Patient Volume


Each provider applying for a Medicaid EHR incentive payment must demonstrate patient volume thresholds for each year of program participation. PLEASE NOTE that CMS Rules do not allow recycling eligibility criteria in subsequent Program Years. This means providers cannot re-use or overlap any dates of a patient volume 90-day time period from a previous Program Year attestation.

The EHRIP Team receives many questions around selecting the correct 90-day Patient Volume time period. We have listed the most frequently found issues below with links to the individual descriptions and solutions.


The CMS EHRIP Definition of Medicaid Encounter

A  patient encounter is any service rendered to an individual on any one day.

Medicaid encounter is any service rendered to an individual on any one day where:

  • Medicaid paid for part or all of the service,
  • Medicaid paid all or part of the individual's premiums, co-payments, and cost-sharing, or
  • The individual was enrolled in a Medicaid program at the time the billable service was provided.
  • For FQHCs allowed to include Needy encounters in their patient volume calculation, services rendered on any one day to an individual can be counted if:
    • The services were furnished at no cost;
    • The services were paid for at a reduced cost based on a sliding scale determined by the individual's ability to pay.

To calculate Medicaid patient volume, an EP must divide:

The total Medicaid encounters in any representative, continuous 90-day period (M90) by

The total for all patient encounters in the same 90-day period.  (A90)

M90 ÷ A90 = Patient Volume

FQHCs calculate patient volume by adding Needy encounters in the same 90-day period (N90):

(M90 + N90) ÷ A90 = FQHC Patient Volume

 

Avoid this common error when calculating patient volume

DO NOT COUNT multiple claims for services for the same patient by the same provider on the same day. Please keep in mind that the patient volume calculation assesses ENCOUNTERS, not claims, and requires the provider to remove duplicate encounters on the same day for both the numerator (M90) and denominator (A90).


EP 90-Day Patient Volume Reporting Period Options

 

Many providers and preparers have questions around selecting the 90-day Patient Volume time period for the two options available, as shown in the MAPIR attestation screens:

Calendar Year Preceding Payment Year
or
12 Months Preceding Attestation Date

 

Entering a start date that violates the rules of your 90-day Patient Volume period option will produce an error message: (“The date that you have specified is invalid)and you will not be able to proceed with your application.

To avoid this confusion, consult this guideline illustrating how to select the right 90-day Patient Volume period: Patient Volume Reporting Period Options.

 

IMPORTANT: The Patient Volume 90-Day period for an individual practioner or any member of a Group Patient Volume Definition cannot overlap a previous Program Year 90-Day Patient Volume Period.  CMS Rules do not allow recycling eligibility criteria in subsequent Program Years, e.g., re-using all or part of a patient volume period from a previous Program Year attestation.


EP Patient Volume Tool

Guidance and a template for compiling the necessary data in the required formats during the attestation process. It is strongly recommended that the Patient Volume Tool be uploaded with each provider's attestation.


Rule References

 

Medicaid EHRIP Patient Volume Requirements

The following excerpts from the official Final Rules establishing the EHR Incentive Program provide definitive guidance for calculating Medicaid patient volume. Yellow highlight generally refers to Eligible Professional criteria, and blue highlight generally refers to Eligible Hospital criteria.

 

Source: Code of Federal Regulations

Title 42: Public Health

PART 495—STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM

Subpart D—Requirements Specific to the Medicaid Program

Sections 495.304 and 495.306

 

Links to the complete Rule language are follows:

75 Federal Register 44565; July 28, 2010

77 Federal Register 54160, Sept. 4, 2012

Electronic Code of Federal Regulations (e-CFR), for an updated, unofficial compilation of CFR material and Federal Register amendments.  

 

Sec.  495.304  Medicaid provider scope and eligibility.

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(c) Additional requirements for the Medicaid EP. To qualify for an EHR incentive payment, a Medicaid EP must, for each year for which the EP seeks an EHR incentive payment, not be hospital-based as defined at Sec. 495.4 of this subpart, and meet one of the following criteria:

(1) Have a minimum 30 percent patient volume attributable to individuals enrolled in a Medicaid program.

(2) Have a minimum 20 percent patient volume attributable to individuals enrolled in a Medicaid program, and be a pediatrician.

