1. Hess, Cathy Thomas BSN, RN, CWCN

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In previous columns, we have discussed the roadmap to Merit-based Incentive Payment System (MIPS) strategy and documentation. Your documentation may be subject to an audit so, you will need to provide information to verify your MIPS participation. This column will begin to discuss the data validation and audit criteria. In the next column, we will review a sample MIPS Audit Checklist. The following information is excerpted from (select hyperlink to MIPS Validation Criteria, April 26 zip file).


The Medicare Access and CHIP Reauthorization Act of 2015 streamlines a collection of programs with a single system where you can be rewarded for better care. You will be able to practice as usual, but you may receive higher Medicare payments based on performance. The 2 paths in this program are MIPS and Advanced Alternative Payment Models:


Under MIPS, 4 connected performance categories will affect your Medicare payments: Quality, Improvement Activities, Advancing Care Information, and Cost. This fact sheet provides a high-level overview of 3 of the MIPS performance categories for the transition year. Detailed criteria are included in an accompanying spreadsheet (, MIPS Data Validation Criteria [zip file]). Note that criteria will be released incrementally according to the following schedule:


* Improvement Activities-Spring 2017


* Quality-Summer 2017


* Advancing Care Information-Summer 2017



The Quality Payment Program Final Rule with comment requires the Centers for Medicare & Medicaid Services (CMS) to provide the criteria we will use to audit and validate measures and activities for the transition year of MIPS for the Quality, Advancing Care Information, and Improvement Activities performance categories.


Data validation is the process of ensuring that a program operates on accurate and useful data. The MIPS requires all-payer data for all data submission mechanisms with the exception of claims and the CMS Web Interface. The data from payers, other than Medicare, will be used for informational purposes to improve future validation efforts and will not be the only source of data used to make final determinations on whether you pass or fail an audit in the transition year.


Under MIPS, the CMS will conduct an annual data validation process. You could receive a request from CMS for an audit, which requires an initial response within 10 business days.


For the transition year, third-party intermediaries such as Qualified Clinical Data Registries, health information technology vendors, qualified registries, or CMS-approved Consumer Assessment of Healthcare Providers and Systems for MIPS survey vendors are required to comply with several procedures as a condition of their qualification and approval to participate in MIPS as a third-party intermediary, including providing the contact information for you and all individual clinicians or groups on behalf of whom it submits data. All entities must provide your phone number, address, and, if available, your e-mail. In accordance with the False Claims Act, you should keep documentation up to 10 years, and CMS may request any records or data retained for the purposes of MIPS for up to 6 years.


The Quality performance category within MIPS assesses health process and outcomes through quality measures.


MIPS-eligible clinicians should demonstrate improved quality above a baseline level (the performance benchmark), which is based on historical or performance period data (or potentially based on 2017 performance data for quality measures with no historic benchmark).


For the transition year, the CMS data validation process for the Quality performance category will apply for claims and registry submissions to validate whether you submitted all applicable measures when submitting fewer than 6 measures, or when you do not submit the required outcome measure or other high-priority measure, or submit less than the full set of measures in the applicable specialty set.


The MIPS Advancing Care Information performance category replaces the Medicare Electronic Health Record Incentive Program for eligible professionals, also known as Meaningful Use. The MIPS Advancing Care Information performance category promotes patient engagement and the electronic exchange of information using certified electronic health record technology. Under this performance category, eligible clinicians will have greater flexibility in choosing measures to report.


You should retain documentation to support their submission for the Advancing Care Information performance category.


The MIPS Improvement Activities performance category assesses how much you participate in activities that make clinical practice better, such as activities related to ongoing care coordination, clinician and patient shared decision-making, regular use of patient safety practices, and expanding practice access.


Under this performance category, you can to choose from many activities to show your performance. It also includes incentives to help you participate in certified patient-centered medical homes and Advanced Alternative Payment Models.


Your documentation used to validate your activities should demonstrate consistent and meaningful engagement within the period for which you attested.


For the transition year of MIPS, the Cost performance category is not assessed.


The Quality Payment Program Service Center can be reached at 1-866-288-8292 (TTY 1-877-715- 6222) or via email at