Cody Frew


Step-by-Step Attestation Guide for Meaningful Use 2015

February 2, 2016


Clinician 9 Minute Read

This attestation guide is designed to help you through the attestation process for the CMS – EHR Incentive Program and is specific to Medicare. If you plan to attest for Medicaid please contact your state Medicaid office for further details.

What You’ll Need to Get Started

  • Meaningful Use Report for each provider attesting with CMS>
  • CQM data for each provider attesting with CMS (contact your EHR/EMR vendor if you need assistance).
  • Security Risk Analysis Documentation
  • Public Health Reporting: Active engagement letter/email or exclusion documentatio
  • EHR Certification Number
  • NPPES login information for CMS attestation website
  • Document any exclusions you will be taking and make sure to attach necessary documentation to prove the exclusion.

    Below is an example exclusion form created by ChartLogic. You can download this form here.

2015MU-0.1

1. Login to your EHR/EMR and generate the report for each provider using the correct date range.

2. Below is an example of a Meaningful Use Report for 2015.

2015MU-2.1

CMS has an Attestation Calculator designed to assist you with the process. Click here to launch.

3. Once you’ve gathered all necessary items to attest, proceed to the following link:

https://ehrincentives.cms.gov/hitech/login.action

Read any system announcements and schedule your attestation accordingly. Click Continue, when ready.

2015MU-3.1

Carefully review the About This Site information. Click Continue, when ready.

2015MU-3.2

Carefully read the information on the Warning page. Check the box to indicate that you are aware of the statements on this page and click Continue, when ready.

2015MU-3.3

The next page will allow you to login or create an NPPES login. If you are having issues with your User ID/Password and are unable to log in, please contact the CMS EHR Incentive Program Information Center: 888-734-6433 / TTY: 888-734-6563

2015MU-3.4

Eligible Physicians (EP) or users working on behalf of an EP can create a NPPES login by following the instructions below:

2015MU-3.5

2015MU-3.6

4. Once successfully logged in, you’ll see three options; Registration, Attestation and Status.

  • Registration: Here you can add personal information and review registration status for the EP.
  • Attestation: Here you can start a new attestation, discontinue, modify, or continue an incomplete attestation.
  • Status: Here you can view the status of an EP’s previous attestations and incentive payments.

When ready, click Attestation to begin the attestation process.

2015MU-4.1

This will take you to the Medicare Attestation Selection page. Here you’ll see previous attestation years to verify your current program year. When ready, click Attest on the current year.

2015MU-4.2

This will take you to the main Attestation page. From here you’ll click Attestation Information to get started.

2015MU-4.3

Verify that the Certification number is correct and select a valid date range for the reporting period. When ready, Click Save & Continue.

2015MU-4.4

The next page will go over measures required by CMS to meet meaningful use. At the bottom of this page, you’ll need to select the public health options you’ll be attesting for. You may need to claim an exclusion if your public health agency does not accept public health reporting data, or you don’t meet the criteria to report on these measures.

If claiming an exclusion on any of the Public Health Reporting Measures, you’ll be required by CMS to report on or also claim an exclusion on the remaining measures listed below.

2015MU-4.5

*If you claim an exclusion on any measure, CMS also wants exclusion information for the remaining measures.

5. Important Information Regarding Exclusions and Attestation:

Not all measures have an available exclusion. For measures with an available exclusion, you will need to specify if the exclusion applies to the provider. You will need to do this for each provider and each excluded measure, per objective. If the exclusion applies, click Yes when asked “Does this exclusion apply to you?” and document the reasons as to why you are excluded from this measure. Use the Meaningful Use Exclusion Document available here.

If you do not qualify for an exclusion, you’ll click No when asked, “Does this exclusion apply to you?” You’ll then have to record a numerator and denominator from the 2015 Meaningful Use Report to satisfy the measure.

Keep copies of all exclusion documentation, as this will assist with any future audits.

6. Below are step-by-step screenshots of the attestation process.

Objective 1: Protect Patient Information

This measure is asking for the Security Risk Analysis that is dated during the reporting period. HealthIT.gov offers a free tool to assist in completing this measure. Click here to launch the tool.

