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Attestation User Guide for Eligible Professionals - Medicare Electronic Health Record (EHR) Incentive Program

Apr 08, 2018

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    ATTESTATIONUSER GUIDE

    Medicare Electronic Health Record

    (EHR) Incentive Program

    For Eligible Professionals

    (04.1 2 .11 ver1)

    APRIL 2011

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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 2

    CONTENTS

    Step 1 . Getting.started... 4

    Step 2 .. 5

    Step 3 .. . Welcome.. 13

    Step 4 .. 14

    Step 5 .. . Topics.for.this.Attestation... 15

    Step 6 .. 16

    Step 7 .. Meaningful.Use.Core.Measures.Questionnaire.(1.of.15)... 17

    Step 8 .. Meaningful.Use.Core.Measures.Questionn18

    Step 9 .. Meaningful.Use.Core.Measures.Questionnaire.(3.of.15)... 19

    Step 10 .. Meaningful.Use.Core.Measures.Questionnair20

    Step 11 .. . Meaningful.Use.Core.Measures.Questionnaire.(5.of.15)... 21

    Step 12 .. Meaningful.Use.Core.Measures.Questionnai22

    Step 13 . Meaningful.Use.Core.Measures.Questionna22

    Step 14 . Meaningful.Use.Core.Measures.Questionna23

    Step 15 .. Meaningful.Use.Core.Measures.Questionnai24

    Step 16 .. .Meaningful.Use.Core.Measures.Questionnaire.(10.of.15)... 25

    Step 17 .. Meaningful.Use.Core.Measures.Questionnaire.(125

    Step 18 .. . Meaningful.Use.Core.Measures.Questionnaire.(12.of.15)... 26

    Step 19 .. Meaningful.Use.Core.Measures.Questionnaire.(27

    Step 20 . Meaningful.Use.Core.Measures.Questionnaire.28

    Step 21 . Meaningful.Use.Core.Measures.Questionnaire.28

    Medicare regulations can be found on the CMS Web site at http://www.cms.gov

    https://ehrincentives.cms.gov

    http://www.cms.hhs.gov/https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/http://www.cms.hhs.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 3

    CONTENTS (cont.)Step 22 Meaningful.Use.Measures..Questionnaire... 29

    Step 23 .. Review.30

    Step 24 .. . .Core.Clinical.Quality.Measures.(CQMs.1.of.3).. 40

    Step 25 .. Core.Clinical.Qual41

    Step 26 .. Core.Clinical.Quality.Measures.(CQMs.3.of.3)... 42

    Step 27 .. Alternative.Clinical.Quality.Measures.(CQMs)... 43

    Step 28 .. Alternative.Clinical.Quality.Measures.44

    Step 29 .. . Topics.for.Attestation... 48

    Step 30 .. 49 .

    Step 31 .. Submission.Process:..Attestation.Statements... 51

    Step 32 .. 52

    Step 33 .. Submission.Receipt..Accepted.Attestation... 53

    Step 34 .. Submission.Receipt..Rejected.Attestation... 54

    Step 34 .. Summary.o55

    Step 35 .. 56

    Step 36 .. Topics.for.Attestation.Resubmission.. 57Step 37 .. Attestation.Statements.and.Con rmation.Page.Resubmission.59

    Step 38 .. 60

    Questions/Help . 61

    Acronym translation . 62

    Disclaimer

    The Centers for Medicare & Medicaid Services (CMS) is providing this material as aninformational reference for eligible professionals.

    Although every reasonable effort has been made to assure the accuracy of the informationwithin these pages at the time of posting, the Medicare program is constantly changing, and itis the responsibility of each provider to remain abreast of the Medicare program requirements.

