MIPS and QCDR Measures, Specifications and Submission Overview

Overview

An important first step in determining whether your practice will use the NRDR Qualified Clinical Data Registry (QCDR) for MIPS participation is to review the available measures and select those relevant to your practice.  This article provides an overview of the different types of measures along with measure details and documents.

Measures Types

Two types of measures are available for MIPS reporting: 

• MIPS measures: These quality measures are officially included in the CMS MIPS program and are available to all MIPS participants regardless of the submission method.

• QCDR measures: These CMS-approved quality measures include:

  1. Measures that originate from the ACR's NRDR, such as ACRad34 (derived from data in the Dose Index Registry) or "simplified" QCDR measures structured like MIPS measures, such as ACRad44 and ACRad45.

  2. Licensed QCDR measures, which are borrowed from other registries.

Measure Selection Guidance

The CMS MIPS program requires individuals or groups to report six quality measures with at least one outcome measure (or high-priority measure if an outcome measure is unavailable). However, to maximize your MIPS final score, the ACR recommends submitting data for more than six measures throughout the performance year and selecting as many as possible for final submission to CMS at the end of the reporting period to maximize your score. You can submit data for as many measures as you want, but the ACR will only submit data to CMS for the measures you officially select for MIPS reporting. 

Measure Submission Process Overview

The data submission process and requirements differ depending on the type of measure.

• MIPS measure data are submitted via Excel or text file uploads through the MIPS Participation Portal.

  • You can also select activities for the Improvement Activities category and the Promoting Interoperability category for submission to CMS.

• QCDR measure data from the DIR and GRID are submitted through the relevant process for each registry.  For details see the DIR and GRID data submission articles.

• The QCDR simplified measures and licensed measures data are submitted via Excel or text file uploads through the MIPS Participation Portal.

Monitoring Performance

The ACR recommends you submit data frequently and regularly monitor your performance to 

stay on top of MIPS reporting requirements and get valuable feedback on opportunities for improving patient care.

• To review GRID and DIR measures' performance: See the GRID Available Reports and DIR Available Reports articles. 

• To review MIPS, QCDR simplified, and licensed measures' performance: Physicians can review MIPS and QCDR performance scores at the TIN and National Provider Identifier (NPI) level through the MIPS Participation Portal.

Measure Documents 

The current and past reporting year measure documents are described and listed in the table below.

MIPS Measures

• The MIPS Measures document lists MIPS quality measures supported in the ACR's MIPS Participation Portal. Data for these measures is organized by modality with links to reporting instructions and detailed specifications for each measure.

• The MIPS Measure Code document details the MIPS measures and their relevant numerator and denominator codes for populating the upload template with measure data before upload to the MIPS Participation Portal.

QCDR Quality Measures

• The QCDR Measures document lists measures from the DIR and GRID, QCDR simplified measures, and licensed measures.

• QCDR Measures Specifications document provides details for each QCDR measure, including numerator and denominator criteria, exclusions, and data sources.