Meaningful Use Attestation and Audit Preparation


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Preparing for Attestation

February 28, 2014 is the last day to register and attest for Meaningful Use for the 2013 year. Here are some tips Practice Fusion users should keep in mind:

1) Confirm that you signed all SOAP notes for all patients seen during your reporting period.

a. Keep in mind that the MU Dashboard updates each night – so any updates you make to your signed SOAP notes will not be  reflected until the following day

2) Confirm that you have achieved Meaningful Use by successfully achieving 13 Core and 5 Menu measures, unless you qualify for exclusions.

3) Take a screen shot or print out the following items in Practice Fusion on the day that you complete the CMS attestation module. Save a dated copy of these screen shots or print outs in your records.

a. Meaningful Use Dashboard

b. ONC Stage 1 – CQM Report

4) Collect documentation that proves your electronic information exchanges, including clinical information exchange, immunization information exchange, and/or syndromic surveillance information exchange. For example, this could be email or other written confirmation of the exchange from the receiving party. Remember that you need to save this confirmation even if the exchange was unsuccessful.

5) Reference the Security risk analysis to complete the Security Audit core measure requirement.

6) Print or save dated documentation records of your lab orders and patient reminders from your reporting period, if applicable.

7) Note which measures for which you will claim an exclusion, if applicable. For information on what the applicable exclusions are for each measure, click here. Prepare any documentation needed to prove that you qualify for that exclusion and save it in your records.

8) If you are claiming an exclusion to either of the public health measures – immunization exchange or syndromic surveillance exchange – be prepared with documentation that you are excluded from both measures, even though you will only claim an exclusion for one.

  • You must select one public health menu measure during attestation, even if you are claiming an exclusion.
  • Remember: you should not claim an exclusion if you attempted to exchange the information, but failed.  A failed attempt to exchange information counts as completing the measure successfully, and you should attest YES to whichever measure you select.

Tips for Completing the CMS Attestation Module

When you are ready to complete the CMS attestation module, go to www.practicefusion.com/attest for links to the CMS system. Review the CMS Attestation Guide and the Practice Fusion Attestation Checklist which contain step-by-step instructions on how to complete the module. Plan to spend 20-40 minutes completing your attestation module.

Keep in the mind the following tips while you are completing the module:

1) You will need your NPPES ID and Password to access the CMS attestation module.

2) Gather the following documents, making sure to save or print a version on the day you complete the CMS attestation module:

a.  Meaningful Use Dashboard

b. CQM Report

3) When prompted to select whether a measure contains all patient records or patient records maintained in the EHR, select the second bullet

Source: CMS Attestation Guide

 

Attestation Tips for the Clinical Quality Measures

1) You must report your CQM values exactly as they appear in the EHR. You are not required to meet all of the CQM thresholds to achieve Meaningful Use (“0” values are acceptable when attesting if that is what appears in your EHR)

2) Exclusions are factored into the calculation and should be reported as “0” during attestation

3) Report on 3 Core and 3 Additional CQMs (you must choose CQMs 55, 56, 61) whether or not they relate to your specialty

a. Additional CQM values are located in the ONC Stage 1 CQM Report under the “Alternate CQM Items” heading. When in the CMS attestation module, you may need to scroll down to find these measures as they are not  listed in numerical order.

4) You must report an Alternate Core CQM for each of your Core CQMs with a “0” denominator value.

5) When prompted to select whether or not you want to participate in the PQRS-Medicare EHR Incentive Pilot, select no, because Practice Fusion is not participating in the pilot.

Source: CMS Attestation Guide

 

Already Attested for 2012? It’s not too late to be prepared!

If you have already completed your attestation for 2012, you can still gather all of the materials listed under Preparing for Attestation. Saving these materials in your record will be useful in the case of an audit.

Please keep in mind that these tips are provided for informational and educational purposes only, and are not intended to provide regulatory or legal advice and should not be relied upon in that regard.  Your practice is unique and therefore you should independently review the regulatory requirements and consult appropriate counsel.

 

Emily Richmond

Emily Richmond, MPH currently serves as Senior Manager, Health Care Quality at Practice Fusion. Read all posts by Emily Richmond

  • robin blamer

    if we already receieved the first 18,000.00-which was done in 2011. Now 2012
    was the first full year using the ehr system–do we need to report anything for 2012 for
    the next payment to be made.

