Merit-based Incentive Payment System 2018 Documentation and Audit Checklist

Reporting your 2018 Merit-based Incentive Payment System (MIPS) documentation is just around the corner. This column reviews the documentation requirements and data validation and audit criteria. This checklist is not exhaustive. Ultimately, it remains your responsibility to create your own audit checklist to meet your practice needs. The Centers for Medicare & Medicaid Services (CMS) references are provided for you to build your resource library.

Participation status

• Determine your 2018 participation.
• Determine if you are reporting as an individual or group.
• Check your 10-digit National Provider Identifier (NPI) number; view your Quality Payment Program participation status by performance year.

Eligible Clinician or Group Reporting Status

• Verify your MIPS participation status.
• Maintain a copy of your NPI and Taxpayer Identification Number (TIN) used during this reporting period.
• If reporting as a group, list each provider by NPI and associated TIN.
• If you report only as a group, you must meet the definition of a group at all times during the performance period and aggregate the group’s performance data across the four MIPS performance categories for a single TIN. Each MIPS-eligible clinician (EC) in the group will receive the same payment adjustment based on the group’s performance.
• Maintain a copy of the EC’s Special Status (based on NPI lookup), if applicable.
• Ensure your Enterprise Identity Data Management Account is up-to-date.

Promoting Interoperability

• This category accounts for 25% of the final score. This percentage can change due to Special Statuses, Exception Applications, or Alternative Payment Model (APM) participation.
• Verify and maintain a copy of your participation status with your NPI.
• For performance year 2018, Certified Electronic Health Record Technology (CEHRT) is required for participation in this category. Obtain/maintain a copy of your CEHRT edition.
• Participants must submit collected data for four or five Base Score measures (depending on the CEHRT Edition) for 90 days or more during 2018, and participants must attest to two statements when submitting: “Prevention of Information Blocking Attestation” and “ONC Direct Review Attestation.”
• Identify the performance period and submission method used for Promoting Interoperability (PI) (either PI Objectives and Measures or 2018 PI Transition Objectives and Measures). If MIPS EC performance score is reweighted, note the applicable reason(s).
• Maintain a copy of measures chosen.
• Maintain evidence to support that the report was generated by the CEHRT (ie, a screenshot). Because some CEHRT cannot generate reports that limit the calculation of measures to a prior time period, CMS suggests that clinicians download and/or print a copy of the report used at the time of data submission for their records.
• Maintain the final report showing all MIPS base and performance data/categories submitted for applicable PI measures per EC, noting any exclusions. Maintain a copy of all aggregated data if reporting as a group.
• Maintain a copy of any bonus points earned during the reporting period.
• 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 PI measures (eg, drug formulary checks, portal enrollment process, etc).
• Refer to the 2018 MIPS Data Validation–Year 2 Promoting Interoperability Performance Category Criteria for specific direction on reporting requirements, validation, and suggested documentation.

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.