CMS updates 2017 MIPS Performance Feedback
September 21, 2018

CMS updates 2017 MIPS Performance Feedback

The Centers for Medicare & Medicaid Services (CMS) recently announced that targeted reviews of certain 2017 Merit-based Incentive Payment System (MIPS) performance scores resulted in the calculation of some Eligible Clinician scores. Due to CMS correcting these scoring errors and being required to maintain budget neutrality, CMS says that some "clinicians will see slight changes in their [2019] payment adjustment."

The calculating errors mostly affected non-anesthesiologists and reflected the misapplication of the 2017 Advancing Care Information (ACI) and Extreme and Uncontrollable Circumstances hardship exceptions, the awarding of Improvement Activity (IA) credit for successful participation in the IA Burden Reduction Study, and the addition of the All-Cause Readmission (ACR) measure to the MIPS final score.

Eligible clinicians may review their revised scores via the Quality Payment Program website. CMS encourages clinicians to review their scores - even if they had previously reviewed them. MIPS ECs and groups who believe an error was made in their scores may request a targeted review. CMS has extended the deadline to request a targeted review to October 15.

Reporting AQI Measure 54: Pencil-Point Needle for Spinal Anesthesia

Practices who are Reporting AQI Measure 54: Pencil-Point Needle for Spinal Anesthesia please be aware that only patients receiving spinal anesthesia will be included in measure performance calculations. Patients receiving epidural/spinal will not be counted in the denominator.

To ensure measure 54 is reported correctly, be sure to report "Neuraxial" as the Anesthesia Category and "Spinal" as the Anesthesia Sub Category when submitting data to AQI. Please direct any questions to

Internal improvement measures available

AQI's Internal Improvement Measures (IIMs) is a collection of 12 measures intended for internal improvement purposes and are optional for practices to report to the National Anesthesia Clinical Outcomes Registry (NACOR). The measures will be available on the NACOR dashboard in October.

Participants in NACOR Basic and Quality Concierge® can report IIMs regardless of their participation in the Merit-based Incentive Payment System (MIPS), or as part of an Advanced Alternative Payment Model (APM). However, CMS will not accept IIM measures as part of an anesthesiologist's or practice's participation in MIPS or as part of an APM. If MIPS-eligible or within an APM, NACOR participants can submit data to AQI NACOR on these IIMs, in addition to reporting MIPS and QCDR measures through the Qualified Registry and Qualified Clinical Data Registry.

Upcoming registration deadlines

The deadline for providers to enroll in Quality Reporting or NACOR Basic for 2018 is October 31, 2018. The deadline to renew ASA 2018 memberships is October 11, 2018. Providers who are not 2018 ASA members by October 11, 2018, will be charged the non-member rate for 2018 reporting. More information about NACOR Quality Reporting is available on the NACOR quality reporting options and mechanisms page.


Have a question about NACOR or AQI? Meet your partners in quality reporting at the AQI Booth in the ASA Resource Center at ANESTHESIOLOGY® 2018 in San Francisco. The AQI team will be at the booth October 13 - 16.

Office Hours FAQs

Do we need additional "EC" (individual provider) agreements to be again signed by each provider if they elect to report as an individual through the QCDR? How do we access this form?

Yes, CMS requires that each eligible clinician who is reporting individually for 2018 quality reporting must submit a consent form. AQI cannot submit data on behalf of the clinician unless the form is signed. The deadline for all provider consents is February 15, 2019. ArborMetrix will be electronically sending consent forms to clinicians this fall. To ensure your clinicians receive this email, review your practice provider lists to ensure all email addresses are updated. This AQI guide provides directions to audit provider lists. To submit consent forms manually, email Margaret Bussan at

Can my providers attest to IA_PSPA_7 if we are registered to report QR and use our data for quality improvement?

No, if you are reporting as a Qualified Registry for 2018 quality reporting, your providers are not eligible to attest to this improvement activity. Even though the data is used for quality improvement, CMS states that only Qualified Clinical Data Registry (QCDR) participants can attest to this improvement activity. Practices reporting as QCDRs that want to attest to the improvement activity can reference the 2018 Suggested Documentation Guidance for MIPS Improvement Activity IA_PSPA_7.

2018 Reporting Deadlines

NACOR Registration: October 31, 2018

January through November 2018 data submission: January 31, 2019

All data submissions: February 15, 2019

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