    Medicare regulations can be found on the CMS Web site at http://www.cms.gov

    https://ehrincentives.cms.gov

    http://www.cms.hhs.gov/https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/http://www.cms.hhs.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 4

    Step 1 Getting Started

    To.receive.an.incentive.payment,.Medicare.Eligible.Professionals.(EPs).must.attest.to.their.meaningful.use.of.certi ed.electronic.health.record.technology.using.this.ATTESTATION.module .(Medicaid.EPs.should.contact.their.states.for.information.about.how.to.attest )

    This.is.a.step-by-step.guide.for.the.Medicare.Eligible.Professionals.(EPs).Electronic.Health.Record.(EHR).Incentive.Program.ATTESTATION.module .This.guide.will.help.you.navigate.the.Attestation.module .The.user.guide.page.layout.consists.of.the.attestation.screen.on.the.left.side.of.the.page.and.written.instructions.with.helpful.tips.on.the.bottom.of.the.page .

    STEPS

    Enter the EHR IncentiveProgram URL (locatedat the top of the page)into your web browser

    Click CONTINUE tostart the attestationprocess

    TIPSTo determine your eligibility, click on theCMS website

    For a list of Eligible Professional Types (EPs),click on Eligible Professionals (EPs) link

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 6

    Step 2 Login Instructions for Users Working on Behalf

    of an Eligible Professional (cont.)STEPS

    Eligible Professionals(EPs) may authorizesurrogate users to workon behalf of the EPin the EHR IncentiveProgram Registration &Attestation system

    Click on the Create aLogin link in the bodyof the screen

    Click YESto access theI&A system

    TIPS User name and password are casesensitive

    If you are an EP who does not havean NPI and/or an NPPES web user account, click on the NPPES link for more information

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 7

    Step 2 Login Instructions for Users

    Working on Behalf of an Eligible Professional (cont.)

    STEPS

    Application andSecurity Check Pageprompts the user toanswer 2 securityquestions

    TIP User name and password are case sensitive

    Click on the HELP tabat the top of the screenfor help creating your I&A user name and

    password

    User IDs cannot be changed. Once you havesuccessfully created a User ID and Secret Question/Answer combinations and submitted the record, the User ID and Secret Question/

    Answer combinations will remain tied to your record and will not be changed

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 8

    Step 2 Login Instructions for Users

    Working on Behalf of an Eligible Professional (cont.)

    STEPS

    Click on AccessRequests

    Click Add AccessRequest

    Click SUBMIT

    TIP At least oneNPI is required to assign access

    In order for a provider to create anonline account, the NPI record must bein the status of Active or Pending Change Request

    Use the Previous button tonavigate between pages inthe system

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 9

    Step 2 Login Instructions for Users

    Working on Behalf of an Eligible Professional (cont.)

    STEPS

    Click on You arerequesting to act onbehalf of an individualprovider

    Click NEXT

    Select Application Type

    EHR IncentiveProgram

    Click NEXT

    TIPS There can be only one Authorized Of cial per organization at any

    given time

    Click on HELP for additional guidance tonavigate the system

    The Help link ison every page

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 10

    Step 2 Login Instructions for Users

    Working on Behalf of an Eligible Professional (cont.)

    STEPS

    Enter the NPI of theindividual provider

    Click SEARCHto displaythe details of the individu

    provider

    Click SAVEto navigate tothe My Access RequestsPage

    Or

    Click SAVE & ADDANOTHER to addmultiple providers

    TIP Clicking Previous will takeyou back to the Select

    Application Type page

    Click on HELP for additional guidance tonavigate the system

    The Help link ison every page

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 11

    Step 2 Login Instructions for Users

    Working on Behalf of an Eligible Professional (cont.)

    STEPS

    Choose the IndividualProvider(s) to add the NPyou wish to access

    You may choose one at atime or click Select All

    Use the ADD ACCESSREQUESTbutton to addthe NPIs you wish toaccess

    Click SUBMIT

    TIPClicking Previous will takeyou back to the Select

    Application Type page

    Click on HELP for additional guidance tonavigate the system

    The Help link ison every page

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 12

    Step 2 Login Instructions for Users

    Working on Behalf of an Eligible Professional (cont.)

