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5 steps to mitigate the risk associated with attesting with a zero denominator

March 5, 2017

Can an Eligible Physician (EP), Eligible Hospital (EH) or Critical Access Hospital (CAH) report a zero denominator for Clinical Quality Measures (CQM)?  The answer is yes; however, this is not the end of the discussion.  By reporting a zero denominator, the EP, EH or CAH is stating that care was not provided to any patients in the denominator population during the EHR reporting period. There is a stark contrast between just reporting zero denominators and claiming that no patients met the denominator population criteria.

On the CMS attestation website, there are statements that must be accepted in order to submit. The last statement concludes “For CQMs, a zero was reported in the denominator of a measure when an eligible hospital or CAH did not care for any patients in the denominator population during the EHR reporting period.”  

This statement assumes that the Certified EHR Technology (CEHRT) and supporting systems are properly configured to include and exclude patients in the measures based on CQM value sets. To assume these measures are working correctly is a gross oversight and potentially negligible.

CMS openly acknowledges issues with the CQM calculations on the JIRA website, however EHR vendors have not been as forthcoming related to their software version issues impacting calculations. We have not encountered a Figliozzi & Company audit requesting CQM data detail, however it is not out of the question even though thresholds are not required.

 

The 5 steps below will mitigate all concerns regarding CQM audits for an EP, EH or CAH and support the claim made during the attestation process. 

   

  1. Request a "known issues" list from your EHR software vendor by CQM measure

  2. Using the eQCM Library documentation, identify the initial patient population and denominator population criteria for all of your CQMs.

  3. Run reports from your admission, demographic and transfer (ADT) system for initial patient populations and denominator populations that are based on ICD-9 and ICD-10 codes for applicable measures. This is the most effective way to confirm accuracy for a large portion of the CQMs.

  4. Identify a subset of patients to audit for each measure and maintain documentation and screenshots.

  5. When an EHR software issue is preventing the initial patient population and or denominator from populating, take screenshots to prove the patient met the criteria even though the certified Meaningful Use report is displaying a zero.

 

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