QCDR for MIPS FAQs

Zach Smith

Modified on: Fri, 19 Apr, 2024 at 8:26 AM

What is a Qualified Clinical Data Registry (QCDR)?

What Quality measures are available for reporting by radiologists?

What are the QCDR reporting requirements?

Why use a QCDR?

How do I get started using NRDR as a QCDR?

How are data submitted to the QCDR?

What are the registration and payment deadline(s) for QCDR?

Are there any Webinars which provide answers to MIPS-related questions?

What is a Qualified Clinical Data Registry (QCDR)?

CMS has approved the ACR National Radiology Data Registry (NRDR™) as a Qualified Clinical Data Registry (QCDR) for the Merit-based Incentive Payment System (MIPS). Under the Medicare Physician Fee Schedule (MPFS) Final Rule, eligible professionals will be able to meet MIPS quality reporting requirements by participating in a QCDR. See more about the NRDR QCDR here.

The NRDR QCDR helps eligible clinicians fulfill their reporting obligations for three MIPS performance categories:

The NRDR QCDR includes measures specially developed for radiology clinicians and approved by CMS for the Quality category. These measures are calculated from each of six databases included in NRDR:

If you’re interested in using the NRDR QCDR for MIPS reporting, view the QCDR Participation Checklist for information about registering your facility and enrolling your physicians in NRDR. All QCDR documents are available here.

What Quality measures are available for reporting by radiologists?

Registry participants are allowed to report a combination of MIPS and QCDR (non-MIPS) measures for the MIPS Quality category. QCDR measures are chosen from across NRDR registries. See Review Available Measures for more information.

What are the QCDR reporting requirements?

By using the QCDR to participate in the MIPS program, radiologists can avoid the -5.0% MIPS payment adjustment for the 2018 performance year, to be applied in 2020. The requirements are as follows. Additional details are available via the links for each performance category:

Quality
- Report at least six measures for at least 50% of the EP’s applicable patients (all patients, not just Medicare) seen during the 2018 participation period. Measures reported can be a combination of MIPS and non-MIPS measures.
- Report on at least one outcome measure. If one outcome measure is not available, then report on a high-priority measure categorized as: appropriate use, patient experience, patient safety, efficiency, or care coordination.
- Clinicians can report as individuals or as a group. Unlike in the 2016 PQRS program, groups do not have to register as GPRO through CMS, and instead can indicate their group status when reporting through the QCDR.
Improvement Activities
- Patient-facing clinicians: report two high-weighted activities, 1 high-weighted activity and 2 medium-weighted activity or four medium-weighted activities
- Non-patient facing clinicians, groups of fewer than 15 participants, and those in rural and professional health shortage areas: report one high-weighted activity or two medium-weighted activities
Promoting Interoperability
- Must use Certified Electronic Health Record Technology (CEHRT) to quality to report. Clinicians not using CEHRT may apply to have their MIPS score reweighted so that PI counts for 0%.
- Fulfill requirements for all base score measures to receive full credit (50 points)
- Report on performance measures, which may count for an additional 90 points.
- Earn up to 15 bonus points by reporting additional measures.

Note: If you are unable to use the QCDR for 2018 MIPS Reporting because of lack of available measures then consider the MIPSwizard to meet your reporting requirements.

Why use a QCDR?

The benefits of using the NRDR QCDR include:

The QCDR supports both individual physicians and physician group practices in meeting MIPS requirements
Manages submission of MIPS (claims-based) and QCDR (registry-based) Quality measure data to CMS
QCDR measures are developed by the ACR and are more applicable to the care radiologists provide
Provides one-stop-shopping for submitting data for MIPS Quality, Improvement Activity, and Promoting Interoperability
Provides direct assistance with compiling the needed data for quality improvement
Provides feedback to registry participants at least quarterly
Allows physicians to review and select measures to report prior to submission

How do I get started using NRDR as a QCDR?

If you are interested in using the NRDR QCDR for MIPS reporting, start by reviewing the QCDR Participation Checklist to learn about registering your facility and enrolling your physicians in NRDR. See our three step process for using a QCDR below:

Step 1. Consider the measures and activities you want to report in order to meet the requirements for Quality, Improvement Activities, and Advancing Care Information.

Data for MIPS measures are submitted via the NRDR MIPS Portal. Data submission for NRDR QCDR measures is through the relevant registry process, i.e. DIR, NMD, etc. See MIPS Data Submission Overview for details.

Need Help Selecting Measures?

The CMS Quality Payment Program MIPS Measure Calculator is a tool for MIPS participants who may need assistance determining which measures are needed for the 2024 MIPS reporting year.

Step 2. If you are interested in using any of the non-MIPS NRDR measures for the Quality category but are NOT currently submitting data to NRDR, register for the National Radiology Data Registry to start that process now.

Note: You do not need to submit data to all the databases; only submit to databases that support measures relevant to your practice. Data may be submitted later in 2024, retrospective to January 1, 2024. Payment is not required until data is submitted.

If you or a facility at which you practice are currently submitting data to NRDR, monitor your data submission and select any additional registries from which you may want to report measures for MIPS. The regularly scheduled registry reports will provide performance scores for measures used in the QCDR for MIPS.

Step 3. Consult the NRDR knowledge base to learn more about registering, data submission, reports, and MIPS/CMS reporting.

How are data submitted to the QCDR?

Data for MIPS Quality measures, Improvement Activities and Promoting Interoperability measures are submitted via the MIPS Portal. For detailed instructions and templates refer to our articles on MIPS reporting.