    STEPS

    Access request receipt

    You will receive an emailnotifcation that theExternal User Services(EUS)Help Desk hasapproved your request

    Record your trackingnumber for use on anycorrespondence

    TIP

    For questions regarding the I&A access contact

    External User Services (EUS )PO Box 792750San Antonio, TX 782161-866-484-8049TTY/[email protected]

    For questions regarding theEHR Incentive Program

    EHR Information Center 1-888-734-6433TTY/1/888-734-6563

    https://ehrincentives.cms.gov

    mailto:[email protected]://ehrincentives.cms.gov/https://ehrincentives.cms.gov/mailto:[email protected]
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 13

    Step 3 Welcome

    STEPS

    Click on the Attestation Tab tocontinue attesting forthe EHR IncentiveProgram

    TIPS

    The Welcome screen consists of ve tabs to navigate through the

    attestation and registration process

    1. Home2. Registration3. Attestation4. Status5. Account Management

    https:/ /ehrincentives.cms.go

    http://ehrincentives.cms.gov/http://ehrincentives.cms.gov/
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    Step 4 Attestation Instructions.

    STEPS

    Click on Attest inthe Action columnto continue theattestation process

    TIPS Modify, Cancel,Resubmit, Reactivate, View and Not Available are theavailable Action web linksfor returning users

    Click on Meaningful User InformationPage for detailed information about meaningful use, speci cation sheets for individual meaningful use objectives,e-speci cation sheets for clinical quality measures, and in-depth information onthe EHR Incentive Program

    Only one action canbe performed at atime on this page

    https:/ /ehrincentives.cms.go

    http://ehrincentives.cms.gov/http://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

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    Step 5 Topics for this AttestationThe.data.required.is.grouped.into.six.topics.for.Attestation .

    STEPS

    Click on

    START ATTESTATION

    to begin the attestationprocess.

    TIPS The topics will only bemarked as completed onceall the information hasbeen entered and saved

    When all topics are checked completed or N/A user canselect PROCEED WITH

    ATTESTATION

    There are six topics that arerequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE FOR ELIGIBLE PROFESSIONALS

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    Step 6 Attestation Information

    STEPS

    Enter your EHRCertifcation Number

    Enter the period startand end date of thereporting period youare attesting

    Click on

    SAVE & CONTINUE

    TIPS The EHRCerti cationNumber is 15 characters long

    To locate your EHR certi cationnumber, click on How do I nd my EHR certi cationnumber?

    Follow theinstructions onthe CHPL websitto obtain your EHR Certi catioNumber

    You will bedirected to theCerti ed HealthIT Product List (CHPL)

    The reporting period must be at least 90days in the samecalender year

    This is the rst of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 7 Meaningful Use Core Measures Questionnaire (1of 15)Read.the.objective.and.measure.and.respond.as.appropriate .

    STEPS

    Select the appropriateoption under PatientRecords

    Answer Yes or Noto the Exclusionquestion

    Click onSAVE & CONTINUE to continue with yourattestation

    If you click NO thescreen will expandand you must enterthe numerator anddenominator for themeasure

    TIPSPatient Records: At the EPs discretion, the numerators

    and denominators of certain measures may be calculated using only the patient records maintained in certi ed EHRtechnology. The EP may also elect to calculate the numeratorsand denominators of these measures using ALL patient records.EPs must indicate which method they used in their calculations

    Exclusion: EPs can be excluded from meeting an objective if they meet the requirements of theexclusion. If the EP cannot meet the speci c exclusion requirementsthen the EP cannot answer Yesto the exclusion question. (If noexclusion is indicated, the EP must report on that measure)

    1This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Medicare EHR Incentive Program User Guide Page 18

    Step 8 Meaningful Use Core Measures Questionnaire (2 of 15)

    STEPS

    Select the appropriateoption under PatientRecords

    Click onSAVE & CONTINUE to continue with yourattestation

    TIPS You may log out at any time and continue your attestation later. All of theinformation that you have entered upuntil this point will be saved within theattestation module

    Log back into the systemand select the Attestationtab to continue your attestation when you return

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 9 Meaningful Use Core Measures Questionnaire (3 of 15)

    STEPS

    Enter the Numeratorand Denominator

    TIPSNumerator and Denominator must be wholenumbers

    Click on HELP for additional guidance tonavigate the system

    The Help link ison every page

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 10 Meaningful Use Core Measures Questionnaire (4 of 15)

    STEPS

    Select the appropriateoption under PatientRecords.