    • Naushad_PF

      Yes, you must attest to Meaningful Use each year to earn that year’s incentive. If you completed your second year of Meaningful Use in 2012, you must attest to a full year reporting period by February 28, 2013. To learn more about how much you can earn each year, view this page: http://www.practicefusion.com/pages/ehr-meaningful-use-criteria.html#how-much-can-i-make

      • anat benjamin

        I completed my first year 90 days in 2011 and I thought I could not attest for the full year until 2013. Is that correct !

        • Emily R_PF Staff

          If you completed your 90-day reporting period in 2011 then your second year of Meaningful Use (with a full year reporting period) would be from January 1, 2012-December 31, 2012. You would not be able to attest until after the reporting period is completed (meaning you would attest some time between January 1, 2013 and February 28, 2013), but your data would be from actions completed in 2012.

        • Naushad_PF

          If you completed 90 days of Meaningful Use in 2011, you would need to have completed a full year of Meaningful Use in 2012 to earn that year’s incentive. That means the attestation window is from Jan 1 – Feb 28th 2013, to attest to a full year of Meaningful Use in 2012.

      • Bradleydanielelliot

        The complete records of patients get easier for any one who get appointed from any clinical data.

  • STol

    How many times can you resubmit?after a rejection

    • Naushad_PF

      You can resubmit an attestation only for a 90 day reporting period, and the start date must be different than the start date you originally attested to. You could technically resubmit the attestation for any start date from January 1 – Oct 3 (275 days) assuming that you were using the EHR during that time frame. You can read more about this topic here: http://www.practicefusion.com/emr-forum/CommentIndex.EHR/9319.

  • Kate Basile

    If we completed our 90 day attestation in 2012 and received our check, do we need to register again to attest for the full year reporting period in 2013? I went to the NPPES site and they said I was not registered???

    • Naushad_PF

      You only need to register once for Meaningful Use unless you switch programs (Medicare or Medicaid) or switch EHR vendors (you’ll enter a new certification number). You will attest each year to Meaningful Use after completing your reporting period.

      If you are having difficulties logging in with your NPPES credentials, please call the PECOS Help Desk at
      1-866-484-8049

    • Naushad_PF

      You will not need to register again unless you switch vendors or practices. You can check your registration status by logging into the CMS Registration and Attestation portal: https://ehrincentives.coms.gov

  • S Abdo

    Thank you PracticeFusion (& Lisa) you are awesome.

  • AnilaKhan

    I attesested for 90 day period in 2012 in MAY now since I am in 2013 do I have to wait till MAy or does the Feb 28 deadline applies to me and I have to re attest within the deadline If yes do I need any other criteria since my meaningful DB says all criteria met

    • Emily R_PF Staff

      The February 28, 2103 deadline is for submitting 2012 attestations (providers completing a full year of meaningful use in 2012 could not begin attesting until after December 31, 2012. For your second year of meaningful use you will have a full year reporting period from January 1, 2013 through December 31, 2013.

  • Dennis Blondo

    If I decide to use another ehr how do I attest using practice fusion part of the year and another ehr for the rest of the year. I am working toward stage 2 full year.

  • Yolanda

    Hello – what is the penalty for not having this system up and running?

    • Emily R_PF Staff

      Medicare providers who do not successfully show meaningful use of a certified EHR by October 1, 2014 will be subject to payment adjustments beginning in 2015. Providers who wait to begin their participating in the CMS EHR Incentive Program (Meaningful Use) until 2014 will have to complete their 90-day reporting period prior to October 1, 2014. The penalty starts off at 1% of annual Medicare payments in 2015, and goes up to 5% in 2020.

  • Yolanda

    Hello – We have 3 doctors, all with different tax id’s, how can I set up the system for each so that each get their incentives?

    • Emily R_PF Staff

      Providers must individually attest to Meaningful Use, so each provider should have their own unique log-in to Practice Fusion. Each provider will have their own Meaningful Use Dashboard that shows results from patients seen by that provider during the reporting period.

  • Marjan

    Do I have to register with The CMS first and then sign up for the 90 days?

