Post-Payment Audit Guidance

Audit Guidance for MU Modified Stage 3

April 2021

Contents

  1. AUDIT GUIDANCE FOR MU MODIFIED STAGE 3

Audit Guidance for MU Stage 3

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 3

EPs must attest to each of the 8 objectives listed for MU3. Please see the audit guidance objectives for MU Stage 3 (2017c2021) and the CMS link below for further details into the objectives.

1.1 Electronic Protected Health information

  • Objective 1
  • Documentation: Submit proof (i.e., report which documents the procedures performed during the analysis and the results of the analysis) that a security risk analysis of Certified EHR Technology was conducted or reviewed no earlier than January 1st of the payment year, and prior to the date of attestation**. Documentation should note deficiencies (if any), and corrective action was taken on noted deficiencies. If deficiencies are identified in this analysis, please supply the implementation plan; this plan should include the completion dates.
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1.2 Electronic Prescribing (e–Rx)

  • Objective 2
  • Documentation: Submit a copy of report* used in determining percentage(s) (numerator/denominator) for this measure that is dated during the EHR Reporting Period. The report must clearly show the system name, provider name, and reporting period.
  • Exclusion: Submit a copy of report* used in determining percentage(s) (numerator/denominator) for this measure showing the EP wrote fewer than 100 permissible prescriptions during the EHR reporting period. The report must clearly show the system name, provider name, and reporting period. Additionally, provide a written explanation of why this exclusion was taken.
  • Alternate Exclusion: If applicable, provide documentation to demonstrate EP does 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 his or her EHR reporting period.
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1.3 Clinical Decision Support (CDS)

  • Objective 3
  • Documentation (1): Submit a screenshot dated during the EHR Reporting Period showing five clinical decision support interventions related to four or more clinical quality measures were enabled and implemented. If a dated screenshot is unavailable, 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. Documentation must clearly indicate the system name, provider name, and reporting period.
  • AND
  • Documentation (2): If over 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 unavailable, a screenshot along with a vendor letter stating the functionality was enabled during the EHR reporting period may be submitted. Documentation must clearly indicate the system name, provider name, and reporting period.
  • Exclusion (2): Submit a copy of report* used in determining percentage(s) (numerator/denominator) for this measure showing EP wrote fewer than 100 permissible prescriptions during the EHR reporting period. The report must clearly show the system name, provider name, and reporting period. Additionally, provide a written explanation of why this exclusion was taken.
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1.4 Computerized Provider Order Entry (CPOE)

  • Objective 4
  • Documentation (1): Submit a copy of report* used in determining percentage(s) (numerator/denominator) for this measure that is dated during the EHR reporting period. The report must clearly show the system name, provider name, and reporting period.
  • Exclusion (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. The report must clearly show the system name, provider name, and reporting period. Additionally, provide a written explanation of why this exclusion was taken.
  • Documentation (2): Submit a copy of report* used in determining percentage(s) (numerator/denominator) for this measure that is dated during the EHR reporting period. The report must clearly show the system name, provider name, and reporting period.
  • Exclusion (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. The report must clearly show the system name, provider name, and reporting period. Additionally, provide a written explanation of why this exclusion was taken.
  • Documentation (3): Submit a copy of report* used in determining percentage(s) (numerator/denominator) for this measure that is dated during the EHR reporting period. The report must clearly show the system name, provider name, and reporting period.
  • Exclusion (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 diagnostic imaging orders. The report must clearly show the system name, provider name, and reporting period. Additionally, provide a written explanation of why this exclusion was taken.
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1.5 Patient Electronic Access to Health Information

  • Objective 5
  • Documentation: Submit a copy of report* used in determining percentage(s) (numerator/denominator) for these measures that is dated during the EHR Reporting Period. The 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.
  • OR
  • If applicable, provide documentation to demonstrate that the EP conducted 50 percent or more of their 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.
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1.6 Coordination of Care

  • Objective 6
  • Documentation: Submit a copy of report* used in determining percentage(s) (numerator/denominator) for these measures that is dated during the EHR reporting period. The report must clearly show the system name, provider name, and reporting period.
  • Exclusions: 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.
  • OR
  • If applicable, provide documentation to demonstrate that the EP conducted 50 percent or more of their 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.
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1.7 Health Information Exchange

  • Objective 7
  • Documentation Requested: Submit a copy of report* used in determining percentage(s) (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. Additionally, please provide a description of your process and/or procedure used to perform the required action(s).
  • Exclusions: 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.
  • OR
  • If applicable, provide documentation to demonstrate that the EP conducted 50 percent or more of their 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.
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1.8 Public Health Reporting

  • Objective 8
  • Documentation (1): 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 OR utilize the Audit Report Card generated by New York State Meaningful Use Registration for Public Health System.
  • Exclusions (1): If applicable, submit documentation to confirm that EP:
    • 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;
    • 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; or
    • Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the EHR reporting period.
  • Documentation (2): 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 OR utilize the Audit Report Card generated by New York State Meaningful Use Registration for Public Health System.
  • Exclusions (2): If applicable, submit documentation to confirm that EP:
    • Is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system;
    • Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or
    • Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs as of 6 months prior to the start of the EHR reporting period.
  • Documentation (3): Submit letter/verification from a public health registry stating that the EP was in active engagement with a public health agency to submit electronic case reporting data during the EHR Reporting Period OR utilize the Audit Report Card generated by New York State Meaningful Use Registration for Public Health System.
  • Exclusions (3): If applicable, submit documentation to confirm that EP:
    • Does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction’s reportable disease system during the EHR reporting period;
    • Operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or
    • Operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the EHR reporting period.
  • Documentation (4): 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 public health registries during the EHR Reporting Period OR utilize the Audit Report Card generated by New York State Meaningful Use Registration for Public Health System.
  • Exclusions (4): If applicable, submit documentation to confirm that EP:
    • Does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the EHR reporting period;
    • Operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or
    • Operates in a jurisdiction where no public health registry for which the EP is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the EHR reporting period.
  • Documentation (5): 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 clinical data registry during the EHR Reporting Period OR utilize the Audit Report Card generated by New York State Meaningful Use Registration for Public Health System.
  • Exclusions (5): If applicable, submit documentation to confirm that EP:
    • Does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the EHR reporting period;
    • Operates in a jurisdiction for which no clinical data registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or
    • Operates in a jurisdiction where no clinical data registry for which the EP is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the EHR reporting period.
  • * A formal document generated from a Certified Electronic Health Record (EHR) system supporting the attested to Meaningful Use measures.
  • ** For Payment Year 2021 only, providers will be given the option to indicate their security risk assessment will be performed after the date of attestation, but prior to 12/31/21.
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