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1. Screenshot from CMS’ QPP Participation Status Tool
at https://qpp.cms.gov/participation-lookup for each
eligible clinician.
2. Screenshot showing your Alternative Payment Model
(APM) participation status, if applicable.
Quality
For the Quality category, you should retain:
1. Claims or medical record documentation for each
measure you submitted for the appropriate reporting
period.
2. Evidence to support certified electronic health record
technology (CEHRT) submission, if bonus was claimed.
3. Documentation to support why fewer than six
measures, or no priority or outcome measure, was
submitted, if applicable.
Improvement Activities
For the Improvement Activities category, it is recommended
to retain:
1. All documentation to support completion or
participation in an activity during the attested
time period (typically 90 days), such as meeting
minutes, policies and procedures, medical records,
or screenshots from your electronic health record or
other internal system.
2. Evidence to support CEHRT submission, if bonus was
claimed.
3. Any specific documentation for the activity you
attested to based on CMS’ Data Validation Criteria.
Criteria are on the CMS QPP resource page and are
specific to each performance year.
Promoting Interoperability
For the Promoting Interoperability category, retain:
1. Documentation or reports from your CEHRT that show
measure requirements were met.
2. A copy of your Security Risk Analysis, either
performed or reviewed during the calendar year of the
performance period.
3. Documentation or reports from your CEHRT verifying
the submitted performance numbers were accurate.
4. Documentation, including internal policies and
procedures, verifying compliance with CMS attestation
statements.
5. Evidence to support reweighting due to special
status or hardship, if applicable. This may include
correspondence from CMS accepting the clinician’s
application for exception, if applicable.
Cost
Because clinicians do not submit data for the Cost category,
you do not need to retain any documentation for this
category.
How long do I need to retain
my documentation?
The False Claims Act encourages you to keep
documentation for up to 10 years and, as stated in the final
rule, CMS may request any records or data retained for the
purposes of MIPS for up to six years.
What are my first steps
if I receive an audit request?
If you receive an audit request from CMS, you must
acknowledge the request within 10 business days. After
this initial response, you should begin to collect all saved
documentation that verifies the MIPS data you submitted.
From the date of the initial request to complete data sharing,
you have 45 calendar days, or an alternative timeframe if
agreed upon by CMS and the MIPS-eligible clinician or group.
How can I stay ready for an audit?
1. Maintain readiness by performing a mock audit.
2. As you prepare for MIPS submission, prepare for an
audit as well by keeping all required documentation in
a secure location.
3. When saving documentation, save it in at least two
formats, such as in paper format in a binder, or
electronically saved to a local desktop computer or
server, a flash drive or the TMF MIPS Toolbox.
4. Organize documents by program year and by group or
individual clinician, based on reporting method.
Free support for MIPS
TMF quality improvement consultants are available at no
cost to help you review your reports and plan for MIPS.
Contact a TMF consultant for any audit or other MIPS-related
questions:
• Call 1-844-317-7609.
• Email QPP-SURS@tmf.org (practices with 15 or fewer
clinicians) or QualityReporting@tmf.org (practices with 16
or more clinicians).
• Complete a Request for Support form. DMJ
Resources
For more information on this topic, access these resources:
• https://tmf.org/qpp for an overview of available QPP
support and how to contact TMF.
• https://tmfqin.org/qpp and create a free QPP Learning and
Action Network (LAN) account. You then can access various
resources and webinars.
• Visit the CMS Resource Library to access the data validation
zip files:
- 2017 Data Validation — https://www.cms.gov/Medicare/
Quality-Payment-Program/Resource-Library/2017-MIPSData
Validation-Criteria-Quality-11-21-17.zip
- 2018 Data Validation — https://www.cms.gov/Medicare/
Quality-Payment-Program/Resource-Library/2018-MIPSData
Validation-Criteria.zip
www.TMFQIN.org / QualityReporting@tmf.org
844-317-7609
This material was prepared by TMF Health Quality
Institute, the Medicare Quality Innovation Network Quality
Improvement Organization, under contract with the Centers
for Medicare & Medicaid Services, an agency of the US
Department of Health and Human Services. The contents do
not necessarily reflect CMS policy.
/www.TMFQIN.org
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