC) at their toll-free number, which may be found on the CMS Contractor Directory website.
See the 2015 MPFS for a list of reduced limiting charges for those non-par EPs who are subject to the 2015 PQRS payment adjustment.
Please contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via [email protected] for help with questions. The Help Desk is available from 7:00 a.m. to 7:00 p.m. central time Monday through Friday.
(FAQ11986)
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What elements need to be included in the Initial Preventive Physical Exam? - The Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare... (more)
- The Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare” Preventive Visit includes all of the elements as defined in our regulations at 42 CFR 410.16. Additional information regarding the elements included in an IPPE can be found in the CMS MLN Quick Reference Information: The ABCs of Providing the Initial Preventive Physical Exam chart.
(FAQ7507)
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Where can I find more information on the Health Risk Assessment for the Annual Wellness Visit?- The Centers for Disease Control and Prevention (CDC) developed an evidence-informed framework docume... (more)
- The Centers for Disease Control and Prevention (CDC) developed an evidence-informed framework document for health risk assessments, A Framework for Patient-Centered Health Risk Assessments: Providing Health Promotion and Disease Prevention Services to Medicare Beneficiaries. This framework includes sections on successful implementation of the HRA, use of HRAs, and follow-up interventions that evidence suggests can influence health behaviors, defining the HRA framework and rationale for its use, history of health risk assessments, and a suggested set of HRA questions.
(FAQ7521)
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How do I change the laboratory director's name on my CLIA certificate of waiver?- You must notify the appropriate State Agency within 30 days about the change in the name of the director for your CLIA c... (more)
- You must notify the appropriate State Agency within 30 days about the change in the name of the director for your CLIA certificate. State Agency contact information is found on the CMS CLIA internet page at http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf
(FAQ12554)
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For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, how should an eligible pro...- EPs, eligible hospitals, and CAHs can add the numerators and denominators calculated by each certified EHR system in ord... (more)
- EPs, eligible hospitals, and CAHs can add the numerators and denominators calculated by each certified EHR system in order to arrive at an accurate total for the numerator and denominator of the measure.
For objectives that require an action to be taken on behalf of a percentage of "unique patients," EPs, eligible hospitals, and CAHs may also add the numerators and denominators calculated by each certified EHR system in order to arrive at an accurate total for the numerator and denominator of the measure. Previously CMS had advised providers to reconcile information so that they only reported unique patients. However,
because it is not possible for providers to increase their overall percentage
of actions taken by adding numerators and denominators from multiple systems,
we now permit simple addition for all meaningful use objectives.
Please keep in mind that patients whose records are not maintained in certified EHR technology will need to be added to denominators whenever applicable in order to provide accurate numbers.
To report clinical quality measures, EPs who practice in multiple locations that are equipped with certified EHR technology should generate a report from each of those certified EHR systems and then add the numerators, denominators, and exclusions from each generated report in order to arrive at a number that reflects the total data output for patient encounters at those locations. To report clinical quality measures, eligible
hospitals and CAHs that have multiple systems should generate a report from
each of those certified EHR systems and then add the numerators, denominators,
and exclusions from each generated report in order to arrive at a number that
reflects the total data output for patient encounters in the relevant
departments of the eligible hospital or CAH (e.g., inpatient or emergency
department (POS 21 or 23)
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
Keywords: FAQ10843
Updated 5/12/2016
(FAQ3609)
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Who are the current Medicare Administrative Contractors (MACs) for each Jurisdiction?- To find the current MACs and their contact information visit the CMS.gov website at: ... (more)
- To find the current MACs and their contact information visit the CMS.gov website at: Who are the MACs.
(FAQ14833)
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For Objective 1: Protect Patient Health Information (ePHI), can the security risk analysis or review take p...- Yes, it is acceptable for the security risk analysis to be conducted outside the EHR reporting period; however, the anal... (more)
- Yes, it is acceptable for the security risk analysis to be conducted outside the EHR reporting period; however, the analysis must be conducted for the certified EHR technology used during the EHR reporting period and the analysis or review must be conducted on an annual basis. In other words, the provider must conduct a unique analysis or review applicable for the EHR reporting period and the scope of the analysis or review must include the full EHR reporting period. The analysis or review for the EHR reporting period must be conducted prior to the date of attestation.
Created 12/11/2015
(FAQ13649)
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Do I have to submit an Electronic Funds Transfer Authorization Agreement (EFT) (Form CMS- 588) with the rev...- All providers/suppliers are required to submit a new Form CMS-588 with their initial enrollment... (more)
- All providers/suppliers are required to submit a new Form CMS-588 with their initial enrollment and their revalidation application. Excluded from this requirement are individual providers reassigning all benefits to a group. Providers/suppliers must include with their Form CMS-588 confirmation of account information on bank letterhead or a voided check. Documentation must contain the name on the account, electronic routing transit number, account number and account type (i.e., checking or savings). The account name to which EFT payments are made must be the legal name of the business as reported to the Internal Revenue Service (IRS).
