2017 Merit-based Incentive Payment System (MIPS) Audit … · 2018-01-18 · Statement 1: A health care provider must attest that it did not knowingly and willfully take action (such

2017 Merit-based Incentive Payment System (MIPS)Audit ChecklistSuggested Documentation

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Quality Reporting Roundtable

IMPLEMENTATION RESOURCE

Quality Reporting Roundtable 2 2017 MIPS Audit Checklist

In the event you receive an audit, you will need to supply

information to substantiate your MIPS participation. It is a

significant undertaking to create robust documentation in

support of your MIPS initiative. This audit checklist, while not

exhaustive, serves as a reference for the types of information

organizations may wish to keep. We expect that providers will

supply information specific to the audit request received. We

encourage organizations to add or substitute documentation

with more appropriate evidence that most accurately reflects

their environment.

Your 2017 MIPS Checklist

Learn more about the Quality Reporting Roundtable

Speak with an expert at advisory.com/research/quality-reporting-roundtable

https://www.advisory.com/research/quality-reporting-roundtable/


Table of Contents

2017 MIPS Checklist

Audit Documentation Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Eligible Clinician (EC) and Group Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Alternative Payment Model (APM) Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

MIPS Reporting Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Certified EHR Technology (CEHRT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Quality Category Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Cost Category Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Improvement Activities (IA) Category Documentation . . . . . . . . . . . . . . . . . . . . . . . . 8

Advancing Care Information (ACI) Category Documentation . . . . . . . . . . . . . . . . . . . . 9

Appendix 1: Suggested Documentation for Improvement Activities

Expanded Practice Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Population Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Care Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Beneficiary Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Patient Safety and Practice Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Achieving Health Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Emergency Response and Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Integrated Behavioral and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Appendix 2: Additional Documentation for ACI Transition Measures

Security Risk Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Electronic Prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Patient Electronic Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Health Information Exchange. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Immunization Registry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Additional Public Health Reporting Bonus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33


Audit Documentation Organization

Confirm that documentation is organized per individual (NPI1 /TIN2 ) or group (TIN), and retain for at least ten years.

If applicable, a Glossary of terms used throughout the documentation.

If applicable, a Table of Contents.

Eligible Clinician (EC) and Group Information

List of MIPS ECs3.

If reporting MIPS as a group, list of NPIs that have reassigned their billing rights to the TIN(s).

Centers for Medicare & Medicaid Services (CMS)-provided lists of any clinicians excluded from MIPS payment adjustments (e.g., clinicians in their first year of billing Medicare).

CMS-provided list of any low-volume clinicians4, see our Guide to MIPS Participation and Special Statuses for more information on MIPS eligibility and reporting requirements.

CMS-provided list of any non-patient facing clinicians5, see our resource on Five Steps for Non-Patient Facing Clinician Success in MIPS.

CMS-provided list of any hospital-based clinicians6, see our resource on Five Steps for Hospital-Based Clinician Success in MIPS.

List of any ECs who have applied for and were approved for ACI hardship exception

Alternative Payment Model (APM) Information (if applicable)

APM agreements.

List of APM participants across all snapshot dates.

For Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) participants, the supplier/provider list across all snapshot dates.

CMS-provided documentation of Qualifying Participant (QP), or Partial QP status.

1) National Provider Identifier.

2) Tax Identification Number.

3) Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and groups that include these clinicians.

4) EC or group that bills Medicare Part B allowed charges less than or equal to $30,000 or provides care for 100 or fewer Part B-enrolled Medicare beneficiaries.

5) EC that bills 100 or fewer patient-facing encounters, or a group with more than 75 percent of ECs that meet the definition of a non-patient facing individual EC.