    Answer Yes or Noto the Exclusionquestion

    Click on

    SAVE & CONTINUE to continue with yourattestation

    If you click NO thescreen will expandand you must enterthe numerator anddenominator for themeasure.

    TIPSClick on HELP for additional guidance tonavigate the system

    The Help link ison every page

    Enter the Numerator and Denominator if the exclusion doesnot apply to you

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 11 Meaningful Use Core Measures Questionnaire (5 of 15)

    STEPS

    Enter a Numerator andDenominator

    Click SAVE &CONTINUE

    NOTE: You may log out aany time and continue youattestation later. All of theinformation that you haveentered up until this point will be saved within theattestation module.

    Log back into the systemand select the Attestationtab to continue your attestation when you return

    TIPS Numerator and Denominator must be wholenumbers

    Click on HELP for additional guidance tonavigate the system

    The Help link ison every page

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE

    FOR ELIGIBLE PROFESSIONALS

    Medicare EHR Incentive Program User Guide Page 22

    Step 12 Meaningful Use Core Measures Questionnaire (6 of 15)

    Step 13 Meaningful Use Core Measures Questionnaire (7 of 15)

    STEPS

    Enter Numerator and

    Denominator and click

    SAVE & CONTINUE

    STEPS

    Enter Numerator and

    Denominator and click

    SAVE & CONTINUE.

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 14 Meaningful Use Core Measures Questionnaire (8 of 15)

    STEPS

    Select the appropriateoption underPatient Records

    Answer Yes or No toExclusion 1

    Select Yes or No for

    Exclusion 2

    If NO is chosen forboth exclusions, enterthe Numerator andDenominator

    Click SAVE &CONTINUE to proceedwith attestation

    TIPS Numerator and Denominator must be whole numbers

    You may select thePREVIOUS PAGE button to go back

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 15 Meaningful Use Core Measures Questionnaire (9 of 15)

    STEPS

    Select the appropriateoption underPatient Records

    Answer Yes or No tothe Exclusion

    If NO is chosen for

    the exclusion, enterthe Numerator andDenominator

    Click SAVE &CONTINUE to proceedwith attestation

    TIP To check your progress click onthe ATTESTATION tab at the top

    of the page and select Modifyin the Action column in the

    Attestation Selection page. Thecompleted topics have a check mark on the TOPICS screen.

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    tep 16 Meaningful Use Core Measures Questionnaire (10 of 15)

    Step 17 Meaningful Use Core Measures Questionnaire (11 of 15)

    STEPS

    Select Yes or No

    Click SAVE &

    CONTINUE

    STEPS

    Select Yes or No

    Click SAVE &

    CONTINUE

    TIPS These objectives must bereported and there are noexclusions to reporting these measures

    Clinical Quality Measures (CQMs) will bereported in another section, but indicate yes or noif you plan to provide data on CQMs directly fromyour certifed EHR

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 18 Meaningful Use Core Measures Questionnaire (12 of 15)

    STEPS

    Select the appropriateoption under PatientRecords

    Select Yes or No for theEXCLUSION

    If the exclusion appliesto you, click SAVE &CONTINUE

    If the exclusion does notapply to you, check No

    Enter the Numeratorand Denominator

    Click SAVE &CONTINUE

    TIPNOTE: You may log out atany time and continue youattestation later. All of theinformation that you haveentered up until this point will be saved within theattestation module

    Log back into the systemand select the Attestationtab to continue your attestation whenyou return

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 19 Meaningful Use Core Measures Questionnaire (13 of 15)

    STEPS

    Select the appropriateoption under PatientRecords

    Select Yes or No for theEXCLUSION

    If the exclusion applies

    to you, click SAVE &CONTINUE

    If the exclusion does notapply to you, check No

    Enter the Numeratorand Denominator

    Click SAVE &CONTINUE

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    ATTESTATION USER GUIDE

    FOR ELIGIBLE PROFESSIONALS

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    Step 20 Meaningful Use Core Measures Questionnaire (14 of 15)

    Step 21 Meaningful Use Core Measures Questionnaire (15 of 15)

    STEPS

    Select Yes or No.

