NACOR practice audits begin
November 6, 2020

NACOR practice audits begin

To remain in good standing as a Qualified Registry and Qualified Clinical Data Registry, AQI and its registry, NACOR, 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 auditing the Quality and Improvement Activity components for randomly selected practices.

AQI sent certified letters this week to practices that have been selected for audit for the Quality Component. The letter includes instructions on how to complete the audit. Practices will have 45 days to complete the audit. For more information, email

November Office Hours

AQI's regularly scheduled Quality Reporting Office Hours are scheduled at 11 a.m. Tuesday, November 10. Office Hour recordings and slides from previous months are now available on the AQI website. If you have a question or topic that you would like addressed during Office Hours, email

2020 Improvement Activities component

Groups attesting to an Improvement Activity in 2020 must have at least 50% of the clinicians (in the group) perform the same activity during any continuous 90-day period, or as specified in the activity description, within the same performance period. The last continuous 90-day period begins on October 2, 2020 and ends December 31, 2020.

This year the Quality and Improvement Activity components will be audited prior to data submission to CMS. Please review the 2020 MIPS Data Validation Criteria for the Improvement Activities to validate that your practice is collecting the required documentation.

To prepare for the audits, practices should:

  • Maintain a list of NPIs of the clinicians who performed the Improvement Activity for up to six years, as well as documentation showing the IA was completed
  • Keep documentation of how the Improvement Activity was completed and make sure the documentation aligns with CMS requirements

AQI will randomly select practices for audits in January or February 2021 (must be completed before CMS Submission). Email with questions.

ASA podcast focuses on quality improvement

The ASA's Central Line podcast series features Dr. Grant Lynde, Associate Professor of Anesthesiology and Vice Chair of Quality Improvement at Emory University. Listen to Dr. Lynde discuss quality improvement initiatives, the role of sustainability, power of data, and the evolution of benchmarking.

2020 Reporting Deadlines

NACOR Registration: October 30, 2020

January through November 2020 data submission: January 29, 2021

Individual Quality Reporting Consent Submission: January 29, 2021

Improvement Activity Attestation: January 29, 2021

CMS Opt-Out for Individual Reporting: January 29, 2021

TIN/NPI Reconciliation: January 29, 2021

All data submissions: February 15, 2021

Contact AQI


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