(3) Practice predominantly in a FQHC or RHC and have a minimum 30 percent patient volume attributable to needy individuals, as defined at
Sec. 495.302.

(d) Exception. The hospital-based exclusion in paragraph (c) of this section does not apply to the Medicaid-EP qualifying based on practicing predominantly at a FQHC or RHC.

(e) Additional requirement for the eligible hospital. To be eligible for an EHR incentive payment for each year for which the eligible hospital seeks an EHR incentive payment, the eligible hospital must meet the following criteria:

(1) An acute care hospital must have at least a 10 percent Medicaid patient volume for each year for which the hospital seeks an EHR incentive payment.

(2) A children's hospital is exempt from meeting a patient volume threshold.

(f) Further patient volume requirements for the Medicaid EP. For payment year 2013 and all subsequent payment years, at least one clinical location used in the calculation of patient volume must have Certified EHR Technology--

(1) During the payment year for which the EP attests to having adopted, implemented or upgraded Certified EHR Technology (for the
first payment year); or 

(2) During the payment year for which the EP attests it is a meaningful EHR user.

 

Sec.  495.306  Establishing patient volume.
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(c) Methodology, patient encounter.

(1) EPs. To calculate Medicaid patient volume, an EP must divide:

(i) The total Medicaid patient encounters in any representative, continuous 90-day period in the calendar year preceding the EP's payment year, or in the 12 months before the EP's attestation; by

(ii) The total patient encounters in the same 90-day period.

(2) Eligible hospitals. To calculate Medicaid patient volume, an eligible hospital must divide--

(i) The total Medicaid encounters in any representative, continuous 90-day period in the fiscal year preceding the hospitals' payment year or in the 12 months before the hospital's attestation; by

(ii) The total encounters in the same 90-day period.

(3) Needy individual patient volume. To calculate needy individual patient volume, an EP must divide--

(i) The total needy individual patient encounters in any representative, continuous 90-day period in the calendar year preceding the EP's payment year, or in the 12 months before the EP's attestation; by

(ii) The total patient encounters in the same 90-day period.

"Needy individuals" are defined as individuals meeting any of the following three criteria: (1) They are receiving medical assistance from Medicaid or the  Children's Health Insurance Program (CHIP); (2) they are furnished uncompensated care by the provider; or (3) they are furnished services at either no cost or reduced cost based on a sliding scale.

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Definition of Medicaid encounter

 

(e) For purposes of this section, the following rules apply:

(1) A Medicaid encounter means services rendered to an individual on any one day where:

(i) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service.

(ii) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, and cost-sharing.

(iii) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided.

(2) For purposes of calculating hospital patient volume, both of the following definitions in paragraphs (e)(2)(i) and (e)(2)(ii) of this section may apply:

(i) A Medicaid encounter means services rendered to an individual per inpatient discharge when any of the following occur:

(A) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service.

(B) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, and/or cost-sharing.

(C) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided.

(ii) A Medicaid encounter means services rendered in an emergency department on any 1 day if any of the following occur:

(A) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service.

(B) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, and cost-sharing.

(C) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided.

(3) For purposes of calculating needy individual patient volume, a needy patient encounter means services rendered to an individual on any 1 day if any of the following occur:

(i) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid for part or all of the service.

(ii) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, or cost-sharing.

(iii) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided.

(iv) The services were furnished at no cost; and calculated consistent with Sec.  495.310(h).

(v) The services were paid for at a reduced cost based on a sliding scale determined by the individual's ability to pay.

(f) Exception. A children's hospital is not required to meet Medicaid patient volume requirements.

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(h) Group practices. Clinics or group practices will be permitted to calculate patient volume at the group practice/clinic level, but only in accordance with all of the following limitations:

(1) The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP.

(2) There is an auditable data source to support the clinic's or group practice's patient volume determination.

(3) All EPs in the group practice or clinic must use the same methodology for the payment year.

(4) The clinic or group practice uses the entire practice or clinic's patient volume and does not limit patient volume in any way.

(5) If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP's outside encounters.


Printer-Friendly Instructions

You can download a PDF of this "Patient Volume" guidance page here (PDF, 120 KB)


For questions, contact the Vermont EHRIP Team at ahs.dvhaEHRIP@vermont.gov

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(Page last updated 12/29/2016)