    Click SAVE &

    CONTINUE

    STEPS

    Select Yes or No.

    Click SAVE &

    CONTINUE

    TIPSThese objectives must bereported and there are noexclusions to reporting these measures

    CQMs will be reported in another section, but indicate yes or no if you plan to provide data onCQMs directly from your certi ed EHR

    This is the second of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 22 Meaningful Use Menu Measures Questionnaire

    STEPS

    Read the instructionsand select fve (5)measures from theMeaningful UseMenu Measuresby clicking on thebox immediatelyfollowing the measure

    Select at least oneand up to two (2)from the PublicHealth list and theremainder from thelist below it

    Click CONTINUE

    TIPS You must select from bothlists even if an exclusionapplies to all measures

    The Attestation modulewill only show you the5 you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 23 Review of the ten Meaningful Use Measures

    Meaningful Use Public Health Measure (1 of 2)

    out of 10 Meaningful Use Menu Measures

    MEASURES

    You must submit atleast one MeaningfulUse Measure from thepublic health list evenif an Exclusion appliesto both

    TIPS You must select from both the PublicHealth list and the Meaningful Uselist that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    a

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Meaningful Use Public Health Measure (2 of 2)

    out of 10 Meaningful Use Menu Measures

    MEASURES

    You must submit atleast one MeaningfulUse Measure from thepublic health list evenif an Exclusion appliesto both

    a

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Menu Measure Objectives (3 of 10)

    MEASURES

    Complete thequestions for the5 measures youselected

    Click SAVE &CONTINUE

    a

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Menu Measure Objectives (4 of 10)

    MEASURES

    Remember, youmust submit at leastone Meaningful UseMeasure from thepublic health list

    a

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Menu Measure Objectives (5 of 10)

    a

    MEASURES

    Complete thequestions for the5 measures youselected

    Click SAVE &CONTINUE

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Additional Menu Measure Objectives (6 of 10)

    a

    MEASURES

    Complete thequestions for the5 measures youselected

    Click SAVE &CONTINUE

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Additional Menu Measure Objective (7 of 10)

    a

    MEASURES

    Complete thequestions for the5 measures youselected

    Click SAVE &CONTINUE

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Additional Menu Measure Objectives (8 of 10)

    MEASURES

    Complete thequestions for the5 measures youselected

    Note that while thisUser Guide reviewsall ten measures, theAttestation modulewill only show youthe fve you selected

    Click SAVE &CONTINUE

    a

    TIP To check your progress click onthe ATTESTATION tab at the topof the page and select Modifyin the Action column in the

    Attestation Selection page. Thecompleted topics have a check mark on the TOPICS screen

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Additional Menu Measure Objectives (9 of 10)

    a

    MEASURES

    Complete thequestions for the5 measures youselected

    Click SAVE &CONTINUE

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

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    Step 23 Review of the ten Meaningful Use Measures (cont.)

    Additional Menu Measure Objectives (10 of 10)

    MEASURES

    Remember, youmust submit at leastone Meaningful UseMeasure from thepublic health list evenif an Exclusion appliesto both

    a

    TIPS You must select from both the PublicHealth list and the Meaningful Use list that follows

    While this User Guide reviews all tenmeasures, the Attestation module will only show you the ve you selected

    This is the third of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 24 Core Clinical Quality Measures (CQMs 1 of 3)EPs.must.report.calculated.CQMs.directly.from.their.certi ed.EHR.technology.as.a.requirement.of.the.EHR.Incentive.Programs .Each.EP.must.report.on.three.