  • llbean1372

    In our practice NP/PAs sees the majority of the patients under physician oversight. The physician does not actually sign the charts, if we are going for the medicare incentive, how does this work?

    • Naushad_PF

      The eligible provider who is achieving Meaningful Use can decide whether or not to include patients seen by the staff in his/her calculations. However, you must remain consistent throughout the entire reporting period. To learn more about this topic, see the CMS FAQ: https://questions.cms.gov/faq.php?id=5005&faqId=3309

  • Deegan Family Practice

    If I have opened my own company as of June 2012, but I was claimed by my previous employer for EMR monies for 2011, do I attest for the first year or for the second year now?

    • Emily R_PF Staff

      Meaningful Use attestation is completed at the provider level. If you are an eligible professional and have not personally registered and completed attestation for the EHR Incentive Program, then you will begin your first year of meaningful use in 2013 with a 90-day reporting period. For information on registering for the EHR Incentive Program, go here: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/RegistrationandAttestation.html

      • InternalMedicineCFO

        I think your answer is misleading….if a previous employer attested on behalf of an individual physician, they have completed their first year of attestation.

        • Emily R_PF Staff

          Hello. Even if a previous employer attested on behalf of an individual provider, that individual EP will have “attested” individually for the purposes of how CMS determines program year because attestation values are based on individual performance. Providers who are unsure about whether they or a previous employer have attested on their behalf should reach out to CMS to determine their MU status.

          • ALD Consulting

            It should be the second year, because the attestation and incentive payments are by individual provider, independently of who received the check.

  • PT

    I am just starting EMR. Do I still have to register by Feb 28 2013 for 2012 or on. Previously, All i have are paper charts. I do have all patient soap notes on computer for last 4 years. Does that qualify as meaningful use.

    • Emily R_PF Staff

      If you are just starting your use of an EHR in 2013, you will complete your 90-day reporting period for your first year of meaningful use sometime in 2013. You will need to register with CMS prior to the end of your reporting period. You can select any day to begin your 90-day reporting period in your Practice Fusion meaningful use Dashboard. There are many requirements to complete meaningful use; having charts on a computer does not suffice. For more information on meaningful use and the EHR incentive program, go to the Practice Fusion Meaningful Use Resource Center at http://www.practicefusion.com/meaningfuluse

  • notsure

    How long does it take for the state (medicaid) to approve our application. what happens after that?

    • Naushad_PF

      Each state Medicaid program is different, but it usually takes 2-3 months to receive payment for AIU or Meaningful Use. I recommend contacting your state EHR Incentive Program to find out more information: http://www.cms.gov/apps/files/statecontacts.pdf

  • http://twitter.com/eDocSecure John Hughes

    Do you know if a
    practice can take an exclusion for the core measure Clinical Summary?

    • Naushad_PF

      You can only claim an exclusion to the clinical summaries measure (Core 13) if the provider has no office visits during the reporting period. According to CMS, office visits include separate, billable encounters that result from evaluation and management services provided to the patient and include: (1) Concurrent care or transfer of care visits, (2) Consultant visits, or (3) Prolonged Physician Service without Direct (Face-To-Face) Patient Contact (tele-health). A consultant visit occurs when a provider is asked to render an expert opinion/service for a specific condition or problem by a referring provider.

  • tim baessler

    we are attesting for the second time for 2012 as we successfully attested for 2011. how long does it usually take to get payment?

    • Naushad_PF

      It usually takes 2 months for the payment to process.

  • meredith english

    I don’t qualify for a tax cut, do I have to still do the attestation? Does the government requires it?

    • Emily R_PF Staff

      Meaningful use of an EHR will be required in 2014, so providers who have not successfully attested prior to October 1, 2014 (for reporting periods that are in 2013 or prior) will be subject to penalties against their Medicare reimbursements.

  • tim baessler

    if it has been two months since attesting and have still not received a check, what is the next step?

