The end of 2017 means we have all (almost) survived our first year of MIPS reporting! Not so bad, right? Monitoring measure reports throughout the reporting period is only ½ the battle. Now is the time to make sure you have all of the necessary documentation in a safe place in case the future brings an audit. I’ve put together an audit check list to help make sure everything is accounted for.
Eligible Clinician and Group Information
- List of MIPS eligible clinician’s, MIPS and billing TINs
- CMS provided list of MIPS excluded clinicians
Reporting Information
- Information about reporting as individuals or as a group
- Submission method information for all categories
- Copy of internal policies regarding MIPS reporting process
Certified EHR Technology
- Contracts or license agreements for all CEHRT used for MIPS
- Installation and implementation for all EHRs
- Documentation to show that all measures reported are certified through the EHR vendor.
Quality Category Documentation
- EHR quality reports for each eligible clinician
- Successful submission report that details specific clinical quality measures submitted
- Documentation to show that one outcome measure was reported
- If the practice is reporting as a group, documentation to show that information was submitted for all clinicians in the tax ID.
- Documentation for option CAHPS Survey data submission
- List of any high priority measures that were reported beyond the requirements for additional credit
Improvement Activities Category Documentation
- Submission report that details specific activities performed
- Evidence to show compliance with specific activities
- Documentation to show that your CEHRT is used to carry out any activities reported
- Documentation to show PCMH participation, if applicable
Advancing Care Information Category Documentation
- Submission report that details specific ACI measures performed and reported
- EHR ACI reports for each eligible clinician. These should include numerator/denominator information for each measure and the EHR vendor logo.
- Documentation from vendor that shows steps for calculation of each percentage-based measure.
- Documentation for public health measures from state agencies
- Documentation from specialized registry for specialized registry reporting
- Security Risk Assessment for reporting period
- System screenshots to show practice workflow for each measure reported
Be sure to check out the QPP website for additional information. As always, we are here to answer any questions regarding reporting or attestation for the quality programs. Find out more ways eMedApps can help you achieve your reporting goals!