6) EC that furnishes 75 percent or more of their covered professional services in the inpatient hospital (Place of Service [POS] 21), on-campus outpatient hospital (POS 22), or emergency room (POS 23) setting.

https://www.advisory.com/Research/Quality-Reporting-Roundtable/Members/Resources/2017/Guide-to-MIPS-Participation-and-Special-Statuses

https://www.advisory.com/Research/Quality-Reporting-Roundtable/Members/Resources/2017/Guide-to-MIPS-Participation-and-Special-Statuses

https://www.advisory.com/Research/Quality-Reporting-Roundtable/Members/Resources/2017/Five-Steps-for-Non-Patient-Facing-Clinician-Success-in-MIPS

https://www.advisory.com/Research/Quality-Reporting-Roundtable/Members/Resources/2017/Five-Steps-for-Non-Patient-Facing-Clinician-Success-in-MIPS

https://www.advisory.com/Research/Quality-Reporting-Roundtable/Members/Resources/2017/Five-Steps-for-Hospital-Based-Clinician-Success-in-MIPS

https://www.advisory.com/Research/Quality-Reporting-Roundtable/Members/Resources/2017/Five-Steps-for-Hospital-Based-Clinician-Success-in-MIPS


MIPS Reporting Information

Decision to report MIPS individually (NPI/TIN), or as a group (TIN).

Documentation of submission method(s) used for all MIPS performance categories, including third-party data submission vendor agreements, and authorization for the third-party vendor to submit data on behalf of the EC or group, if applicable.

Internal policies or standard operating procedures that explain MIPS reporting process (e.g., roles and responsibilities, vendor-supplied user guides, data definitions, and data calculations for MIPS measures).

Summary of bonus points earned across relevant MIPS performance categories.

If informal review initiated, copies of communications with CMS and subsequent determination.

Certified EHR Technology (CEHRT)7

Contracts or license agreements for all CEHRT used for MIPS. If self-certifying, certificate(s) from Office of the National Coordinator for Health IT (ONC) certification body.

Installation and implementation dates for all CEHRT.

Screenshots of the Certified Health IT Product List (CHPL) website indicating the CEHRT products selected to secure a CMS Certification ID Number.

If EHR reporting is used to submit Quality measure data, documentation to show that all measures reported are certified by the EHR vendor(s) and meet the most recent electronic specification.

7) CMS has yet to determine how they will collect information about the CEHRT used for MIPS, we envision that they may use a process similar to Meaningful Use requirements.


Statement 1: A health care provider must attest that it did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.

Example: Contract terms, policies, other organizational policies that provide access to patients’ health information.

Statement 2: A health care provider must attest that it implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times:

(1) connected in accordance with applicable law;

Example: Policies to ensure information exchange processes comply with applicable federal or local laws, e.g., patient privacy or security requirements.

(2) compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170;

Example: Vendor-supplied documentation about standards, implementation specifications and certification criteria.

(3) implemented in a manner that allowed for timely access by patients to their electronic health information (including the ability to view, download, and transmit this information); and

Example: Existing portal provision policies to demonstrate active processes and education for patients about the availability of the portal.

(4) implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers (as defined by 42 USC 300jj(3)), including unaffiliated health care providers, and with disparate certified EHR technology and vendors.

Example: Policies that specify information exchange practices (e.g., activation for new trading partners, turnaround time, security protocols in use, etc.).

Statement 3: A health care provider must attest that it responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. § 300jj(3)), and other persons, regardless of the requestor’s affiliation or technology vendor.

Example: Policy on turnaround time for requests for electronic health information from patients, providers, and others; documentation of education provided to clinicians to support compliance with prevention of information blocking policies.

CMS-REQUIRED ATTESTATION STATEMENTS AND SUGGESTED DOCUMENTATION EXAMPLES

Documentation to substantiate compliance with CMS-required attestation statements.

Note: CMS will not allow ECs to report MIPS without acknowledgement that they satisfy the statements in the gray box below.


ONC-Direct Review (Required)

(1) acknowledge the requirement to cooperate in good faith with ONC direct review of their health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and

(2) if requested, cooperated in good faith with ONC direct review of their health information technology certified under the ONC Health IT Certification Program, as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the EP, eligible hospital, or CAH in the field.

ONC-ACB Surveillance (Optional)

(1) acknowledge the option to cooperate in good faith with ONC-ACB surveillance of their health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and

(2) if requested, cooperated in good faith with ONC-ACB surveillance of their health information technology certified under the ONC Health IT Certification Program, as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the EP, eligible hospital, or CAH in the field.

ONC-RELATED ATTESTATION STATEMENTS

Documentation to substantiate compliance with ONC direct review and/or optional ONC-Authorized Certification Body (ACB) surveillance.

