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Alicia Blakey, MS
Administrator, Quality Management Programs
September 21, 2017
QCDR Webinar #6 Avoid Costly Errors: Submit MIPS and Non-
MIPS Quality Data Accurately
What we will cover
QCDR Overview and Process MIPS Performance Category Requirements Data Submission Tips for MIPS and Non-MIPS Quality
Measures Key Takeaways
Registries that Support QCDR
Using NRDR as a QCDR The NRDR and MIPS Portal gives clinicians and groups control over the
MIPS data collection and reporting process. Specifically, the portal helps clinicians with:
Collecting Data: The MIPS portal accepts data and information for all MIPS Quality,
Improvement Activities (IA), and Advancing Care Information (ACI) performance categories. Enhancements expected before end of 2017 reporting.
Monitoring Performance: Throughout the year clinicians and groups can get a
snapshot of their official performance to date, by reporting NPI and TIN, to identify potential gaps and opportunities.
Reporting to CMS: Clinicians can use their MIPS Portal performance data to
identify and select those measures best representing their individual or group practice. NRDR will then submit the selected measures and activities to CMS before the performance year reporting deadline.
Note: Registry vendors are required to capture data on Medicare and Non-Medicare patients to satisfy data completeness.
MIPS Participation Requirements
Facility or group must have a signed participation agreement with MIPS registry selected on NRDR account
Physician NPI and TIN information required on all accounts
Monitor performance via feedback reports and/or MIPS portal
If you are still deciding to use the QCDR, please do so by 10/31/17; some data must be submitted at this time.
QCDR participants can submit data for 3 out of 4 MIPS performance categories
Indicate your GPRO status in NRDR and MIPS portal
MIPS QCDR Timeline
October 31, 2017 Some data submitted for each registry used
November 30, 2017 QCDR participants must add physicians/ locations and TINs
January 31, 2018 QCDR participants finalize data submission to ACR
March 15, 2018 MIPS Reporting Fee Due
March 31, 2018 QCDR’s deadline to send data to CMS for MIPS
See QCDR Participation Checklist for complete
timeline
High-Level QCDR Process Step 1: View available measures and improvement activities and select appropriate registries for reporting in NRDR
Step 2: Add your physicians using the Manage Physician function in the NRDR
Step 3: Add your physician group TIN and supporting documentation using the Manage Physician Group TIN function in the NRDR (Select GPRO here)
Step 4: Start submitting your measure data for the MIPS performance year
Step 5: Monitor performance data in your feedback report or via the MIPS portal
MIPS Performance Categories
Calculating Final MIPS Performance Score
Category Patient Facing Clinicians
Non-Patient Facing Clinicians
Points Available*
Quality 60% 85% 60
Advancing Care Information
25% N/A 50% pts – base 90% pts – performance 15% pts – bonus 100% max
Improvement Activities
15% 15% 40
Cost** 0% 0% 0
MIPS Final Score 100% 100% 100
*Points are assigned based on CMS benchmarks and performance thresholds **Cost category not calculated in 2017 reporting year
Quality Performance Category (60% or 85%)
- Clinicians and groups can achieve 60 points - Report 6 measures and earn 3-10 points per measure - Of these measures report 1 outcome measure, or high priority measure if outcome unavailable Bonus points available and capped at 6 points - 2 points for additional outcome measures - 1 point for additional high priority measures - 1 point for end to end reporting
Improvement Activities Performance Category (15%)
- Clinicians and groups can achieve 40 points. - 93 activities categorized as medium-
or high-weighted activities. - Activity must be completed for at least 90 days. - For patient-facing clinicians, medium-weighted activities
are worth 10 points and high-weighted worth 20. - For non-patient-facing or small/rural clinicians, point
values are doubled: 20 for medium weight, 40 for high. - Activity selection and attestation will be completed
through the MIPS portal.
Advancing Care Information (0% or 25%)
In the ACI performance category, MIPS eligible clinicians may earn a maximum score of up to 155% but score is capped at 100%. The score is a combined total of the following three scores:
1. 50%: Required Base Score 2. 90%: Performance Score 3. 15%: Bonus score (up to 15%) The bonus and performance scores are added to the base score to get the total
ACI performance score. Clinicians must use CEHRT to report ACI information. There are two measure sets
for reporting.
Reporting is optional for non-patient facing and hospital based MIPS clinicians; the category will be “reweighted” to zero. If clinicians choose to report they will be scored.
MIPS Participation Options for 2017
QCDR participants will select performance period in MIPS portal. 90 days; if 90 days must be October through December Full year Quality measures must have overlapping performance period for all to count per CMS. Data completeness = at least 50% for measures to be scored
MIPS and Non-MIPS Data Submission Overview QCDR participants can submit data to ACR for both MIPS and Non-MIPS quality measures for
successful MIPS participation. - MIPS measures are submitted via Excel or text file uploads through the MIPS Portal. - Non-MIPS measures are submitted through the relevant process for each registry. Data submission methods vary by registry. ACR recommends you continue to monitor your performance and submit data frequently to
the respective NRDR data registries and the MIPS Portal. - Registry participants receive quarterly QCDR Preview reports for Non-MIPS measures at the facility level and by physician. - Registry participants can also review both MIPS and Non-MIPS performance scores at the TIN and NPI level through the MIPS Portal. Data Submission details available at www.acr.org/qcdr under “How to Submit Data”
Data submission deadline is 1/31/2018
NRDR Database/Measures # of measures
CT Colonography Registry (CTC)
2
National Mammography Database (NMD) Screening Mammography Note: 2017 participation relies on 2016 data
5
Dose Index Registry (DIR) CT Radiation Dose
3
General Radiology Improvement Database (GRID) Report Turn Around Times
6
Lung Cancer Screening Registry (LCSR) Note: 2017 participation relies on 2016 data
3
Interventional Radiology Registry (IR) 5
Merit Based Incentive Payment System (MIPS) 50+
QCDR Supported Measures
MIPS Portal Navigation
To access the MIPS Participation Portal, start by logging in to the NRDR Portal with your username and password.
