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Merit-based Incentive Payment System 2018 Documentation and Audit Checklist

Hess, Cathy Thomas, BSN, RN, CWCN

doi: 10.1097/01.ASW.0000547265.16040.59
DEPARTMENTS: PRACTICE POINTS

Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via e-mail: chess@nethealth.com.

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.1,2

Participation status 3

  • 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 4
  • 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 5
  • 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.”6
  • 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.7
    • Quality Performance 8
  • Quality accounts for 50% of the final score. This percentage can change due to Special Statuses, Exception Applications, not being scored on any cost measures, or APM participation.
  • Verify and maintain a copy of your participation status with your NPI.
  • Participants must submit data for at least six measures for the 12-month performance period.9
  • Participants should submit collected data for at least six measures. One of these measures should be an outcome measure; if you have no applicable outcome measure, you can submit a high-priority measure instead. Make sure to maintain a copy of measures chosen.
  • Identify the reporting period and submission method used for Quality reporting.
  • Obtain/maintain a copy of your CEHRT edition.
  • Maintain the final report for each EC.
  • Maintain a copy of all aggregated data if reporting as a group and proof the data were submitted for all ECs within the TIN.
  • Maintain copies of any third-party vendor agreements implemented during the reporting period.
  • Maintain a copy of all applicable policies and/or procedures supporting Quality reporting.
  • Review 2018 MIPS Data Validation–Year 2 Quality Performance Measure Criteria for specific direction for 2018 reporting requirements.7
    • Improvement Activity 10
  • This category accounts for 15% of the final score. This percentage can change due to Special Statuses, Exception Applications, or APM participation.
  • To earn full credit in this category, participants must submit one of the following combinations of activities (performed for 90 days or more during 2018):11
    • - two high-weighted activities
    • - one high-weighted activity and two medium-weighted activities
    • - at least four medium-weighted activities
  • You will receive double points for each high- or medium-weighted activity you submit if you are an individual clinician, group, or virtual group who holds any special status.
  • Obtain and maintain screenshots of any functionality enabled or used to support specific Improvement Activity (IA) categories.
  • Maintain documentation to support compliance for each IA category completed during the reporting period and a copy of measures chosen.
  • Maintain the final report for each EC.
  • Maintain copies of any third-party vendor agreements implemented during the reporting period.
  • Maintain a copy of all applicable policies and/or procedures supporting IA reporting.
  • Review 2018 MIPS Data Validation–Year 2 Improvement Activity Performance Category Criteria for specific direction for 2018 reporting requirements;8 note the suggested documentation necessary to maintain your IA.
  • Cost accounts for 10% of the final score. This percentage can change in light of APM participation and the volume of attributed patients. In the event that there are not enough attributed beneficiaries for the Medicare Spending Per Beneficiary and Total Per Capita Cost measures, the Cost performance category weight will be added to the Quality performance category.
  • There is no data submission requirement for the Cost performance category. Cost measures are evaluated automatically through administrative claims data.
    • Data Validation and Audit Criteria 7
  • Under MIPS, CMS will conduct an annual data validation and audit process. If selected for a data validation or audit, you will have 45 calendar days to complete data sharing as requested or an alternate time frame that is mutually agreed upon.
  • In accordance with the False Claims Act, you should keep documentation for up to 6 years in case CMS requests it.
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References

1. Centers for Medicare & Medicaid Services. 2018 Resources. 2018. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html. Last accessed September 25, 2018.
2. Centers for Medicare & Medicaid Services. 2018 Merit-based Incentive Payment System (MIPS) Participation & Overview. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-MIPS-participation-and-overview-fact-sheet.pdf. Last accessed September 25, 2018.
3. Centers for Medicare & Medicaid Services. About MIPS Participation. https://qpp.cms.gov/participation-lookup/about. Last accessed September 25, 2018.
4. Centers for Medicare & Medicaid Services. Individual or Group Participation. https://qpp.cms.gov/mips/individual-or-group-participation. Last accessed September 25, 2018.
5. Centers for Medicare & Medicaid Services. 2018 MIPS Promoting Interoperability Performance Category Fact Sheet. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Promoting-Interoperability-Fact-Sheet.pdf. Last accessed September 25, 2018.
6. Centers for Medicare & Medicaid Services. The Merit-based Incentive Payment System (MIPS) Advancing Care Information Prevention of Information Blocking Attestation. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/ACI-Information-Blocking-fact-sheet.pdf. Last accessed September 25, 2018.
7. Centers for Medicare & Medicaid Services. 2018 Resources: MIPS Data Validation Criteria. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Resources.html. Last accessed September 25, 2018.
8. Centers for Medicare & Medicaid Services. 2018 MIPS Quality Performance Fact Sheet. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Quality-Performance-Category-fact-sheet.pdf. Last accessed September 25, 2018.
9. Centers for Medicare & Medicaid Services. Quality Measures Requirements. https://qpp.cms.gov/mips/quality-measures. Last accessed September 25, 2018.
10. Centers for Medicare & Medicaid Services. 2018 MIPS Improvement Activities Fact Sheet. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Improvement-Activities-Performance-Category-fact-sheet.pdf. Last accessed September 25, 2018.
11. Centers for Medicare & Medicaid Services. Improvement Activities Requirements. https://qpp.cms.gov/mips/improvement-activities. Last accessed September 25, 2018.
12. Centers for Medicare & Medicaid Services. 2018 Merit-based Incentive Payment System (MIPS) Cost Performance Category Fact Sheet. www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Cost-Performance-Category-Fact-Sheet.pdf. Last accessed September 25, 2018.
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