1. Oregon’s Medicaid EHR Incentive Program
Calculating Patient Volume:
What You Need to Know to Successfully Attest
Presented by:
Joni Moore, Program Analyst Lead
Jessica Wilson, Program Auditor

2. Agenda Welcome Review of Patient Volume (PV) Calculation
Common Errors in Calculating Patient Volume
Tips for Submitting Future Attestations
Program Resources
Questions and Answers

3. Review of Patient Volume (PV) Calculation

4. Review of Patient Volume Calculation
To meet the 30% Medicaid patient volume requirement* for eligible professionals (EP) there are two ways you can calculate your patient volume:
Individual – Uses the EP’s encounters only
Group – Uses the encounters of all providers in the practice, regardless of their eligibility or desire to attest
For eligible hospitals (EH), the Medicaid patient volume requirement is 10%
*20% requirement for pediatricians

5. What is an “Encounter”?
According to CMS, a Medicaid encounter is defined as:
Services rendered on any one day to a Medicaid-enrolled individual, regardless of payment liability, including zero-pay claims.
(Only one encounter per patient, per day, per provider)
Zero-pay claims can include but are not limited to:
Claim denied because the Medicaid beneficiary has maxed out the service limit, the service wasn’t covered under the State’s Medicaid program, the claim wasn’t submitted timely, or the claim was paid at $0 because another payer’s payment exceeded the Medicaid payment
Note: Non-Medicaid encounters are also counted as one per patient, per day, per provider (denominator)

6. Non-FQHC/RHC Providers
For individual or group patient volume:
Select any consecutive 90 day period of time in the prior calendar year or 12 months preceding the date of attestation
Numerator: Include all encounters of Medicaid-eligible patients for the 90 day period
Apply the Oregon CHIP proxy (Total Medicaid encounters x 95.6%)
Include out-of-state Medicaid encounters if applicable (after CHIP proxy is applied to Medicaid encounters)
Denominator: Include all encounters for the 90 day period
Do not apply the CHIP proxy to the denominator
Include all out-of-state encounters if applicable

7. Non-FQHC/RHC Providers
Example 1: Individual patient volume
132 Oregon Medicaid patient encounters for the 90 day period
317 total encounters for the 90 day period
Calculation:
Numerator: 132 x .956 ⃰⃰ = (rounded = 126)
Denominator: 317
Patient Volume: 126 / 317 = 39.7% (rounded = 40%)
⃰⃰ Oregon CHIP proxy 95.6%

8. Non-FQHC/RHC Providers
Out-of-state Encounters
Add any out-of-state Medicaid encounters to the Oregon Medicaid count after the CHIP proxy is applied. All out-of-state encounters must be included in the denominator as well.
Example 1 continued:
Total out-of-state encounters: 46
Total out-of-state Medicaid encounters: 27
Calculation
Numerator: 126 Oregon Medicaid (after CHIP proxy) + 27 out-of-state Medicaid = 153
Denominator: 317 Oregon encounters + 46 out-of-state = 363
Patient Volume: 153/363 patient volume = 42% (rounded)

9. Non-FQHC/RHC Providers
Example 2: Group patient volume
2,056 Oregon Medicaid patient encounters for the 90 day period
6,329 total encounters for the 90 day period
*This includes the encounters of all the providers at the clinic, not just the eligible provider types, or those attesting for an incentive payment
Calculation:
Numerator: 2,056 x .956 ⃰⃰ = 1,966 (rounded)
Denominator: 6,329
Patient Volume: 1,966 / 6,329 = 31% (rounded)
⃰⃰ Oregon CHIP proxy 95.6%

10. FQHC/RHC Providers For individual or group patient volume:
Select any consecutive 90 day period of time in the prior calendar year or 12 months preceding the date of attestation
Numerator: Include all encounters of Medicaid-eligible and Needy patients for the 90 day period
Do not apply the CHIP proxy
Include out-of-state Medicaid encounters if applicable
Denominator: Include all encounters for the 90 day period
Include all out-of-state encounters if applicable

