LCSR Quarterly Aggregate Report
Modified on: Wed, 10 Jul, 2019 at 10:15 AM
The LCSR Quarterly Aggregate Report summarizes data for your facility and physicians and compares results to similar facilities and the entire registry to help you focus on quality patient care.
Reports are available under Aggregate Reports menu item in the NRDR Homepage Facility Management menu and are posted quarterly per the schedule, below:
Jan. – Mar.
Jan. – Jun.
Jan – Sep.
Jan. – Dec.
For facilities with a Master-Child hierarchy, copies of each child facility report are also available for download through the Master Facility account, allowing the Master Facility Administrator to download all reports.
The rest of this article briefly describes each section of the PDF version of the report. You can also listen to our webinar on Understanding Your Feedback Report for more information.
The Facilities Map displays the geographic distribution of facilities that contributed data for the given reporting period, grouped by Census Division. The map provides a visual representation of which facilities are included in the Division comparison statistics included in the report.
The Measures Definitions table provides a brief description of each measure listed in the report.
Measures for your facility are compared to the entire registry as well as to similar facilities. “Similar” facilities are those with the same
Facility Type – e.g. Community, Academic, Freestanding, etc.
Location – e.g. Metropolitan, Suburban, Rural
The Facilities Characteristics section summarizes the frequency of each facility characteristic. Each chart shows your facility name and characteristic in the title, and the distribution of each characteristic across the entire registry.
Facility and Physician Data
LCSR measures are grouped into four sections:
Section 1 includes facility-level preliminary data for screening exams in the current reporting period.
Section 2 includes facility-level data for exams from the prior calendar year with a follow-up through the current reporting period.
Sections 3 and 4 follow the same format as Sections 1 and 2, with data by physician National Provider Identifier (NPI).
Each section contains a National Comparison table showing measures for your facility, or a single physician, and the entire LCSR Registry.
Note: The National Comparison table is also available as an Excel spreadsheet for facilities with a Master-Child hierarchy and shows data for all Child facilities side-by-side.
A Regional Comparison table is also provided in Sections 1 and 2 and compares your facility’s measures to facilities of the same type, in the same type of location, and in the same Census Division.
Because NRDR is a CMS-approved Qualified Clinical Data Registry, LCSR Non-MIPS measures are automatically calculated using data submitted to the registry. These measures are available to physicians to submit to CMS, via the NRDR MIPS Portal, to meet MIPS reporting requirements.
Preliminary results are provided for the facility overall, as well as for each physician in separate tables.
Note: QCDR preliminary results are aggregated by physician NPI to provide detailed performance results whereas official MIPS results are reported to CMS by Taxpayer Identification Number (TIN); consequently, physicians reporting to CMS as part of a group TIN will see only the group's aggregated results in the MIPS Portal.
Physicians Participating in ABQ PQI Projects
LCSR is certified as a Practice Quality Improvement (PQI) project for ABR Part IV Maintenance of Certification. The LCSR Quarterly Aggregate Report includes a table of all physicians currently listed as participating in an ABR PQI project through the LCSR. However, it is no longer necessary for the ACR to track your project. Consult ABR PQI Projects for more details.
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