What Internal Audit Steps Should Every Practice Take Before CMS Submission?

Submitting data to CMS is one of those tasks that sounds straightforward until you realize how many moving parts are involved. A missed measure, an incomplete record, or a data entry mistake can drag down your MIPS score and leave money on the table.

The good news is that a solid internal audit can catch most of these issues before they become problems. Taking time to review your data and documentation ahead of submission gives you the chance to fix errors and strengthen your overall performance.

Key Takeaways

An internal audit helps identify data gaps and reporting errors before CMS submission deadlines.
Verifying measure selection against your specialty and patient population prevents wasted effort on irrelevant metrics.
Checking data completeness rates reduces the risk of measures being excluded from scoring.
Reviewing Promoting Interoperability requirements confirms your EHR usage meets CMS standards.
Documenting improvement activities with clear evidence protects your attestations from future audits.

Start With a Full Data Review

Before you submit anything, you need to know exactly what you’re working with. Pull reports from your EHR and registry to see where your data stands across all MIPS categories. Look at your Quality measures first since they carry the most weight. Are you meeting the minimum case requirements? Do you have at least 20 patients per measure with a 75% data completeness rate?

This is where many practices run into trouble. They select measures at the start of the year and assume everything is tracking correctly, only to discover gaps when it’s too late. A thorough internal audit checklist for mips submission should include verification of patient counts, performance rates, and documentation for every measure you plan to report.

Related: What is MIPS in Healthcare

Verify Your Measure Selection

Not all measures work equally well for every practice. If you choose measures that don’t align with your specialty or patient population, you might struggle to meet benchmarks or case minimums. During your audit, ask whether each measure still makes sense given the patients you’ve actually seen this year.

CMS publishes detailed mips quality performance category specs that outline what qualifies for each measure. Cross-reference your selections against these specifications to confirm you’re tracking the right data points. Check whether your chosen measures have favorable benchmarks too, since reporting on a measure where you perform below the national average will hurt your score.

hands of doctor holding notepad and pen

Check for Documentation Gaps

Documentation issues are one of the common mips reporting challenges that trip up practices year after year. Your clinical notes need to support every data point you report. If a measure requires documentation of a specific intervention or screening result, that information must appear in the patient’s record in the event of a CMS audit.

Run through a sample of patient charts for each measure you’re reporting. Can you find the documentation that supports your reported performance? Missing documentation can lead to audit issues down the road, even if CMS accepts your initial submission.

Review Promoting Interoperability Requirements

The Promoting Interoperability category has its own rules that can catch practices off guard. You need to demonstrate meaningful use of certified EHR technology and produce a valid CERHT ID, and the requirements for clinical data submission are specific about what qualifies. During your audit, confirm that your EHR meets certification standards and that you’ve completed all required measures.

Pay attention to the security risk analysis requirement. This is mandatory every year, and failing to complete it means you cannot receive credit for the PI category. If your practice qualifies for a PI hardship exception, verify that you’ve submitted the application before the deadline.

Validate Improvement Activities

Improvement Activities are often the easiest category to complete, but that doesn’t mean you should skip the audit step. You need to attest to specific activities your practice performed during the reporting period of at least 90 days, and those attestations should be backed by evidence.

Create a file for each activity you plan to report. Include dates, descriptions of what you did, and any supporting documents like meeting notes or policy updates. Review the list of approved activities to make sure the ones you’re claiming still qualify, since CMS updates this list periodically.

clinic management team discussion

Run a Final Score Estimate

Once you’ve reviewed all your data, run a score calculation to see where you stand. Many mips reporting solutions include real-time calculators that estimate your final score based on current data. This highlights areas where improvement is still possible before you submit.

Compare your estimated score against the performance threshold for the current year. Scoring above the threshold means you’ll receive a positive payment adjustment, while falling below puts you at risk for a penalty. You can also review mips performance feedback reports from prior years to see how CMS evaluated your past submissions.

Create a Submission Timeline

Don’t wait until the last minute to submit. Build a timeline that includes deadlines for data review, error correction, and final submission. CMS sets specific windows for MIPS reporting, and missing them can result in automatic penalties regardless of your actual performance.

If you’re using a registry to submit on your behalf, confirm their internal deadlines since they may need your final data several weeks early. Assign clear responsibilities to team members so everyone knows their role in the submission process.

Partner With a Registry That Supports Your Audit

Working with a qualified registry can make the audit process smoother. The right partner provides tools for tracking your data, flagging potential issues before they become problems, and calculating your estimated score in real time. To see how this works, schedule a demo with Patient360 to explore the platform’s audit and reporting features.

Conclusion

A thorough internal audit before CMS submission is one of the smartest investments you can make in your practice’s financial health. By reviewing your data, verifying measure selections, and documenting everything properly, you set yourself up for a successful submission. Start early, follow a clear checklist, and lean on tools and partners that can help you get it right.