1. Meaningful Use Audit Webinar Series March 25, 2015: An Overview of the Meaningful Use Audit Process 1 in 10 providers will receive a MU audit letter April 1, 2015: Preparing for EHR Incentive Program Audit Tips and Suggestions The time to prepare for an audit is before you receive the letter April 8, 2015: EHR Incentive Program Appeals Process Steps to Complete a Meaningful Use Audit Appeal

2. Preparing for EHR Incentive Program Audit Tips and Suggestions
Brenda Simms RN, BSN, CHTS-CP
Meaningful Use Specialist
IL-HITREC
Northern Illinois University
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

3. Disclaimer
This webinar is based on official guidance provided by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC), experiences from IL-HITREC, and other Regional Extension Centers. It is by no means all-inclusive of the types of documentation you must keep to support your attestation, but this webinar provides a starting point. IL-HITREC is not giving legal advice. If you are audited, you should consult your Certified EHR Technology (CEHRT) vendor and/or legal advisor.

4. The time to prepare for an audit is before you receive the letter.
“You cannot escape the responsibility of tomorrow by evading it today." Abraham Lincoln
The time to prepare for an audit is before you receive the letter.

5. Preparing for Audit Treat a Meaningful Use Audit as a Team Sport:
Secure Administrative Buy-In and Involvement:
The Auditor may ask to interview administration/management
Include Stake Holders from other departments
Develop a formal MU Audit Team with an oversight committee
Designate a person or committee to oversee and coordinate meaningful use criteria and share the work load
Designate a facility “Primary Contact”
Team Approach provides coverage if the Primary Contact is unavailable

6. Preparing for Audit
Establish a process for building an “EHR Attestation Binder”:
Comprehensive book of evidence in both electronic and paper form
Define Terms
Organize book by objectives
Develop an Audit Plan:
Written compliance plan and data repository
Gather supporting data for each MU objective/validate data
Develop and maintain detailed policy and procedures for use of your certified EHR technology
Conduct internal audits on compliance
Maintain all supporting data for six years post-attestation
Document payment calculations and cost report data

7. 11/12/2017 6:48 AM
Source Documentation
Primary Documentation is referred to as “Source Documentation”
The numerators and denominators for the measures
The time period the report covers
Evidence to support that it was generated for that EP, eligible hospital, or CAH [e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.]
Evidence to support that the report was generated by the certified EHR system (e.g., screenshot of the report before it was printed from the system)
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

8. 11/12/2017 6:48 AM
Source Documentation
Documentation should be saved for 6 years post-attestation to support Meaningful Use Objectives and Clinical Quality Measures:
Maintain paper copies
Maintain electronic copies
Maintain cost reports to calculate payment
Organize and categorize your information and keep it up to date!
Anticipate what an auditor might ask for before the audit
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

9. Points to Remember Make sure your numbers are accurate
11/12/2017 6:48 AM
Points to Remember
Make sure your numbers are accurate
Your numerators and denominators are from your certified EHR
Identify reporting period specific to provider (NPI)
System audit log provides documentation that functions are enabled, along with screenshots for “Yes or No” functions
Drug Allergy interaction and clinical decision support must be enabled during the entire reporting period
Security Risk Analysis must be specific to your practice:
Not generalized and performed yearly prior to attestation
Mitigation Plan for identified deficiencies
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

10. Stage 1 Non-Percentage-Based Objectives
Meaningful Use Objective
Audit Validation
Suggested Documentation
Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support
Functionality is available, enabled, and active in the system for the duration of the EHR reporting period.
One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
Report ambulatory or hospital clinical quality measures
Clinical quality measure data is reported directly from certified EHR systems.
Report from the certified EHR system to validate all clinical quality measure data entered during attestation.
Exclusions
Documentation to support each exclusion to a measure claimed by the provider.
Report from the certified HER system that shows a zero denominator for the measure or otherwise documents that the provider qualifies for the exclusion.
Source: cms.gov

11. Stage 1 Non-Percentage-Based Objectives
Meaningful Use Objective
Audit Validation
Suggested Documentation
Electronic Exchange of Clinical Information
One test of certified EHR technology’s capacity to electronically exchange key clinical information to another provider of care with a distinct certified EHR
or other system capable of receiving the information was performed during the EHR reporting period.
Dated screenshots from the EHR system that document a test exchange of key clinical information (successful or unsuccessful) with another provider of care during the reporting period.
A dated record of successful or unsuccessful electronic transmission (e.g., , screenshot from another system, etc.).
A letter or from the receiving provider confirming a successful exchange, including specific information such as the date of the exchange, name of providers, and whether the test was successful.

