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Eligible Professionals (EPs): Stage 3 Updates

Meaningful Use (MU) Updates from the PFS Final Rule:

Time Frames:

  • For Program Year 2020, the reporting period will be 90 days for MU and 90-days for eCQMs. 
  • The Attestation Submission Period for Program Year 2020 will be November 1, 2020 through March 31, 2021 (11:59 P.M., Central) IF you are ready. CMS defines “ready” as having completed your annual SRA. If you have yet to complete your SRA, you are required to wait until it is completed.
  • For Program Year 2021, the reporting period will be 90 days for MU and eCQMs. EPs may be attesting to both Program Year 2020 and Program Year 2021 in Calendar Year 2021 if the EP is eligible for both. The Attestation Submission Period for Program Year 2021 will be July 1, 2021 through September 30, 2021 (11:59 P.M., Central).
  • All incentive payments must be paid by December 31, 2021. To accomplish this, cutoff dates will obviously be earlier to allow all processing and strictly adhered to.

MU Measures For Program Years 2020 and 2021:

  • There is a total of 8 objectives for EPs, each of which would have one or more associated measures. 
  • Stage 3 Objective 6 Coordination of Care thresholds for Measure 1, View, Download, & Transmit is 5% and Measure 2, Secure Messaging is 5%, and Measure 3, Patient generated health data is 5% but only 2 of the 3 thresholds must be met.
  • The requirement for Stage 3 Immunization Registry is to be doing bi-directional exchange or moving towards bi-directional exchange with the Immunization Registry. You must have documentation to confirm EP’s bi-directional status with the Immunization Registry. For questions related to bi-directional exchange, contact TennIIS.MU@tn.gov.

Clinical Quality Measures (CQMs) for Program Years 2020 and 2021

  • There are 47 eCQMs aligned with MIPS.
  • EPs may report a consecutive 90-day eCQM reporting period or a full calendar year for 2020, and EPs must report a consecutive 90-day eCQM reporting period for 2021.
  • EPs must attest to at least one eCQM Outcome Measure or one High Priority Measure if there is not an Outcome Measure available or relevant. EPs will continue to report 6 eCQMs relevant to the EP's scope of practice.