The U.S. Congress enacted the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA) on April 16, 2015. On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services issued its final rule regarding MACRA’s Quality Payment Program and other aspects of the legislation. This final rule was published in the Federal Register on November 4, 20161, and went into effect on January 1, 2017.

Both MACRA and the CMS final rule make several significant changes to the Medicare payment system. In this article, I will address only their impact on the computerized provider order entry (CPOE) meaningful use provisions of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Incentive Programs).

CPOE requirements for the Incentive Programs

According to the October 16, 2015, CMS final rule for Stage 3 of the Medicare and Medicaid EHR Incentive Programs, for each reporting period, more than 60 percent of the following must be entered into the CPOE system by “a licensed health care professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant”2
  • Medication orders
  • Laboratory orders
  • Diagnostic imaging orders 
In the Stage 3 final rule, CMS took the position that “CPOE … duties should be considered clinical in nature, not clerical. Therefore, CPOE … duties, as noted above, should be viewed in the same category as any other clinical task which may only be performed by qualified medical or clinical staff.”3

Changes to the Medicare CPOE requirements

MACRA mandated that the Medicare EHR Incentive Program come to an end on December 31, 2016, and be replaced by the Quality Payment Program. One of the new payment mechanisms for Medicare established by MACRA and CMS is the Merit-Based Incentive Payment System (MIPS). Under the primary reporting method of MIPS, an eligible provider/clinician is not required to report and attest to CMS that the three categories of orders are being entered by credentialed medical assistants or licensed health care professionals. This change was made by CMS because eligible providers under the Medicare Incentive Program were complying so consistently with the CPOE requirement that future reporting was deemed unnecessary.4

The Centers for Medicare & Medicaid Services, however, offers eligible providers/clinicians an alternate reporting method under MIPS. Under this method, providers/clinicians are permitted to report on optional measures, such as CPOE.4

Eligible providers/clinicians should note that having credentialed medical assistants (or licensed health care professionals) enter medication, laboratory, and diagnostic imaging orders does not become irrelevant under MIPS. To the contrary, MIPS eligible clinicians who utilize CPOE are still expected to utilize appropriately credentialed clinical staff to enter the orders.5

The CPOE requirements under the Medicaid Incentive Program are unchanged

An overlooked but very crucial fact is that MACRA made no changes to the Medicaid EHR Incentive Program. As a result, providers participating in the Medicaid Incentive Program must continue to comply with the requirement that more than 60 percent, respectively, of medication, laboratory, and  diagnostic imaging orders must be entered into the CPOE system by credentialed medical assistants or licensed health care professionals in order to receive incentive payments under the Medicaid EHR Incentive Program.6 The Medicaid Incentive Program will be in existence until at least the end of the calendar year 2021, so providers are well-advised to pay heed to which personnel are entering orders into the CPOE system, both currently and in the future.

Providers/clinicians are allowed to participate in MIPS as well as the Medicaid Incentive Program

Some providers/clinicians were eligible to participate in both the Medicare and Medicaid EHR Incentive Programs; however, providers/clinicians could participate in only one of the two. This was changed by MACRA. Some providers/clinicians can now participate in both a MACRA Quality Payment Program (such as MIPS) and the Medicaid Incentive Program, and can receive payments under both programs.

As stated above, providers participating in the Medicaid EHR Incentive Program must continue to attest to CMS that more than 60 percent, respectively, of their medication, laboratory, and diagnostic imaging orders during the reporting period have been entered by credentialed medical assistants or licensed health care professionals. Consequently, providers/clinicians participating in both the Medicaid Incentive Program and MIPS should consider utilizing the MIPS alternate reporting system, because these providers/clinicians already have to attest to compliance with the greater-than-60 percent order entry requirements of the Medicaid program.

Questions about the transition from the Medicare EHR Incentive Program to the Quality Payment Program and MIPS (or other payment mechanisms) can be directed to to Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org.