Data submission for NRDR QCDR Quality measures is done through the relevant registry process; e.g., DIR, GRID, NMD, etc. For more details see our data submission articles for each applicable registry.

What are the registration and payment deadline(s) for the QCDR?

For the 2024 Qualified Clinical Data Registry option fees are per physician per year, and in addition to NRDR participation fees. Fees are discounted for ACR Members.

Register your physicians or group practice with the NRDR for MIPS Participation by October 31, 2024.

Enroll each participating physician for MIPS, using the Manage Physicians page, by November 30, 2024.

See Key Dates and Milestones for more information.

Are there any Webinars which provide answers to MIPS-related questions?

Information regarding previously recorded and future webinars on MIPS, the Value Modifier and the NRDR MIPS (formerly PQRS) Qualified Clinical Data Registry (QCDR) is available here.

The NRDR QCDR helps eligible clinicians fulfill their reporting obligations for three MIPS performance categories:

The NRDR QCDR includes measures specially developed for radiology clinicians and approved by CMS for the Quality category. These measures are calculated from each of six databases included in NRDR:

If you’re interested in using the NRDR QCDR for MIPS reporting, view the QCDR Participation Checklist for information about registering your facility and enrolling your physicians in NRDR. All QCDR documents are available here.

Registry participants are allowed to report a combination of MIPS and QCDR (non-MIPS) measures for the MIPS Quality category. QCDR measures are chosen from across NRDR registries. See Review Available Measures for more information.

By using the QCDR to participate in the MIPS program, radiologists can avoid the -5.0% MIPS payment adjustment for the 2018 performance year, to be applied in 2020. The requirements are as follows. Additional details are available via the links for each performance category:

Report at least six measures for at least 50% of the EP’s applicable patients (all patients, not just Medicare) seen during the 2018 participation period. Measures reported can be a combination of MIPS and non-MIPS measures.

Report on at least one outcome measure. If one outcome measure is not available, then report on a high-priority measure categorized as: appropriate use, patient experience, patient safety, efficiency, or care coordination.

Clinicians can report as individuals or as a group. Unlike in the 2016 PQRS program, groups do not have to register as GPRO through CMS, and instead can indicate their group status when reporting through the QCDR.

Patient-facing clinicians: report two high-weighted activities, 1 high-weighted activity and 2 medium-weighted activity or four medium-weighted activities

Non-patient facing clinicians, groups of fewer than 15 participants, and those in rural and professional health shortage areas: report one high-weighted activity or two medium-weighted activities

Must use Certified Electronic Health Record Technology (CEHRT) to quality to report. Clinicians not using CEHRT may apply to have their MIPS score reweighted so that PI counts for 0%.

Fulfill requirements for all base score measures to receive full credit (50 points)

Report on performance measures, which may count for an additional 90 points.

Earn up to 15 bonus points by reporting additional measures.

Note: If you are unable to use the QCDR for 2018 MIPS Reporting because of lack of available measures then consider the MIPSwizard to meet your reporting requirements.

The benefits of using the NRDR QCDR include:

The QCDR supports both individual physicians and physician group practices in meeting MIPS requirements

Manages submission of MIPS (claims-based) and QCDR (registry-based) Quality measure data to CMS

QCDR measures are developed by the ACR and are more applicable to the care radiologists provide

Provides one-stop-shopping for submitting data for MIPS Quality, Improvement Activity, and Promoting Interoperability

Provides direct assistance with compiling the needed data for quality improvement

Provides feedback to registry participants at least quarterly

Allows physicians to review and select measures to report prior to submission

If you are interested in using the NRDR QCDR for MIPS reporting, start by reviewing the QCDR Participation Checklist to learn about registering your facility and enrolling your physicians in NRDR. See our three step process for using a QCDR below:

Step 1. Consider the measures and activities you want to report in order to meet the requirements for Quality, Improvement Activities, and Advancing Care Information.

Data for MIPS measures are submitted via the NRDR MIPS Portal. Data submission for NRDR QCDR measures is through the relevant registry process, i.e. DIR, NMD, etc. See MIPS Data Submission Overview for details.

Need Help Selecting Measures?

The CMS Quality Payment Program MIPS Measure Calculator is a tool for MIPS participants who may need assistance determining which measures are needed for the 2024 MIPS reporting year.

Step 2. If you are interested in using any of the non-MIPS NRDR measures for the Quality category but are NOT currently submitting data to NRDR, register for the National Radiology Data Registry to start that process now.

Note: You do not need to submit data to all the databases; only submit to databases that support measures relevant to your practice. Data may be submitted later in 2024, retrospective to January 1, 2024. Payment is not required until data is submitted.

Step 3. Consult the NRDR knowledge base to learn more about registering, data submission, reports, and MIPS/CMS reporting.

Data for MIPS Quality measures, Improvement Activities and Promoting Interoperability measures are submitted via the MIPS Portal. For detailed instructions and templates refer to our articles on MIPS reporting.

Data submission for NRDR QCDR Quality measures is done through the relevant registry process; e.g., DIR, GRID, NMD, etc. For more details see our data submission articles for each applicable registry.

For the 2024 Qualified Clinical Data Registry option fees are per physician per year, and in addition to NRDR participation fees. Fees are discounted for ACR Members.

Register your physicians or group practice with the NRDR for MIPS Participation by October 31, 2024.

Enroll each participating physician for MIPS, using the Manage Physicians page, by November 30, 2024.

See Key Dates and Milestones for more information.

Information regarding previously recorded and future webinars on MIPS, the Value Modifier and the NRDR MIPS (formerly PQRS) Qualified Clinical Data Registry (QCDR) is available here.

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