The case number threshold exemption for hospital CQM reporting helps reduce the burden placed on hospitals that very seldom have cases that would be counted in the denominator of certain CQMs. Eligible hospitals and critical access hospitals (CAHs) with a low number of inpatient discharges per electronic health records (EHR) reporting period as defined by a CQM's denominator population, could be exempted from reporting on that CQM.
The CQM case number threshold exemption for eligible hospitals and CAHs is available beginning in FY2013 for all stages of meaningful use (MU). The hospital must submit the aggregate population and sample size counts for Medicare and non-Medicare discharges for the EHR reporting period for the CQM(s) for which the hospital seeks an exemption.
To meet the threshold for exemption from reporting a CQM, the following criteria must be met for the corresponding EHR reporting periods: 1st year of demonstrating MU ;90-day EHR reporting period 5 or fewer discharges during the EHR reporting period 2nd year or beyond of demonstrating MU Full year EHR reporting period 20 or fewer discharges during the EHR reporting period In FY 2014, three-month quarter EHR reporting period with 5 or fewer discharges during the EHR reporting period Discharges are defined by the CQM’s denominator population Applies on a CQM by CQM basis
When invoking the case number threshold exemption in FY 2013: All 15 of the CQMs from Stage 1 final rule are required.The number of CQMs required to report is reduced by the number of CQMs for which the hospital does not meet the case number threshold of discharges.
When invoking the case number threshold exemption in FY 2014: 16 CQMs covering at least 3 domains from a list of 29 CQMs are required.The same process as in FY 2013 is employed, but in order to be exempted from reporting fewer than 16 CQMs, the hospital would need to qualify for the case number threshold exemption for more than 13 of the 29 CQMs. If the CQMs for which the hospital can meet the case number threshold of discharges do not cover at least 3 domains, the hospital would be exempt from the requirement to cover the remaining domains.
To view the rules that include this policy for the Medicare and Medicaid EHR Incentive programs, please visit: Stage 2 Final Rule (77 FR 54080): http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf
Interim Final Rule (77 FR 72988 – 72989):
Created on 7/1/2013