Post-Payment Audit Guidance

MU Audit Guidance–Stage 2–2014

January 2018

Contents

  1. AUDIT GUIDANCE FOR MU STAGE 2 (2014) CORE OBJECTIVES
  2. AUDIT GUIDANCE FOR MU STAGE 2 (2014) MENU OBJECTIVES

Audit Guidance for MU Stage 2

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 2 (2014) CORE OBJECTIVES

EPs must attest to 17 Core Objectives and three of the six Menu Objectives.

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

1.1 CPOE for Medication, Laboratory, and Radiology 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 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 medication, radiology, or laboratory orders. 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 E–Prescribing (e–Rx)

  • Core 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 fewer 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.
  • OR, if eligible, include documentation reflecting that the EP does not have a pharmacy within their organization and there were no pharmacies that accept electronic prescriptions within 10 miles of the EP´s practice location at the start of the EP´s EHR 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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1.3 Record Demographics

  • 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 Record Vital Signs

  • 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 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 three 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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1.5 Record Smoking Status

  • 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.
  • 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 neither saw nor admits any 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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1.6 Clinical Decision Support Rule (CDS)

  • Core Measure 6
  • Measure 1: Submit a screenshot, dated during the EHR Reporting Period, showing that five clinical decision support interventions were enabled and implemented. If a dated screenshot is not available, a screenshot, along with a vendor letter stating that five clinical decision support interventions related to four or more clinical quality measures were implemented during the EHR Reporting Period, may be submitted.
  • Measure 2: If more than 100 medication orders were written during the EHR Reporting Period, submit documentation to confirm that drug–drug and drug–allergy interaction functionality was enabled during the EHR Reporting Period. 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: For the second measure, 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 medication orders. 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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1.7 Patient Electronic Access

  • 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.
  • 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 ordered nor created any of the information listed for inclusion as part of both measures, except for "Patient name" and "Provider´s name and office contact 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.
  • OR, if EP conducted 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability, according to the latest information available from the FCC, on the first day of the EHR Reporting Period, include documentation to support this claim. Also, include on the Signed Checklist that was provided by your Auditor, an explanation of why this exclusion was taken.
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1.8 Clinical Summaries

  • 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 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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1.9 Protect Electronic Health Information

  • Core Measure 9
  • Submit proof that a security risk analysis of CEHRT 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; this plan should include the completion dates.
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1.10 Clinical Lab–Test Results

  • Core Measure 10
  • 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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1.11 Patient Lists

  • Core Measure 11
  • Submit at least one report listing patients of the EP with a specific condition dated during the EHR Reporting Period. Report must clearly show the system name, provider name, and reporting period.
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1.12 Preventive Care

  • 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 has had no office visits in the 24 months before 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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1.13 Patient-Specific Education Resources

  • 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 Medication Reconciliation

  • Core Measure 14
  • 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.

1.15 Summary of Care

  • Core Measure 15
  • 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 who transferred a patient to another setting or referred a patient to another provider less than 100 times during the EHR Reporting Period is excluded from all three measures. Report must clearly show the system name, provider name and reporting period. Also include an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor.

1.16 Immunization Registries Data Submission

  • Core Measure 16
  • Submit letter/verification from a public health registry confirming that the EP was registered with the PHA within 60 days of the start of the EHR Reporting Period and ongoing submission was achieved as the EP was in one of the following statuses:
    • Registered and awaiting an invitation to test;
    • Registered and engaged in testing;
    • Registered and achieved ongoing submission, or;
    • Achieved ongoing submission during previous EHR Reporting Period and continues throughout the current EHR Reporting Period
  • Exclusion: Submit an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor. Explanation should address how EP meets one or more of the following criteria:
    • The EP does not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction´s immunization registry or immunization information system during the EHR reporting period
    • The EP operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required for CEHRT at the start of their EHR reporting period;
    • The EP operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data; or
    • The EP operates in a jurisdiction for which no immunization registry or immunization information system that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs.

