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eHealth Tidbit: How to Prepare for a Meaningful Use Audit

Any provider attesting to receive an EHR incentive payment for either the Medicare or Medicaid programs can potentially be subject to an audit. Here's what you need to know to make sure you are prepared.

Your documentation should include either a report from your EHR system or screenshots to support the yes/no measures. If these reports do not include evidence that they were generated by the EHR, such as including the EHR logo, you should also create step-by-step screenshots showing how the reports were generated.

You should be able to provide verification of the EHR version being used during the EHR reporting period (invoices showing an active license may not be enough). Any communication with CMS regarding your MU attestation and including questions submitted and/or responses received, should be carefully documented with the case number, time, and date of your calls.

It is also recommended that you take screenshots to support your answers to any yes/no measures at both the beginning and end of your attestation periods.

Keep all of the reports used for attestation!

MU Objective Suggested Documentation

Drug-drug/drug-allergy interaction checks and clinical decision support

One or more screenshots from the certified EHR system that are dated during the EHR reporting period. Also, it is a good practice to include any policy and procedures being implemented to support the Clinical Decision Support rule process.
Ambulatory clinical quality measure reporting A report from a certified EHR system to validate all clinical quality measure data entered during attestation.

Protection of electronic health information

A report that documents the procedures performed during the security risk analysis of the EHR and the results. Report should be dated prior to the end of the reporting period and should include evidence to support that it was generated for that provider's system (e.g., National Provider Identifier, CMS certification number, provider name, or practice name).

Drug formulary checks

One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.

Public Health objective

Dated screenshots from the EHR system that document a test submission to the registry or public health agency (successful or unsuccessful). Should include evidence to support that it was generated for that provider's system (e.g., National Provider Identifier, CMS certification number, provider name, or practice name). (Specific to Stage 1 submitted prior to 12/15/15).

A letter or email from the registry or public health agency confirming the receipt of registration to engage within 60 days after the start of the EHR reporting period.

Proof of communications with public health agency that active testing is taking place.

A letter or email from the registry or public health agency confirming the connection and successful submission of data to the registry.

Exclusions

Report from the certified EHR system that shows a zero denominator for the measure or other documentation as to why the provider qualifies for the exclusion.

*Adapted from EHR Incentive Programs Supporting Documentation for Audits handout. Centers for Medicare & Medicaid Services. Available at: http://go.cms.gov/WjRCM6. Updated February 2013. Accessed Sept. 5, 2013.

As always, if you have any questions or would like further assistance, please contact your eHealth Specialist.