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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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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/8/7/2019 Attestation User Guide for Eligible Professionals - Medicare Electronic Health Record (EHR) Incentive Program
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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mailto:[email protected]://nppes.cms.hhs.gov/NPPES/Welcome.dohttps://pecos.cms.hhs.gov/http://onc-chpl.force.com/ehrcert/CHPLHomehttp://www.cms.hhs.gov/EHRIncentiveProgramshttps://ehrincentives.cms.gov/https://ehrincentives.cms.gov/http://www.cms.hhs.gov/EHRIncentiveProgramshttp://onc-chpl.force.com/ehrcert/CHPLHomehttps://pecos.cms.hhs.gov/https://nppes.cms.hhs.gov/NPPES/Welcome.domailto:[email protected]8/7/2019 Attestation User Guide for Eligible Professionals - Medicare Electronic Health Record (EHR) Incentive Program
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Acronym Translation
A CR ONYM S
Click Here
Register for CMSElectronic Health Record Incentives
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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NOTES:
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