Alicia Blakey, MS

Administrator, Quality Management Programs

September 21, 2017

QCDR Webinar #6 Avoid Costly Errors: Submit MIPS and Non-

MIPS Quality Data Accurately

What we will cover

QCDR Overview and Process MIPS Performance Category Requirements Data Submission Tips for MIPS and Non-MIPS Quality

Measures Key Takeaways

Registries that Support QCDR

Using NRDR as a QCDR The NRDR and MIPS Portal gives clinicians and groups control over the

MIPS data collection and reporting process. Specifically, the portal helps clinicians with:

Collecting Data: The MIPS portal accepts data and information for all MIPS Quality,

Improvement Activities (IA), and Advancing Care Information (ACI) performance categories. Enhancements expected before end of 2017 reporting.

Monitoring Performance: Throughout the year clinicians and groups can get a

snapshot of their official performance to date, by reporting NPI and TIN, to identify potential gaps and opportunities.

Reporting to CMS: Clinicians can use their MIPS Portal performance data to

identify and select those measures best representing their individual or group practice. NRDR will then submit the selected measures and activities to CMS before the performance year reporting deadline.

Note: Registry vendors are required to capture data on Medicare and Non-Medicare patients to satisfy data completeness.

MIPS Participation Requirements

Facility or group must have a signed participation agreement with MIPS registry selected on NRDR account

Physician NPI and TIN information required on all accounts

Monitor performance via feedback reports and/or MIPS portal

If you are still deciding to use the QCDR, please do so by 10/31/17; some data must be submitted at this time.

QCDR participants can submit data for 3 out of 4 MIPS performance categories

Indicate your GPRO status in NRDR and MIPS portal

MIPS QCDR Timeline

October 31, 2017 Some data submitted for each registry used

November 30, 2017 QCDR participants must add physicians/ locations and TINs

January 31, 2018 QCDR participants finalize data submission to ACR

March 15, 2018 MIPS Reporting Fee Due

March 31, 2018 QCDR’s deadline to send data to CMS for MIPS

See QCDR Participation Checklist for complete

timeline

High-Level QCDR Process Step 1: View available measures and improvement activities and select appropriate registries for reporting in NRDR

Step 2: Add your physicians using the Manage Physician function in the NRDR

Step 3: Add your physician group TIN and supporting documentation using the Manage Physician Group TIN function in the NRDR (Select GPRO here)

Step 4: Start submitting your measure data for the MIPS performance year

Step 5: Monitor performance data in your feedback report or via the MIPS portal

MIPS Performance Categories

Calculating Final MIPS Performance Score

Category Patient Facing Clinicians

Non-Patient Facing Clinicians

Points Available*

Quality 60% 85% 60

Advancing Care Information

25% N/A 50% pts – base 90% pts – performance 15% pts – bonus 100% max

Improvement Activities

15% 15% 40

Cost** 0% 0% 0

MIPS Final Score 100% 100% 100

*Points are assigned based on CMS benchmarks and performance thresholds **Cost category not calculated in 2017 reporting year

Quality Performance Category (60% or 85%)

- Clinicians and groups can achieve 60 points - Report 6 measures and earn 3-10 points per measure - Of these measures report 1 outcome measure, or high priority measure if outcome unavailable Bonus points available and capped at 6 points - 2 points for additional outcome measures - 1 point for additional high priority measures - 1 point for end to end reporting

Improvement Activities Performance Category (15%)

- Clinicians and groups can achieve 40 points. - 93 activities categorized as medium-

or high-weighted activities. - Activity must be completed for at least 90 days. - For patient-facing clinicians, medium-weighted activities

are worth 10 points and high-weighted worth 20. - For non-patient-facing or small/rural clinicians, point

values are doubled: 20 for medium weight, 40 for high. - Activity selection and attestation will be completed

through the MIPS portal.

Advancing Care Information (0% or 25%)

In the ACI performance category, MIPS eligible clinicians may earn a maximum score of up to 155% but score is capped at 100%. The score is a combined total of the following three scores:

1. 50%: Required Base Score 2. 90%: Performance Score 3. 15%: Bonus score (up to 15%) The bonus and performance scores are added to the base score to get the total

ACI performance score. Clinicians must use CEHRT to report ACI information. There are two measure sets

for reporting.

Reporting is optional for non-patient facing and hospital based MIPS clinicians; the category will be “reweighted” to zero. If clinicians choose to report they will be scored.

MIPS Participation Options for 2017

QCDR participants will select performance period in MIPS portal. 90 days; if 90 days must be October through December Full year Quality measures must have overlapping performance period for all to count per CMS. Data completeness = at least 50% for measures to be scored

MIPS and Non-MIPS Data Submission Overview QCDR participants can submit data to ACR for both MIPS and Non-MIPS quality measures for

successful MIPS participation. - MIPS measures are submitted via Excel or text file uploads through the MIPS Portal. - Non-MIPS measures are submitted through the relevant process for each registry. Data submission methods vary by registry. ACR recommends you continue to monitor your performance and submit data frequently to

the respective NRDR data registries and the MIPS Portal. - Registry participants receive quarterly QCDR Preview reports for Non-MIPS measures at the facility level and by physician. - Registry participants can also review both MIPS and Non-MIPS performance scores at the TIN and NPI level through the MIPS Portal. Data Submission details available at www.acr.org/qcdr under “How to Submit Data”

Data submission deadline is 1/31/2018

NRDR Database/Measures # of measures

CT Colonography Registry (CTC)

2

National Mammography Database (NMD) Screening Mammography Note: 2017 participation relies on 2016 data

5

Dose Index Registry (DIR) CT Radiation Dose

3

General Radiology Improvement Database (GRID) Report Turn Around Times

6

Lung Cancer Screening Registry (LCSR) Note: 2017 participation relies on 2016 data

3

Interventional Radiology Registry (IR) 5

Merit Based Incentive Payment System (MIPS) 50+

QCDR Supported Measures

MIPS Portal Navigation

To access the MIPS Participation Portal, start by logging in to the NRDR Portal with your username and password.

