Short Demo for PC Attestation (coming soon)Short Demo for PC Attestation (duration: 6:00 minutes)
https://attendee.gotowebinar.com/recording/2525920586566070019
What’s in this section:
General Information about Perinatal Care Attestation
Examples
How to Attest
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General Information
For CY2021CY2024: Hospitals can attest to submitting TWO FOUR quarters of ePC measures -06 measure (eCQMseCQM) instead of four quarters of chart-abstracted PC measures for their Perinatal Care measures via the Chart-Abstracted Submission menu.For CY2022: Hospitals can attest to submitting THREE quarters of ePC measures (eCQMs) instead of four quarters of chart-abstracted PC -06 measures for their Perinatal Care measures via the Chart-Abstracted Submission menu.
NOTE: This is a one for one replacement:
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Correct: submit ePC- |
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06 instead of PC- |
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06 Not Correct: submit ePC-02 instead of PC- |
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May replace none, some, or all required PC measures with ePC measures.
For CY2021: 2 quarters of PC eCQM data = 4 quarters of the associated chart-abstracted PC measure data
For CY2022: 3 quarters of PC eCQM data = 4 quarters of the associated chart-abstracted PC measure data
06 |
If an organization is uncertain the eCQM data can be submitted (e.g., ePC-06), we strongly suggest the chart-abstracted data is entered until it is certain the eCQM data can be successfully submitted.
A PC measure submitted as a chart-abstracted measure for all 4 quarters, may also be submitted as an eCQM.
If applicable, every ePC eCQM submitted for (CY2021 2 quarters / CY2022 3 quarters) counts towards both an organization's PC requirement and eCQM requirement.
2. Examples:
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Example 1
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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Y
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Y
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Y
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Y
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HCO submits all 4 quarters of only chart-abstracted measures on all PC measures; no ePC eCQM data are used to meet the Perinatal Care requirement.
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eCQM
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N
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N
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N
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N
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Example 2a (CY2021)
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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Y
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Y
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N
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N
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Organizations should begin submitting chart-abstracted PC-06 for 1Q and subsequent quarters if they are uncertain they can submit ePC-06 (eCQM) - see examples below.
REMINDER: In order to meet chart-abstracted measure requirements, data is submitted for four quarters. Submitting less than four quarters of an eCQM does not meet the requirement.
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Correct: submit PC-06 as a chart abstracted measure for 1Q, 2Q, then switch to eCQMs and submit ePC-06 data for four quarters Not Correct: submit PC-06 as a chart abstracted measure for 1Q, 2Q, then switch to eCQM and submit quarters 3Q and 4Q |
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Examples: |
HCO submits all 4 quarters of chart-abstracted PC
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eCQM
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N
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N
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Y
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Y
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Example 2b (CY2022)
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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Y
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N
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N
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N
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-06 and ePC-02 and ePC-07
The Perinatal Care requirement is met by submitting four quarters of chart-abstracted PC
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-06, plus four quarters of ePC
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eCQM
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N
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Y
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Y
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Y
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Example 3a (CY2021)
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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N
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N
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N
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N
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HCO does not submit 1Q chart-abstracted PC measures and is required to submit 2 quarters of ePC eCQM data. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement.
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eCQM
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N
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Y
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Y
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N
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Example 3b (CY2022)
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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N
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N
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N
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N
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HCO does not submit 1Q chart-abstracted PC measures and is required to submit 3 quarters of ePC eCQM data. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement.
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eCQM
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N
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Y
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Y
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Y
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Example 4a (CY2021)
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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Y
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Y
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Y
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Y
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HCO submits 1 chart-abstracted PC measure for all 4 quarters.
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eCQM
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N
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Y
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Y
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N
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HCO submits 3 ePC eCQMs for 2 quarters. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement; hospital must submit one additional eCQM.
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Example 4b (CY2022)
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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Y
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Y
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Y
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Y
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HCO submits 1 chart-abstracted measure PC for all 4 quarters.
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eCQM
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N
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Y
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Y
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Y
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HCO submits 3 ePC eCQMs for 3 quarters. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement; hospital must submit one additional eCQM.
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-02, and ePC-07 eCQM data.
HCO submits first quarter of chart-abstracted PC-06 measure, then switches to submitting all four quarters of ePC-06 as an eCQM instead
The Perinatal Care requirement is met by submitting four quarters of ePC-06, ePC-02, and ePC-07 eCQM data.
HCO receives feedback on both chart-abstracted data submitted for the first quarter, and eCQM data submitted.
HCO does not submit chart-abstracted PC-06 measures during 1Q
The HCO is required to submit eCQM ePC-06 data in order to meet the PC requirement, in addition to ePC-02 and ePC-07 for the entire calendar year.
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How To Attest: |
Click on the open button for the Perinatal Care measure for which you wish to attest to submit via eCQM.
Select the toggle on the right-hand side, “Attest to submit via eCQM”. By clicking on that toggle, you are attesting that you will be submitting this measure as eCQM data instead of aggregate chart-abstracted data.
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This attestation begins with the currently open quarters for which aggregate data has not already been submitted, as well as applying to future quarters of the specified measure.
Aggregate data which has already been submitted, including the open quarters, will continue to be used by The Joint Commission.
If aggregate data has been entered into open quarters, you may delete it prior to attesting to submitting eCQM data. However, if data was entered for closed quarters, that data may not be deleted because it was already used in Joint Commission analysis.
After clicking the attest toggle, you will see the following message under the quarter tabs: “By clicking this link, you are agreeing that you will be submitting the required information via the eCQM Submission process. Are you sure you want to continue?”
If you return to the Measure List page, this chart-abstracted measure will now be shown as complete for all open quarters.
Note that while “Attest to submit via eCQM” is selected, you cannot change or remove already entered Chart-Abstracted data for that measure.
If you previously selected “Attest to submit via eCQM” but now wish to enter chart-abstracted data instead for an open quarter, simply click on the toggle to turn the attestation selection off. This will allow you to enter chart-abstracted data for each open quarter.
When “Attest to Submit via eCQM” is selected, the chart-abstracted data may no longer be changed. The data are visible within the Chart-Abstracted module as a reference for what was or will be submitted. This action applies to all open and future quarters."
If all four quarters of a measure have been entered as chart-abstracted data, attestation for that measure is not allowed. Organizations can opt to:
Leave the attestation button set to “Off” and submit both chart-abstracted and eCQM data for the measure; feedback on all entered/submitted data will be provided.
Clear all quarters of chart-abstracted data for the measure, then attest to submit the measure as an eCQM (if applicable to the organization requirements).