What type of documentation is required for percentage-based measures?

To ensure you are prepared for a potential audit, save any electronic or paper documentation that supports your attestation. Also save the documentation that supports the values you entered in the Attestation Module for clinical quality measures. Hospitals should also maintain documentation that supports their payment calculations. The primary documentation that will be requested in all reviews is the source document(s) that the provider used when completing the attestation. This document should provide a summary of the data that supports the information entered during attestation. Ideally, this would be a report from the certified EHR system. Providers should retain a report from the certified EHR system to validate all clinical quality measure data entered during attestation, since all clinical quality measure data must be reported directly from the certified EHR system.

This primary document will be the starting point of most reviews and should include, at minimum:
• The numerators and denominators for the measures.
• The time period the report covers.
• Evidence to support that it was generated for that eligible hospital, or CAH (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.).

Although the summary document is the primary review step, there could be additional and more detailed reviews of any of the measures, including review of medical records and patient records. The provider should be able to provide documentation to support each measure to which he or she attested, including any exclusions claimed by the provider.