Inpatient Prospective Payment System (IPPS) Final Rule for 2018: Summary of Health IT

Inpatient Prospective Payment System (IPPS) Final Rule for 2018: Summary of Health IT Related Requirements for 2017 & 2018

Key Takeaways:

CMS has lowered the number of eCQMs providers must meet from 8 to 4 for 2017 and 2018 (with special alignment rules for Medicaid EPs which are different to better align with clinicians in the Medicare Incentive-based Program (MIPS)).
Providers may use 2014 or 2015 CEHRT in 2018.
Providers may meet Modified Stage 2 or Stage 3 (optional) in 2018. Stage 3 is mandatory starting 2019.

Electronic Clinical Quality Measures (eCQMs) Required under the Medicare Hospital Inpatient Quality Reporting (IQR) Program

Issue / Previously Finalized / Proposed / New Finalized Policy
eCQMs: Number that must be reported / For 2016 reporting (2018 IQR payment determination) hospitals must report 4 eCQMs.
In last year’s rule CMS finalized an increase for 2017 reporting to 8 eCQMs. In April 2017 CMS proposed lowering this requirement to 6 eCQMs / For 2017 and 2018:

CMS lowered eCQMs even further to only requiring 4, maintaining the 2016 amount for two more years.
CMS considers hospitals who have met the eCQM requirements for the Hospital IQR Program will be considered to have successfully reported the eCQM requirements under Meaningful Use, a policy they are continuing.
CMS asserts that, “Our data show that 95 percent of hospitals already attest to successful electronic clinical quality measure reporting under the EHR Incentive Program and, accordingly, we believe the majority of hospitals will be able to successfully report electronic clinical quality measures, meeting the Hospital IQR Program requirements.”
If a hospital can’t meet the IQR eCQM reporting requirements due to extraordinary circumstances, they can consider filing for an ECE. The Hospital IQR Program’s ECE policy is available here and the EHR Incentive Program’s hardship exception policy can be found here.

eCQMs: Required Number of Reporting Quarters / For 2016 reporting, one quarter of reporting was required, from either the third or fourth quarter of 2016. In last year’s rule CMS finalized a full year of reporting (four quarters) for 2017 reporting. In April, they proposed reducing this to any two selected quarters for 2017 and the first three quarters for 2018. / CMS will now only require a single self-selected quarter for reporting in both 2017 and 2018. This is the same as 2016 reporting except that hospitals may choose any calendar quarter for reporting in each of these years.
CEHRT Requirements / For 2017 reporting, 2014 or 2015 CEHRT may be used.
2015 CEHRT required for use in 2018 / For 2017 and 2018:

CMS will continue to allow use of 2014 Edition, 2015 Edition, or combo of both for 2018 reporting.
If EHR technology is not certified to all 15 eCQMs available to report, provider will be required to have its EHR technology certified to all 15 eCQMs that are available to report in the Hospital IQR Program.
Must use most current version of eCQM specifications:
For 2017: This is Spring 2016.
For 2018: This is Spring 2017.
A hospitals’ EHR technology certified to all 15 eCQMs does not need to be recertified each time it is updated to a more recent version of the eCQMs.

eCQM data validation process / Previously adopted was a requirement for 32 case submissions (8/quarter) for the FY 2020 IQR payment determination, validating data from the 2017 reporting period. /

Because CMS has reduced the number of quarters a hospital must report their eCQMs to a single quarter in 2017 and 2018, the number of cases they must report for data validation has been reduced to 8.
CMS is extending their policy that the accuracy of eCQM data submitted for validation will not affect a hospital's validation score for 2021 payment.

Extraordinary Circumstances Extension or Exception (ECE) / Disparate policies. /

CMS aligns a variety of hardship policies including those for the Hospital IQR Program, Hospital OQR Program, IPFQR Program, ASCQR Program, and PCHQR Program, as well as the Hospital VBP Program, HAC Reduction Program, and the Hospital Readmissions Reduction Program so that they now share common processes for ECE requests.
CMS has also renamed the programs to be the “Extraordinary Circumstances Exceptions (ECE) policy.” They have a single application and the same criteria but are still separate policies within each program.