(FAQ3709)
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Do specialty providers have to meet all of the meaningful use objectives for the Medicare and Medicaid EHR ...- There are ten objectives for EPs, and nine objectives for eligible hospitals and CAHs. These objectives are required for... (more)
- There are ten objectives for EPs, and nine objectives for eligible hospitals and CAHs. These objectives are required for all providers for an EHR reporting period beginning in 2017. Objectives and measures that do not have exclusion criteria or alternate exclusions and specifications must be met by the provider.
However, certain objectives do provide exclusions. If an EP meets the criteria for that exclusion, then the EP can claim that exclusion during attestation. However, if an exclusion is not provided or if the EP does not meet the criteria for an existing exclusion,
then the EP must meet the measure of the objective in order to successfully
demonstrate meaningful use and receive an EHR incentive payment. Failure to
meet the measure of an objective or to qualify for an exclusion for the
objective will prevent a provider from successfully demonstrating meaningful
use and receiving an incentive payment.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
Keywords: FAQ10469
Updated 5/12/2016
(FAQ3069)
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How is hospital-based status determined for eligible professionals in the Medicare and Medicaid Electronic ...- A hospital-based eligible professional (EP) is defined as an EP who furnishes 90% or more of their covered professional ... (more)
- A hospital-based eligible professional (EP) is defined as an EP who furnishes 90% or more of their covered professional services in either the inpatient (Place of Service 21) or emergency department (Place of Service 23) of a hospital. Covered professional services are physician fee schedule (PFS) services paid under Section 1848 of the Social Security Act. CMS uses PFS data from the Federal fiscal year immediately preceding the calendar year for which the EHR incentive payment is made (that is, the "payment year") to determine what percentage of covered professional services occurred in either the inpatient (Place of Service 21) or emergency department (Place of Service 23) of a hospital. The percentage determination is made based on total number of Medicare allowed services for which the EP was reimbursed, with each unit of a CPT billing code counting as a single service. States will use claims and/or encounter data (or equivalent data sources at the State's option) to make this determination for Medicaid. States may use data from either the prior fiscal or calendar year. EPs can learn whether or not they are considered hospital based for the Medicare EHR Incentive Program by registering now for the Medicare EHR Incentive Program. For the Medicaid EHR Incentive Program, EPs should contact their states for more information. For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
Keywords: FAQ10464
(FAQ3061)
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How will an eligible professional (EP) know when (s)he has reported on all 20 unique patients for measures ...- The EP will need to pay close attention to PQRS measures group patient sample criteria, and rep... (more)
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The EP will need to pay close attention to PQRS measures group patient sample criteria, and report on at least 20 unique Medicare Part B Fee-for-service (FFS) patients to whom the measures group applies (when reporting via registry, a minimum of 11 eligible patients must be Medicare Part B FFS). Immediate feedback as to whether the EP has accurately identified and reported all 20 required unique patients is not available. The EP can check the Remittance Advice to ensure that quality-data codes (QDCs) reported were processed and denied as indicated by remark code N365 on the Explanation of Benefits or “EOB” when reporting via claims. CMS also recommends reporting on more than 20 patients, in case there are issues that may lead to exclusions from the 20 patient sample.
The N365 denial code is just an indicator that the QDC codes were recognized by the carrier/MAC as being part of the PQRS program. It does not guarantee the QDC is valid for the measure or that incentive quotas were met.
For additional questions, please contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via email to [email protected]. They are available from 7:00 a.m. to 7:00 p.m. Central Time Monday through Friday.
(FAQ2475)
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When eligible professionals work at more than one clinical site of practice, are they required to use data ...- CMS considers these two separate, but related issues. Meaningful use: Any eligible professional demonstrating meaningful... (more)
- CMS considers these two separate, but related issues. Meaningful use: Any eligible professional demonstrating meaningful use must have at least 50% of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives. Therefore, States should collect information on meaningful users' practice locations in order to validate this requirement in an audit. Patient volume ;Eligible professionals may choose one (or more) clinical sites of practice in order to calculate their patient volume. This calculation does not need to be across all of an eligible professional's sites of practice. However, at least one of the locations where the eligible professional is adopting or meaningfully using certified EHR technology should be included in the patient volume. In other words, if an eligible professional practices in two locations, one with certified EHR technology and one without, the eligible professional should include the patient volume at least at the site that includes the certified EHR technology. When making an individual patient volume calculation (i.e., not using the group/clinic proxy option), a professional may calculate across all practice sites, or just at the one site. For more information on applying the group/clinic proxy option, see FAQ #10362 or http://questions.cms.hhs.gov/app/answers/detail/a_id/10362/kw/group%20practice/session/For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10416
(FAQ3015)
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PQRS Measure #145: Radiology: Exposure Time Reported for Procedures Using Fluoroscopy, does the final repor...- For 2016 PQRS, the final report would need to include radiation exposure indices... (more)
- For 2016 PQRS, the final report would need to include radiation exposure indices, or exposure time AND number of fluorographic images in order to meet performance for Measure #145. The Numerator Statement found with the measure: Final reports for procedures using fluoroscopy that include radiation exposure indices or exposure time and number of fluorographic images (if radiation exposure indices are not available) correctly describes what should be reported. It is appropriate to report G9500 if the final report either contains radiation exposure indices or exposure time AND number of fluorographic images.
