QCDR for MIPS Reporting Startup Guide

Introduction

Thank you for your interest in using the ACR’s National Radiology Data Registry (NRDR) Qualified Clinical Data Registry (QCDR) for your Merit-based Incentive Payment System (MIPS) reporting to the Centers for Medicare and Medicaid Services (CMS). 

Whether you’re new to the NRDR or your facility already participates in one of the registries, getting set up for MIPS reporting is easy, and this guide will get you underway. The following steps walk you through tasks such as how to set up a new NRDR account (for newcomers), add the QCDR for MIPS reporting to your NRDR facility account, add physicians and registry users, submit quality measure data, and finalize your CMS submission.

Each step provides hyperlinks to relevant articles in the NRDR Support Knowledge Base—the NRDR user guide—and information on the CMS Quality Payment Program’s (QPP’s) website.  Get started by reviewing the benefits of using the ACR’s QCDR for MIPS reporting.

The NRDR support team welcomes your questions via submitting a ticket or emailing NRDRsupport@acr.org.  

Steps for Facilities New to NRDR Participation

1. Identify who will serve as the Corporate Account Administrator and Facility Administrator. 
   1. Read the NRDR Accounts and User Profiles and Identify Corporate and Facility Administrators articles. 
2. Set up your ACR Login account to log in to the NRDR Portal and gain access to an account setup.
   1. Read the article ACR Login and Multifactor Authentication.
3. Set up your corporate account, one or more facility accounts, and user profiles that define which registries a user may access and with what permissions, e.g., updating account information and viewing reports. Sign the NRDR agreement and submit payment. 
   1. Read the articles The Application Process, Registration and Participation Fees and MIPS Reporting Fees
4. Each individual Tax ID Number (TIN) should have its own facility ID in NRDR. For groups with only one TIN, it is sufficient to only register one facility even if your group reads for multiple physical locations. Groups billing under multiple TINs must register a facility for each TIN.
   1. Users still have the option to register facilities for each separate physical location; this will allow for more granular reports at the facility level. However, for MIPS purposes this is not required.

Note: If your practice has multiple physical locations, the corporate account should represent your overall business entity rather than an individual facility.

Steps for Facilities Participating in the ACR’s NRDR QCDR for the First Time 

Alert box: Be aware of the QCDR Key Dates and Milestone

1. Learn about the overall requirements to participate in the CMS Traditional MIPS reporting option.
   1. Read the article on the CMS QPP website: Traditional MIPS Overview
2. Learn about MIPS and QCDR quality measures—the two overarching measure types available for MIPS reporting.  Review the measures and respective specifications to determine which measures apply to your practice.
   1. Read the article MIPS and QCDR Measures and Specifications
3. Add the Dose Index Registry (DIR) or the General Radiology Improvement Database (GRID) to your NRDR registration if you plan to submit measures from either of these registries.
4. Enroll facilities in the QCDR for MIPS reporting. 
   1. Read the articles Add a New Facility or Registry and Complete a Facility Information Form

Note: Registering for the QCDR will enable you to report on the three performance categories: Quality (MIPS and QCDR measures), Improvement Activities and Promoting Interoperability. CMS calculates the cost category based on your Medicare claims data.

1. Add physician groups and physicians in the NRDR Portal. 
   1. In the NRDR Portal, add your physician group for each facility and the corresponding Tax ID information and TIN confirmation documentation.
      1. Read the articles Manage Physician Groups and Manage Physician Group TINs and Managing the Group TIN Documentation. 
   2. Add your physicians and other clinicians participating in MIPS so that they can access the MIPS Portal and so that measure data is accurately attributed to each. 
      1. Read the article: Manage Physician Dictionary and Users

Note: Use the bulk file upload template to add all your physicians and corresponding information.  

1. Add additional users to your NRDR account from your practice who will submit measure data or someone from a third-party vendor submitting data on your behalf.
   1. Read the article: Invite New Users to Create a NRDR Account

Note: The feature to add new users is only available to Corporate Account Administrators, Facility Administrators and Registry Administrators. 

Step 4: Select MIPS and QCDR Measures 

1. Review the available measures and their specifications to confirm which measures are most relevant for you to report.  Learn the different mechanisms for submitting MIPS and QCDR measures.
   1. Read the article: MIPS and QCDR Measures Data Submission Overview

Step 5: Select Improvement Activities and Promoting Interoperability Measures in the MIPS Portal

1. Review and plan which improvement activities (IA) and Promoting Interoperability (PI) measures (as applicable) you will submit.
   1. Read the article: Improvement Activity Selection in the MIPS Portal
   2. Read the article: PI Measure Selection in the MIPS Portal

Step 6: Submit Quality Measure Data in the MIPS Participation Portal and Review Your Performance

1. Review the process for submitting MIPS and simplified QCDR measures via data upload in the MIPS Participation Portal. 
   1. Read the article How to Upload MIPS Quality Measure Data
2. Review the Upload Data page for errors after your data submission has been processed. 
   1. Read the article:  Review Uploaded Quality Measure Data
   2. Read the article: Common MIPS Data File Errors
3. Submit measure data throughout the year and monitor your performance on each measure. Data for both MIPS and QCDR measures will appear in the MIPS Participation Portal under the Performance Report tab. Data reports will be updated within roughly 24 hours of your measure data being submitted. The Interactive Quality Measure report can be found in the MIPS Participation Portal left menu. This report provides both summary and detailed information about your quality measures.
   1. Read the articles here: Understanding Your MIPS Report 

Step 7: Submit Quality Measure Data Via the GRID or DIR and Review Reports

1. Confirm your active participation in the GRID or DIR for submitting respective QCDR measures.
2. Review reports regularly to ensure no lapses in data submission occur and to monitor your performance.
   1. Read the article GRID Facility Comparison Report and GRID Exam Level Report for performance insights, including a Registry Comparisons (Deciles) dashboard that presents performance data specific to MIPS reporting.
   2. Read the articles DIR CT Facility Comparison Report and DIR Available Reports for performance insights.  

Step 8: Final Submissions for MIPS Reporting

1. Select and submit your measures to CMS when the MIPS performance period has ended. This feature is usually available in early January, with the CMS deadline typically set to March 31.
   1. Read the article Select and Submit MIPS Quality Measures to CMS
2. Submit improvement activities and attest to PI Measures to CMS 
   1. Read the article Submit Improvement Activities and Promoting Interoperability Measures to CMS
3.       After submitting Quality measures, IA and PI Measures (if applicable) to CMS, review your preliminary MIPS score. This typically does not account for certain bonus points and reweighting scenarios, but it does give you a general idea of how you’ll perform compared to the performance threshold.
   1. Read the article Review Your MIPS Final Score.