Preparing for a MIPS Audit

Thursday, August 30, 2018 | Cherie Kelly-Aduli

In Year 3 of the Quality Payment Program (QPP) clinicians have 7% of their Medicare Part B reimbursement at risk for non-participation in the MIPS program. With that being said, providers can score a perfect 100 and still have their positive payments adjusted negatively if they are unable to provide proof of their work. Unfortunately, there has not been much published by CMS on exactly what is required in the event of a MIPS audit. Below is a list of recommended screenshots to help you organize your documentation.

NPI Lookup Tool
First you will want to see if your provider is considered a MIPS eligible clinician by going to the NPI look up tool located here. Keep in mind that if you work under multiple tax IDs you may be exempt from one but still meet the minimum threshold under another tax ID. If you are exempt you will want to take a screenshot stating that you are not required to participate in the MIPS program.

EHR Certification
For Meaningful Use audits providers were required to have a letter from their EHR vendor verifying that they were using CEHRT for the time period in which they attested in addition to providing proof of payments to the EHR vendor. This may sound like overkill for MIPS but I think you should probably have this as part of your file in the event that you are audited.

Quality Measures Documentation 
Data validation will occur for claims and registry measures if a provider or group does not submit the correct amount or type of measures required under MIPS. This process is very similar to MAV (Measures Applicability Validation) for PQRS.

  • If you are planning to report through your EHR you will want to take a screenshot of your Quality scores from a report generated by your EHR. This report should include all of the measures you are planning to submit with their numerator and denominator amounts for the time frame in which you are planning to attest. Since providers are only responsible for submitting six (6) quality measures I would recommend going down to the patient level and taking screenshots of the measures being met.
  • If you report through a CMS-approved registry vendor you will want to make sure to keep documentation from the registry stating that your data was successfully submitted to CMS. You will also want to keep a copy of the quality reports from your EHR in addition to screenshots of your data in the actual registry.
  • If CAHPS is one of your quality measures you will want to make sure you have a screenshot/receipt from the CMS-approved survey vendor stating that you are enrolled in this measure.

Promoting Interoperability Documentation (aka the Advancing Care Category)

  • Print a report from your Certified EHR of the measures with numerator and denominator calculations for each of your providers. The report should include the EHR vendor logo and the timeframe of which you are attesting. I also recommend collecting screenshots of the workflows for each measure reported. 
  • Gather all documentation for public health measures from your state agencies such as emails or receipts stating that you submitted your documentation to the state.
  • For specialized registry reporting you will want to take a screenshot showing that the registry you are participating in is a CMS-approved registry in addition to receipts showing proof of payment to the specialized registry. Some QCDRs interface with EHRs while others require you to log in to a separate portal to enter your data so you will want to take screenshots in either at the patient level.
  • The Security Risk Assessment should be performed or reviewed for the Performance Year in which you are reporting. You will want a copy of this assessment in your file as this seems to be the most audited measure. It is very important to review and update your policies each year!

Improvement Activities (IA) Documentation 

  • The CMS Resource Library includes a list of the data validation criteria for each of your Improvement Activities. There you will also find a list of suggested documentation for all of the Improvement Activities. Prepare your documentation accordingly. Click here to view the data validation criteria for Improvement activities:
  • If you choose activities that require CEHRT you will want a few patient level screenshots of the activity being completed in your EHR (for the same timeframe in which you plan to attest).

Cost Category

  • Since the cost measure is calculated through administrative claims you will not be responsible for providing any documentation in this category.

CMS can request any of your MIPS records or data for up to six (6) years after the program year in which you attested. Knowing this you will want to have your documentation in both hard and electronic copies for at least 10 years. Once you receive your initial letter from CMS stating that you have been selected for an audit you will have 10 days to respond to their letter. The maintenance of your data is critical to your overall success in the MIPS program. Reach out to MedAxiom if you need further assistance in preparing you documentation for an audit. 



Illustration: Lee Sauer

About the Author
Cherie Kelly-Aduli

Cherie Kelly-Aduli is the CEO of QPP Consulting Group in Mandeville, Louisiana, and a MedAxiom consultant. She has over 16 years of experience in healthcare operations, population health and accountable care. Prior to opening her own firm, Cherie was the Director of Clinical Operations and subsequently Director of Population Health and Accountable Care for the Louisiana Heart Hospital and Medical Group located in Lacombe, Louisiana.

Throughout her career Cherie has been highly successful in efficient practice management, practice adoption of electronic health records, and assisting providers with exceeding standards for patient satisfaction. As payors and patients have transitioned to "pay for value," Cherie has been instrumental in leading private practices and hospital systems to achieve high quality outcomes under the Meaningful Use, PQRS and Value Based Modifier programs; she is now assisting groups with their adoption of the Merit Based Incentive Payment system under MACRA.

To contact, email:

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