CMS provides guidance on patient volume calculations under Stage 2 final rule


The final rule for Stage 2 of the Medicare and Medicaid EHR Incentive Programs provides new criteria that eligible professionals (EPs) and eligible hospitals must meet in order to qualify for available incentives. According to the Centers for Medicare & Medicaid Services (CMS), which administers the programs, the Stage 2 final rule includes important changes to the Medicare EHR Incentive Program – notably, determination of patient volume calculations.

In a notice circulated on Aug. 28, CMS stated that the changes to Medicaid patient volume calculations are applicable to EPs regardless of the stage of the EHR Incentive Program in which they are participating.

CMS provided answers to the following frequently asked questions regarding patient volume calculations.

Medicaid changes to patient volume calculations
Q: The Stage 1 rule stated that, in order for a Medicaid encounter to count toward the patient volume of an EP, Medicaid had to either pay for all or part of the service, or pay all or part of the premium, deductible or coinsurance for that encounter. The Stage 2 rule now states that the Medicaid encounter can be counted toward patient volume if the patient is enrolled in the state's Medicaid program (either through the state's fee-for-service programs or the state's Medicaid managed care programs) at the time of service without the requirement of Medicaid payment liability. How will this change affect patient volume calculations for Medicaid eligible providers?

A: Billable services provided by an EP to a patient enrolled in Medicaid would count toward meeting the minimum Medicaid patient volume threshold, regardless of Medicaid's payment liability for the services, and irrespective of whether the provider is in Stage 1 or Stage 2 of the incentive program. Click here for additional detail from CMS.

CHIP patients eligible to be included in Medicaid patient volume totals
Q: The Stage 2 Rule describes changes to how a state considers CHIP patients in the Medicaid patient volume total when determining provider eligibility. Patients in which kinds of CHIP programs are now appropriate to be considered in the Medicaid patient volume total?

A: States that have offered CHIP as part of a Medicaid expansion under Title 19 or Title 21 can include those patients in their provider's Medicaid patient volume calculation as there is cost liability to the Medicaid program in either case. (In Stage 1, only CHIP programs created under a Medicaid expansion via Title 19 were eligible.) This change to the patient volume calculation is applicable to all EPs, regardless of the stage of the incentive program in which they are participating. Click here for additional detail from CMS.

For more information from CMS on the Stage 2 final rule, click here.