11. FQHC/RHC Providers Example: Individual patient volume Calculation:
52 Oregon Medicaid patient encounters for the 90 day period
302 Needy encounters for the 90 day period
551 total encounters for the 90 day period
No out-of-state encounters
Calculation:
Numerator: = 354 ⃰
Denominator: 551
Patient Volume: 354/ 551= 64% (rounded)
⃰⃰ FQHC/RHC = No CHIP proxy
Note: For group pv, just be sure to include all the encounters of all providers

12. Additional Info. for Group Patient Volume
Do not limit encounters in any way - make sure all encounters for all providers and practice locations are included in the calculation, including:
Providers who are no longer at the clinic but were there during the 90 day patient volume timeframe
Providers who do not qualify or will not be applying for the incentive program
Include prenatal visits and CCARE if applicable
Consider whether your clinic bills with more than one NPI
If an EP works for multiple practices, the patient volume only includes his/her encounters associated with the group practice attesting

13. Common Errors in Calculating Patient Volume

14. Duplicate Encounters
Common Error 1: Including duplicate encounters in the numerator and/or denominator for patient volume calculations Example 1: A Medicaid-eligible patient was seen 3 times on the same day, by the same provider. How would you account for this in the numerator and the denominator?

15. This would only result in one encounter; it would be counted once in the denominator, and since he/she is a Medicaid-eligible patient, once in the numerator because the patient was seen by the same provider on the same day.
Example of patient volume spreadsheet listing encounters:
Note: An encounter is counted as one per patient, per day, per provider. This logic is used for both the numerator and the denominator. Do not include duplicate encounters in the patient volume calculation.

16. Example 2: A non-Medicaid Patient is seen by 3 different providers on the same day. How would you account for this in the numerator and the denominator?

17. All three encounters would be included in the denominator because all three services were provided by different providers; however, because the patient is not a Medicaid patient, none of the encounters would be included in the numerator
Example of patient volume spreadsheet listing encounters:
Note: This scenario only applies to group patient volume

18. Unique Patient Counts
Common Error 2: Using the unique patient counts for the numerator and denominator when determining patient volume Example 3: A Medicaid-eligible patient is seen by the same provider four different days during the 90 day patient volume period. How would you account for this in the numerator and the denominator?

19. All four encounters would be included in the denominator, and since he/she is a Medicaid-eligible patient, in the numerator as well, because the services were provided on different days
Example of patient volume spreadsheet listing encounters:
Note: Unique patient counts are used for certain Meaningful Use measures, not for patient volume

20. CPT Codes
Common Error 3: Using CPT codes (procedure counts) for the numerator and denominator when calculating patient volume
Example 4: A non-Medicaid patient was seen for an office visit and had two additional procedures done on the same day by the same provider, for a total of three procedures:
99211 – Office, or other outpatient visit for the evaluation and management of an established patient
12001 – Simple repair of superficial wound including hands and feet
90698 – DTP vaccination for intramuscular use
How would you account for this in the numerator and the denominator?

21. Only one encounter would be included in the denominator, because the patient was seen by the same provider on the same day. No encounters are included in the numerator because he/she was not a Medicaid-eligible patient.
Note: Do not base encounters off of the CPT codes or amount of procedures/services a patient receives. CPT codes should not be included in the patient volume spreadsheet provided to EHR Incentive Program staff

22. Tips for Submitting Future Attestations

23. Verification of Billing
Upload a patient volume spreadsheet in Excel format to MAPIR during attestation (not required); encounters are verified by claims submitted
Communicate with billing department

24. Patient Volume Spreadsheet
Spreadsheet must include the following data elements:
Date of Service
Patient Medicaid ID
Amount Billed
If Attesting as a Group – Rendering Provider’s NPI

25. Example of PV Spreadsheet

26. Audit Reminder
Please note – you are required to maintain all EHR Incentive program attestation documentation for at least seven (7) years
45 CFR (d)(1)
A covered entity may disclose protected health information to a health oversight agency for oversight activities authorized by law, including audits…or other activities necessary for appropriate oversight of…
(iii) Entities subject to government regulatory programs for which health information is necessary for determining compliance with program standards…

27. Program Resources

28. If You Need Additional Information
2016 Specification Sheets:
Public Health:
Incentive Program EP worksheet:

29. Questions? Medicaid.EHRIncentives@dhsoha.state.or.us
Phone: