Meaningful Use Toolkit for EP

This toolkit provides definitions, info sheets, tips, user guides for Meaningful Use and the Medicaid EHR Incentive Program for Eligible Professionals (EP).

Psychiatric Clinical Nurse Specialists (PCNS) are now Eligible to Participate
CMS recently approved Psychiatric Clinical Nurse Specialists as a new category of Eligible Professionals (EPs). Starting with Program Year 2016, PCNS can earn Medicaid EHR Incentives. To participate, PCNS must start with the Special Enrollment process, which is Step 1 on the Registration Tab.

The Registration and Attestation process for PCNS is identical to the process for all other EPs. For 2016, PCNS will need to either Adopt, Implement, or Upgrade to Certified EHR Technology (CEHRT), or attest to Meaningful Use. Follow the Tour by Specialty for Behavioral Health to check our resources to select and/or purchase CEHRT.

Note: Program Year 2016 is the last year for EPs, including PCNS, to initiate program participation. Interested PCNS can start to participate now, and must register and complete their 2016 attestation on or before May 31, 2017.

Overview of New Requirements for Program Year 2015 to 2017
Meaningful Use (MU) refers to the use of Certified Electronic Health Record Technology (CEHRT) in a meaningful way to increase efficiency, reduce costs, and improve patient care. By demonstrating Meaningful Use, an Eligible Professional (EP) can earn financial incentives and/or avoid Medicare Part B payment penalties.
 

 
 

What an EP needs to know for Program Year 2016

On Oct 16, 2015, CMS published the Final Rule specifying the criteria participants must meet to qualify for the Medicare and Medicaid EHR Incentive Programs in 2015 and beyond. The rule's provisions state the 2015-2017 requirements for a Modified Stage 2, and the rules for MU Stage 3. Watch the video to learn about the Final Rule.

  • An EP needs to attest to a single set of objectives and measures, known as Modified Stage 2. This set replaces the original core and menu sets for Stages 1 and 2 as defined for prior program years.

  • Modified Stage 2 requires an EP to meet 10 objectives, including one consolidated public health reporting objective. An EP also still needs to meet the requirements for the Clinical Quality Measures (CQMs).

  • ​If an EP was scheduled to attest to MU Stage 1 under the old rules, alternate exclusions are available that allow exclusion of Modified Stage 2 CPOE measures 2 and 3 for which there is no Stage 1 equivalent. For all EPs, there are alternate exclusions available for Public Health Reporting measures 2 and 3.

  • Program Year 2016 is the last year an EP can initiate participation in the Medicaid EHR Incentive Program.

  • The AIU and MU attestation deadline is May 31, 2017, and MAPIR is open for attestations now.

  • The MU reporting period for EPs will be any continuous 90-day period* from Jan 1, 2016 through Dec 31, 2016.
    *CMS reduced the original 365-day MU reporting period to a 90-day period for program year 2016 and 2017. Providers originally scheduled to attest for the 365-day MU reporting period can attest for the 90-day period after Jan 1, 2017, when the new 90-day rule goes into effect.

  • An EP must attest to the MU objectives and measures using EHR technology certified to the 2014 Edition.

  • The available alternate exclusions will be phased out after 2017.

Use the information presented in the Program, Registration, Attestation, and other tabs to apply for incentives. 

 

Documentation Requirements and Key Program Updates for 2016

MeHI Presentations
Documentation Guide
CMS Spec Sheets​
Attestation Document
Attestation Document



Info Sheet
Table
Group Proxy Guide

 

Modified Stage 2 Meaningful Use Presentations for Each Objective
2016 Supporting Documentation Guide for EPs - Version 5/15/2017 (Changes listed in blue)
2016 Modified Stage 2 Specification Sheets for EPs
MU Aggregation Form - Version 5/15/2017
Security Risk Analysis/Review Cover Sheet
The cover sheet can be signed by an authorized individual, e.g. Chief Medical Officer, Chief Information Officer, Director of Compliance, Consultant, Eligible Provider, Designee
2015-2016 Medicaid 1115 Waiver Population Grid
2016 Chip Factor
Calculating Patient Volume Threshold Using Group Proxy Methodology "Last update 2015"

