November 1, 2017 | Cathy Thomas Hess, BSN, RN, CWCN

3 Minute Read

Merit-Based Incentive Payment System: Referencing Source Documents

In the last installment in this column, October’s Merit-Based Incentive Payment System Audit Checklist for 2017, we reviewed a sample MIPS Audit Checklist to support your documentation. One of the items included in the checklist was source documents. Source documents are the primary documentation requested for review during an audit (postattestation or reporting). At times during your reporting time frame, you may need to gather additional information to support or clarify your MIPS documentation methodology. If the information influences your documentation practice, it may be considered a source document. Let’s take a look at referenceable sites that may be used to obtain documentation during your reporting period.

For example, some of the information you reference may be found within the Centers for Medicare & Medicaid (CMS) Quality Payment Program site. Some information may be collected through written electronic responses received from the Quality Payment Program help desk. And some responses may be generated from previously submitted questions found within the CMS’s Frequently Asked Questions (FAQs) page.1 Let’s take a look at a few of these to provide you with examples for your review.

Sample CMS FAQ 1

Question to CMS: I am reporting Measure 317 for program year 2017. During a primary care physician visit, the blood pressure measurement was prehypertensive. How do I meet the intent of the measure if the eligible clinician believes no follow-up is clinically indicated?

CMS Response: If the blood pressure is prehypertensive at a primary care physician encounter, no additional follow-up would be needed. This would meet the intent of the measure. Report G8950—Pre-hypertensive or hypertensive blood pressure reading documented, AND the indicated follow-up is documented. Please contact the QualityNet Help Desk or via e-mail should you have questions regarding this topic.2

To read the full article in “Advances in Skin & Wound Care” by Cathy Thomas Hess, click here.

Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.

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Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.

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