    core.CQMs.(or.alternate.core).and.three.additional.quality.measures .If.one.or.more.core.CQMs.is.outside.your.scope.of.practice,.you.will.have.to.report.on.an.equal.number.of.alternate.core.CQM(s) .If.the.denominator.value.for.all.three.of.the.core.CQMs.is.zero,.an.EP.must.report.a.zero.denominator.for.all.such.core.measures,.and.then.must.also.report.on.all.three.alternate.core.CQMs .If.the.denominator.value.for.all.three.of.the.alternate.core.CQMs.is.also.zero.an.EP.still.needs.to.report.on.three.additional.clinical.quality.measures .Zero.is.an.acceptable.denominator.provided.that.this.value.was.produced.by.certi ed.EHR.technology .

    You will be reporting on a minimum of 6 CQMs or a maximum of 9 CQMs.

    STEPS

    Enter Clinical QualityMeasure 1 of 3

    Enter Demoninatorand Numerator

    Click SAVE &CONTINUE toproceed with

    attestation

    TIPS

    TIPS

    Numerator and Denominator must be whole numbers

    The Denominator must beentered before the Numerator on the remaining screens

    This is the fourth of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    1

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    Step 25 Core Clinical Quality Measures (CQMs 2 of 3)

    STEPS

    Enter Clinical QualityMeasure 2 of 3

    Enter Demoninatorand Numerator

    Click SAVE &CONTINUE toproceed with

    attestation

    TIPS Numerator and Denominator must be whole numbers

    The Denominator must beentered before the Numerator on the remaining screens

    This is the fourth of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

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    Step 26 Core Clinical Quality Measures (CQMs 3 of 3)

    STEPS

    Enter Clinical QualityMeasure 3 of 3

    Enter Demoninatorsand Numerators

    Click SAVE &CONTINUE toproceed with

    attestation

    You will navigateto step 28 unlessyou entered adenominator of zeroin one of the coreCQM measures

    TIPS Enter the number of exclusions after thenumerator

    While the EHR may have been con gured to produce calculations of the measures, theinformation reported for this objective only includes the denominator, numerators and if applicable, the exclusion data for that measure

    This is the fourth of six topicsrequired for attestation 2 3 4 5 6

    TOPICS PROGRESS

    1

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    Step 27 Alternate Clinical Quality Measures (CQMs)

    STEPS

    The screen willprompt you with thenumber of alternatecore CQMs youmust select, and thatnumber is based onthe number of zerosyou reported in thedenominators of core CQMs

    Select your CQMsand Click CONTINUE

    TIPSIf you entered a denominator of

    zero for one of your CQMs, youmust submit one Alternate CoreClinical Quality Measure

    If you entered adenominator of zerofor two of your CQMs,you must submit two

    Alternate Core Clinical Quality Measures

    If you entered adenominator of zero for all of your CQMs, youmust submit all of the

    Alternate Core Clinical Quality Measures

    This is the fth of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    1

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    Step 28 Alternate Clinical Quality Measures Questionnaire

    STEPS

    Enter theDenominator andNumerator for eachpopulation criteria

    Click SAVE &CONTINUE

    TIPS All elds must becompleted

    Only the additional Clinical Quality Measuresyou selected will be presented on the screen

    This is the fth of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    1

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    Step 28 Alternate Clinical Quality Measures (cont.)

    STEPS

    Enter numerator(s),denominator(s) andexclusion

    Click SAVE &CONTINUE

    TIPS All elds must becompleted

    Only the additional Clinical Quality Measuresyou selected will be presented on the screen

    This is the fth of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    1

    https://ehrincentives.cms.gov

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    Step 29 Additional Clinical Quality Measures Question n aire

    STEPS

    Select three (3)Additional ClinicalQuality Measures byclicking on the boximmediately followingthe measures

    Click CONTINUE

    TIPS You will be prompted to enter a numerator, denominator and exclusion on the next pages

    Only the additional Clinical Quality Measures you selected will be

    presented on the screen

    This is the sixth of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

    1

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    Step 29 Additional Clinical Quality Measures (cont.)