Note: CMS will not allow ECs to report MIPS without acknowledgement that they satisfy the statement(s) in the gray box below, as applicable. Suggested documentation to retain includes communication and evidence of your cooperation with ONC and/or ONC-ACB(s).

Quality Category Documentation

Copy of successful submission report that details specific clinical quality measures (CQMs) submitted.

Documentation to support at least one outcome measure was reported, or if no outcome measure is applicable, another high-priority measure.

If reporting as a group, policy and/or other proof that shows quality data was submitted for all ECs in the TIN, including any individuals who may subsequently be excluded from MIPS payment adjustments (e.g., Qualifying Participants in the APM track; new Medicare clinicians; low-volume clinicians).

Evidence to support compliance with data completeness criteria, per specific data submission mechanism8.

8) For Qualified Registry, QCDR, and EHR reporting, data should reflect at least 50% of all relevant cases across all payers. For Claims-based reporting, data should reflect at least 50% of all relevant Medicare Part B cases. For CMS Web Interface and CAHPS, data must be reported for all sampled patients


Cost Category Documentation Note: the Cost category is not included in the 2017 MIPS score

CMS-supplied feedback reports (e.g., Quality and Resource Use Report [QRUR], or other CMS information).

9) Outcomes, appropriate use, patient safety, efficiency, patient experience, and care coordination measures

10) Data must be captured in CEHRT, and reported to CMS electronically without manual manipulation

Evidence of report validation efforts to confirm accurate performance, if available.

If combining performance from multiple sources, evidence of the data aggregation, measure calculation, and reporting process.

If reporting as a group, documentation of optional Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS Survey data submission.

List of any additional high priority measure(s)9 reported beyond the one required outcome measure to earn bonus point(s).

Documentation to demonstrate end-to-end electronic reporting criteria10 were satisfied (available for Qualified Registry, Qualified Clinical Data Registry [QCDR], EHR, and CMS Web Interface reporting) to earn bonus point(s), if applicable.

If ECs participate in an MSSP or Next Generation ACO, evidence that the ACO entity successfully reported Quality measures on behalf of all participants.

If ECs participate in an MSSP ACO, and the ACO fails to report Quality data on behalf of the participant TINs, evidence that Quality measures were submitted per group reporting requirements.

Improvement Activities (IA) Category Documentation

Copy of successful submission report that details specific activities performed.

Evidence to support compliance with specific activities reported (see Appendix 1 for suggested documentation across all activities available).

Documentation to support successful participation in the CMS Improvement Activities study, if applicable.


Advancing Care Information (ACI) Category Documentation

Copy of successful data submission report, including any ACI-specific attestation statements requested by CMS, if applicable.

Performance reports for each measure that show the numerator/denominator and reporting period with the vendor’s logo. If the vendor logo is unavailable, collect screenshots to demonstrate how the reports are generated from each system.

If applicable, documentation to support exclusion(s) available for certain required Base Score measures (i.e., electronic prescribing, send a summary of care, and/or request/accept summary of care).

Evidence to support compliance with specific ACI measures where additional documentation is recommended (see Appendix 2).

Documentation from vendor that explains parameters used to calculate each percentage-based measure, if available.

If applicable, self-developed or non-certified reports used for any measure, including report parameters and documentation to support the use of these reports.

Evidence of report validation efforts to confirm accurate performance, if available.

If applicable, screenshots of any CMS or ONC Frequently Asked Question (FAQ) or other documentation used to support ACI-related policies and decisions.

If applicable, internal policy and/or reference to current state or local privacy laws that stipulate patient portal/personal health record access rights or limitations for certain populations (e.g., minors, proxies, etc.).

Proof to support that CEHRT is used to carry out any activities reported, if applicable.

Note: use of CEHRT to perform specific activities earns bonus points toward the ACI category.

Evidence to support rural or Health Professional Shortage Area (HPSA) practice designation, if applicable.

Documentation to support participation in a Patient-Centered Medical Home, if applicable.

If ECs participate in a MIPS APM, retain the CMS “Scores for Improvement Activities in MIPS APMs in the 2017 Performance Period” document to show that no additional reporting is required

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Learn-more-about-improvement-activities-and-APMs.pdf

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Learn-more-about-improvement-activities-and-APMs.pdf


If applicable, policy on redaction of certain data elements that could cause potential patient harm for the Patient Electronic Access and Health Information Exchange measures.