2015MU-Q 1

Objective 2: Clinical Decision Support Rule

2015MU-Q 2A

2015MU-Q 2B

Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 2B.1

Objective 3: CPOE – Medications, Labs, and Radiology

2015MU-Q 3A

Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 3A.1

2015MU-Q 3B

Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 3B.1

2015MU-Q 3C

Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 3C.1

Objective 4: Electronic Prescribing

2015MU-Q 4Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 4.1

Objective 5: Health Information Exchange – Summary of Care

2015MU-Q 5

Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 5.1

Objective 6: Patient Education

2015MU-Q 6

Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 6.1

Objective 7: Medication Reconciliation

2015MU-Q 7Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 7.1

Objective 8: Timely Access

2015MU-Q 8A2015MU-Q 8B

Indicate whether this exclusion applies to you or not. If not:

2015MU-Q 8B.1

Objective 9: Secure Messaging

2015MU-Q 9

Objective 10: Public Health Reporting

Measures 10A, 10B, and 10C will require your state’s Department of Health (DOH) to have the ability to accept this information. Please visit your state’s DOH website to verify the capability to report on Immunization registry, Syndromic Surveillance, or other specialized registries.

2015MU-Q 10A

2015MU-Q 10B

2015MU-Q 10C

7. Once you’ve completed Attestation Information and Meaningful Use Objectives, you’ll click Clinical Quality Measures to complete the last portion of attestation.

2015MU-7.1

This will bring you to Reporting Clinical Quality Measures. For example, ChartLogic software is certified for nine CQM measures. You’ll click Option 2 to select the correct CQM measures.

2015MU-7.2

You’ll now be on the CQM Selection page. Read the Instructions listed below and select the nine CQM measures. Click Save & Continue.

2015MU-7.3

All nine CQM Measures are required to be reported on for successful attestation. To obtain CQM data please contact your EHR/EMR vendor.

Measure ID Measure Title CMS Domain
CMS138 Preventative Care and Screening: Tobacco Pop/Pub Health
CMS153 Chlamydia Screen for Women Pop/Pub Health
CMS117 Childhood Immunization Status Pop/Pub Health
CMS166 Use of Imaging Studies for Low Back Pain Efficient use of Healthcare Resources
CMS165 Controlling High Blood Pressure Clinical Process
CMS126 Use of Appropriate Medication for Asthma Clinical Process
CMS127 Pneumonia Vaccinations for the Elderly Clinical Process
CMS123 Diabetes Foot Exam Clinical Process
CMS65 Hypertension: Improve in Blood Pressure Clinical Process

At this point in the attestation, you are ready to record CQM data.

  • Provider Percentage from the CQM report will populate the ‘Performance Rate’ field listed below.
  • ‘0’ will always be added to the Exception or Exclusion field for CQMs.

2015MU-7.4q

2015MU-7.5q

2015MU-7.6q

2015MU-7.7q

2015MU-7.8q

2015MU-7.9q

2015MU-7.10q

2015MU-7.11q

2015MU-7.12q

8. Once you are done, click save and continue. It will then take you back to the main page showing that all three items are completed. You will need to click continue attestation.

2015MU-8.1

On the next page you will be asked to ensure that this information is correct. Once you review this data for accuracy, you will have the option to submit.

After submitting your attestation, we suggest printing the acceptance receipt and keep all reports, exclusions and supporting documentation for this attestation period.  This information will be required as proof of your answers in the event of an audit.

What You’ll Need in Case of a CMS Audit

  • Copy of MUC 2015 Report form EHR/EMR for the reporting period.
    • Verify that all information on the report is clearly visible. Incomplete or unreadable reports will be rejected in the case of an audit.
  • Copy of CQM data from EHR/EMR for the reporting period.
  • Security Risk Analysis dated during the reporting period.
    • This is the sole responsibility of your practice.
  • Documentation proving your answers for public health options 10A, 10B, and 10C. Examples of the documentation include:
    • Email/letter from state or local health agencies indicating that you are actively engaged
    • Email/letter from state or local health agencies indicating that you are not required to participate
    • Dated screenshot from the state or local health agency indicating that you are not required to participate

If you have any questions related to attestation or would like to purchase attestation assistance, please contact ChartLogic: 800-838-5899 or contact us.



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