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Merit-Based Incentive Payment System: Referencing Source Documents

Hess, Cathy Thomas BSN, RN, CWCN

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Advances in Skin & Wound Care: November 2017 - Volume 30 - Issue 11 - p 528
doi: 10.1097/01.ASW.0000526155.90143.08
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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

Sample CMS FAQ 2

Question to CMS: We are revising our policy on scribes for the Medicare and Medicaid EHR Incentives Programs such that scribes may document in an EHR as long as the physician delegates this action and signs and verifies the documentation, and the action is in accordance with applicable state law.

CMS Response: The 21st Century Cures Act amended The Health Information Technology for Economic and Clinical Health Act (title XIII of division A of Public Law 111–5) by adding section 13103(c), which allows a physician (as defined in section 1861(r)(1) of the Social Security Act) to “delegate electronic medical record documentation requirements specified in regulations promulgated by the CMS to a person performing a scribe function who is not such physician if such physician has signed and verified the documentation,” and the action is in accordance with applicable state law. Previously, the Medicare and Medicaid EHR Incentive Programs did not specify the documentation requirements.

For additional information on electronic medical record documentation, please refer to other CMS requirements such as the Medicare physician fee schedule as well as FAQ 19061.3

Keep Asking Questions

Take some time to navigate within the CMS FAQ webpage. Enter your questions or seek clarification on previously submitted questions and CMS responses. And as always, continue your diligent documentation for your Advancing Care Information, Improvement Activities, and Clinical Quality Measures!


1. Centers for Medicare & Medicaid Services. Frequently Asked Questions. 2016. Last accessed September 25, 2017.
2. Centers for Medicare & Medicaid Services. Frequently Asked Questions: FAQ17869. Last accessed September 25, 2017.
3. Centers for Medicare & Medicaid Services. Frequently Asked Questions: FAQ20477. Last accessed September 25, 2017.
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