Resources to Learn more about the Final Rule

CMS Fact Sheet
CMS Final Rule

CMS Fact Sheet

MeHI Slides
CMS Slides

CMS Recording
 

 

2016 Alternate Specifications and Exclusions for EP scheduled to attest to Stage 1
Stage 3 and Modifications to Meaningful Use 2015 through 2017
2015-2017 Modified Stage 2 Overview

Final Rule on MU Modifications for 2015-2017 and Stage 3 MU
Final Rule and What You Need to Know for 2015-2017
Final Rule and What You Need to Know for 2015-2017
Enter name (use prefilled password & key). Click View Recording. Enter email & company. Click View Recording.

Medicaid EHR Incentive Program

An EP can earn incentives from the Medicaid EHR Incentive Program to adopt, implement, or upgrade (AIU) to Certified EHR Technology (CEHRT) and demonstrate Meaningful Use (MU). 

The last year to start participation is Program Year 2016.

The MAPIR attestation system is open for Program Year 2016 attestations. The attestation deadline is May 31, 2017.

 
Getting Started Resources

CMS Website
CMS Website
CMS Website
CMS Website


MeHI Training Slides
Presentations
FAQ sheets

 

Program Basics
Educational Resources
FAQ
Requirements for Previous Program Years

Adopt / Implement / Upgrade and Modified Stage 2 Training Slides for EPs
Recent Medicaid EHR Incentive Payment Program Presentations
Frequently Asked Questions About the Medicaid EHR Incentive Payment Program

Eligibility and Enrollment Information  

MeHI Website
Checklist and Forms

Checklist
CMS Info Sheet
Info Sheet

Fact Sheet
Checklist
Fact Sheet
Checklist

 

EHR Incentive Program Eligibility Overview for Professionals
Special Enrollment Checklist for EPs 

Updated on 7/18/16 to include Psychiatric Clinical Nurse Specialists
Checklist for Practitioner Panel EPs
Additional Requirements for EPs Practicing in Multiple Locations - Updated March 2016
Resident Participation Requirements

Fact Sheet EPs not practicing predominately at an FQHC/RHC
Checklist for EPs not practicing predominately at an FQHC/RHC
Fact Sheet for EPs practicing predominately at an FQHC/RHC
Checklist for EPs practicing predominately at an FQHC/RHC

Related Government Websites

EOHHS Website
CMS Website
HealthIT.gov Website

 

MassHealth EHR Incentive Program Website
Centers for Medicare and Medicaid EHR Incentive Programs Website
Office of the National Coordinator for Health Information Technology (ONC) Website

Related Government Roadmap Documents

MA eHealth Plan
ONC Roadmap

 

The Massachusetts State Medicaid Health Information Technology Plan (SMHP)
ONC Nationwide Interoperability Roadmap

Medicaid EHR Incentive Program Registration
To participate in the EHR Incentive Program, EPs must be recognized in MMIS, MassHealth's Medicaid Management Information System. EPs are required to register through the CMS Registration and Attestation System (R&A). The data entered (name, address, NPI,...) will be matched against MMIS. To successfully register with CMS, EPs must have:

  • National Provider Identifier (NPI)
  • Identify and Access (I&A) Id and Password
  • Payee Tax Identification Number (TIN)
  • EHR Certification Number

A successful registration results in a “Welcome to MAPIR” email notification with instructions on how to access MAPIR to begin the attestation process.

Note: EPs can register and attest themselves and/or can authorize a designee to act on their behalf. 