If combining performance from multiple sources, evidence of the process used to add together multiple numerator and/or denominator values to arrive at the final performance reported (e.g., across multiple CEHRT systems, and/or across multiple ECs if reporting as a group).

If reconciling performance from different reports, evidence of the process used to determine accurate numerator and denominator values (e.g., primary EHR provides the denominator, and a third-party patient portal provides the numerator).

Documentation to explain extenuating circumstances that would impact denominator values (e.g., ECs that took leaves of absence or those with limited patient encounters during the reporting year).

If ECs participate in an MSSP ACO, evidence that ACI measures were submitted per group reporting requirements.

Quality Reporting Roundtable 11 2017 MIPS Audit Checklist | Appendix 1

Suggested Documentation for Improvement Activities

APPENDIX 1


Expanded Practice Access

Activity Suggested Documentation

Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:

• Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);

• Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or

• Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.

Internal policy on how access is enabled to patients (i.e., electronically through the use of portals, expected response times, hours of operation) and/or documentation to show that patients were seen outside normal business hours. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults, or teleaudiology pilots that assess ability to still deliver quality care to patients.

Internal policy and/or medical records on how telehealth is used to expand access to care signed by practice manager, and/or contracts with telehealth providers.

Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.

Copy of survey used and report or other data analysis results of those data; copy of the improvement plan and documentation of progress.

As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services (e.g., investment of on-site diabetes educator).

Statement on the additional activities that improved access and/or QIN/QIO-supplied documentation to support these activities.


Population Management


Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, patient self-management program) for 60% of practice patients in the transition year and 75% of practice patients in year 2 who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).

Internal policy on the program details and report to prove that thresholds were met and if available, report parameters to calculate the percentage.

MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60% or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities:

• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;

• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions;

• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or

• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.

The performance threshold will increase to 75% for the second performance year and onward.

Clinicians would attest that, 60% for the transition year, or 75% for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.

Internal policy on the program details and report to prove that threshold was met, and if available, report parameters to calculate the percentage. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.


Population Management (continued)


Participating in a Rural Health Clinic (RHC), Indian Health Service (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.

Statement on quality reporting initiatives, copies of reports, if available; and/or RHC/IHS/FQHC-supplied documentation to support these activities.

For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having:

• For the first performance year, at least 60% of medical records with documentation of an individualized glycemic treatment goal that:

— a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and

— b) Is reassessed at least annually.

• The performance threshold will increase to 75% for the second performance year and onward.

Clinicians would attest that, 60% for the transition year, or 75% for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.

Internal policy on the program details and report to prove that threshold was met, and if available, report parameters to calculate the percentage. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.




Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Statement on the activities to improve management of a specific chronic condition and/or QIO-supplied documentation to support these activities.

Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Statement on the activities to improve healthcare disparities (including reference to any external resources used) and/or QIO-supplied documentation to support these activities.

Use of a QCDR to generate regular performance feedback that summarizes local practice patterns and treatment outcomes, including for vulnerable populations.

QCDR-supplied documentation to support this activity.

Participation in CMMI models such as Million Hearts Cardiovascular Risk Reduction Model Campaign.

CMMI-supplied documentation to support this activity.

Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.

Research study-supplied documentation to support this activity.




Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).

Registry-supplied documentation to support this activity.

Implementation of regular reviews of targeted patient population needs which includes access to reports that show unique characteristics of eligible professional’s patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.

Internal policy on the review process and how treatment was tailored to meet the population’s needs and report to demonstrate the targeted population.

Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.

Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management.

Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.

Internal policy on empanelment procedure and list of patients empaneled.




Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:

• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; plan of care for chronic conditions; and advance care planning;

• Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target;

• Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;

• Use panel support tools (registry functionality) to identify services due;

• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or

• Routine medication reconciliation.

Internal policy and/or medical records to show chronic and preventative care taken for empaneled patients. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:

• Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;

• Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or

• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.

Internal policy on longitudinal care management processes for high risk patients. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.




Provide episodic care management, including management across transitions and referrals that could include one or more of the following:

• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or

• Managing care intensively through new diagnoses, injuries and exacerbations of illness.

