CMS Pub. 100-22, ch. 1, § 70.1.3

Measures for EHR-based Reporting

(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)

Beginning with the 2010 Physician Quality Reporting System, an individual eligible professional

who chooses to report on individual Physician Quality Reporting System quality measures rather

than measures groups has the additional option of reporting on the individual Physician Quality

Reporting System quality measures via a qualified EHR product in lieu of submitting the quality

measures data on claims or via a qualified registry (see §50).

For 2010 and 2011, the criteria for determining whether an eligible professional satisfactorily

reports data on individual Physician Quality Reporting System quality measures for reporting via

an EHR was identical to the criteria for satisfactory reporting of individual Physician Quality

Reporting System quality measures via a qualified registry. However, there was only one

reporting period available for EHR-based reporting of individual measures: the 12-month

30

reporting period beginning January 1st. Consequently, there is only one reporting option for

EHR-based reporting of individual measures for the 2010 and 2011 Physician Quality Reporting

System. To qualify to earn a 2010 and 2011 Physician Quality Reporting System incentive

payment through EHR-based reporting of individual measures, each eligible professional must

meet the following criteria for satisfactory reporting:

• Report at least 3 individual Physician Quality Reporting System measures; and

• Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the

measure applies.

The following changes to the EHR-based reporting option were introduced for the 2012

Physician Quality Reporting System: (1) allowing EHR-based reporting via a qualified direct

EHR product or a qualified EHR data submission vendor, and (2) adding criteria under EHR-based reporting that are identical to the criteria for meeting the clinical quality measure objective

of achieving meaningful use under the Medicare EHR Incentive Program. The reporting options

for satisfactory reporting via the EHR-based reporting mechanism in 2012 are summarized in

Table 5 below.

Table 5: Criteria for Satisfactory Reporting of Individual Measures through EHR

31

Reporting

Mechanism

Reporting Criteria Reporting

Period

Qualified Direct

EHR Product

• Report at least 3 individual Physician Quality

Reporting System EHR measures; and

• Report each measure on at least 80 % of the

Medicare Part B FFS patients to whom the

measure applies.

• Measures within a measures group with a zero

percent performance rate will not be counted.

January 1, 2012

– December 31,

2012

Qualified EHR

Data Submission

Vendor

• Report at least 3 individual Physician Quality

Reporting System EHR measures; and

• Report each measure on at least 80 % of the

Medicare Part B FFS patients to whom the

measure applies.

• Measures within a measures group with a zero

percent performance rate will not be counted.

January 1, 2012

– December 31,

2012

Direct EHR

Technology that

is both

“qualified” for

the Physician

Quality

Reporting

System and

Certified EHR

Technology

• Report on ALL three Medicare EHR Incentive

Program core measures.

• If the denominator for one or more of the

Medicare EHR Incentive Program core

measures is zero, report on up to three Medicare

EHR Incentive Program alternate core

measures; and

• Report on three (of the 38) additional measures

available for the Medicare EHR Incentive

Program.

January 1, 2012

– December 31,

2012

EHR Data

Submission

Vendor

Technology that

is both

“qualified” for

the Physician

Quality

Reporting

System and

Certified EHR

Technology

• Report on ALL three Medicare EHR Incentive

Program core measures.

• If the denominator for one or more of the

Medicare EHR Incentive Program core

measures is zero, report on up to three Medicare

EHR Incentive Program alternate core

measures; and

• Report on three (of the 38) additional measures

available for the Medicare EHR Incentive

Program.

January 1, 2012

– December 31,

2012