Tuesday, February 7, 2012

Attesting to Meaningful Use Quality Measures

I was recently asked how eligible professionals should report the Meaningful Use Clinical Quality Measures if there are zero denominators (i.e. you do not have any hypertensives, adults, or patients with 2 or more visits in the measurement period)

Here's the answer as I understand the regulations and FAQs:

1.  Report on the 3 Core measures if you can, which include
*Hypertension: Blood Pressure Measurement
*Tobacco Use Assessment and Tobacco Cessation Intervention
*Adult Weight Screening and Follow-up

2.  If any of the 3 Core measures has a zero denominator, replace them one-for-one with one of the 3 alternate core measures.   If you can’t get to 3 non-zero denominators between the core and alternate core, report on all 6 (even if it means that you have to report 6 zero denominators)
*Weight Assessment and Counseling for Children and Adolescents
*Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
*Childhood Immunization Status

3.  Regardless of the above, you MUST report on 3 of the remaining 38 Additional Set measures.  If you are reporting any zero denominators from these Additional Set measures, you must attest that you have no other non-zero denominator measures.  Essentially, you have to confirm that you’re not running away from non-zero denominator measures.

In summary, the minimal requirement is for 6 measures (3 core or alternate core, 3 additional set).  You may have to report up to 9 measures if there are zero denominators involved.  If you can’t find 3 non-zero denominators among the core and alternate core, you have to report on all 6 (even if it means that you’re reporting 6 zero denominators).  In addition, you still have to report on 3 from the remaining 38 additional set measures.  If any of these 3 additional set measures is a zero denominator, you must confirm that you don’t have a non-zero denominator for any of the remaining 35 that you’re not reporting on.
Micky Tripathi posted a blog about this last summer that provides additional detail.

You'll find the FAQs that address the Clinical Quality Measures here.

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