From CMS…

Thursday, October 3rd is the Start of the Last 90-Day EHR Reporting Period for the Promoting Interoperability Programs

The Centers for Medicare & Medicaid Services (CMS) would like to remind Medicare Promoting Interoperability Program participants that the electronic health record (EHR) reporting period in 2019 is a minimum of any continuous 90-day period in CY 2019, through December 31, 2019.

Thursday, October 3rd is the last possible start date for the 90-day EHR reporting period for new and returning eligible hospitals, dual-eligible hospitals, and critical access hospitals (CAHs) in 2019. Failure to demonstrate that a hospital or CAH is a meaningful EHR user for a continuous 90-days will result in a downward payment adjustment.

In addition to a continuous 90-day EHR reporting period and other program requirements, Medicare Promoting Interoperability Program participants must:
• Use 2015 Edition Certified EHR Technology (CEHRT) for a minimum of any continuous 90-day period
Note: The 2015 Edition CEHRT did not have to be implemented on January 1, 2019, but the functionality must be in place by the first day of the EHR reporting period.
• Submit a “yes” to the Prevention of Information Blocking Attestations
• Submit a “yes” to the ONC Direct Review Attestation
• Report the required numerator and denominator or yes/no measures from each of the four objectives or claim their exclusion(s)
• Earn a minimum total score of 50 points
• Report on four self-selected eCQMs from the set of 16 available

For More Information
To learn more about these requirements, please review the:
2019 Medicare Promoting Interoperability Program Requirements
FY 2019 IPPS and Medicare Promoting Interoperability Program Overview Fact Sheet

For more information on the Promoting Interoperability Programs, visit the Promoting Interoperability Programs website.

Contact us at Kentucky REC with your questions about the Promoting Interoperability Program. Our team of experts is here to help: 859-323-3090.


The quality team at Kentucky REC is excited to host a collaborative webinar with two guest experts: Bruce Maki, a Regulatory Analyst and Program Manager for QPP Advisors at Altarum in Michigan; and Samuel Ross, a Health Informatics Facilitator from Chicago Health IT Regional Extension Center. Bruce and Samuel bring knowledge and skill in healthcare policy and the Quality Payment Program.

Together we will answer your questions and concerns about the QPP. Whether you are in a large or small practice, this session will help you better understand your flexibilities within the program and grasp how to shoot for that potential positive incentive.

Webinar – QPP Year 3: Experts Answer Your QPP Questions
Tuesday October 22, 12:30 – 1:30 p.m. ET

Contact us at Kentucky REC with your questions about the Quality Payment Program. Our team of experts is here to help: 859-323-3090.


Is your organization facing a recently issued audit from CMS?

Are you aware of the steps to take in filing a hardship exception application?

Do you know what the process is to request a targeted review on your feedback report?

Now is the time to make a difference for your practice for the previous years of the QPP, and for 2019.

Knowing these subjects in detail gives you the power to shape your performance in the QPP, correct inaccuracies, and close out previous program years with confidence. Being up to date with audit, hardship, and targeted review opportunities are great ways to control your data and scores in the program, and ensure that your provider(s) performance is accurate before public reporting.

We will discuss what each of these procedures are, what to expect, how to address them, and when they should be a major focus for your organization.

Webinar – QPP Year 3: Audits, Hardships, and Targeted Reviews
Thursday Sept 26, 12:30 – 1:30 p.m. ET

Contact us at Kentucky REC with your questions about the Quality Payment Program. Our team of experts is here to help: 859-323-3090.




Webinar – Medicaid Promoting Interoperability for EPs: How to Succeed in Stage 3
Wednesday Sept. 25, 12:00 – 1:00 p.m. ET

As we approach the end of 2019, it is crucial to be making progress toward meeting the Promoting Interoperability (MU) Stage 3 objectives and measure. Your Health IT advisors at the KY REC are ready to assist you along the way. Below is important information regarding the EHR incentive program and recommended beginning steps for success. Contact us to schedule a meeting to review your Stage 3 reports and assist with your workflow assessments for the new measures.

EHR Reporting Period for 2019
For 2019, the EHR reporting period for Medicaid EPs is a minimum of any continuous 90 day period within the calendar year. Attestations must be submitted by 03/31/2020 for the Kentucky Medicaid EHR Incentive Program.

2015 Edition Certified EHR Technology
All participants in the Medicaid Promoting Interoperability Program are required to use 2015 Edition CEHRT. The 2015 Edition CEHRT did not have to be implemented on January 1, 2019. However, the functionality must be in place by the first day of the EHR reporting period and the product must be certified to the 2015 Edition criteria by the last day of the EHR reporting period.

Electronic Clinical Quality Measures (eCQM) for 2019
Medicaid EPs who are returning participants must report on a one year eCQM reporting period, and first-time meaningful users must report on a 90-day eCQM reporting period. EPs are required to report on any six eCQMs related to their scope of practice. In addition, Medicaid EPs are required to report on at least one outcome measure. If no outcome measures are relevant to that EP, they must report on at least one high-priority measure. If there are no outcome or high priority measures relevant to an EP’s scope of practice, they must report on any six relevant measures.

Here is a list of available eCQMs for EPs in 2019.

Objectives and Measures: EPs must attest to Stage 3 Objectives and Measures for 2019:


Specification sheet links for Stage 3 Measures can be found here.

