Execution TIPS for Successful QCDR Reporting. Alicia Blakey, ACR Priya Sharma, ACR Cory Lydon, Mecklenburg Radiology Associates August 17, 2017

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1 Execution TIPS for Successful QCDR Reporting Alicia Blakey, ACR Priya Sharma, ACR Cory Lydon, Mecklenburg Radiology Associates August 17, 2017

2 QCDR Overview Timeline and Key Dates What we will cover NRDR and MIPS Portal Navigation QCDR User Experience: Mecklenburg Radiology Associates Key Considerations for Using a QCDR

3 Registries that Support QCDR

4 MIPS Qualified Clinical Data Registry The ACR National Radiology Data Registry (NRDR ) has been approved as a Qualified Clinical Data Registry (QCDR) for the CMS Merit-Based Incentive Payment System (MIPS) for Key benefits: The QCDR will support both individual physicians and physician group practices in meeting MIPS requirements for 3 out of 4 performance categories Manage submission of MIPS and Non-MIPS measure data to CMS QCDR Non-MIPS measures are developed by ACR and are more applicable to the care radiologists provide Provide direct assistance with compiling the needed data for quality improvement Provide feedback to registry participants at least quarterly Allow physicians to review and select measures and activities to report prior to CMS submission

5 Using QCDR for MIPS By using the QCDR to participate in the MIPS program, radiologists can avoid the -4.0% MIPS 2019 negative payment adjustment for not reporting and potentially earn an incentive. To satisfy MIPS requirements clinicians and groups can use the QCDR to report on three out of the 4 MIPS performance categories: Quality, Improvement Activities, and Advancing Care Information if applicable. The fourth category, Cost, will be weighted to 0% during 2017 and will not require data submission. GPROs are not required to register with CMS to report as a group; let ACR know and CMS will assess your group s performance by TIN and apply one payment adjustment. Prior to submission of performance data by NRDR QCDR to CMS, physicians and group practices can select, confirm and attest to the accuracy and completeness of data.

6 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 1, 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

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

9 QCDR Supported Measures 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 General Radiology Improvement Database (GRID) Report Turn Around Times 3 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+

10 ACR MIPS Measure Calculator 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. We will continue to enhance this web resource.

11 QCDR Participation Checklist Checklist.pdf?la=en First-time Users Existing Users

12 NRDR Registration Complete a New Facility Registration for each of your locations Child facility each location will be registered independently as a child facility. Master facility a corporate account that will link all of your child facilities together and consolidate billing. If you are uncertain if your locations are currently registered, submit a ticket at so that it can be researched. Register all your master and child facilities for MIPS Click Registration on the left side menu to see the current status of your registrations. If you do not see MIPS in the list of registries in the table, you will need to register this facility for MIPS. If you see MIPS but there is a No in the Accepted? column, we are missing a signed agreement or addendum. If you have previously submitted an agreement/addendum for PQRS, we do not need another. If it is a child facility, but your facility has submitted an agreement/addendum for the Master facility, please let us know so that registration of the child facilities can be accepted.

13 Registration continued a signed Participation Agreement and BAA to nrdr@acr.org for registration acceptance. If you are adding MIPS to an existing registration and have submitted an agreement previously, please a signed Addendum. Fee Schedule Registries Fee Only billed at the Master Facility $500 one time registration fee Annual fee based on your number of radiologists and locations (If you participate in DIR or GRID, the rest of the registries are included in the cost) MIPS Reporting Fee Billed at the facility physicians are first added ACR members: $199 per physician/year Nonmembers: $1,299 per physician/year MIPS reporting fee is due March 1, 2018

14 What to do if your hospitals are already participating in NRDR? There are 2 paths to choose from: You can join the Hospital s Registration The hospital may allow you to join their facility(ies) as a Registry Administrator You would add your TIN(s) and Physicians to their locations You would upload MIPS files to the Master You would not incur registry fees as the hospital is already invoiced You can register your own Facility Enroll your physicians in MIPS Add your Physician Group TIN Make sure that your physicians and TINs are added to the hospitals locations in the system Upload MIPS files to your Facility If you are only enrolling in MIPS, you would not incur a facility fee, but any other registries would have a fee (physician fees are separate) If you are uncertain as to whether the hospitals your physicians read at are currently in NRDR, submit a ticket at with a list of the hospital names and addresses so that it can be researched. Please note that not all hospitals will allow radiology groups access to their registries.

