• MIPS Manual 2017—How to Document the ACI Measures

    Written By: Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Molly Peltzman, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This content complements EyeNet’s MIPS Manual 2017.


    On Aug. 10, 2017, CMS published the following validation guidelines and documentation suggestions for the ACI measures.

    Note: CMS indicates that documentation needs to be “from certified electronic health record technology (CEHRT) and be inclusive of 1) The time period the report covers (reporting period), 2) clinician identification, e.g., National Provider Identifier (NPI) 3) Evidence to support that the report was generated by the CEHRT (e.g., screenshot of the report before it was printed from the system)/ Because some CEHRT is unable to generate reports that limit the calculation of measures to a prior time period, CMS suggests that clinicians download and/or print a copy of the report used at the time of data submission for their records.”

    Security Risk Analysis

    Validation: Security risk analysis of the certified EHR technology was performed or reviewed prior to the date of attestation on an annual basis and for the certified EHR technology used during the EHR reporting period. It is acceptable for the security risk analysis to be conducted outside the MIPS performance period; however, it must be conducted within the calendar year of the MIPS performance period (Jan.1–Dec. 31).

    Suggested documentation: Report that documents the procedures performed during the analysis and the results. Report should be dated within the calendar year of the MIPS performance period and should include evidence to support that it was generated for that clinician’s system (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), clinician name, practice name, etc.). Note: The measure requires clinicians to address encryption/security of data stored in CEHRT.  At minimum, clinicians should be able to show a plan for correcting or mitigating deficiencies and that steps are being taken to implement that plan.

    e-Prescribing

    Validation: At least one permissable perscription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically via CEHRT.

    Suggested documentation: Report or screenshot of patient prescription/record that indicates the number of times where electronic prescribing was performed in accordance with CMS standards for electronic prescribing (45 CFR 423.160(b)).

    Note: Under the proposed MIPS rule for 2018, CMS has included an exclusion for the e-Prescribing measure that would—if included in the final rule—apply retroactively to the 2017 performance year.

    Validation for proposed e-Prescribing exclusion: The 2018 NPRM [Notice of Proposed Rulemaking] proposed an exclusion for the e-prescribing measure for any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period. In order to submit an exclusion for this measure, clinicians must select an exclusion for this measure. Any submission of a numerator or denominator for the e-prescribing measure will void out the exclusion.

    Suggested documentation for proposed e-Prescribing exclusion: Report from the CEHRT that shows the number of times that the clinician e-prescribes.

    Provide Patient Access

    Validation: Availability for the patient or patient-authorized representative of the patient’s health information using any application of the clinician’s choice meeting the technical specifications of the application programming interface of the clinician’s certified EHR.

    Suggested documentation: Dated report, screenshot, or other information that documents the number of times a patient or patient authorized representative is given access to view, download, or transmit their health information. This could include instructions provided to the patient on how to access their health information including the website address they must visit, the patient’s unique and registered username or password, and a record of the patient logging on to show that the patient can use any application of their choice to access the information and meet the API technical specifications.

    Send a Summary of Care

    Validation: A summary care record is electronically created and sent when a patient is transitioned or referred to another setting or provider of care. 

    Suggested documentation: Dated report that indicates the number of summary of care records that were created for transitions of care or referrals to another setting of care or health care provider using the CEHRT and that were electronically exchanged.

    Note: Under the proposed MIPS rule for 2018, CMS has included an exclusion for the Send a Summary of Care measure that would—if included in the final rule—apply retroactively to the 2017 performance year.

    Validation for proposed Send a Summary of Care exclusion: The 2018 NPRM [Notice of Proposed Rulemaking]  proposed an exclusion for the Summary of Care measure for any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.

    Suggested documentation for Send a Summary of Care exclusion: Dated report from the CEHRT that shows the number of times that the clinician transfers of refers patients to another setting of care during the performance period.  

    Request/Accept a Summary of Care

    Validation: Receives or retrieves and incorporates an electronic summary care record into the EHR when a patient is transitioned or referred to the clinician. 

    Suggested documentation: Dated report or screenshot that shows the number of times the clinician electronically received and recorded a summary of care into the CEHRT for a transition of care, referral received, or patient encounter in which the clinician has never before encountered the patient.

    Note: Under the proposed MIPS rule for 2018, CMS has included an exclusion for the Request/Accept a Summary of Care measure that would—if included in the final rule—apply retroactively to the 2017 performance year.

    Validation for proposed Request/Accept a Summary of Care exclusion: The 2018 NPRM [Notice of Proposed Rulemaking] proposed an exclusion for the Request/Accept Summary of Care measure for clinicians for whom the total of transitions or referrals received and patient encounters in which the clinician has never before encountered the patient, is fewer than 100 during the performance period.

    Suggested documentation for Request/Accept a Summary of Care exclusion: Dated report from the CEHRT that shows the number of times the clinician transitions or refers or has patient encounters in which the clinician has never before encountered the patient.

