Medicaid EHR Incentive program rules for calculating patient volume

Jan. 17, 2011 - PRLog -- The Medicaid EHR Incentive program on the CMS.gov website is a good resource for the basic rules of the program, however it didn’t seem to address how to calculate if an EP qualifies under the “30% of patient volume” for Eligible Providers (EP’s) or 20% for Pediatrician EP’s. Here is the answer straight from the Federal Register on page 44485:

“For Medicaid EPs, the general rule (subject to the two exceptions listed below) is that the EP must have at least 30 percent patient volume attributable to those who are receiving Medicaid. Section 1903(t)(2)(A)(i) of the Act provides authority to the Secretary to establish the methodology by which such patient volume will be estimated; our proposed methodologies which follow, are based on this discretion.

To establish such patient volume, we proposed that the EP have a minimum of 30 percent of all patient encounters attributable to Medicaid over any continuous, representative 90-day period within the most recent calendar year prior to reporting. There are two statutory exceptions to the general 30 percent rule discussed previously. The first exception is that a pediatrician may have at least 20 percent patient volume attributable to those who are receiving medical assistance under the Medicaid program, as estimated in accordance with a methodology established by the Secretary (section 1903(t)(2)(A)(ii) of the Act).

Again, the method we proposed to use was that the pediatrician have a minimum 20 percent of all patient encounters attributable to Medicaid over any continuous, representative 90-day period within the most recent calendar year prior to reporting. The second exception is that Medicaid EPs practicing predominantly in an FQHC or RHC must have a minimum of 30 percent patient volume attributable to ‘‘needy individuals.’’ Again, the method we would use is that 30 percent of all patient encounters be attributable to needy individuals over any continuous 90-day period within the most recent calendar year prior to reporting.”

In essence, this would mean that an EP/practice could choose any 90-day period in 2011 between January 1 – December 31, 2011 to report their percentage of patient encounters. Notice that, unlike the Medicare EHR Incentive, it is not based on billings. Instead it is based on the percentage of the overall volume of patient visits that were Medicaid participants.

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