    STEPS

    Only the additionalClinical QualityMeasures you selectedwill be presented onthe screen

    Enter Denominator,Numerator andExclusion for the three(3) Additional ClinicalQuality Measureschosen

    Click SAVE &CONTINUE

    This is the sixth of six topicsrequired for attestation 1 2 3 4 5 6

    TOPICS PROGRESS

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    Step 30 - Topics for this Attestation

    STEPS

    When all topicsare marked ascompleted or N/A,you may proceedwith Attestation

    ClickPROCEED WITHATTESTATIONto complete theAttestation process

    The next screenallows you to viewyour entries beforethe fnal submission

    If you choose not toview the summaryof measures you willnavigate to step 32on page 51

    TIPS Click on the MODIFY ATTESTATION to start the process from the AttestationInformation screen

    Clicking MODIFY will navigate back to therst page of the Attestation module. You must

    page through the entire module to completeyour attestation

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    Step 31 Summary of Measures

    STEPS

    Select the measure list

    table to edit a measure

    Click SAVE ANDCONTINUE

    TIPS

    Clicking Save and Continue or Return toSummary Page will bring you back to theMeasure List Table

    CMS recommends you review all of their attestation informationbefore submitting. EPs who fail their attestation can submit their information again, but cannot submit information for the exact same 90-day

    period. The 90-day period can be aday later (3/1-5/31 vs. 3/2-6/1), but that will mean that EPs may have torecalculate all of their numerator and denominator information

    https://ehrincentives.cms.gov

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    Step 31 Summary of Measures (Cont.)

    STEPS

    Click NEXT PAGEtoreview the remainingsummary of measures

    You may EDITanymeasure from thisscreen

    Click CONTINUETO ATTESTto skipviewing the summaryof measures andproceed with yourattestation

    TIPS Click NEXT PAGE to view additional Meaningful UseMenu Measures

    Click on HELP for additional guidance tonavigate the system

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    Step 33 Attestation Disclaimer

    STEPS

    If you answer YESyou will navigateto the AttestationDisclaimer page

    Read the disclaimerand click on AGREE or DISAGREE

    If AGREEis Chosenand you have metall meaningful useobjectives andmeasures you will

    receive the AcceptedAttestationsubmission receipt

    TIPS If DISAGREE is chosen youwill move back to the HomePage and your attestationwill not be submitted

    CMS recommends you review all of their attestation informationbefore submitting. EPs who fail their attestation can submit their information again, but cannot submit information for theexact same 90-day period. The 90-day period can be a day later (3/1-5/31 vs. 3/2-6/1), but that will mean that EPs may have torecalculate all of their numerator and denominator information

    https://ehrincentives.cms.gov

    https://ehrincentives.cms.gov/https://ehrincentives.cms.gov/
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    Step 34 Submission Receipt (Accepted Attestation)

    STEPS

    The AcceptedAttestation submissionreceipt containsattestation trackinginformation

    This concludes the

    Attestation Process

    Click on SUMMARYOF MEASUREStoview the Summaryand Detail of theCore Measures MenuMeasures and ClinicalQuality Measures

    TIPS Please print this receipt for your records. Youwill not receive acon rmation email

    The Summary will indicatewhether the measure isaccepted or rejected

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    Step 35 Submission Receipt (Rejected Attestation)

    STEPS

    Your attestation was

    rejected. You did notmeet one or more of themeaningful use minimumstandards.

