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2012-2013 CQMs

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* Core Measure 10 for Payment Year 2012 is unique as it refers to a later part of attestation, the Clinical Quality Measures (CQMs).  For eligible professionals attesting to Stage 1 Meaningful Use for Payment Year 2013 and beyond, this separate affirmation of reporting CQMs will not be required as a core measure. CQMs must nevertheless be reported in every year of meaningful use.

Measure at a Glance

Type: enabled function

Denominator: specific to each CQM

Duration: calculated over the entire reporting period

Objective: Report ambulatory clinical quality measures to CMS.
Measure: Successfully report to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS.
Exclusion: No exclusion.

CMS Technical Specification

CMS Overview of CQMs

TennCare Notes
As the CMS overview shows, there are three core CQMs, three alternate core CQMs, and 38 additional CQMs for the 2012-2013 CQMs. An EP must attest to all three core CQMs. If any of the core CQMs has a denominator of zero, the attester will be presented a screen to attest to the alternate core CQMs.  The provider should attest to an alternate core CQM for each core CQM with a denominator of zero. Following the attestation to core CQMs and alternate core CQMs (if any), the provider will be presented with a screen to select at least three additional CQMs to which to attest.

CQMs are calculated for the EHR reporting period. For an EP’s first year of meaningful use, the reporting period is 90 days; for subsequent years, it is the full calendar year unless the year is 2014. (All reporting periods in 2014, regardless of stage, are 90 days.) This reporting period allows a provider to review his documentation and activities for the same patient population he reported for his core and menu measures. In 2014 and beyond, however, all EPs, regardless of Stage, will instead by reporting on the 2014 CQMs, which have a different structure and reporting mechanism.

All certified EHR technology is certified to calculate all three core CQMs, all three alternate core CQMs, and at least three additional CQMs. Eligible professionals are not required to attest to three additional CQMs that have been individually tested and certified, if indeed their EHR can calculate additional CQMs for which it was not certified, but the Certified Health IT Product List will show which additional CQMs have been certified for each product.  

For Stage 1 Meaningful Use, there are no thresholds associated with CQMs. Numerators of zero are acceptable as long as they are reported as generated by certified EHR technology. Denominators of zero indicate that the patient population described by the measure was not seen by the EP.

For eligible professionals pursuing meaningful use for 2012, attesting to the CQMs through the attestation portal fulfills this measure. The attestation portal will require EPs to affirm that they are meeting the core measure as well as list one CQM to which they are attesting.

Relevant CMS FAQs

  • 10072, 10144, and 10145: attesting to CQMs for which EPs have no data
  • 10142: attesting to a core CQM with a denominator of zero and choosing an alternate core
  • 10075: navigating the alternate core and additional CQMs
  • 10839: attesting to CQMs with incomplete clinical data
  • 10648: selecting measures when certified EHR technology cannot calculate all CQMs
  • 10649: selecting additional CQMs for which the EHR technology is not certified

Additional Resources
TennCare has additional webpages with more information on the individual CQMs for 2012 and 2013:

Federal Regulations Governing CQMs

CMS' Final Rule

§ 495.6(d)(10) see objective, measure and exclusion above

Standards and Certification Final Rule

§ 170.302(j) Calculate and submit clinical quality measures

  1. Calculate
    1. Electronically calculate all of the core clinical measures specified by CMS for eligible professionals.
    2. Electronically calculate, at a minimum, three clinical quality measures specified by CMS for eligible professionals, in addition to those clinical quality measures specified in paragraph (1)(i).
  2. Submission. Enable a user to electronically submit calculated clinical quality measures in accordance with the standard and implementation specifications specified in Sec. 170.205(f).

§ 170.205(f) Quality reporting. Standard. The CMS Physician Quality Reporting Initiative (PQRI) 2009 Registry XML Specification (incorporated by reference in Sec. 170.299). Implementation specifications. Physician Quality Reporting Initiative Measure Specifications Manual for Claims and Registry (incorporated by reference in Sec. 170.299).