[EHR Incentive Programs] If none of the core, alternate core, or additional clinical quality measures adopted for the Medicare and Medicaid Electronic Health Record (EHR) incentive programs apply, am I exempt from reporting on all clinical quality measures?
This FAQ applies to providers who are reporting 2013 CQMs. In the event that none of the 44 clinical quality measures (CQMs) applies to an EP's patient population, the EP is still required to report a zero for the denominators for all six of the core and alternate core CQMs. If all of the remaining 44 CQMs included in Table 6 of our final rule do not apply to the EP, then the EP is still required to report on at least three of the additional CQMs of their choosing from Table 6 of the final rule (other than the six core/alternative core measures). If the EP reports zero values for these three additional, menu-set CQMs, then for the remaining menu-set CQMs, the EP will also have to attest that all the other menu-set quality measures calculated by the certified EHR technology have a value of zero in the denominator. In other words, the EP is required is required to try to find at least three measures in the menu set for which the denominator is other than zero. If s/he cannot, then the EP must still choose three menu-set measures on which to report. S/he may report zero denominators for some or all of these measures, but must accompany such "zero denominator" reporting with an attestation that all of the other menu-set measures calculated by the certified EHR technology have a value of zero in the denominator. A zero report in the menu-set is not sufficient without such accompanying attestation. We refer readers to page 44410 of the preamble to the final rule.