Step 1: Assign a Designee (Optional for EPs)

I&A Instructions
I&A FAQ Sheet
Go to I&A System

 Go to PECOS System

 

Identity & Access Quick Reference Guide to assign designee to attest on behalf of EP
Identity & Access FAQs
Identity & Access Management System (Login with your PECOS Username and Password)

Provider Enrollment, Chain, and Ownership System (Includes the I&A system)

Step 2: Register in the CMS R&A System

Registration Instructions
Go to CMS R&A System
CMS Checklist

 

CMS Registration & Attestation (CMS R&A) User Guide for EPs
Centers for Medicare & Medicaid Services Registration & Attestation System
Registration, Attestation, PECOS Checklist

Step 3: Special Enrollment (Upon Request only, for EPs not recognized or inactive in MMIS )

Checklist and Forms
 

 

Special Enrollment Checklist for EPs 
Updated on 7/18/16 to include Psychiatric Clinical Nurse Specialists

Medicaid EHR Incentive Program Attestation
Annual attestation must be completed by the designee assigned to attest on behalf of the EP. To attest, use MAPIR, the state's attestation system, which is accessible via the Provider Online Service Center on the MassHealth website. Log into MAPIR using the Virtual Gateway username and password provided during registration. MAPIR will guide you in entering the data required to demonstrate an EP meets the program requirements.

EPs or appointed designees must upload supporting documentation to the EP’s MAPIR application prior to submittal for review.  Please reference the 2016 Supporting Documentation requirement Grid below.

Supporting Documentation Requirements

Documentation Guide
CMS Spec Sheets
Attestation Document
Attestation Document



Info Sheet

 

2016 Supporting Documentation Guide for EPs - Version 5/15/2017 (Changes listed in blue)
2016 Modified Stage 2 Specification Sheets for EPs
MU Aggregation Form - Version 5/15/2017
Security Risk Analysis/Review Cover Sheet
The cover sheet can be signed by an authorized individual, e.g. Chief Medical Officer, Chief Information Officer, Director of Compliance, Consultant, Eligible Provider, Designee
2015-2016 Medicaid 1115 Waiver Population Grid

MAPIR System for Medicaid EHR Incentive Attestations

MAPIR Guide
Go to MAPIR System

 

MAPIR Guide for EPs - All Parts - Version 4/8/2016
MassHealth Provider Online Service Center (Select "EHR Incentive Program" at left of page)

                  Documentation for Medicare Incentive Program Attestations (Includes tips helpful for Medicaid Attestations)

CMS User Guide

 

CMS Modified Stage 2 Attestation User Guide for EPs (Takes time to load)

Attestation Resources for Prior Program Years

Documentation Guide
Documentation Guide
Flexibility Rule
User Guide

User Guide
User Guide

 

2015 Supporting Documentation Guide for EPs - Version 7/27/2016
2014 Supporting Documentation Guide for all Participants
Flexibility in Certified EHR Technology for 2014 for EPs
2014 CMS Stage 1 Attestation User Guide for EPs (Takes time to load)
2013 CMS Stage 1 Attestation User Guide for EPs (Takes time to load)
CMS Stage 2 Attestation User Guide for EPs (Takes time to load)

Adopt, Implement, or Upgrade (AIU) to CEHRT
The first year of participation, an EH needs to attest that it meets the program's eligibility criteria, and demonstrate it has Adopted, Implemented, or Upgraded (AIU) to Certified EHR Technology (CEHRT). As of 2014, participants have the option to immediately attest to Meaningful Use in the first year, skipping AIU attestation. To qualify for AIU, either:
   Adopt:          Acquire, purchase or secure access to CEHRT
   Implement:   Install or initiate the use of CEHRT
•   Upgrade:      Expand existing EHR functionality to CEHRT
 

 AIU Resources

MeHI EHR Toolkit
MeHI Website Tips
EHR Workbook

ONC Website
ONC Guide
ONC Info Sheet
Go to CEHRT Website

 

EHR Planning and Procurement Toolkit
EHR Implementation Tips
EHR System Selection Workbook

This workbook was developed by NJ-HITEC, with funding from the Regional Extension Center award issued by ONC.
Health IT Playbook
ONC EHR Contract Guide
ONC Guide to Understanding EHR Vendor Contract Terms
ONC Certified Health IT (CHPL) Product List including CEHRT systems

Attesting to Modified Stage 2 Meaningful Use
Starting in 2015, an EP needs to attest to Modified Stage 2, which replaces the original Stages 1 and 2 defined for prior program years. Modified Stage 2 requires an EP to meet 10 objectives, including one consolidated public health reporting objective. An EP also needs to meet the Clinical Quality Measures (CQMs) requirements.​

An EP who was scheduled to attest to MU Stage 1 under the old rules can use alternate specifications and exclusions allowing lower thresholds for certain measures and exclusion of Modified Stage 2 measures without Stage 1 equivalents.
 

