2018 MIPS data submission deadlines approaching

The first 2019 MIPS reporting deadline is January 31, 2020. The following items are due to NACOR on this date:

  • Data from January through November 2019. Practices are encouraged to upload data files prior to the deadline to allow time for review, and to submit corrected files if any errors are identified.
  • Attesting to 2019 Improvement Activities (including date ranges that the activities were performed)
  • Reconciliation of provider lists ensuring all NPIs are assigned the proper provider type (MD-Anesthesia, CRNA, DO, AA, SRNA, Resident, etc.)
  • CMS Opt-Out for providers who are reporting as individuals
  • Provider consents for clinicians reporting as individuals

The 2019 data completeness requirements for those reporting MIPS are six measures, including one outcome measure, for 60 percent of the eligible cases over a 12-month period (1/1/19 - 12/31/19) The final deadline to submit December 2019 data and any corrected files is February 14, 2020. For more information, email AskAQI@asahq.org.

Reporting MIPS 44 and 76

Multiple practices have indicated they are submitting data for measures MIPS 044 and 076, but are not seeing the measure cards in the dashboard. Review of the data shows that appropriate measures codes are being submitted for these measures, but the measure name is incorrect in the xml file. Specifically, the leading zero is missing from the measure name (e.g., MIPS 44 instead of MIPS044 and MIPS76 instead of MIPS076).

The following is a sample validation email sent indicating these errors:

  • The 'https://www.aqihq.org/AQIXMLResources/AQISchema.xsd:QCDRMeasure' element is invalid - The value 'MIPS44' is invalid according to its datatype 'https://www.aqihq.org/AQIXMLResources/AQISchema.xsd:QCDRMeasureType' - The Pattern constraint failed (occurs 37 times). The first twenty AnesthesiaRecordIds of the records containing the error are: (removed)
  • The 'https://www.aqihq.org/AQIXMLResources/AQISchema.xsd:QCDRMeasure' element is invalid - The value 'MIPS76' is invalid according to its datatype 'https://www.aqihq.org/AQIXMLResources/AQISchema.xsd:QCDRMeasureType' - The Pattern constraint failed (occurs 84 times). The first twenty AnesthesiaRecordIds of the records containing the error are: (removed)

For more information email AskAQI@asahq.org.

Attesting to Improvement Activities via NACOR

Clinicians can attest to 2019 Improvement Activities using the provider list in the NACOR Dashboard. In this step-by-step tutorial, clinicians learn how to select the Improvement Activity to which they will attest through either the individual or group reporting option.

As participants of NACOR, practices can attest to activity IA_PSPA_1: Participation in an AHRQ-listed patient safety organization. This is a medium-weighted activity worth 10 points. Practices also must document the date range that the Improvement Activity was performed in the practice list in the NACOR dashboard. For more information, email AskAQI@asahq.org.

Practice self-audits underway

To remain in good standing as a Qualified Registry and Qualified Clinical Data Registry, AQI's NACOR registry is required to submit an annual data validation plan to the Centers for Medicare & Medicaid Services (CMS). To help ensure continued compliance with CMS data validation standards, AQI is incorporating a self-audit requirement for randomly selected NACOR practices.

AQI will randomly select 15 cases for practices to audit. Practices that have been selected for self-audit will be notified via email in the next two weeks and receive a Self-Audit User Guide and instructions on how to access the audit forms. For more information, email Annette Antos, AQI Senior Registry Operations Manager, at a.antos@assahq.org.

2019 Resources

2019 NACOR registration

2019 Policies and Procedures

2019 Individual Quality Reporting consent form

2019 NACOR pricing (PDF)

2019 QCDR Measure Specifications (PDF)

2019 Recommended Improvement Activities

NACOR Data Definitions

NACOR News Library

Read past issues of AQI's NACOR News.

Office Hours FAQs

Question: If a provider has left the practice half way through the year - does the practice need to report the provider's cases?

If the practice is reporting as a group and the provider performed cases in 2018, the practice needs to be reporting 60% of all eligible cases for that provider regardless if they are still at the practice or not as CMS is evaluating the data at the TIN level not the individual NPI. If the practice is individually reporting, the data will follow the provider's NPI.

Question: In regards to the reporting year on the AQI website it state to submit 60% of eligible cases and we understand it is not pick your pace but does this mean 60% of 2018 cases? Can you elaborate?

The 2018 MIPS reporting requirement is to report on 60% of the denominator eligible cases for 6 measures including 1 outcome measure for the 12 month reporting period (1/1/2018 - 12/31/18). For example, If your practice is reporting MIPS 76 - Prevention of Central Venous Catheter (CVC - Related Bloodstream Infections and places 75 central lines during 2018 your practice would need to report on 45 cases which is 60% of the eligible cases.

Question: Is it possible for all providers in a practice to be non-MIPS eligible and not required to submit data as individuals, but are eligible as a group?

Yes if the individual providers do not meet the 2018 MIPS participation criteria (billed $90,000 or less in Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare secondary Payer) and have 200 or fewer Medicare Part B FFS beneficiaries) the practice can be MIPS eligible as a group if the group has billed $90,000 or more in PFS services furnished to Medicare Part B beneficiaries and have 200 or more Medicare Part B beneficiaries.