NACOR Quality Reporting – Roles & Responsibilities

The Anesthesia Quality Institute’s (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) is an approved Qualified Registry (QR) and Qualified Clinical Data Registry (QCDR) for the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) Quality Payment Program.

Regardless of the reporting option you choose, participating in MIPS requires coordination and input from multiple parties. The following roles and responsibilities lay the foundation for successful quality reporting.


  • Offer four options for MIPS reporting: QR Individual Reporting; QR Group Practice Reporting; QCDR Individual Reporting, QCDR Group Practice Reporting and Quality
  • Support the Improvement activity attestation process
  • Support a wide range of anesthesia measures for each reporting option
  • Provide website resources to help practices navigate complex MIPS reporting:
    • Educational materials
    • Sample quality capture forms
    • Templates for commonly reported Improvement Activities
    • A list of vendors who have reported their ability to meet AQI NACOR’s file formatting and content requirements
  • Provide Account Manager support:
    • NACOR report interpretation available upon request
    • Monthly webinars
    • Answer measures-related questions via e-mail:
  • Offer NACOR Dashboard reports to help practices monitor QCDR and QR measure compliance
  • Submit QCDR and QR files to CMS in accordance with regulatory requirements

Practice Roles & Responsibilities:

  • Understand MIPS reporting and performance requirements
  • Verify eligible clinicians MIPS eligibility prior to registration on the Quality Payment Program website using the participation lookup tool ( Engage with your AQI Account Manager to ensure the practice is compliant with the MIPS program
  • Update all provider information and practice information in the NACOR dashboard on a yearly basis
  • Notify AQI of any AQI champion contact changes
  • Ensure the accuracy and quality of data submitted to NACOR
  • Monitor MIPS reporting compliance via NACOR dashboard reports
  • Meet NACOR deadlines
  • Choose a physician anesthesiologist or other quality champion to manage and oversee the practice quality reporting. These activities typically include:
    • Reading the NACOR User Guide for Quality Reporting
      • Selecting a reporting option — QR Individual Reporting; QR Group Practice Reporting;
        QCDR Individual Reporting or QCDR Group Practice Reporting
    • Completing the contracting process and NACOR Quality Reporting Order Form
      • NACOR Participation Agreement and the ASA Quality Reporting Agreement are required
  • Identify measures that may be reported for all eligible clinicians (ECs) in the practice
  • Operationalize the data collection, data formatting, and data submission processes:
    • Determine whether the practice will utilize the service(s) of a vendor(s) or in-house IT staff. When making this decision, consider the type of IT support available within the practice, the IT systems the practice already has in place and the amount of time the quality champion can dedicate to the project. Practices struggling with pulling data from their systems for submission to NACOR may consider using the Quality ConciergeTM For more information, email
  • Complete provider list audits in the NACOR dashboard:
    • Verify practice TIN and provider NPI
    • If reporting as individuals, "Opt Out" clinicians whose data you do not wish to report to CMS.
  • Take advantage of the resources AQI provides:
    • Utilize the training materials under Resources in the NACOR application to learn the administrative and reporting features in NACOR.
    • Review online QR and QCDR reports monthly to identify potential gaps. Follow up with your ECs, in-house IT staff or vendor(s) and take the necessary corrective action. Reports include group performance metrics, individual performance metrics and quality measure compliance reports with drill—down capabilities for more granular data.
    • Review the monthly NACOR Quality Reporting Virtual Office Hour webinar.
    • Read AQI NACOR News and other listserv communications and follow recommended actions.

Shared Responsibilities between the Practice and IT Staff or Vendor(s):

  • Establish a quality control process with the practice's vendor(s) or in-house IT staff.
  • Merge data from multiple sources into one file prior to submission to AQI NACOR. Additional fee- based services for merging multiple files are available by contacting
  • Verify the accuracy of the file format and content before submitting files to AQI NACOR.
  • Notify vendor if the AQI Practice Champion receives a failed data validation email so data files can be corrected and resubmitted.