Meaningful Use and Modified Stage 2 Overviews

MU MeHI Presentations
MU MeHI Website

MU MeHI Website

Documentation Guide
CMS Spec Sheets
CMS Worksheet


CMS Tip Sheet
CMS Fact Sheet
CMS Table

 

Modified Stage 2 Meaningful Use Presentations for Each Objective
Meaningful Use Overview
Meaningful Use Rules and Definitions

2016 Supporting Documentation Guide for EPs - Version 5/15/2017 (Changes listed in blue)
2016 Modified Stage 2 Specification Sheets for EPs
2016 Attestation Worksheet for EPs

What's changed for 2015 through 2017
2015-2017 Modified Stage 2 Overview
2015-2017 Modified Stage 2 Objectives and Measures Table for EPs

Modified Stage 2 - Alternate Specifications and Exclusions

CMS Fact Sheet

 

2016 Alternate Specifications and Exclusions for EP scheduled to attest to Stage 1

MU - Clinical Quality Measures 

CMS Website Page
CMS Website Page

MU Info Sheet

 

2016 CQM Library
2015 CQM Reporting Options "Last update 2015"
Clinical Quality Measures Reference Guide for EPs "Last update 2014"

MU - Privacy & Security

MU Info Sheet
Attestation Document



CMS Tip Sheet

 

Privacy and Security Guide
Security Risk Analysis/Review Cover Sheet
The cover sheet can be signed by an authorized individual, e.g. Chief Medical Officer, Chief Information Officer, Director of Compliance, Consultant, Eligible Provider, Designee
Security Risk Analysis "Last update Mar 2016"

MU - Health Information Exchange

CMS Tip Sheet

 

Health Information Exchange "Last update Mar 2016"

MU - Patient Engagement

CMS Tip Sheet
ONC Fact Sheet

 

Patient Electronic Access "Last update Mar 2016"
Providing Patient-Specific Education Resources

MU - Medication Reconciliation

ONC Toolkit

 

Medication Reconciliation Toolkit

MU - Prior Program Year Resources

Documentation Guide
CMS Spec Sheets
CMS Fact Sheet
CMS Worksheet
CMS Tip Sheet
MU Info Sheet

MU FAQ Sheet
MU Tip Sheet
MU Ruling
MU Calculator

 

2015 Supporting Documentation Guide for EPs - Version 7/27/2016
2015 Modified Stage 2 Specification Sheets for EPs
2015 Alternate Specifications and Exclusions for EP scheduled to attest to Stage 1
2015 Attestation Worksheet for EPs
What you need to know for 2015 for EPs
2014 Stage 1 vs. Stage 2 Meaningful Use Comparison Table for EPs
Stage 1 Meaningful Use Frequently Asked Questions
Stage 1 Tip Sheet: 2013 Meaningful Use Stage 1 Changes
Stage 2 Final Rules: Medicare & Medicaid EHR Incentive Program
Stage 1 Meaningful Use Attestation Calculator (Takes time to load)

Public Health Measures Reporting

MU Modified Stage 2 requires EPs to attest to the Public Health Reporting objective, which requires using Certified EHR Technology (CEHRT) to submit data to public health and/or specialized registries.

The Public Health Reporting objective requires active engagement with one or more of the following:

  1. Immunization Registry
  2. Syndromic Surveillance Registry;
  3. Specialized Registry.

Watch this video, read the details below, or visit this website to learn how the Massachusetts Department of Public Health (MDPH) assists EPs in meeting the objectives.