12. Stage 1 Non-Percentage-Based Objectives
Meaningful Use Objective
Audit Validation
Suggested Documentation
Protect Electronic Health Information
Security risk analysis of the certified EHR technology was performed prior to the end of the reporting period
Report the documents the procedures performed during the analysis 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., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.]
Drug Formulary Checks
Functionality is available, enabled, and active in the system for the duration of the EHR reporting period.
One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
Generate Lists of Patients by Specific Conditions
One report listing patients of the provider with a specific condition.
Report from the certified EHR system that is dated during the EHR reporting period selected for attestation. Patient-identifiable information may be masked/blurred before submission.

13. Stage 2 Non-Percentage-Based Objectives
Meaningful Use Objective
Audit Validation
Suggested Documentation
Clinical Decision Support Rule
Functionality is available, enabled, and active in the system for the duration of the EHR reporting period.
One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
Generate Lists of Patients by Specific Conditions
One report listing patients of the provider with a specific condition.
Report with a specific condition that is from the certified EHR system and is dated during the EHR reporting period selected for attestation. Patient‐ identifiable information may be masked/blurred before submission.

14. Organize Your Documentation
Create an EHR Incentive Binder To:
Tell the Story About Your Journey to Meaningful Use
Prepare Your Facility Information Before You Receive an Audit Notification
Keep the Binder Up To Date
Keep the Binder Organized
Provider Meaningful Use Data Should be Separated by Provider
If You Have to “Dig” for Information It Opens the Door for the Auditor to “Dig” Deeper
EHR Incentive
Program Binder
For:
Facility Name
Attestation Year

15. EHR Certified Software
Contract
Invoice
Purchase Order
Lease Documents
License Documents
ONC Certification ID Number
Vendor Contacts, Help Desk Number, Site ID Number
Software Version
List of Software Updates
EHR Incentive
Program Binder
For:
Facility Name
Attestation Year

16. System Administrators and Designated “Acting on Behalf Of”
List Responsible Staff:
Provider Registration
Attestation
Acting on Behalf Of
Keep Administrators UP TO DATE
Obtain and Secure Passwords in case of staff departure or unexpected absence
Registration Data of Responsible Staff
Current Copy of CMS EHR Incentive Program
Registration and Attestation Guide
EHR Incentive
Program Binder
For:
Facility Name
Attestation Year

17. Provider Registration/Attestation Information
Spreadsheet with list of providers
CMS Registration ID, License Number, Facility NPI and Tax ID Number (TIN)
Multiple Location Info Lists if applicable
Attestation
Documentation of PECOS/CMS Information – Review and Update Quarterly or More Often
Attestation:
Date of Attestation
Reporting Period for Meaningful Use

18. Eligibility Requirements: Volume
Document how you calculated your patient volume:
Calculations
Reports Used
Pre- Approval (State specific)
Hospital Payment Calculations – Cost reports and Hospital Calculation worksheets
Copies of Cost Report Used

19. Meaningful Use Source Documentation
Meaningful Use Dashboard by Provider
Reasons for Claiming Exclusions (MU Worksheet)
Screen Shots of Non-Percentage Measures:
Screen Shots of Enabling Functionality
Drug to Drug; Drug to Allergy, CDS for Entire Reporting Period
Policy and Procedure for Clinical Summaries
Public Health Registry Tests and Ongoing Electronic Transmission

20. HIPAA Security Risk Analysis
Documentation:
Physical Inspection Report
List of Deficiencies and Mitigation Plan
Stage 2 Encryption/Security of Data
Copy of Business Associate Agreements readily available

21. Additional Documentation
Copy of Core Measures used in Attestation
Copy of Menu Measures used in Attestation
Copy of Clinical Quality Measures Grid used in Attestation (Including Recommended)
Copy of Stage Appropriate Attestation Guides
Copy of “CMS Tip Sheets” Used to aid in Interpretation of Measures
List of Clinical Labs and LOINC Codes
Copy of Public Health with Test File
Copy of Public Health Verifying Test

22. About IL-HITREC
The Illinois Health Information Technology Regional Extension Center (IL-HITREC), under contract with the Illinois Department of Health and Family Services (HFS), is providing education, outreach and support to Medicaid providers for the Electronic Health Record (EHR) Provider Incentive Payment (PIP) Program. Northern Illinois University (NIU) serves as the Illinois Health Information Technology Regional Extension Center providing EHR and meaningful use services to providers in Illinois, outside the City of Chicago 606 zip code area.

23. announcing References 11/12/2017 6:48 AM
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

24. Contacts
Telligen ILHITREC Linda Brewer Brenda Simms Sr. Quality Improvement Facilitator Meaningful Use Specialist CHITREC Telligen HITREC Sam Ross Antonio Vega Clinical Implementation Manager HIT Advisor Telligen Telligen Terrey Currie Sarah Cottington Quality Improvement Facilitator Sr. Quality Improvement Facilitator
This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-IL-D1-03/15-079