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QCDR Checklist - 2024 Performance Year

All physicians and group practices, whether first-time or returning participants, should review MIPS reporting requirements and determine if they are able to meet them using a QCDR for the upcoming performance year. We strongly recommend you have your NRDR facility administrator and physician(s) champion manage the entire QCDR process on your behalf.

See NRDR MIPS/CMS Reporting for information on requirements for MIPS Quality Measures, Improvement Activities, and Promoting Interoperability.

Note: QCDR requirements and measures change annually, so check requirements each year. The NRDR QCDR supports both individual and Group Practice Reporting Option (GPRO) reporting for MIPS.

First-Time QCDR Users

Complete the items in this section only if you are using the ACR's QCDR for MIPS reporting for the first time.

Any physician or group practices looking to use the QCDR to satisfy MIPS requirements must have an NRDR account.

Note: Read about the Registration Process to get an overview of what you need to do.

- Create a Corporate Account and then register your imaging sites to obtain a NRDR Facility ID for each one. Your Facility Administrator will manage the QCDR process.

By October 31, 2024, to participate in the QCDR, add MIPS to your NRDR registration in the portal.

Note: If you used the QCDR in prior years for PQRS reporting you do not need to modify your account. For MIPS participation, physician groups must have data submitted to one or more of the NRDR registries by October 31, 2021.

- Log in to the NRDR Portal, select Registration Information and add MIPS Measures Participation to your account.

By October 31, 2024, physician group practices must complete a participation agreement or addendum if selecting quality measures (MIPS and/or Non-MIPS measures) for MIPS participation

Note: If your group used the QCDR in prior years for PQRS reporting you do not need to submit an additional agreement or addendum. Documents must be modified if you select additional registries or add facilities to your existing NRDR accounts.

- NRDR Participation Agreement or Addendum

By November 30, 2024, add Physician Group TIN using the Manage Physician Group TIN function on the NRDR Portal. If reporting as a GPRO select GPRO to notify ACR staff. GPROs will be assessed as a group for all MIPS performance categories and will not be required to register with CMS prior to submitting data.

Note: Tax Identification Number(s) are required for MIPS participation. You must provide supporting documentation to show your TIN is active and used to bill Medicare Part B services.

- Log in to the NRDR Portal and select Manage Physician Group TIN

By November 30, 2024, enroll all physicians in MIPS by NPI in the QCDR using the Manage Physicians function on the NRDR Portal and select Y for MIPS participation.

- Log in to the NRDR Portal and select Manage Physicians

By November 30, 2024, for MIPS participants, each physician user must complete registration for the MIPS portal at least once. The physician must log in to the MIPS Participation Portal to complete registration and review the ACR QCDR participant responsibilities outlined. If you have a large number of physicians to register please contact ACR staff for assistance.

Note: Physicians must confirm accuracy of NPI and current e-mail address. If registration for the portal is not complete the physician group practice will not be able to access the MIPS Portal or performance data.

- Log in to the NRDR Portal to register for MIPS

All QCDR Users

Complete these tasks annually, even if you have previously registered to use the NRDR QCDR for MIPS.

By November 30, 2024, physician group practices review TIN(s) for each facility and registry used for MIPS participation and make any edits or modifications as needed.

Note: GPROs must select GPRO under Manage Physician Group TIN. For 2021, group practices are not required to register with CMS if submitting through the registry.

- Log in to the NRDR Portal and select Manage Physician Group TIN to make any changes

Set up and begin submitting data – QCDR participants can use the MIPS Portal for Quality, Improvement Activities and Advancing Care Information performance categories.

Data for Quality measures may be submitted either through the MIPS Portal (for MIPS measures) or through relevant NRDR measures (for QCDR non-MIPS measures).

Note: Data submission requirements differ for MIPS and Non-MIPS measures; please assess your ability to meet these requirements. Only participate in the registries from which you plan to submit measures to CMS.

Improvement Activities may be selected through the MIPS Portal.

Promoting Interoperability attestation and measures are available through the MIPS Portal.

- Review the MIPS Measures and QCDR Measures supported by the QCDR

- Determine whether you need to register for any other NRDR registries so you can report the Non-MIPS Measures associated with them

- Review Improvement Activities requirements and suggested activities so you can plan on what to implement and report

- Review Promoting Interoperability requirements

Between January 31 and February 28, 2025, physicians and group practices must review 2024 performance rates on QCDR supported measures, and submit updated data if needed. Use MIPS portal to complete.

- Log in to the NRDR Portal, select MIPS Participation Portal, then select Data Collection and Reports

- Select the Performance Report tab and review your quality measures

Between January 31 and March 30, 2025 physicians and group practices must select measures and activities to be submitted for the 2024 performance year and provide information on total relevant exams performed for those measures. Use MIPS Portal to complete.

Note: For GPROs the facility administrator can select measures, provide exam counts and attest to final quality measures and improvement activities.

- Log in to the NRDR Portal, select MIPS Participation Portal, then select Data Collection and Reports

- Select Quality measures for Submission to CMS

- Select Improvement Activities 

- Select PI Measures

By March 15, 2025, total payment* is due for the MIPS Participation Portal. Payment may be made by credit card or check. 

*Fees are in addition to NRDR participation fees

- Review MIPS reporting fees

- 2024 Physician Invoices will be sent to the facility administrator in January 2025

- Submit payment

By March 25, 2025, physician and group practices must attest to the accuracy of data submitted for the 2024 MIPS reporting year and authorize the ACR to submit data to CMS. This is handled in the MIPS portal. No measures or activities will be sent to CMS without attestation complete.

Note: For GPROs the facility administrator can complete attestation. For individual reporters, only the physician can complete attestation.

- Log in to the NRDR Portal, select MIPS Participation Portal, select Data Collection and Reports, then select CMS Submission

- Review selections and attest to measures and activities

By March 31, 2025, this is the last day the NRDR QCDR will submit quality measure data and improvement activities and promoting interoperability attestations to CMS. Submissions to CMS will begin early March.

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