 

Immunization Registry Reporting
MIIS, the Massachusetts Immunization Information System, is a web-based registry that collects patient immunization data. MIIS accepts electronic immunization messages (VXU) from CEHRT systems in the HL7 2.5.1 format. This satisfies Meaningful Use purposes. Technical specifications can be found on the MIIS Providers webpage

Note that pursuant to M.G.L. Chapter 111, Section 24M, all licensed health care providers who administer immunizations are required to report immunization data to MIIS. EPs can claim an exclusion for the MU measure if they do not administer immunizations to any of the populations for which data is collected during the EHR reporting period.

For more information, and to register intent to submit immunization data, contact the MIIS Help Desk at 617-983-4335 or miishelpdesk@state.ma.us.
The MDPH also holds weekly MIIS Technical Support calls:
When: Every Thursday from 10:BAM to 11:00 AM EST
Phone: (605) 562-3000. Enter Access Code: 580574#

Syndromic Surveillance Reporting
MDPH accepts syndromic surveillance data from hospital emergency departments only. EPs can claim an exclusion for this measure. Save or print a screenshot of the MDPH Meaningful Use and Public Health Reporting webpage to document the reason for claiming the exclusion. 

Specialized Registry Reporting
EPs who do not collect data relevant to a Specialized Registry within their "jurisdiction" may claim an exclusion for this measure, since there is no Specialized Registry available relevant to their scope of practice. However, the definition of “jurisdiction” is dependent on the type of registry, and the scope of "jurisdiction" may be local, state, regional or national.

EPs may be able to meet the Specialized Registry measure by reporting to a national clinical data registry:

  • Some national professional associations, such as the American College of Cardiology, American Academy of Ophthalmology, and American College of Rheumatology have made clinical data registries available to their members.

The Commonwealth of Massachusetts offers two options for Specialized Registry Reporting:

  1. The Massachusetts Cancer Registry (MCR) supports electronic reporting from CEHRT systems. If you are an EP who treats cancer patients and are interested in reporting to the MCR, contact Susan T. Gershman at susan.gershman@state.ma.us
     
  2. The Bureau of Infectious Disease Prevention at the MDPH has implemented electronic infectious disease case reporting into a specialized registry, the Massachusetts Virtual Epidemiologic Network (MAVEN). The registry accepts electronic medical case reports for acute hepatitis, active tuberculosis, and sexually-transmitted diseases. As onboarding participants is resource intensive, MDPH limits participation via a threshold based on incidence of reportable conditions seen by providers over a 12-month period. For EPs, the combined number of cases of syphilis, gonorrhea, chlamydia, acute hepatitis, and active tuberculosis seen at your facility must be greater than 1,000 in the most recent 12-month period. If your facility meets the threshold and you are interested in reporting data to this registry, contact Sita C. Smith at sita.c.smith@state.ma.us.

At this time, the MDPH has not declared the Prescription Drug Monitoring Program (PDMP) a Specialized Registry.

Reporting Requirements

Measure
MU Measure Description
Action to Meet MU Measure
Eligible Professionals

1

Immunization Registry

  1. Demonstrate active engagement* with the Massachusetts Immunization Information System (MIIS); or
     
  2. Claim an exclusion if no immunizations are administered.

2

Syndromic Surveillance Registry

  1. Claim an exclusion (MDPH only accepts syndromic surveillance data from hospital emergency departments)

3

Specialized Registry

  1. Demonstrate active engagement* with the MDPH Cancer Registry if applicable;
     
  2. Demonstrate active engagement* with the Massachusetts Virtual Epidemiologic Network (MAVEN) if applicable;
     
  3. Demonstrate active engagement* with another specialized registry (such as a clinical data registry offered through a national professional association) if applicable; or
     
  4. Claim an exclusion or an alternate exclusion if none of the above apply.

*CMS defines “active engagement” as any one of the following:

  • Completed Registration to Submit Data – must be completed within 60 days of start of EHR reporting period;
  • Testing and Validation – must respond to requests within 30 days; failure to respond twice within an EHR reporting period would result in failure to meet the measure;
  • Production

EPs who select YES to any of the three options should not claim any exclusions associated with that measure. Medicaid Program participants who claim an exclusion for a public health reporting measure are responsible for ensuring they meet the qualifications and retain all required documentation to fully support their attestation selection.