Internal policy on episodic care management processes across patient transitions and referrals. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following:

• Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups;

• Integrate a pharmacist into the care team; and/or

• Conduct periodic, structured medication reviews.

Internal policy and/or medical records to show medication management processes to address efficiency, effectiveness, and safety. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Care Coordination


Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or group to close the referral loop or where the referring MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the certified EHR technology.

Copy of a specialist report that shows communication between clinicians, or documentation of inquiries made. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.

Internal policy and/or medical records to show turnaround time to communicate abnormal test results.

Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.

QIN/QIO-supplied documentation to support additional activity implemented.


Care Coordination (continued)


Participation in the CMS Transforming Clinical Practice Initiative.

TCPI-supplied documentation to support participation.

Membership and participation in a CMS Partnership for Patients Hospital Engagement Network.

Hospital Engagement Network supplied documentation to support member and participant status.

Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).


Implementation of regular care coordination training.

Internal training manual or other policy on training activities.

Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).

Internal policy to show implementation of care coordination activities. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).

Internal policy on development of at-risk patient care plans shared with patient or caregiver. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).

Internal policy on practices/policies to follow patient-centered action plan within 30 days of discharge including a copy of a patient-centered plan.


Care Coordination (continued)


Establish standard operations to manage transitions of care that could include one or more of the following:

• Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or

• Partner with community or hospital-based transitional care services.

Internal policy on transitions of care procedures.

Establish effective care coordination and active referral management that could include one or more of the following:

• Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings;

• Provide patients with information that sets their expectations consistently with the care coordination agreements;

• Track patients referred to specialist through the entire process; and/or

• Systematically integrate information from referrals into the plan of care.

Internal policies on care coordination and referral management activities.

Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following:

• Participate in a Health Information Exchange if available; and/or

• Use structured referral notes.

Documentation to support that patient information was successfully sent and received (e.g., submission log with successful activity). If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:

• Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or

• Provide a guide to available community resources.

Documentation of policies/practices that enable patients to access neighborhood/community-based resources.


Beneficiary Engagement


In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.

Documentation to support collection of patient reported outcomes. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision making capabilities.


Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.

QIN/QIO-supplied documentation to support this activity.

Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence.

Vendor-supplied documentation to support enhanced patient portal functionalities. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on section 508 of the Rehabilitation Act that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973.

Vendor-supplied or internal documentation to demonstrate compliance with the Rehabilitation Act or to enable access to websites/tools for patients with cognitive disabilities.

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp


Beneficiary Engagement (continued)


Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.

Copy of survey used and report or other data analysis results of those data, description of survey follow-up procedures, and a copy of the improvement plan.

Participation in a QCDR, that promotes use of patient engagement tools.


Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.


Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.


Participation in a QCDR, that promotes implementation of patient self-action plans.


Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.


Use evidence-based decision aids to support shared decision-making.

Internal policy on evidence-based decision aids utilized to demonstrate patient engagement in the shared decision-making process, (e.g., a sample of a decision aid).

Regularly assess the patient experience of care through surveys, advisory councils, and/or other mechanisms.

Documentation of regular patient experience assessments.

Engage patients and families to guide improvement in the system of care.

Internal policies/practices to include patients and families in care system improvement efforts.




Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.

EHR-supplied documentation to include patients and families in care plan development, including goal prioritization. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, teach back, action planning or motivational interviewing.

Internal policies/practices that promote self-management according to evidence-based techniques.

Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health).

Documentation of patient self-management tools used in support of this activity.

Provide peer-led support for self-management. Internal policy and/or records to show the mechanism to provide peer-led support for self-management.

Use group visits for common chronic conditions (e.g., diabetes).

Internal policy and/or medical records to show group visit procedures for chronic conditions.

Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.

Documentation of programs or coaching used in support of chronic disease self-management.

Provide self-management materials at an appropriate literacy level and in an appropriate language.

Copy of materials used for self-management that demonstrate appropriate literacy level and available in other languages, as appropriate. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.




Provide a pre-visit development of a shared visit agenda with the patient.

Documentation of pre-visit procedures to include patients in the development of a shared agenda.

Provide coaching between visits with follow-up on care plan and goals.

Documentation of coaching used in support of care plan and goals, (e.g., a sample of a plan shared with a patient).

