Are You Ready for a MIPS Audit? Tips for Documentation and Compliance

With CMS increasing its oversight of MIPS submissions, audits are a growing reality for many clinicians. Proper preparation and documentation are key to ensuring compliance and avoiding penalties. This guide walks you through the steps to audit-proof your MIPS reporting.

1. Maintain Thorough Documentation

Audit readiness starts with comprehensive record-keeping for all submitted data. Here’s what to track:

• Quality Measures: Maintain patient-level data to support your reported performance. Include numerator/denominator calculations, evidence of compliance, and any exclusions applied.

• Promoting Interoperability: Keep screenshots or logs from your EHR showing that measures like e-Prescribing or patient portal usage were met.

• Improvement Activities: Document the activities you attest to with supporting evidence, such as meeting minutes, staff training records, or patient engagement logs.

Retention Period: CMS requires all MIPS documentation to be kept for six years after the performance year.

2. Conduct Internal MIPS Audits

Performing a self-audit can help identify gaps in your documentation and correct issues before they become problems:

• Randomly select a few reported measures and verify that the data aligns with your records.

• Check that your submission matches what is reflected in your EHR or registry.

• Review your Improvement Activities documentation for completeness.

  
  

3. Understand Common Audit Triggers

Certain patterns can make your submission more likely to be audited:

• Inconsistent Data: Conflicts between claims and registry submissions.

• Incomplete Data: Missing numerator/denominator information or failure to meet data completeness thresholds.

• High Performance Scores: While not always a trigger, unusually high scores may attract scrutiny.

  
  

4. Develop an Audit Response Plan

If you are selected for an audit, having a response plan in place can streamline the process:

• Designate a staff member to coordinate with auditors.

• Ensure your documentation is readily accessible.

• Respond promptly and professionally to all CMS inquiries.

  
  

Preparing for a MIPS audit may seem daunting, but with thorough documentation and proactive internal reviews, you can ensure compliance and avoid penalties. A MIPS consultant can provide additional support by reviewing your submissions and creating an audit readiness plan tailored to your practice. Contact us today to see if we can help! 803-205-2544

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