Eligible Professionals - Attestation

Program Announcement

 

To receive a Wisconsin Medicaid EHR Incentive Program payment, Eligible Professionals must attest to the adoption, implementation, upgrade or Meaningful Use of CEHRT. Meaningful Use is the standard by which providers demonstrate the use of CEHRT in ways that can positively affect the care of patients. To meet meaningful use requirements and receive an incentive payment, providers must meet a set number of objectives and measures established by the Centers for Medicare and Medicaid Services (CMS) for the EHR Incentive Program. More detailed information is provided below.

Certified EHR Technology

Before an Eligible Professional can attest to meeting EHR Incentive Program requirements, he or she must acquire or have access to  CEHRT.

  • In Program Year 2015, all Eligible Professionals are required to use technology certified to the 2014 Edition.
  • In Program Years 2016 and 2017, Eligible Professionals can choose to use technology certified to the 2014 Edition, the 2015 Edition, or a combination of the two editions.
  • In Program Year 2018 and subsequent Program Years, all Eligible Professionals are required to use technology certified to the 2015 Edition.

For more information on CEHRT, please refer to the Certified Health IT Product List. If you need help obtaining the CMS EHR Certification ID used in the registration and attestation process, use this walk-through document to understand how to generate a CMS EHR Certification ID using the Certified Health IT Product List.

 

Adopt, Implement, Upgrade

Eligible Professionals participating in their first year do not have to attest to Meaningful Use criteria; rather, they may demonstrate that they have adopted, implemented, and upgraded CEHRT:

  • Adopt: Eligible Professionals must demonstrate acquisition, installation, or contractual proof of an acquisition or future acquisition of CEHRT in the first payment year.

  • Implement: Eligible Professionals must meet the criteria for adopting CEHRT and demonstrate actual implementation, installation, or utilization of CEHRT.

  • Upgrade: Eligible Professionals must meet the criteria for adopting and implementing, and demonstrate expansion of, CEHRT functionality such as the addition of an e-prescribing functionality or computerized physician order entry.

Meaningful Use

The last year for an Eligible Professional to initiate participation in the Medicaid EHR Incentive Program is 2016. Calendar Year 2021 is the last year a participant may receive an incentive payment.

The criteria for Meaningful Use will be staged in three steps over the course of the program:

  • Stage 1 sets the baseline for electronic data capture and information sharing.

  • Stage 2 and Modified Stage 2 advances clinical processes.
    CMS established a modified set of criteria for attestation in Program Years 2015 through 2017, known as Modified Stage 2. Modified Stage 2 replaces the core and menu structure of Stages 1 and 2 with a single set of objectives and measures, and establishes several other changes to the EHR Incentive Program.

  • Stage 3 improves outcomes.

The table below indicates what stage of Meaningful Use must be reported based on the first year an Eligible Professional began participation in the Wisconsin Medicaid EHR Incentive Program. It is assumed that an Eligible Professional’s first year of participation is the AIU phase and his or her participation occurs in consecutive years; however, Eligible Professionals may participate in non-consecutive Program Years and may attest to Meaningful Use the first year of participation.

First Year of Participation (AIU)
Stage of Meaningful Use by Program Year
2015
2016
2017
2018+
2011
Modified Stage 2 Modified Stage 2 Modified Stage 2 or Stage 3 Stage 3
2012
Modified Stage 2 Modified Stage 2 Modified Stage 2 or Stage 3 Stage 3
2013
Modified Stage 2* Modified Stage 2 Modified Stage 2 or Stage 3 Stage 3
2014
Modified Stage 2* Modified Stage 2* Modified Stage 2 or Stage 3 Stage 3
2015
AIU Modified Stage 2* Modified Stage 2 or Stage 3 Stage 3
2016
N/A AIU Modified Stage 2 or Stage 3 Stage 3

* In 2015 and 2016, Modified Stage 2 includes alternate exclusions and specifications for certain objectives and measures for Eligible Professionals scheduled to demonstrate Stage 1 of Meaningful Use. (Eligible Professionals who successfully attest to any stage of Meaningful Use in two prior years of participation are scheduled to demonstrate Stage 2 and may not use alternate exclusions and specifications in 2015 and 2016, with the exception of the public health reporting alternate exclusions available in 2015 and 2016.) Alternate exclusion reporting continues in 2016 for Computerized Provider Order Entry (CPOE) and public health only.