CQM Reporting Requirements for the Medicare and Medicaid EHR Incentive Programs for CY 2017

Number of eCQMs that must be reported / In last year’s rule CMS finalized 8 eCQMs for 2017. In April 2017 CMS proposed lowering to 6 eCQMs for 2017. /

CMS finalized 4 self-selected eCQMs for 2017 & 2018 and 16 CQMs for hospital attesters under Medicare and Medicaid (attestation is not an option under Medicare after 2017 unless electronic reporting is not feasible; just Medicaid).
NOTE: There are different requirements for Medicaid EPs detailed below.

Required Number of Reporting Quarters / In last year’s rule CMS finalized a full year of reporting (4 quarters) starting in 2017. In April, they proposed reducing this to any twoselected quarters for 2017 and the first three quarters for 2018. / For 2017 and 2018 CMS shortened the reporting period for eCQMs even further from their earlier proposal to be any continuous 90-day period. While the below policies are not new they are worth restating:

For 2017: If a hospital can’t meet the eCQM reporting requirements, it can report CQMs by attestation for purposes of MU and if it satisfies all other program requirements, it would avoid the MU penalty.
Hospitals meeting eCQMs requirements for the Hospital IQR Program will be considered to have successfully reported the eCQM requirement to the Medicare and Medicaid EHR Incentive Programs as well.
For 2018: Attesting no longer available under MU program for hospitals and CAHs (except when electronic reporting is not feasible; in this case reporting is a full year for attestation).

Different Requirements for Medicaid EPs / In the 2018 proposed IPPS rule CMS called for alignment of the CQMs available to EPs in the Medicaid MU program with the CQMs available to clinicians participating in MIPS. Previously Medicaid MU EPs have been required to report on 9 CQMs covering at least 3 NQS domains from a list of 64 CQMs. / To better align Medicaid EPs under the MU program with Medicare EPs under the MIPS program, CMS has finalized the following policies for Medicaid EPs under MU (at this time the policy applies to 2017 only; future rulemaking will consider policies for 2018):

Reporting Period: A 90-day reporting period for eCQMs (attestation is not an option under MIPS) regardless of submission option for Medicaid EPs.
CQMs Available: CMS is aligning the CQMs available for reporting by Medicaid EPs under MU with the same ones available to Medicare clinicians in MIPS. The set of 53 CQMs available to MIPS participants is a subset of the 64 CQMs currently available under the Medicaid EHR Incentive Program.
Number of CQMs: CMS has removed the requirement to report on CQMs across three of the six NQS domains that existed in previous years of the Medicaid EHR Incentive Program. And, Medicaid EPs will now be asked to report on any six measures that are relevant to the EP’s scope of practice to better align with the data submission criteria for the MIPS quality performance category in 2017.

CEHRT Requirements / 2015 CEHRT required for use in 2018. / For 2017 and 2018 CMS will allow use of 2014 Edition, 2015 Edition, or a combination of both.

Medicare Hospital & CAH Meaningful Use Policies

Issue / Previously Finalized / Proposed / New Finalized Policy
Reporting Requirements /

CMS previously finalized a one-year reporting period for 2018.

A minimum of any continuous 90-day period in 2018 for new and returning participants attesting to CMS or their State Medicaid agency.
CMS rejected requests to extend the 90-day reporting period beyond 2018.
Providers may begin the EHR reporting period and implement their EHR technology before it is certified.
Certification need only be obtained prior to the end of the EHR reporting period, however, CMS cautions that providers startingthe EHR reporting period without the certification complete, run the risk of not being a meaningful EHR user for that EHR reporting period. See FAQ2893.
Regarding Medicaid providers, CMS allows states to determine the method of reporting CQMs (attestation or electronic reporting) and the submission periods for reporting CQMs, subject to prior approval by CMS. (page 1959)

De-Certified EHR Exception / Prior to the 21st Century Cures Act CMS was not required to do this. /