Important Beginning Steps to Be Successful
  • Contact your vendor to determine:
    1. When will I receive my 2015 CEHRT upgrade?
    2. Are my Stage 3 reports available?
    3. Is the Application Program Interface (API) enabled?
      • Do you have instructions available on how to use the API that can be given to our patients?
    4. Are there instructions or training materials available to learn about the new features with our upgrade?
      • New clinical reconciliation button?
      • How to incorporate summary of care into EHR?
      • Sending patient education to portal?
      • Submitting patient generated health data?
  • Schedule your Security Risk Analysis for 2019 with the Kentucky REC
  • Run your Stage 3 Promoting Interoperability (MU) reports regularly and work with your Health IT advisor to review
  • Run your patient volume report for 90 days in April – June and return to your Health IT advisor

IMPORTANT — If you are planning on attesting to the Immunization Registry public health option, be sure to sign the new bi-directional immunization registry addendum with the Kentucky Health Information Exchange. The old immunization registry addendum WILL NO LONGER BE ACCEPTED for attestations. This must be signed within 60 days of the start of your reporting period.

Contact us at Kentucky REC with your questions about Promoting Interoperability. Our team of experts is here to help: 859-323-3090.



The Kentucky Diabetes Prevention and Control Program (KDPCP) at the Kentucky Department for Public Health (KDPH) recently received a multi-year grant from the Centers for Disease Control and Prevention (CDC) to improve diabetes clinical outcomes. Through the grant, the state of Kentucky has chosen to focus on the implementation of a robust Diabetes Clinical Quality Improvement Learning Collaborative (DLC). We have one space left for a motivated practice. The FINAL DEADLINE to join is Monday, September 23rd.


Contact us at 859-323-3090 or email Kentucky REC.

The Basics:

  • 12 month Learning Collaborative
  • Health care organizations learn from each other and experts in the field
  • Participants will undertake small tests of change to reach self-identified objectives within their own organizations

Focus: Health care organizations will make “breakthrough” increases in the adoption and use of clinical systems and care practices to improve health outcomes in people with diabetes


Health Care Systems/Clinical Practices can improve clinical outcomes for your patients and practice. This learning collaborative can contribute to and augment your other quality improvement programs and initiatives to improve healthcare, reduce cost, and move to value based care.


1. Requirements: practice established for at least one year; minimum two full time employees; have at least 100 adult patients with diabetes diagnosis
2.  Complete an application
3.  One year commitment


The Kentucky Department for Public Health (KDPH) serves as the lead agency for facilitation of the CDC grant.

The KY Regional Extension Center (KY REC) serves as the lead agency for the pilot and will facilitate meetings and serve as expert consultant in electronic health record workflow.
The Kentucky Health Information Exchange (KHIE) serves as an important partner to set up LHDs and YMCA with CareAlign DSM accounts/mailboxes to support bi-directional exchange of secure patient health information with select practices.

Questions? Contact us at 859-323-3090 or Kentucky REC.

More details can be found here.
Application can be accessed here.


Excerpted and edited from CMS Daily Digest Bulletin available at

If you participated in the Merit-based Incentive Payment System (MIPS) in 2018, your performance feedback, which includes your MIPS final score and payment adjustment factor(s), is now available for review on the Quality Payment Program website. The MIPS payment adjustment you will receive in 2020 is based on your final score. A positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished under the Medicare Physician Fee Schedule in 2020.

MIPS eligible clinicians or groups (along with their designated support staff or authorized third-party intermediary), including APM participants, may request that CMS review their performance feedback and final score calculation through a process called targeted review. The deadline to submit your request is September 30, 2019 at 8:00 PM (EDT).

When to Request a Targeted Review

If you believe an error has been made in your 2020 MIPS payment adjustment factor(s) calculation, you can request a targeted review until September 30, 2019 at 8:00 PM EDT. The following are examples of circumstances in which you may wish to request a targeted review:
• Errors or data quality issues for the measures and activities you submitted
• Eligibility and special status issues (e.g., you fall below the low-volume threshold and should not have received a payment adjustment)
• Being erroneously excluded from the APM participation list and not being scored under the APM scoring standard
PLEASE NOTE: The above is not a comprehensive list of circumstances.

CMS encourages you to contact the Quality Payment Program if you believe a targeted review of your MIPS payment adjustment (or additional MIPS payment adjustment) is warranted. We’ll help you to determine if you need to submit a targeted review request.

How to Request a Targeted Review

You can access your MIPS final score and performance feedback and request a targeted review by:
• Go to the Quality Payment Program website
• Log in using your HCQIS Access Roles and Profile System (HARP) credentials; these are the same credentials that allowed you to submit your MIPS data. Please refer to the QPP Access User Guide for additional details, including if you do not have a HARP account or role.

When evaluating a targeted review request, CMS may require additional documentation to support the request. If your targeted review request is approved, CMS may update your final score and/or associated payment adjustment (if applicable), as soon as technically feasible. CMS will determine the amount of the upward payment adjustments after the conclusion of the targeted review submission period.

Please note that targeted review decisions are final and not eligible for further review.
For More Information

To learn more about the steps for requesting a targeted review, please review the following:
2018 Targeted Review Fact Sheet
2018 Targeted Review Frequently Asked Questions


If you have questions about your performance feedback or MIPS final score, or whether you should submit a targeted review request, please contact the Quality Payment Program by:
• Phone: 1-866-288-8292/TTY: 1-877-715-6222
• Email:

Contact us at Kentucky REC with your questions about the Quality Payment Program. Our team of experts is here to help: 859-323-3090.