Authors

  1. Hess, Cathy Thomas BSN, RN, CWCN

Article Content

In last month's column, we reviewed the data validation and audit criteria for the Merit-Based Incentive Payment System (MIPS). This article reviews a sample MIPS Audit Checklist to support your documentation. This checklist is not exhaustive. Ultimately, you must create your own audit checklist to meet your practice needs.

 

As stated by the Centers for Medicare & Medicaid Services (CMS), "in accordance with the False Claims Act, you are encouraged to keep documentation up to 10 years and, as stated in the final rule, CMS may request any records or data retained for the purposes of MIPS for up to 6 years."1 Under MIPS, CMS will conduct an annual data validation process. In addition, you could receive a request from CMS for an audit, which requires an initial response within 10 business days.1 Be sure you have the following items.

 

Source Document(s)

 

* Source documents are the primary documentation requested for review during the audit. These are the documents the provider generated when completing the performance data. They should provide a summary of the data that support the information entered for reporting and will be the starting point of most reviews.

 

Eligible Clinician (EC) or Group Reporting Status

 

* Have a copy of your National Provider Identifier (NPI) Tax Identifier Number (TIN) used during this reporting period.

 

* If reporting as a group, list each provider by NPI and TIN; provide a copy of the documentation to support the fact that the EC has reassigned his/her Medicare billing rights to the TIN.

 

* Verify your MIPS status through the CMS look-up tool at https://qpp.cms.gov/participation-lookup.

 

* Maintain a copy of the EC's Special Status if applicable.

 

Advancing Care Information (ACI)

 

* Identify the reporting period and submission method used for ACI (either Objectives and Measures or 2017 ACI Transition Objectives and Measures). If the MIPS EC performance score is reweighted, note the applicable reason(s).

 

* Maintain a copy of your Certified EHR Technology edition.

 

* Maintain a copy of the measures you chose. Consider downloading a comma-separated values (CSV) file of the measures for your records.2

 

* Maintain the final report showing all MIPS base and performance data/categories submitted for applicable ACI measures per the EC, noting any exclusions. Maintain a copy of all aggregated data if reporting as a group.

 

* Maintain evidence to support that the final report was generated for a specific EC, eligible hospital, or critical access hospital (eg, NPI, CMS certification number, practice name, etc).

 

* Maintain a copy of any bonus points earned.

 

* Maintain copies of any third-party vendor agreements implemented during the reporting period.

 

* Obtain and maintain screenshots of any functionality enabled or used to support specific ACI measures.

 

* Obtain and maintain a copy of the security risk analysis that was completed and supporting policies.

 

* Maintain a copy of all applicable policies and/or procedures supporting ACI reporting.

 

Quality

 

* Identify the reporting period and submission method used for quality reporting.

 

* Maintain a copy of your Certified EHR Technology edition.

 

* Report at least 6 measures, including 1 outcome measure, (if not available, report another high-priority measure); if you have fewer than 6, report on each measure that is applicable.

 

* Maintain a copy of the measures you chose, including the outcome measure reported or a high-priority measure. Consider downloading a CSV file of the measures for your records.3

 

* Maintain a final report for each EC that shows all submitted measures, criteria, and the submission method.

 

* Maintain a copy of all aggregated data if reporting as a group and proof that the data were submitted for all ECs within the TIN.

 

* Maintain a copy of any bonus points earned.

 

* Maintain copies of any third-party vendor agreements implemented during the reporting period.

 

* Maintain a copy of all applicable policies and/or procedures supporting quality reporting.

 

Improvement Activity (IA)

 

* Obtain/maintain screenshots of any functionality enabled or used to support specific IA categories.

 

* Have documentation to support compliance for each IA category completed during the reporting period.

 

* Maintain a copy of measures chosen. Consider downloading a CSV file of the measures for your records.4

 

* Maintain a final report for each EC that shows all submitted measures, criteria, and the submission method.

 

* Maintain copies of any third-party vendor agreements implemented during the reporting period.

 

* Maintain a copy of all applicable policies and/or procedures supporting IA reporting.

 

REFERENCES

 

1. Centers for Medicare & Medicaid Services Quality Payment Program. 2017 MIPS Data Validation and Auditing. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Quality-Measurement/Quality-Payment-Program/Remediated-MIPS-Data-Validation-Fact-Sheet-2017-04-24.pdf. Last accessed August 23, 2017. [Context Link]

 

2. Centers for Medicare & Medicaid Services Quality Payment Program. Advancing Care Information. https://qpp.cms.gov/mips/advancing-care-information. Last accessed August 23, 2017. [Context Link]

 

3. Centers for Medicare & Medicaid Services Quality Payment Program. Quality Measures. https://qpp.cms.gov/mips/quality-measures. Last accessed August 23, 2017. [Context Link]

 

4. Centers for Medicare & Medicaid Services Quality Payment Program. Improvement Activities. https://qpp.cms.gov/mips/improvement-activities. Last accessed August 23, 2017. [Context Link]