 
 

Patient Volume Threshold (PVT)
To qualify, an EP's Medicaid Patient Volume must meet a 30% Patient Volume Threshold during a 90-day reporting period (20% for Board-Certified Pediatricians). There is an FQHC/RHC and a non-FQHC/RHC method to calculate Patient Volume. EPs in a group practice can use the Group Proxy Methodology to calculate Patient Volume.

 2016 CHIP Factors for Eligible Professionals (Children's Health Insurance Program)
 For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
 If you selected a 90 day PVT reporting period in:
 - 2015: use the 2015 Calendar Year factor listed below.
 - 2016: use the 2016 factor corresponding to the last day of the period. 

2015 Calendar Year 2016: Jan 1 - Mar 31 2016: Apr 1 - Jun 30 2016: Jul 1 - Sep 30 2016: Oct 1 - Dec 31
3.20%    3.46%     3.67%       3.81%     3.93%
PVT Resources

MeHI Website Page
Info Sheet
Tip Sheet
Group Proxy Guide
Info Sheet

 

Medicaid Patient Volume for EPs
Calculating Patient Volume Threshold
Patient Volume Thresholds
Calculating Patient Volume Threshold Using Group Proxy Methodology "Last update 2015"
2015-2016 Medicaid 1115 Waiver Population Grid

Templates to Calculate Patient Volume by Individual EP

PVT Template
PVT Template
FQHC Template

 

Individual EP - Paid Claims (Updated 5-25-17)
Individual EP - Enrollee (Paid, Zero Paid, and Denied Claims) (Updated 5-25-17)
FQHC Threshold Verification

Templates to Calculate Patient Volume based on the Group Proxy Methodology 

Group Proxy Template
Group Proxy Template
FQHC Template​

 

Group - Paid Claims (Updated 5-25-17)
Group - Enrollee (Paid, Zero Paid, and Denied Claims) (Updated 5-25-17)
FQHC Threshold Verification (Same form as for Individual EP)

PVT - Prior Program Year Resources

 2015 CHIP Factors for Eligible Professionals (Children's Health Insurance Program)
 For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
 If you selected a 90 day PVT reporting period in:
 - 2014: use the 2014 Calendar Year factor listed below.
 - 2015: use the 2015 factor corresponding to the last day of the period. 

2014 Calendar Year 2015: Jan 1 - Mar 31 2015: Apr 1 - Jun 30 2015: Jul 1 - Sep 30 2015: Oct 1 - Dec 31
2.75%    2.76% *     2.89% *       3.06% **     3.20% **

Table notes:
*    Q1-Q2 factors changed as of 7/8/16. If you submitted before 7/8/16, you will only need to update your application if we ask you to do so.
**  Q3-Q4 factors are new as of 7/8/16. If you submitted before 7/8/16 using an estimated factor, you will be asked to update the application.

Medicaid EHR Incentive Program - Validation and Audits
All Medicaid EHR Incentive Program applications will go through a pre-payment validation process. After the incentives have been paid, the provider may also be selected for a post-payment audit. The audits are performed by EOHHS (Medicaid-only EH), or CMS (Dual-eligible Medicare and Medicaid EH), or their contractors. For audit purposes, all supporting documentation must be retained for at least six years after attestation.

Pre-Payment Validation Resources

MeHI Website

 

Validation Process Overview

Post-Payment Audit Resources

CMS Fact Sheet
CMS Tip Sheet
CMS Tip Sheet

 

Audit Overview (Last update Feb 2013)
Supporting Documentation for Audits (Last update Feb 2013)
Supporting Documentation for Audits (Stage 2) (Last update Feb 2014)

new
program
reg
attest
aiu
mu
public
pvt
audits