Pursuant to the new law, CMS is implementing a new exception that helps EPs, eligible hospitals and CAHs who are unable to comply with the requirements for being a meaningful EHR user because their CEHRT has been decertified, to avoid a financial penalty.
The new exception would work as follows:
EPs: Starts with 2016 reporting year (for 2018 payment). May file if EHR was decertified any time during the 12-month period preceding the applicable reporting period for 2018 payment year (or any 90-day continuous period during the applicable EHR reporting period for the 2018 paymentdepending on whether the EP has successfully demonstrated Meaningful Use in a prior year). Must file by October 1, 2017.
EHs: Starts with 2017 reporting year (2019 payment adjustment). May file if EHR decertified any time during last 12-month period prior to applicable payment year (or during the applicable EHR reporting period for the payment adjustment year). Must file by July 1 of the year before the impacted payment year (for FY19 file by July 1, 2018).
CAHs: If EHR decertified any time during 12-month period preceding applicable EHR reporting period or during the applicable reporting period (or during the applicable EHR reporting period for the payment year), must file by November 30 after end of applicable payment year (i.e.,for FY18 payment file by November 30, 2018).

No providers can file for more than five years.

EPs working in Ambulatory Surgical Center (ASCs) / Prior to passage of the 21st Century Cures Act no exception from meaningful use requirement applied to EPs working in ASCs. / Pursuant to the new law, CMS is exempting EPs from MU penalties who deliver “substantially all” of their covered professional services in an ASC.
This is defined as furnishing 75% or more of their covered professional services in an ASC as identified by place of service code 24 listed on claims.
CEHRT / Until this final rule was published CMS’ policy called for requiring the use of 2015 Edition CEHRT beginning in 2018. / CMS has changed their policy to reflect provider and vendor readiness issues and is now allowing providers to use 2014, 2015 or a combination of both Editions of CEHRT for 2018 for meeting Meaningful Use.
Stage 2 vs Stage 3 & 2014 CEHRT vs 2015 CEHRT / Prior to CMS finalizing this rule, the previously adopted mandate called for moving to Stage 3 beginning in 2018. /

With this new rule, CMS has changed their policy to permit providers to meet Modified Stage 2 or Stage 3 in 2018, consistent with their changed policy to permit the use of either (or both of) the 2014 or 2015 Editions of CEHRT.
Thus, upon attestation for an EHR reporting period in CY 2018, providers may select one of these options and attest to the applicable objectives and measures based on their Edition of CEHRT.
A healthcare provider using a combination of 2014 and 2015 Edition CEHRT could attest to the Stage 3 or the Modified Stage 2 objectives and measures.
Providers who choose to attest to Modified Stage 2 will attest to only the Modified Stage 2 objectives and measures at § 495.22.
Providers who choose to attest to Stage 3 will attest to only the Stage 3 objectives and measures.
Providers seeking to attest to Stage 3 in 2018 using a combination of 2014 and 2015 Editions of CEHRT cannot do so without the support of certain functions that are only available for certification as part of the 2015 Edition certification criteria.

Alignment of CEHRT across all Medicareprograms calling for its use / Many stakeholders including CHIME have requested CMS align the certification requirements across all the CMS programs that call for its use. / CMS has stated, “We may not be able to align CEHRT requirements across all programs as each program has different statutory authority and requirements. However, to reduce burden and promote interoperability, we will continue to align the CEHRT requirements where feasible. We cannot eliminate all requirements of CEHRT as suggested by the commenter because the statute includes certain baseline requirements
(see, for example, section 1848(o)(4) of the Act).”
Medicaid / Prior to the finalization of this new rule, it was CMS’ requirement that Medicaid providers move to Stage 3 in 2018. The existing requirement calls for Medicaid providers to meet the highest set of threshold measures (even higher than those that must be met by Medicare hospitals). / CMS will now allow Medicaid providers to meet Modified Stage 2 again in 2018 and will not mandate the move to Stage 3 in 2018. And, they may continue using 2014 CEHRT, 2015 CEHRT or a combination of both in 2018.
Changes to the measures / CMS finalized Modified Stage 2 and Stage 3 requirements in prior rules. / There are no changes to Meaningful Use measures made in the final IPPS rule.

References & Resources

CMS Final IPPS Rule for 2018
CMS PPTs on IPPS Final Rule for 2018
Maintenance of Technical Specifications for Quality Measures: The technical specifications for chart-abstracted clinical process of care measures used in the Hospital IQR Program, or links to websites hosting technical specifications, are contained in the CMS/The Joint Commission (TJC) Specifications Manual for National Hospital Inpatient Quality Measures (Specifications Manual). This Specifications Manual is posted on the QualityNet website at: (page 1322)