    Please reassess/modify yourpractice so that you canmeet the measure(s)

    Review your documentationto ensure the correct

    information was enteredat attestation for each of the objectives and theirassociated measures

    If an error is found, you maymake the correction andresubmit your attestation forthis same reporting period.Or you may submit an

    attestation with informationfor a different reportingperiod during the frstpayment year to successfullydemonstrate meaningful use

    Click on SUMMARY OFMEASURESto review thestatus of the Core Measures,Menu Measures, and ClinicalQuality Measures

    Choose the appropriatemeasure link from thesummary of measures list

    TIPS You may select the STATUS tab for additional information about your EHRincentive program participation

    Click on HELP for additional guidance tonavigate the system

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    Step 36 Summary of Measures Rejected Attestation

    STEPS

    Summary of Meaningful Use CoreMeasures

    Review each measurefor the Accepted/

    Rejected status

    Click NEXT PAGEtocontinue with theMenu measures

    Print the Summary of Measures page for your future reference

    TIP

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    Step 38 Topics for Attestation Resubmission

    STEPS

    Click PROCEED WITHATTESTATION

    Click on each of thelinks in the Summaryof Measures to viewthe details of the listtables of the CoreMeasures, MenuMeasures and ClinicalQuality Measures

    TIPS

    Click CONTINUE to skip viewing the summary and proceed with theattestation submission process

    Click PREVIOUS to go back to previous screen

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    Step 38 Topics for Attestation Resubmission (cont.)

    STEPS

    Select EDITto changea measure beforecompleting yourattestation

    TIP

    CMS recommends you review all of their attestation information beforesubmitting. EPs who fail their attestation can submit their information again, but cannot submit information for the exact same 90-day period. The 90-day period can be a day later (3/1-5/31 vs. 3/2-6/1), but that will mean that EPs may haveto recalculate all of their numerator and denominator information

    https://ehrincentives.cms.gov

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    Step 39 Attestation Statements and Confrmation Page

    Resubmission

    STEPS

    Check each box nextto each statementto attest

    Click on AGREE

    Click on YESat

    You are about to submit thisattestation. Are yousure?

    To continue withyour attestation

    TIP

    Select the DISAGREE button to go to theHome Page (your attestation will not besubmitted), or the AGREE button to proceed with the attestation submission process

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    Step 40 Attestation Disclaimer

    STEPS

    Read the AttestationDisclaimer andClick on AGREEorDISAGREE

    TIP If DISAGREE is chosen you will be directed back to the Medicare Attestation Instructions page toModify or Cancel your attestation

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    Have Questions?

    RESOURCESContact the EHR Information Center Help Desk for Questions concerning

    registration and attestation, (888) 734-6433 / TTY: (888) 734-6563Hours of operation: Monday-Friday 8:30 a.m. 4:30 p.m. in all time zones

    (except on Federal holidays)

    Identi cation & Authentication System (I&A) Help Desk for assistance, PECOS External User Services (EUS) Help Desk

    Phone: 1-866-484-8049E-mail: [email protected]

    NPPES Help Desk for assistance. Visit;https://nppes.cms.hhs.gov/NPPES/Welcome.do

    (800) 465-3203 / TTY (800) 692-2326

    PECOS Help Desk for assistance.Visit; https://pecos.cms.hhs.gov /

    (866)484-8049 / TTY (866)523-4759

    Certi ed health IT Product website - Of ce of the National Coordinator (ONC)http://onc-chpl.force.com/ehrcert/CHPLHome

    EHR Incentive Program; visit http://www.cms.gov/EHRIncentivePrograms /

    STEPS

    The HELPlink is onevery screen. ClickHELP for additionalinformation

    https://ehrincentives.cms.gov

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    Acronym Translation

    A CR ONYM S

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    CCN CMS Certification NumberCMS Centers for Medicare & Medicaid ServicesCQM Clinical Quality MeasuresDMF Social Security Death Master FileEH Eligible HospitalEHR Electronic Health RecordEIN Employers Identification NumberEP Eligible Professional

    FI Fiscal IntermediaryFQHC Federally Qualified Health CenterI&A Identification & Authentication SystemIDR Integrated Data RepositoryLBN Legal Business NameMAC Medicare Administrative ContractorMAO Medicare Advantage OrganizationNLR National Level RepositoryNPI National Provider IdentifierNPPES National Plan and Provider Enumeration System

    OIG Office of the Inspector GeneralPECOS Provider Enrollment, Chain and Ownership SystemRHC Rural Health CenterSSN Social Security NumberTIN Tax Identification Number

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