15 Manage Physicians Physicians must be enrolled in MIPS if you plan to submit MIPS and Non-MIPS measures to CMS Physicians must be added to all facilities (Master/Child) Physicians are given login credentials once added to NRDR; single sign-in across NRDR and physician portals All physicians must register to use the MIPS Portal in order to upload data files or view available measures. Assistance is available if you need to register a large number of physicians at once*** If you have a large number of physicians download Excel template to upload physician list to multiple locations/accounts***

16 There are two options in adding a physician: Manual entry into the Manage Physician page The Physicians Template upload The Benefits of Using the Physicians Template Upload: Easily add multiple physicians at once Can be uploaded to all facilities Eliminates the 2 nd step to add physicians at the registry level on the NRDR website NRDR staff can troubleshoot the errors

17 Manage Physician Group TIN Add your physician group TIN using the Manage Physician Group TIN function in the NRDR Date available from field is relevant to the start date your TIN became active through the IRS; not required to add an end date**** Be sure to upload a document that confirms your physician group TIN is active and valid for Medicare billing (professional component and global billing) Appropriate forms of documents are: 1. Submitted claim; 2. Tax document or 3. Other official document that includes the TIN If you are participating as a GPRO be sure to select the GPRO box Be sure to select the appropriate registry and locations where the TIN should be applied If you bill Medicare for more than one TIN we can accept all TINs

18 Make sure to check off the appropriate child facilities when adding your TINs The GPRO column indicates whether the TIN has been added as GPRO

19 How are Quality measures attributed to physicians? NPI + TIN = MIPS & Non-MIPS Measures If we do not have both the TIN and NPI we will be unable to attribute your measure data to a physician View available measures in the MIPS Portal

20 How to Submit Data? QCDR participants can submit data to ACR for both MIPS and Non-MIPS measures for successful MIPS participation. Attestation of Improvement Activities and Advancing Care Information measure data will be collected in the MIPS portal. ACR collects quality measure data in the following ways: 1. Manual web based entry 2. Flat file/excel file upload 3. Web services API 4. Automation - TRIAD 5. HL7 message transmission and use of structured report templates (IR only) NOTE: Data submission requirements differ for MIPS and Non-MIPS measures. Data need not be submitted for all NRDR registries, only to registries that support measures relevant to your practice for MIPS participation. For more information visit

21 Data Submission Table NRDR-databases-and-submissions-Table.pdf?la=en

22 Registry Specific Tips DIR 3 new quality measures for 2017 (ACRad 31, ACRad 32 and ACRad 33) GRID Must submit exam level data; measures revised for 2017 (ACRad and ACRad 25) LCSR and NMD Require 2 years of data; screening exam and 12 month follow-up IR Newest registry for 2017 has MIPS and Non-MIPS measures available for reporting via data file upload or HL7 and structured report templates CTC Only registry that requires manual data entry (ACRad 1 and ACRad 2) QCDR reporters should be sure TIN and NPI are updated on all accounts

23 MIPS Portal QCDR participants access a portal designed especially to manage the MIPS participation process Portal Registration Required for Data Upload MIPS portal provides: Location for MIPS measure file upload Review of quality measure performance scores and comparison to benchmarks; review accuracy of volume Selection of measures and required attestations prior to CMS submission Physician and group level performance data available for all physicians across multiple locations and TINs

24 QCDR User Experience Cory Lydon, Former Billing Director, Reporting Analyst and MIPS QCDR Profile: # of facilities: 3 (Hospital, Breast Center and Physician Group) # of physicians: 61 QCDR experience: 2 nd year QCDR participant Registry participation: DIR, LCSR, NMD and MIPS

25 Lessons Learned from Mecklenburg Coordination between hospital and breast center and physician group critical to report non-mips measures Collaboration with ACR staff to set up registration and account for all physicians and TINs Plan to upload MIPS quality measure data at least monthly to the MIPS portal Monitor reporting and performance rates in MIPS portal Communicate performance results to internal team Timeline is not ideal was not aware of non-mips measures until June MIPS portal is hard to navigate; process is not intuitive

26 QCDR Feedback Reports QCDR provides registry comparison feedback reports to participants at least quarterly at facility and physician level Importance of reports check performance scores for improvement and analyze data submission for completeness and accuracy Access to Individual physician level reports with performance rates prior to CMS submission Physician has the ability to review, select and attest to performance prior to CMS submission

27 NRDR QCDR Preview Report Schedule Q1 (Jan-Mar) Issued: May Q2 (Apr-Jun) Issued: August Q3 (Jul-Sept) Issued: November Q4 (Oct-Dec) Issued: February

28 Key Considerations for Using a QCDR Facility/Registry Administrator manages account information for MIPS participation Be sure your registry account indicates MIPS Review measures list (MIPS and Non-MIPS) and data submission requirements (varies by registry) Submit data frequently to enhance your quarterly feedback report this will help determine available measures Use MIPS portal to view performance rates and available measures

29 Websites & Resources To view past recordings and slides see Webinars and Presentations» nrdr.acr.org nrdrsupport.acr.org 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

30 Save the Dates: Upcoming Events Avoid Costly Errors: Submit MIPS and Non-MIPS Data Accurately Thursday, September 21 1pm - 2pm ET Register» 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»

31 Contact Us Submit a Ticket nrdrsupport@acr.org Phone x3535