Patient Safety and Practice Assessment


Participation in an AHRQ-listed patient safety organization.

Patient safety organization-supplied agreement to prove participation.

Participation in Maintenance of Certification Part IV for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results.

Registry-supplied documentation or internal statement to describe MOC Part IV-related performance improvement procedures.

For eligible professionals not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS®.

Documentation to support new engagement in MOC Part IV.

Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website)

Evidence to show AHRQ survey data was successfully submitted.

http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html


Patient Safety and Practice Assessment (continued)


Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of six months.

Copy of PDMP registration, and documentation to support participation for at least six months.

Clinicians would attest that 60% for the first year, or 75% for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than three days.

Policy on the program details and report to prove that threshold was met, and if available, report parameters to calculate the percentage.

Use of QCDR data, for ongoing practice assessment and improvements in patient safety.


Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator.

Documentation of specialty-specific tools used in support of this activity.

Completion of the American Medical Association’s STEPS Forward program.

Documentation to confirm program completion of one or more module categories.

Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine.

Documentation to prove training is complete and copy of approved waiver.

Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).

Evidence to show participation in CAHPS survey or CAHPS supplemental items survey.

Participation in designated private payer clinical practice improvement activities.

Private payer-supplied documentation to support clinical practice improvement activities.

Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.

Joint Commission-supplied documentation to show participation in the initiative.




Participation in other quality improvement programs such as Bridges to Excellence.

Internal policy on participation in quality improvement program, and/or third-party-supplied documentation to prove external program participation, if applicable.

Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics.

Internal policy and/or documentation to show implementation of clinical guidelines and activities to support condition-specific antibiotic stewardship program(s).

Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.

Screenshots and/or descriptions of decision support interventions and copy of treatment protocols developed to improve standards of care. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following:

• Train appropriate staff on interpretation of cost and utilization information; and/or

• Use available data regularly to analyze opportunities to reduce cost through improved care.

Internal policy to describe analytic capability and practices to manage total cost of care.

Measure and improve quality at the practice and panel level that could include one or more of the following:

• Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or

• Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.

Internal policy to describe procedures to measure and improve quality for total patient population and across panels.




Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following:

• Train all staff in quality improvement methods;

• Integrate practice change/quality improvement into staff duties;

• Engage all staff in identifying and testing practices changes;

• Designate regular team meetings to review data and plan improvement cycles;

• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or

• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families.

Internal policy to describe that all staff actively participate in the quality improvement model adopted and procedures to encourage model adoption across the practice.

Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following:

• Make responsibility for guidance of practice change a component of clinical and administrative leadership roles;

• Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or

• Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.

Internal policy to describe clinical and administrative leadership engagement in practice improvement.

Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).

Internal policy to show implementation and/or progress made on the fall screening and assessment program.


Achieving Health Equity


Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.

Internal policy and/or medical records to show expected response times for Medicaid patients.

Participation in a QCDR, demonstrating performance of activities for use of standardized processes for screening for social determinants of health such as food security, employment and housing. Use of supporting tools that can be incorporated into the certified EHR technology is also suggested.

QCDR-supplied documentation to support this activity. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Participation in a QCDR, demonstrating performance of activities for promoting use of patient-reported outcome (PRO) tools and corresponding collection of PRO data (e.g., use of PQH-2 or PHQ-9 and PROMIS instruments).


Participation in a QCDR, demonstrating performance of activities for use of standard questionnaires for assessing improvements in health disparities related to functional health status (e.g., use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment).


Emergency Response and Preparedness


Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of six months as a volunteer for disaster or emergency response.

Documentation to support participation in DMAT or CERT teams for at least six months.

Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.

Documentation to support participation in humanitarian relief for at least 60 days.


Integrated Behavioral and Mental Health


Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.

Internal policy and/or medical records to show diabetes screening for the specified patient population.

Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.

Internal policy and/or medical records to show tobacco use prevention and intervention for behavioral or mental health patients.

Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions.

Internal policy and/or medical records to show alcohol use prevention and intervention for behavioral or mental health patients.

Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.

Internal policy and/or medical records to show depression screening for patients with co-occurring behavioral or mental health conditions.

Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.

Internal policy and/or medical records to show major depressive disorder prevention and intervention for patients with co-occurring behavioral or mental health conditions.