EHR Reporting Period for Meaningful Use

The following are the EHR reporting periods for Meaningful Use:

  • In Program Year 2015, the EHR reporting period for all Eligible Professionals, regardless of previous participation, is any continuous 90-day period between January 1, 2015, and December 31, 2015.
  • In Program Year 2016, the EHR reporting period for Eligible Professionals who are attesting to Meaningful Use criteria for the first time (new meaningful users) will be any continuous 90-day period between January 1, 2016, and December 31, 2016. The EHR reporting period for Eligible Professionals who have successfully demonstrated a stage of Meaningful Use in a prior year (returning meaningful users) will be the full calendar year from January 1, 2016, through December 31, 2016.
  • In Program Year 2017, the EHR reporting period for new meaningful users, as well as for Eligible Professionals who choose to attest to Stage 3, will be any continuous 90-day period between January 1, 2017, and December 31, 2017. The EHR reporting period for returning meaningful users who are attesting to Modified Stage 2 will be the full calendar year from January 1, 2017, through December 31, 2017.
  • In Program Year 2018 and subsequent Program Years,  all Eligible Professionals, except new meaningful users, will be allowed to select any continuous 90-day period as from January 1, 2018, through December 31, 2018 as their EHR reporting period.

Note: Eligible Professionals are not required to attest in consecutive years and may attest to the AIU phase and then a 90-day EHR reporting period in a subsequent year of participation.

Modified Stage 2 Meaningful Use

The requirements for Modified Stage 2 contain 10 objectives for Eligible Professionals, including one consolidated public health reporting objective. Each objective has one or more measures to which the Eligible Professional are required to attest. Since the changes in the final rule occurred after some Eligible Professionals had already started to work toward Meaningful Use in 2015, there are alternate exclusions and specifications within individual objectives for Eligible Professionals in Program Years 2015 and 2016.

For more information on the Eligible Professional Modified Stage 2 requirements for Program Year 2015, review the Eligible Professional 2015 Meaningful Use Specification Sheets.

For more information on the Eligible Professional Modified Stage 2 requirements for Program Year 2016, review the Eligible Professional 2016 Meaningful Use Specification Sheets.

Stage 3 Meaningful Use

The requirements for Stage 3 contain eight objectives for Eligible Professionals, including one consolidated public health reporting objective.

For information about the objectives and measures for Stage 3, Eligible Professionals should refer to the Federal Register.

More information on the Eligible Professional Stage 3 requirements is forthcoming. The CMS Medicare and Medicaid EHR Incentive Program website will be updated to include new information and resources reflecting the latest requirements for participation in Stage 3.

Process for Reporting Public Health Objectives

All Eligible Professionals, regardless of their stage of Meaningful Use, are required to register with the Wisconsin Department of Health Services (DHS), Division of Public Health (DPH), to initiate an onboarding process for the public health report objective. Eligible Professionals attesting to Modified Stage 2 Meaningful Use are required to register with DPH either before their EHR reporting period starts or within 60 days from the beginning of their EHR reporting period. For current registration information, Eligible Professionals should refer to the Public Health Meaningful Use website.

2014 Clinical Quality Measures (CQMs)

In addition to meeting the Meaningful Use measures, Eligible Professionals are also required to report on the 2014 CQMs in order to successfully participate in the program.

Although CQMs are reported separately from Meaningful Use measures, all Eligible Professionals are still required to report CQMs in order to demonstrate Meaningful Use. The reporting period for CQMs is the same as the Meaningful Use EHR reporting period for that Program Year.

All Eligible Professionals, regardless of their stage of Meaningful Use, are required to report on nine of the 64 CQMs finalized in 2014 in the Stage 2 rule. Zero is an acceptable value for the CQM denominator, numerator, and exclusion fields and will not prevent you from demonstrating Meaningful Use or receiving an incentive payment. Eligible Professionals can meet the CQM requirements even if one or more CQMs have “0” in the denominator, provided that this value was produced by CEHRT.

Wisconsin Medicaid recommends Eligible Professionals report on the priority CQMs identified in Attachment 5. See the CMS page on 2014 Clinical Quality Measures and the CQM Tipsheet to learn more about CQMs.

Meaningful Use Supporting Documentation

All information is subject to audit at any time and must be maintained by Eligible Professionals for a period of six years. If selected for an audit, the applicant must be able to supply supporting documentation. Refer to the EHR Incentive Program section of the ForwardHealth Online Handbook for a table that contains examples of supporting documentation an Eligible Professional would be expected to provide if selected for an audit.

Although Eligible Professionals are not required to upload CEHRT-generated Meaningful Use reports to support attestation, they are highly encouraged to do so in order to expedite the processing of applications. Documentation examples include:

  • Report(s) generated by CEHRT supporting all Meaningful Use objective and measure attestations.
  • Security Risk Analysis Report.
  • Additional documentation supporting attestations.

 

Last Revised: June 1, 2016