Clinical, Financial and Administrative Insights For Physicians

Meaningful Use Audit - An Essential Checklist for Physicians Implementing Certified EHR

Posted by Suzanne Prasad

There is a 20% chance that you as an eligible provider may get audited and will be required to substantiate every single measure, eligibility requirement, or even ownership of a certified EHR.

Once you assume that a meaningful use audit is probable, the next step is to find ways to prepare for it. Meaningful use audit conducted by the Centers for Medicare & Medicaid Services, or one of its agents, compares the information entered into the attestation system Meaningful Use Audit Checklistwith documentation maintained by the provider. Without proper documentation, medical professionals can lose EHR incentive payments provided as part of the Health Information Exchange program.

What Do Auditors Look For?

The primary auditing agent Figloiozzi and Company offers information about what they look for in an audit via an article by iHealthBeat. They break down the data to four types:

  • ONC-ATCB Certification Documentation – proof from the Office of the National Coordinator for Health IT that the providers EHR system is certified for meaningful use attestation.
  • Documentation supporting the attestment to the core set of meaningful use criteria
  • Documentation supporting the attestment to the menu set items included in the meaningful use criteria
  • Methodology for determining emergency department admissions for hospitals only

Core Measures Checklist

Documentation can be broken down to two key sections:

  • Core measures
  • Menu items

By creating a checklist for each category, providers ensure they have all the necessary documentation is one central binder for each annual attestment. The core measures focus on the required objectives for each stage.

1. CPOE for Medications

Providers must offer the report used to obtain the numerator and denominator or a document to explain a claim of exclusion. Include:

  • EP reported using all patient records
  • EP reported using only patient records on the EHR

2. Drug Interaction Check

Screenshot of EHR settings that show active drug-drug and drug-allergy checking during the reporting period. When possible, store an interaction alert audit report, as well.

3. Problem List

Store the report used to obtain the numerator and denominator

4. e-Prescribing

Documentation used to obtain numerator and denominator or report that documents claim of exclusion. Include either:

  • EP reported using all patient records
  • EP reported using only patient records maintained in the certified EHR

5. Active Medication List

 Store the report used to obtain numerator and denominator

6. Medication Allergy List

Store the report used to obtain numerator and denominator

7. Demographics

Store the report used to obtain numerator and denominator

8. Vital Signs

Documentation used to obtain numerator and denominator or report that documents claim of exclusion. Include either:

  • EP reported using all patient records
  • EP reported using only patient records maintained in the certified EHR

Meaningful Use EHR Audit9. Smoking Status

Documentation used to obtain numerator and denominator or report that documents claim of exclusion. Include either:

  • EP reported using all patient records
  • EP reported using only patient records maintained in the certified EHR

10. Clinical Quality Measure (CQMs)

  • List of core or alternate core CQMs submitted
  • List of three additional CQMs selected
  • Store report used to obtain numerator and denominator for each CQM

11. Clinical Decision Support Rule (CDS)

Provide a screenshot from the EHR that shows the clinical decision support rule  with any other documentation to prove CDS in use during the entire reporting period. If necessary, contact your vendor audit documentation.

12. Electronic Copy of Health Information

Documentation used to obtain numerator and denominator or report that documents claim of exclusion. Include either:

  • EP reported using all patient records
  • EP reported using only patient records maintained in the certified EHR

13. Clinical Summaries

Documentation used to obtain numerator and denominator or report that documents claim of exclusion plus:

  • A copy of the clinical summary showing use of all required components
  • EP reported using all patient records
  • EP reported using only patient records maintained in the certified EHR

14. Electronic Exchange of Clinical Information:

Testing documentation including screenshots that show the test sending the data and one showing receipt

15. Protect Electronic Health Information

Security risk analysis to determine vulnerability or a letter explaining the deficiencies and signed proof of corrections

In addition to a checklist for core measures, providers should create one for the five menu items selected required complete with audit documentation.

You can download a complete copy of a formatted, printable checklist from HealthInfoNet. With the list in place, staff should build a binder book of evidence to support attestment choices to give to reviewers during a meaningful use audit.

This is the second of a three-part series on meaningful use audits. The first post: Meaningful Use Audit: What Physicians Must Expect from it? is available for reviewThe next blog will offer a practical survival guide, should you face the auditor.

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RevenueXL Inc. provides best value comprehensive solutions to medical practices. Our solutions include affordable Electronic Medical Records Software (a.k.a. EMR or EHR Software), Patient Portal, and Practice Management or Medical Billing software and revenue cycle services including medical billing, medical coding, coding audits and account receivables management services. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

Tags: Meaningful use, Certified EHR Software, Meaningful Use Audit

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