This article has been adapted from a series of posts on Executive Director Balasa’s Legal Eye: On Medical Assisting blog in April.

Because most CMAs (AAMA) work under the direct supervision of “eligible professionals” (as defined in the rules of the Centers for Medicare and Medicaid Services [CMS]), the following will focus on the provisions of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Program that are applicable to eligible professionals, not those provisions that are applicable to “eligible hospitals” and “critical access hospitals.”

Are there differences between the Medicare EHR Incentive Program and the Medicaid EHR Incentive Program?

Yes. A detailed discussion of the differences is beyond the scope of this article. However, an important fact is that eligible professionals cannot participate in both the Medicare and Medicaid EHR Incentive Programs. They must choose which of the two programs they want to participate in.

Are these programs mandatory?

In a sense, they are not. However, note the following from the CMS guide “An Introduction to the Medicare EHR Incentive Program for Eligible Professionals”:

Medicare eligible professionals who do not meet the requirements for meaningful use by 2015 and in each subsequent year are subject to payment adjustments to their Medicare reimbursements that start at 1 percent per year, up to a maximum 5 percent annual adjustment.

Are there different definitions of “eligible professionals” for the EHR incentive programs?

Yes. Once again, an in-depth treatment will not be presented. Physicians, osteopaths, and dentists are deemed to be eligible professionals under both programs, however.

How do eligible professionals qualify for incentive payments under the programs?

Eligible professionals qualify for incentive payments by demonstrating “meaningful use” of “certified EHR technology.” More specifically, meaningful use is proven (in part) by meeting minimum requirements for each Core Objective. The minimum requirements for each Core Objective are referred to in the CMS rules and publications as “measures.” The measures are sometimes quantitative in nature.

Are there any exemptions for certain eligible professionals?

Yes. CMS has provided “exclusions” for eligible professionals who cannot meet some of the Core Objectives because of the small size of their practices, or the highly specialized nature of their practices.

Are there partial payments if an eligible professional meets some, but not all, of the Core Objectives?

No. An eligible professional must meet all Core Objectives. Failure to meet any one Core Objective would result in no incentive payment.

What Core Objective pertains to the permissibility of CMAs (AAMA) entering orders into the EHR?

The relevant Core Objective under Stage 1 of the Incentive Program is titled “CPOE for Medication Orders.” The Stage 2 Core Objective is “CPOE for Medication, Laboratory, and Radiology Orders.”

What does “CPOE” stand for?

CPOE stands for “computerized provider order entry.” CPOE is defined as follows:

“A provider’s use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device.”

What are the measures for these Core Objectives in Stages 1 and 2?

For Stage 1 the measure is as follows:

“More than 30 percent of all unique patients with at least one medication in their medication list seen by the eligible professional (EP) have at least one medication order entered using CPOE.”

The Stage 2 measure is more expansive:

“More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using CPOE.”

Are there exclusions for these measures?

Yes. The Stage 1 exclusion is “any EP who writes fewer than 100 prescriptions during the EHR reporting period.” Under Stage 2 the exclusion is “any EP who writes fewer than 100 medication, radiology, or laboratory orders during the EHR reporting period.”

Who can enter orders into the EHR for meeting the Stage 1 and 2 measures?

Stage 1 of the Incentive Program specified that only “licensed health care professionals” could enter orders into the CPOE system for meaningful use calculation purposes. At the urging of the American Association of Medical Assistants and other parties, on August 23, 2012, CMS issued a final rule allowing “credentialed medical assistants” to enter orders into the CPOE system for the purpose of calculating compliance with this Core Objective. The CMS Stage 2 Eligible Professional Meaningful Use Core Measures document, issued in October of 2012, includes the following statement:

“Any licensed healthcare professionals and credentialed medical assistants can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE…”

How does CMS define “credentialed medical assistants”?

According to the 2012 CMS document cited immediately above, “Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant.” That is, a clinic or health system cannot give a “credential” to its medical assistants and argue successfully that such a “credential” meets the CMS requirements.

Does an associate degree, certificate, or diploma from an academic medical assisting program fall within the CMS definition of a medical assisting credential?

In my opinion, the context of the August 23, 2012 CMS final rule does not allow an associate degree, certificate, or diploma from a medical assisting program to be considered a medical assisting credential.

Would a “credential” based solely on experience and recommendations meet the CMS definition of a medical assisting credential?

No. The intent of CMS was that a medical assistant pass some sort of examination in order to be considered a “credentialed medical assistant.”

Do medical assistants have to be credentialed to enter medication, laboratory, and radiology orders into the EHR if such entry is not being counted toward meeting the measure for the Core Objective “CPOE for Medication, Laboratory, and Radiology Orders”?

No. There is no other CMS regulation, federal law, or state law that requires medical assistants to be credentialed as a prerequisite for entering orders into the Electronic Health Record if such entry is not being counted toward meeting the Stage 1 and Stage 2 percentage requirements. In other words, the absolute legal requirement is that medical assistants be credentialed (as defined in the CMS final rule) when entering orders for calculating compliance with the “CPOE for Medication, Laboratory, and Radiology Orders” Core Objective.

A. When does the CMS final rule allowing credentialed medical assistants to enter orders into the CPOE go into effect? I have been told that it does not go into effect until 2014.

B. Does the CMS final rule only apply to entry of orders under Stage 2 of the Incentive Program? I have been told that the rule does not apply to entry of orders under Stage 1.

Note the following answer to CMS FAQ 7693:

We [CMS] have revised the description of who can enter orders into the EHR and have it count as CPOE and have it count for purposes of the CPOE measure. This revision is available for EHR reporting periods in 2013 and beyond regardless of what stage of meaningful use the provider is attesting to. [Emphasis added.]

A. The CMS rule allowing credentialed medical assistants to enter medication, laboratory, and radiology orders into the CPOE system is in effect for reporting periods in 2013. It is not correct to assert that the CMS rule does not go into effect until 2014.

B. The above CMS FAQ clearly states that the rule allowing credentialed medical assistants to enter orders into the CPOE system applies to all stages of the Medicare and Medicaid Incentive Program. Thus, it applies to Stage 1 as well as Stage 2, and will apply to Stage 3 when it goes into effect.

Questions? Contact Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or 800/228-2262.