Post-Payment Audit Guidance

MU Guidance–Stage 1–2013

December 2016

Contents

  1. AUDIT GUIDANCE FOR MU STAGE 1 CORE MEASURES (2013)
  2. AUDIT GUIDANCE FOR MU STAGE 1 MENU MEASURES (2013)

Audit Guidance for MU Stage 1 (2013)

This document is designed to give detailed instructions on which documents Eligible Providers (EPs) should be saving in the event that they are selected for audit.

1. AUDIT GUIDANCE FOR MU STAGE 1 CORE MEASURES (2013)

EPs must attest to 14 Core Measures and five of the 10 Menu Measures.

https://www.cms.gov/Regulations–and–Guidance/Legislation/EHRIncentivePrograms/RequirementsforPreviousYears

1.1 CPOE for Medication Orders

  • Core Measure 1
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of the report used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows the EP wrote fewer than 100 prescriptions. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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1.2 Drug Interaction Checks

  • Core Measure 2
  • Submit a screenshot dated during the EHR Reporting Period showing that drug–drug and drug–allergy functionality is turned–on/enabled. If a dated screenshot is not available, a screenshot, along with a vendor letter stating the functionality was turned on during the EHR Reporting Period, may be submitted.
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1.3 Maintain Problem List

  • Core Measure 3
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
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1.4 Electronic Prescribing (e–Rx)

  • Core Measure 4
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of the report used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows the EP wrote fewer than 100 prescriptions. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
  • OR, if eligible, include documentation reflecting that the EP did not have a pharmacy within their organization and that there were no pharmacies that accepted electronic prescriptions within 10 miles of the EP´s practice location at the start of the EP´s EHR Reporting Period.
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1.5 Active Medication List

  • Core Measure 5
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
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1.6 Medication Allergy List

  • Core Measure 6
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
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1.7 Record Demographics

  • Core Measure 7
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
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1.8 Record Vital Signs

  • Core Measure 8
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows the EP saw no patients two years of age or older. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
  • An EP who believes that all three vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice would be excluded from this requirement. Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
  • An EP who believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, would be excluded from recording blood pressure. Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
  • An EP who believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, would be excluded from recording height/length and weight. Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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1.9 Record Smoking Status

  • Core Measure 9
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP saw no patients 13 years of age or older. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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1.10 Clinical Quality Measures (CQMs)

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1.11 Clinical Decision Support Rule

  • Core Measure 11
  • Submit a screenshot dated during the EHR Reporting Period showing that at least one CDS rule was implemented. If a dated screenshot is not available, a screenshot, along with a vendor letter stating the functionality was in use during the EHR Reporting Period, may be submitted.
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1.12 Electronic Copy of Health Information

  • Core Measure 12
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP had no requests from patients, or their agents, for an electronic copy of patient health information. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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1.13 Clinical Summaries

  • Core Measure 13
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP had no office visits. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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1.14 Protect Electronic Health Information

  • Core Measure 14
  • Submit proof that a security risk analysis of Certified EHR Technology was conducted or reviewed prior to the end of the EHR Reporting Period (i.e. report that documents the procedures performed during the analysis, and the results of the analysis). If deficiencies are identified in this analysis, please supply the implementation plan, including the completion date.
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2. AUDIT GUIDANCE FOR MU STAGE 1 MENU MEASURES (2013)

2.1 Drug Formulary Checks

  • Menu Measure 1
  • Submit a dated screenshot from the EHR Reporting Period showing that either an internal or external formulary check was enabled. If a dated screenshot is not available, a screenshot, along with a vendor letter stating the functionality was enabled during the EHR Reporting Period, may be submitted.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP wrote fewer than 100 prescriptions. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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2.2 Clinical Lab Test Results

  • Menu Measure 2
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP ordered no lab tests for which results were either in a positive/negative or numeric format. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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2.3 List of Patients by Condition

  • Menu Measure 3
  • Submit a copy of report* listing patients with a specific condition from the EHR system that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
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2.4 Patient Reminders

  • Menu Measure 4
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP saw no patients 65 years of age or older, or five years of age or younger. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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2.5 Patient Electronic Access

  • Menu Measure 5
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP neither orders nor creates lab tests or information that would be contained in the problem list, medication list, or medication allergy list. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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2.6 Patient–specific Education Resources

  • Menu Measure 6
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
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2.7 Medication Reconciliation

  • Menu Measure 7
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP was not the recipient of any transitions of care. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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2.8 Transition of Care Summary

  • Menu Measure 8
  • Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage (numerator/denominator) for this measure that is dated during the EHR Reporting Period that shows that the EP neither transferred a patient to another setting nor referred a patient to another provider. Report must clearly show the system name, provider name, and reporting period. Also, include on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
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2.9 Immunization Registries Data Submission

  • Submit a letter/verification from a public health registry confirming that at least one test/submission took place during the EHR Reporting Period.
  • Exclusion: On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken, reflecting that the EP administered no immunizations during the EHR Reporting Period, no immunization registry has the capacity to receive the information electronically, or it was prohibited during the EHR Reporting Period.
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2.10 Syndromic Surveillance Data Submission

  • Menu Measure 10
  • Submit a letter/verification from a public health registry confirming that at least one test/submission took place during the EHR Reporting Period.
  • Exclusion: On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken, reflecting that the EP did not collect any reportable syndromic information on their patients during the EHR Reporting Period, did not submit such information to any Public Health Agency that has the capacity to receive the information electronically, or if it was prohibited.
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* A formal document generated from a Certified Electronic Health Record (EHR) system supporting the attested to Meaningful Use measures.