Additionally, the definition for image count includes only images that require additional exposure to ionizing radiation, not those that are captured electronically from the imaging chain without additional exposure.
Please contact the QualityNet Help Desk at 1-866-288-8912 or via e-mail at [email protected] should you have additional questions regarding this topic.
(FAQ14769)
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For the Medicare and Medicaid EHR Incentive Programs, how does an eligible professional (EP) determine whet...- All cases where the EP and the patient have an actual physical encounter with the patient in which they render any servi... (more)
- All cases where the EP and the patient have an actual physical encounter with the patient in which they render any service to the patient should be included in the denominator as seen by the EP. Also a patient seen through telemedicine would still count as a patient "seen by the EP." However, in cases where the EP and the patient do not have an actual physical or telemedicine encounter, but the EP renders a minimal consultative service for the patient (like reading an EKG), the EP may choose whether to include the patient in the denominator as "seen by the EP" provided the choice is consistent for the entire EHR reporting period and for all relevant meaningful use measures. For example, a cardiologist may choose to exclude patients for whom they provide a one-time reading of an EKG sent to them from another provider, but include more involved consultative services as long as the policy is consistent for the entire EHR reporting period and for all meaningful use measures that include patients "seen by the EP." EPs who never have a physical or telemedicine interaction with patients must adopt a policy that classifies as least some of the services they render for patients as "seen by the EP" and this policy must be consistent for the entire EHR reporting period and across meaningful use measures that involve patients "seen by the EP" -- otherwise, these EPs would not be able to satisfy meaningful use, as they would have denominators of zero for some measures.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
Keywords: FAQ10664
(FAQ3307)
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For the Physician Quality Reporting System (PQRS) program, how is Measure #110, (NQF 0041): Preventive Care...- There are two quality actions that will meet performance for Measure #110 Preventive Care and Screening: Influenza Immun... (more)
- There are two quality actions that will meet performance for Measure #110 Preventive Care and Screening: Influenza Immunization. The first quality action is actual administration of the vaccine. The other quality action is documentation that the immunization had been delivered during the current immunization season, therefore, if the Eligible Professional documents the immunization was administered by another provider the quality action for the numerator has been met. For PQRS program years 2015 and 2016, the influenza immunization should be reported once for visits during January 1 through March 31 and reported once for visits October 1 through December 31 (of the current reporting period) for the prior year flu season and current year flu season. For example, if a patient is seen in February and received his or her flu shot in November of the prior year, the eligible professional would report G8482. If the same patient returns in October, within the same reporting period, and receives a flu shot for the current season, the eligible professional would again report G8482.
If it is determined that a patient received the influenza immunization by another provider (between August 1 through March 31), it is appropriate to report G8482. In circumstances where the patient has been given an order to receive the flu shot for the current season or the vaccination was not currently available, the eligible professional should report G8483: Influenza Immunization not Administered for Documented Reasons.
Please contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via e-mail at [email protected] should you have questions regarding this topic.
(FAQ12260)
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Can hospitals bill Medicare for the lowest level ER visit for patients who check into the ER and are "triag...- No. The limited service provided to such... (more)
- No. The limited service provided to such patients is not within a Medicare benefit category because it is not provided incident to a physician's service. Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician's service and under the order of a physician or other practitioner practicing within the extent of the Act, the Code of Federal Regulations, and State law. Therapeutic services provided by a nurse in response to a standing order do not satisfy this requirement.
(FAQ2297)
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How does CMS interpret zero percent (0%) performance rates for a measure with multiple performance rates?- For any PQRS program year, if specified within the meas... (more)
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For any PQRS program year, if specified within the measure, CMS will utilize the performance rate that indicates an overall percentage of performance for the measure to determine if the eligible professional (EP) or group practice has a zero percent (0%) performance rate. For measures that do not specify an overall rate, CMS will calculate an overall performance rate for the measure based on the data submitted.
If a zero (0) percent performance rate exists within the overall percentage of the measure, the EP or group practice will fail the measure. For measures where a lower rate indicates better performance, a 0% overall performance rate will be counted as satisfactorily reporting but a 100% overall performance rate will fail the measure.
Please contact the QualityNet Help Desk at 1-866-288-8912 or via e-mail at [email protected] should you have additional questions regarding this topic.
(FAQ11944)
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