Once you are logged in, select MIPS Participation Portal from the NRDR menu, and then Data Collection and Reports to open the MIPS Portal.

MIPS Measure Data Elements

Patient and Physician Fields Exam_Date_Time Physician_Group_TIN Physician_NPI Patient_ID Patient_Age Patient_Gender Patient_Medicare_Beneficiary Patient_Medicare_Advantage Exam_Unique_ID

Measure Information Fields Measure_Number CPT_Code Denominator_Diagnosis_Code Numerator_Response_value Measure_Extension_Num Extension_Response_Value Resource MIPS Data Upload File

Specification

2017 MIPS Measure Coding CPT, Numerator and Diagnosis Codes

2017 MIPS Measure Codes

Sample MIPS Data File (excel)

Review MIPS Quality Measure Data MIPS data files have to be uploaded to the MIPS portal you should review the

status of the upload as well as the actual measures calculated from the data. Upload files are processed overnight and results are usually available in

Performance Report tab within 24 hours.

Common MIPS Data Submission Errors Physician registration for MIPS Portal is required Understand CMS MIPS Measure Specifications Review ACR MIPS data file specifications and template File naming convention - Example MIPS_20170919-181224.xlsx File size limitations - Excel: no more than 10,000 records per file - Text: no more than 30,000 records per file Multiple CPT codes can be reported in a single record or separated

by multiple records Download Log File from MIPS portal to uncover errors The requirements for data submission can be found on

https://www.acr.org/qcdr under "How to Submit Data”

Non-MIPS Data Submission

Non-MIPS measures are developed by ACR and may be more meaningful and applicable to the care radiologists provide.

Data for Non-MIPS measures are submitted through the relevant process for each registry. Data submission methods vary by registry.

24 Non-MIPS quality measures are available spanning across all six NRDR Databases.

The requirements for data submission can be found on https://www.acr.org/nrdr under the relevant registry’s webpage.

Common Non-MIPS Data Submission Errors

Register your facility and physicians in NRDR for MIPS

NPI and TIN information provided on all accounts Review Non-MIPS measure detailed specifications LCSR and NMD data require 2 years of data (2016,

2017) for 12 month follow up/measure outcome Submit your data frequently and often Feedback is provided on a quarterly basis

Registry level Submission Tips for Non-MIPS Measures

NRDR Non-MIPS Submission Requirements

CT Colonography Registry (CTC) Manual data entry on web form

Dose Index Registry (DIR) TRIAD, exam name mapping and localizers

General Radiology Improvement Database (GRID)

Exam level data required

Interventional Radiology (IR) Structured report template and HL7 messaging

Lung Cancer Screening Registry (LCSR) 2016 screening exams with 12 month follow-up

National Mammography Database (NMD)

2016 screening exams with 12 month follow-up

For more details see NRDR Data Submission Table

Key Takeaways

Register your facility and physicians in NRDR for MIPS

Understand measure specifications for MIPS and Non-MIPS measures; numerator/denominator statements are critical to satisfying the measure

Review data submission requirements and processes Monitor MIPS portal to view exam counts and

performance data Notify ACR of any discrepancies in data submitted to

the NRDR or MIPS portal

ACR MIPS Measure Calculator http://qpp.acr.org

This web based tool is available to help practices understand MIPS requirements and browse quality measures, advancing care information measures and improvement

activities available for 2017 reporting.

Important Updates

Q2 QCDR Preview Reports available by end of September MIPS portal enhanced to collect improvement activities and

ACI measures if applicable – coming soon New look for CMS submission in tab in MIPS portal to provide

more details on measure performance data for selection and attestation – coming soon

2016 PQRS and QRUR feedback reports available now; informal reviews can be filed by 12/1/17

2016 quality data posted on Physician Compare December; Join webinar on 9/28/17

Subscribe to QPP list serve for timely updates on MIPS - https://qpp.cms.gov/

Websites & Resources Websites www.acr.org/qcdr www.acr.org/nrdr nrdr.acr.org www.qpp.acr.org NRDR Help Desk nrdrsupport.acr.org Core Documents QCDR Participation Checklist 2017 MIPS Supported Measures 2017 Non-MIPS Supported Measures Non-MIPS Detailed Specifications with Appendix NRDR Data Submission Table MIPS Improvement Activities Past Webinar Recordings and Slides Webinars and Presentations »

Save the Dates: Upcoming Events October 13-14, 2017 Annual Quality and Safety

Conference in Boston, MA Making the Most of QCDR: Navigating the MIPS

Portal Thursday, October 19 ~ 1pm - 2pm ET | Register »

Understanding QCDR Feedback Reports Thursday, November 16 ~ 1pm - 2pm ET | Register »

Prepare for 2017 MIPS QCDR Data Submission Deadlines Thursday, December 21 ~ 1pm - 2pm ET | Register »

Contact Us

Submit a Ticket https://nrdrsupport.acr.org

Email nrdrsupport@acr.org

Phone 1-800-227-5463 x3535