Once you are logged in, select MIPS Participation Portal from the NRDR menu, and then Data Collection and Reports to open the MIPS Portal.
MIPS Measure Data Elements
Patient and Physician Fields Exam_Date_Time Physician_Group_TIN Physician_NPI Patient_ID Patient_Age Patient_Gender Patient_Medicare_Beneficiary Patient_Medicare_Advantage Exam_Unique_ID
Measure Information Fields Measure_Number CPT_Code Denominator_Diagnosis_Code Numerator_Response_value Measure_Extension_Num Extension_Response_Value Resource MIPS Data Upload File
Specification
2017 MIPS Measure Coding CPT, Numerator and Diagnosis Codes
2017 MIPS Measure Codes
Sample MIPS Data File (excel)
Review MIPS Quality Measure Data MIPS data files have to be uploaded to the MIPS portal you should review the
status of the upload as well as the actual measures calculated from the data. Upload files are processed overnight and results are usually available in
Performance Report tab within 24 hours.
Common MIPS Data Submission Errors Physician registration for MIPS Portal is required Understand CMS MIPS Measure Specifications Review ACR MIPS data file specifications and template File naming convention - Example MIPS_20170919-181224.xlsx File size limitations - Excel: no more than 10,000 records per file - Text: no more than 30,000 records per file Multiple CPT codes can be reported in a single record or separated
by multiple records Download Log File from MIPS portal to uncover errors The requirements for data submission can be found on
https://www.acr.org/qcdr under "How to Submit Data”
Non-MIPS Data Submission
Non-MIPS measures are developed by ACR and may be more meaningful and applicable to the care radiologists provide.
Data for Non-MIPS measures are submitted through the relevant process for each registry. Data submission methods vary by registry.
24 Non-MIPS quality measures are available spanning across all six NRDR Databases.
The requirements for data submission can be found on https://www.acr.org/nrdr under the relevant registry’s webpage.
Common Non-MIPS Data Submission Errors
Register your facility and physicians in NRDR for MIPS
NPI and TIN information provided on all accounts Review Non-MIPS measure detailed specifications LCSR and NMD data require 2 years of data (2016,
2017) for 12 month follow up/measure outcome Submit your data frequently and often Feedback is provided on a quarterly basis
Registry level Submission Tips for Non-MIPS Measures
NRDR Non-MIPS Submission Requirements
CT Colonography Registry (CTC) Manual data entry on web form
Dose Index Registry (DIR) TRIAD, exam name mapping and localizers
General Radiology Improvement Database (GRID)
Exam level data required
Interventional Radiology (IR) Structured report template and HL7 messaging
Lung Cancer Screening Registry (LCSR) 2016 screening exams with 12 month follow-up
National Mammography Database (NMD)
2016 screening exams with 12 month follow-up
For more details see NRDR Data Submission Table
Key Takeaways
Register your facility and physicians in NRDR for MIPS
Understand measure specifications for MIPS and Non-MIPS measures; numerator/denominator statements are critical to satisfying the measure
Review data submission requirements and processes Monitor MIPS portal to view exam counts and
performance data Notify ACR of any discrepancies in data submitted to
the NRDR or MIPS portal
ACR MIPS Measure Calculator http://qpp.acr.org
This web based tool is available to help practices understand MIPS requirements and browse quality measures, advancing care information measures and improvement
activities available for 2017 reporting.
Important Updates
Q2 QCDR Preview Reports available by end of September MIPS portal enhanced to collect improvement activities and
ACI measures if applicable – coming soon New look for CMS submission in tab in MIPS portal to provide
more details on measure performance data for selection and attestation – coming soon
2016 PQRS and QRUR feedback reports available now; informal reviews can be filed by 12/1/17
2016 quality data posted on Physician Compare December; Join webinar on 9/28/17
Subscribe to QPP list serve for timely updates on MIPS - https://qpp.cms.gov/
Websites & Resources Websites www.acr.org/qcdr www.acr.org/nrdr nrdr.acr.org www.qpp.acr.org NRDR Help Desk nrdrsupport.acr.org Core Documents QCDR Participation Checklist 2017 MIPS Supported Measures 2017 Non-MIPS Supported Measures Non-MIPS Detailed Specifications with Appendix NRDR Data Submission Table MIPS Improvement Activities Past Webinar Recordings and Slides Webinars and Presentations »
Save the Dates: Upcoming Events October 13-14, 2017 Annual Quality and Safety
Conference in Boston, MA Making the Most of QCDR: Navigating the MIPS
Portal Thursday, October 19 ~ 1pm - 2pm ET | Register »
Understanding QCDR Feedback Reports Thursday, November 16 ~ 1pm - 2pm ET | Register »
Prepare for 2017 MIPS QCDR Data Submission Deadlines Thursday, December 21 ~ 1pm - 2pm ET | Register »
Contact Us
Submit a Ticket https://nrdrsupport.acr.org
Email [email protected]
Phone 1-800-227-5463 x3535