Questions regarding Modified Stage 2 Meaningful Use are generated in the normal course of business. It is important to know where to obtain accurate answers to be compliant with the program. Recently, Centers for Medicare & Medicaid Services (CMS) has changed the system it uses for frequently asked questions (FAQs). To access all of the FAQs about the Electronic Health Record (EHR) Incentive Programs, visit www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/FAQs_2016.pdf. Below is an excerpt of a few of the questions and answers provided on the CMS website for your review.1
FAQ: Under the Medicare and Medicaid EHR Incentive Program, who is responsible for demonstrating meaningful use of certified EHR technology, the provider or the vendor?
CMS Reply: To receive an EHR incentive payment, the provider (eligible professional [EP], eligible hospital, or critical access hospital [CAH]) is responsible for demonstrating meaningful use of certified EHR technology under both the Medicare and Medicaid EHR incentive programs.
FAQ: What is meaningful use, and how does it apply to the Medicare and Medicaid EHR Incentive Programs?
CMS Reply: Under the Health Information Technology for Economic and Clinical Health Act, which was enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), incentive payments are available to EPs, CAHs, and eligible hospitals that successfully demonstrate meaningful use of certified EHR technology. The Recovery Act specifies 3 main components of meaningful use: the use of a certified EHR in a meaningful manner (eg, e-prescribing), the use of certified EHR technology for electronic exchange of health information to improve quality of healthcare, and the use of certified EHR technology to submit clinical quality and other measures. In the final rule on the Medicare and Medicaid EHR Incentive Program, CMS has defined stage 1 of meaningful use. To view the final rule, visit http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf.2
FAQ: If a provider purchases a complete EHR but opts to use alternate certified EHR modules for certain meaningful use functionality, will that provider qualify as a meaningful user under the Medicare and Medicaid EHR Incentive Programs?
CMS Reply: To successfully demonstrate meaningful use, a provider must do 3 things:1. Have certified EHR technology capable of demonstrating meaningful use, through either a complete certified EHR or a combination of certified EHR modules;2. Meet the measures or exclusions for 20 meaningful use objectives (19 objectives for eligible hospitals and CAHs); and3. Meet those measures using the capabilities and standards that were certified to accomplish each objective. If a provider can meet all of these requirements, that provider may qualify for an incentive payment under the Medicare and Medicaid EHR Incentive Programs.
FAQ: When providing the clinical summary as part of an office visit to meet the measure “clinical summaries provided to patients or patient-authorized representatives within 1 business day for more than 50% of office visits” (§ 495.6(j)(11)(ii)), can a provider determine whether to include information that was not changed or addressed during the visit?
CMS Reply: Yes. Most of the elements listed in the regulation have text associated with them that are meant to provide additional context, such as “for or of the office visit,” “current,” “pending,” “during the visit,” “if applicable to the visit,” “recent,” and “future.” Some elements listed do not have these qualifiers because we believed the context was implicit.
Those elements are clinical instructions, laboratory test results, referrals to other providers, demographic information, smoking status, and care plan field(s), including goals and instructions. All of these elements have to be included only if changed because of the visit in question. For example, the laboratory test results included in a clinical summary only need to be those ordered or reviewed during the visit and do not need to be laboratory test results from prior visits or other providers. Similarly, referrals are those made as a result of the visit, and care plans are those pertaining to the visit. Smoking status and demographics are those updated at the visit. A provider is free to include any information that was not updated at the visit just as they are free to include any information not listed in the regulation. To be certified, an EHR must include the ability for the provider to customize the data included in the clinical summary.
Meaningful use drives meaningful documentation coupled with the ability to measure and track the quality of healthcare services provided by EPs and hospitals within our healthcare system. It is important to keep abreast of resources that can accurately answer questions you may have through your documentation timeline. Here’s to compliant documentation!