1.17 Use Secure Electronic Messaging

  • Core Measure 17
  • 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 during the EHR Reporting Period. Report must clearly show the system name, provider name and reporting period. Also include an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor.
  • OR, if EP conducted 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR Reporting Period, include documentation to support this claim. Also include an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor.
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2. AUDIT GUIDANCE FOR MU STAGE 2 (2014) MENU OBJECTIVES

2.1 Syndromic Surveillance Data Submission

  • Menu Measure 1
  • Submit letter/verification from a public health registry that confirms that the EP was registered and in one of the following statuses during the EHR reporting period:
    • Registered and awaiting an invitation to test;
    • Registered and engaged in testing;
    • Registered and achieve ongoing submission, or;
    • Achieved ongoing submission during previous EHR Reporting Period and continues throughout current EHR Reporting Period.
  • Exclusion: Submit an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor. Explanation should address how EP meets one or more of the following criteria:
    1. The EP is not in a category of providers that collect ambulatory syndromic surveillance information on their patients during the EHR Reporting Period;
    2. The EP operates in a jurisdiction for which no Public Health Agency is capable of receiving electronic syndromic surveillance data in the specific standards required by CEHRT at the start of their EHR Reporting Period;
    3. The EP operates in a jurisdiction where no Public Health Agency provides information timely on capability to receive syndromic surveillance data; or
    4. The EP operates in a jurisdiction for which no Public Health Agency that is capable of accepting the specific standards required by CEHRT at the start of their EHR Reporting Period can enroll additional EPs.
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2.2 Electronic Notes

  • 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 had no office visits. Report must clearly show the system name, provider name and reporting period. Also include an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor.
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2.3 Imaging Results

  • Menu 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.
  • 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 less than 100 tests whose result is an image during the EHR Reporting Period; or documentation that supports that EP had no access to electronic imaging results at the start of the EHR Reporting Period. Report must clearly show the system name, provider name and reporting period. Also include an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor.
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2.4 Family Health History

  • 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 had no office visits. Report must clearly show the system name, provider name and reporting period. Also include an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor.
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2.5 Report of Cancer Cases

  • Menu Measure 5
  • Submit letter/verification from a public health central cancer registry that confirms that the EP was registered and in one of the following statuses during the EHR reporting period:
    • Registered and awaiting an invitation to test;
    • Registered and engaged in testing;
    • Registered and achieve ongoing submission, or;
    • Achieved ongoing submission during previous EHR Reporting Period and continues throughout current EHR Reporting Period.
  • Exclusion: Submit an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor. Explanation should address how EP meets one or more of the following criteria:
    1. The EP does not diagnose or directly treat cancer;
    2. The EP operates in a jurisdiction for which no public health agency is capable of receiving electronic cancer case information in the specific standards required for CEHRT at the beginning of their EHR reporting period;
    3. The EP operates in a jurisdiction where no PHA provides information timely on capability to receive electronic cancer case information; or
    4. The EP operates in a jurisdiction for which no public health agency that is capable of receiving electronic cancer case information in the specific standards required for CEHRT
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2.6 Report Specific Cases

  • Menu Measure 6
  • Submit letter/verification from a specialized registry that that confirms that the EP was registered and in one of the following statuses during the EHR reporting period:
    • Registered and awaiting an invitation to test;
    • Registered and engaged in testing;
    • Registered and achieve ongoing submission, or;
    • Achieved ongoing submission during previous EHR Reporting Period and continues throughout current EHR Reporting Period.
  • Exclusion: Submit an explanation of why this exclusion was taken on the Signed Checklist that was provided by your Auditor. Explanation should address how EP meets one or more of the following criteria:
    1. The EP does not diagnose or directly treat any disease associated with a specialized registry sponsored by a national specialty society for which the EP is eligible, or the public health agencies in their jurisdiction;
    2. The EP operates in a jurisdiction for which no specialized registry sponsored by a public health agency or by a national specialty society for which the EP is eligible is capable of receiving electronic specific case information in the specific standards required by CEHRT at the beginning of their EHR reporting period;
    3. The EP operates in a jurisdiction where no public health agency or national specialty society for which the EP is eligible provides information timely on capability to receive information into their specialized registries; or
    4. The EP operates in a jurisdiction for which no specialized registry sponsored by a public health agency or by a national specialty society for which the EP is eligible that is capable of receiving electronic specific case information in the specific standards required by CEHRT at the beginning of their EHR reporting period can enroll additional EPs.
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* A formal document generated from a Certified Electronic Health Record (EHR) system supporting the attested to Meaningful Use measures.