Office Hours scheduled December 10
December 6, 2019

Office Hours scheduled December 10

Attend AQI's next Office Hours webinar and find out the latest information on 2019 MIPS Reporting. AQI is hosting its regularly scheduled Office Hours at 11 a.m. Central, Tuesday, December 10. Miss Office Hours in November? Check out the video.

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

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

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 '' element is invalid - The value 'MIPS44' is invalid according to its datatype '' - The Pattern constraint failed (occurs 37 times). The first twenty AnesthesiaRecordIds of the records containing the error are: (removed)
  • The '' element is invalid - The value 'MIPS76' is invalid according to its datatype '' - The Pattern constraint failed (occurs 84 times). The first twenty AnesthesiaRecordIds of the records containing the error are: (removed)

Email with any questions.

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

2019 Reporting Deadlines

NACOR Registration: October 31, 2019

January through November 2019 data submission: January 31, 2020

Individual Quality Reporting Consent Submission: January 31, 2020

Improvement Activity Attestation: January 31, 2020

CMS Opt-Out for Individual Reporting: January 31, 2020

TIN/NPI Reconciliation: January 31, 2020

All data submissions: February 14, 2020

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