    Patient-Specific Education

    Validation: Use of certified EHR technology to identify and provide those patient-specific education resources, if appropriate in section 170.204(b)(1) or (2) and by any means other that the method specified in paragraph (a)15(i). [“other that the” is CMS wording; presumably it should be “other than the”]

    Suggested documentation: Dated report or screenshot that shows the number of times that appropriate patient-specific educational resources were electronically identified and provided to the clinician’s patient.

    View, Download, or Transmit (VDT)

    Validation: Use of the clinician’s patient certified EHR technology by a patient or patient-authorized representative to view, download, or transmit to a third party their health information.

    Suggested documentation: Dated report or screenshot that shows the number of times a patient or patient-authorized representative is granted timely access to view, download, or transmit to a third party their health information or accessed their health information through the use of an API [application programming interface] or both.

    Secure Messaging

    Validation: Use of secure electronic messaging to communicate with patients on relevant health information.

    Suggested documentation: Dated report or screenshot that documents the number of times that a secure message was sent, or sent in response to a secure message sent by the patient or patient-authorized representative, using the electronic messaging function of the CEHRT.

    Patient-Generated Health Data

    Validation: Incorporation of patient-generated health data into the certified EHR.

    Suggested documentation: Dated report or screenshot that documents the number of times that patient generated health data including a copy of the data, e.g., social service data, advance directives, or home health tracking device information, has been captured into the CEHRT.

    Clinical Information Reconciliation

    Validation: Performs medication, medication allergies, and current problem list review and reconciliation for at least one transition of care, referral received, or patient encounter in which the clinician has not before encountered the patient.

    Suggested documentation: Dated report or screenshot that documents the number of times that the clinician performed clinical reconciliation for  1) medication reconciliation including the name, dosage, frequency, and route of each medication, 2) medication allergies, and 3) current problem list review and reconciliation.

    Immunization Registry Reporting

    Validation: Active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the registry/immunization information system.

    Suggested documentation:

    • Dated screenshots from the that [CMS wording] document successful submission to the registry or public health agency. Should include evidence to support that it was generated for that clinician’s system (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • A dated record of successful electronic transmission (e.g., screenshot from another system, etc.). Should include evidence to support that it was generated for that clinician (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.)OR
    • Letter or email from registry or public health agency confirming receipt of submitted data, including the date of the submission and name of sending and receiving parties. 

    Syndromic Surveillance Reporting

    Validation: Active engagement with a public health agency or one or more clinical data registries to submit syndromic surveillance data from an urgent care ambulatory setting where the jurisdiction accepts syndromic data from such settings and the standards are clearly defined.

    Suggested documentation:  

    • Dated screenshots from CEHRT that document successful submission to the registry or public health agency. Should include evidence to support that it was generated for that clinician’s system (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • A dated record of successful electronic transmission (e.g., screenshot from another system, etc.). Should include evidence to support that it was generated for that clinician (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • Letter or email from registry or public health agency confirming receipt of submitted data, including the date of the submission and name of sending and receiving parties.

    Electronic Case Reporting

    Validation: Active engagement with a public health agency or one or more clinical data registries to electronically submit case reporting of reportable conditions.

    Suggested documentation:

    • Dated screenshots from CEHRT that document successful submission submission to the registry or public health agency. Should include evidence to support that it was generated for that clinician’s system (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • A dated record of successful electronic transmission (e.g., screenshot from another system, etc.). Should include evidence to support that it was generated for that clinician (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • Letter or email from registry or public health agency confirming receipt of submitted data, including the date of the submission and name of sending and receiving parties. 

    Public Health Registry Reporting

    Validation: Active engagement with a public health agency or one or more clinical data registries to electronically submit data to public health registries.

    Suggested documentation:

    • Dated screenshots from CEHRT that document successful submission to the registry or public health agency. Should include evidence to support that it was generated for that clinician’s system (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • A dated record of successful electronic transmission (e.g., screenshot from another system, etc.). Should include evidence to support that it was generated for that provider (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • Letter or email from registry or public health agency confirming receipt of submitted data, including the date of the submission and name of sending and receiving parties.

    Clinical Data Registry Reporting

    Validation: Active engagement with a one or more clinical data registries to electronically submit clinical data.

    Suggested documentation:

    • Dated screenshots from the CEHRT that document successful submission to the registry or public health agency. Should include evidence to support that it was generated for that clinician’s system (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • A dated record of successful electronic transmission (e.g., screenshot from another system, etc.). Should include evidence to support that it was generated for that provider (e.g., identified by National Provider Identifier (NPI), clinician name, practice name, etc.), OR
    • Letter or email from registry or public health agency confirming receipt of submitted data, including the date of the submission and name of sending and receiving parties.

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    Next: Read more about the ACI measure set or download an at-a-glance PDF of the ACI measure set (plus measure descriptions)

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