Post-Payment Audit Guidance

Audit Guidance for MU Modified Stage 2

December 2016

Contents

  1. AUDIT GUIDANCE FOR MU MODIFIED STAGE 2

Audit Guidance for MU Modified 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 MODIFIED STAGE 2

EPs must attest to each of the 10 objectives including, including one Public Health measure for EPs previously scheduled to be in Stage 1 in 2015, and two Public Health measures for EPs previously scheduled to be in Stage 2 in 2015. Please see the below audit guidance objectives for MU Modified Stage 2 (2015–2017).

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

1.1 Protect Patient Health Information

  • Objective 1
  • Submit proof that a security risk analysis of CEHRT was conducted prior to the date of attestation (i.e. report that documents the procedures performed during the analysis and the results of the analysis). The security risk analysis must be conducted on an annual basis and the scope of the analysis must include the full EHR Reporting Period. If deficiencies are identified in this analysis, please supply the implementation plan, including the completion date.
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1.2 Clinical Decision Support

  • Objective 2
  • 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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1.3 Computerized Provider Order Entry (CPOE)

  • Objective 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 for Measure 1: 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.
  • Exclusion for Measure 2: 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 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.
  • Alternate Exclusion for Measure 2: 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 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.
  • Exclusion for Measure 3: 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 radiology 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.
  • Alternate Exclusion for Measure 3: 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 radiology 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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1.4 Electronic Prescribing (e–Rx)

  • Objective 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 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 that there are 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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1.5 Health Information Exchange

  • Objective 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 who transferred a patient to another setting, or referred a patient to another provider, fewer 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 on the Signed Checklist that was provided by your Auditor an explanation of why this exclusion was taken.
  • Alternate Exclusion: On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken
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1.6 Patient Specific Education

  • Objective 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.
  • 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.
  • Alternate Exclusion: On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken.
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1.7 Medication Reconciliation

  • Objective 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.
  • Alternate Exclusion: On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken.
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1.8 Patient Electronic Access

  • Objective 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 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 4Mbps 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.
  • Alternate Exclusion Measure 2: On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken.
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1.9 Secure Electronic Messaging

  • Objective 9
  • Submit a screenshot dated during the EHR Reporting Period showing that the capability for patients to send and receive a secure electronic message with the EP was fully enabled during the EHR Reporting Period. 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.
  • 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 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.
  • Alternate Exclusion: On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken.
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1.10 Public Health Reporting

  • Objective 10
  • An EP scheduled to be in Stage 2 in 2015 must meet two measures. All EPs must meet two measures in 2016 and 2017.
  • Immunization Registry Reporting:
    Submit letter/verification from a public health registry stating that the EP was in active engagement with a public health agency to submit immunization data during the EHR Reporting Period.
  • Syndromic Surveillance Reporting:
    Submit letter/verification from a public health registry stating that the EP was in active engagement with a public health agency to submit syndromic surveillance data during the EHR Reporting Period.
  • Specialized Registry Reporting:
    Submit letter/verification from a public health registry stating that the EP was in active engagement with a public health agency to submit data to a specialized registry during the EHR Reporting Period.
  • Exclusion: Measure Option 1 - Immunization Registry Reporting:
  • On the Signed Checklist that was provided by your Auditor, include an explanation of why this exclusion was taken. Explanation should address how EP meets one or more of the following criteria:
    1. Does not administer any 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
    2. Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR Reporting Period
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* A formal document generated from a Certified Electronic Health Record (EHR) system supporting the attested to Meaningful Use measures.