Integration facilitation, and promotion of the colocation of mental health and substance use disorder services in primary and/or non-primary clinical care settings.

Internal policy and/or medical records to show integration and promotion mental health and substance use disorder services across clinical care settings.


Integrated Behavioral and Mental Health (continued)


Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that could include one or more of the following:

• Use evidence-based treatment protocols and treatment to goal where appropriate;

• Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;

• Ensure regular communication and coordinated workflows between eligible clinicians in primary care and behavioral health;

• Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;

• Use of a registry or certified health information technology functionality to support active care management and outreach to patients in treatment; and/or

• Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.

Internal policy and/or medical records to show behavioral health services are available for at-risk patients, including those with behavioral health needs, dementia, or poorly controlled chronic conditions. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.

Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).

Vendor-supplied documentation to support enhanced behavioral health data capture, and internal policy on how data is used for behavioral health decision-making. If applicable, statement to describe use of CEHRT to carry out the activity and screenshots of CEHRT functionality used.


Additional Documentation for ACI Transition Measures (i.e., Modified Stage 2)

APPENDIX 2


Security Risk Analysis

A copy of the security risk analysis (SRA) or the review of the most recent SRA and any relevant policies and/or procedures that address technical, administrative, and physical security safeguards, including location-specific risks, and encryption of data at rest.

Proof that a new SRA was performed upon installation of a new ONC Edition CEHRT, if applicable.

If deficiencies are identified within the SRA or the review, a remediation plan, with accountabilities clearly assigned and timelines for resolution established.

Any documentation to substantiate progress toward remediation of deficiencies identified.

Proof that the SRA or the review addresses all CEHRT, and is completed prior to the end of the reporting year.

If applicable, enterprise-wide SRA or review should list specific practice locations covered.

Electronic Prescribing

Documentation to support drug formulary checks are enabled.

Policy to support whether controlled substances are included or excluded from the measure calculation.

Patient Electronic Access

Policy that describes how a patient is provided all of the necessary information needed to view, download, or transmit their health information.

A sample Consolidated Clinical Document Architecture (C-CDA) with all Patient Electronic Access-required data and their coded content, where applicable.

If applicable, policy on definition of “care team member,” as this is a required data element on the portal.


Health Information Exchange

A C-CDA with all Health Information Exchange-required data and their coded content, where applicable.

If applicable, policy on definition of “care team member,” as this is a required data element on the portal

Documentation to ensure “reasonable certainty” that only successful transmissions of summary of care records (i.e., those received by the receiving provider) count toward the numerator.

Policy to include or exclude transitions to receiving providers with access to the sending provider’s EHR (note: if included, providers must have different billing identifiers [i.e., NPI or CCN], and a C-CDA must be sent in order to count toward the numerator).

Documentation of how the C-CDA is generated from CEHRT, and subsequently transmitted electronically (including multiple electronic methods, if applicable).

Immunization Registry

Documentation that substantiates one or more of the Active Engagement options:

1. Registration of intent by the first 60 days of the reporting period.

2. Testing and validation.

3. Production data submission.

Additional Public Health Reporting Bonus (Syndromic Surveillance or Specialized Registry)

Documentation that substantiates one or more of the Active Engagement options:

1. Registration of intent by the first 60 days of the reporting period.

2. Testing and validation.

3. Production data submission.

LEGAL CAVEAT

Advisory Board is a division of The Advisory Board Company. Advisory Board has made efforts to verify the accuracy of the information it provides to members. This report relies on data obtained from many sources, however, and Advisory Board cannot guarantee the accuracy of the information provided or any analysis based thereon. In addition, Advisory Board is not in the business of giving legal, medical, accounting, or other professional advice, and its reports should not be construed as professional advice. In particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate for a given member’s situation. Members are advised to consult with appropriate professionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. Neither Advisory Board nor its officers, directors, trustees, employees, and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by Advisory Board or any of its employees or agents, or sources or other third parties, (b) any recommendation or graded ranking by Advisory Board, or (c) failure of member and its employees and agents to abide by the terms set forth herein.

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Documents

2017 Merit-based Incentive Payment System (MIPS) Audit … · 2018-01-18 · Statement 1: A health care provider must attest that it did not knowingly and willfully take action (such