    • Naushad_PF

      You can log into to the CMS Registration and Attestation system to check the status of your payment for more information: https://ehrincentives.cms.gov/. You can also call the EHR Incentive program hotline: (888) 734 – 6433

  • LG MD

    I have a question regarding the Feb 28 deadline. We have started using Practicefusion in 2011, however we have been using it mainly to send eScripts. We haven’t been completely using to do patients Charts in 2012, though we used it at a primitive level. we have completely adopted to using EHR completely starting jan 1, 2013. (we have decided that we were not going to attest for the year of 2012). Do we still have to attest for the 2012 period? Hope i was able to explain our situation clearly, Answers are highly appreciated. thank you

    • Naushad_PF

      Since you did not achieve Meaningful Use in 2012, you cannot attest and the February 28th deadline does not apply to you this year. Since you have completely adopted Practice Fusion this year, you can definitely attempt to earn incentives beginning in 2013! Visit http://www.practicefusion.com/meaningfuluse to learn more.

  • Kimberly Smith

    If you attested in 2011 but forgot to turn data in for 2012 can you still turn in a full year of 2013 by February 28, 2014 and receive the 2nd year payment check? Or 3rd year or none.

    • tomyr95

      Did you ever get your answer? I’m interested in this question too.

    • Naushad_PF

      Hi Kimberly and Tomyr95: If you forgot to attest for 2012, it is too late at this point and you will lose out on the 2012 incentive. You can, however, achieve a full year of Meaningful in 2013 and attest for your 3rd year incentive, which would be $8,000 for Medicare. See this page for information on payout timelines: http://www.practicefusion.com/pages/ehr-meaningful-use-criteria.html

      It is extremely important that you continue Meaningful Use in 2013 to avoid a Medicare penalty in 2015.

  • tom

    does the staff have to be certified to work with her to meet the criteria

    • Naushad_PF

      Staff who are working in the office are able to help the provider meet the criteria. For example, a nurse could assist by entering in vital signs, or the office manager can enroll patients in the PHR. In order to do so, each individual in the practice would need to have a username and could complete actions that their permission level allows (click on the gear icon in the upper right corner of the EHR to adjust the settings). The provider’s staff would not be able to e-prescribe, for example.

  • Emily

    I have docs that just completed their 90 day reporting period for Stage 1 in 2013. When is my deadline to attest for them? Feb. 28, 2014 or is is 60 days after the reporting period ends?

    • Naushad_PF

      February 28, 2014 is the deadline to attest for the 2013 program year, regardless of your 90 day reporting window.

  • Michele

    How many screenshots are required to upload for documentation of the core measures etc

    • Naushad_PF

      You should either print out or take a screen shot of the Meaningful Dashboard & ONC Stage 1 – CQM Report on the day that you attest for your own records and maintain the documentation for 6 years. There is no requirement for uploading documentation when you attest.

  • Samantha

    If a provider changes practices (Tax ID number) can they still continue to attest?

    • Naushad_PF

      You can still attest if you change practices. You can update your Tax ID number in the CMS Registration and Attestation System, under the “Registration” tab: https://ehrincentives.cms.gov/

  • Paul

    For the public health measures, our county cannot accept syndromic information, but our state can accept immunization data. I had planned on using a letter from the county to document the exclusion, but do I have to do the immunization report instead (this is less relevant to my practice)? That is what it seems like looking at the above summary,

    • Naushad_PF

      Hi Paul, that is a great question. You should report on the public health measure that you can successfully achieve instead of a measure that you are excluded from. You should keep this consistency throughout the menu set. Make sure to keep documentation of the data exchange with your registry, whether or not it’s successful.

  • Pablo Costas

    Can the 90 day reporting period overlap two continuous calendar years? Is there any benefit in this?

    • Naushad_PF

      Your reporting period for Meaningful Use must be contained within the calendar year.

  • SLOmedicine

    We need clarification on the number of core measures, CMS website states that we need to meet 14 core measures but you have 13 on your website. The PDF for CMS states 15. We are a bit confused.

    • Naushad_PF

      Hi there, you need to attest to 13 core measures for Stage 1 of Meaningful Use for 2013 as well as 2014. There were originally 15 core measures, but in 2013, one of the core measures was removed and “Report Clinical Quality Measures” was removed from the core set into its own category for attestation. To see the list of Stage 1 criteria, visit Practice Fusion’s Meaningful Use center: http://www.practicefusion.com/meaningful-use-criteria-stage-1/