First Quality Reporting Deadline January 29
The first 2020 Quality Reporting deadline is January 29, 2021. The following items are due to NACOR on this date:
- Data from January through November 2020. 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 2020 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.
Email askaqi@asahq.org with any questions.
Individual Provider Consents
AQI's NACOR is collecting consent forms from each Eligible Clinician (EC) who is enrolled in 2020 individual quality reporting, as required by the Centers for Medicare & Medicaid Services (CMS). All providers must sign the consent form by January 29, 2021. AQI will only submit data to CMS for individual quality reporting for providers who have signed consent forms.
Scan and email consents (Exhibit A to the Addendum for Quality Reporting) to Javeria Ali. For practices that submitted paper consent forms and received receipt confirmation from AQI, no further action is required.
For questions about consents, email Javeria Ali.
Attesting to Improvement Activities via NACOR
Clinicians can attest to 2020 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. For practices with multiple tax ID numbers (TINs), make sure the correct TIN is listed in the drop-down menu before attesting to the activity.
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.
To earn full credit for the Improvement Activity Component, you must earn 40 points. Medium weighted IAs are worth 10 points and highly-weighted activities are worth 20 points. If the practice or clinician qualifies for a special status, these points may be doubled.
For more information, email askaqi@asahq.org.
FTP Access: Inactive After 90 Days
For security reasons, all FTP accounts (for those who upload data to NACOR) will be disabled if no activity occurs within a 90-day window. As data submission deadlines approach, you may not have access to log in to the FTP when you are ready to submit data.
If you suspect your account has been disabled due to inactivity, submit a help desk ticket by emailing NACORSupport@asahq.org. FTP access has no impact on user access to the NACOR dashboard.
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- Business Risk: A Legislative Perspective
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New QCDR Measures Available for 2021 Reporting
AQI NACOR Qualified Clinical Data Registry (QCDR) participants have the opportunity to report new quality measures for the 2021 MIPS performance year. In addition to CMS approving AQI NACOR as a QCDR, the agency also approved AQI NACOR to report these measures on behalf of their participants:
- ePreop31: Intraoperative Hypotension among Non-Emergent Noncardiac Surgical Cases
- AQI69: Intraoperative Antibiotic Redosing
- AQI70: Prevention of Arterial Line-Related Bloodstream Infections
- AQI71: Ambulatory Glucose Management
- AQI72: Perioperative Anemia Management
Over the course of the reporting year, the ASA Committee on Performance and Outcomes Measurement (CPOM) reviews available quality measures and recommends their inclusion in the AQI NACOR QCDR. In 2020, CPOM worked with the Intraoperative Hypotension measure developer and steward to amend the measure in a way that should make reporting easier and more meaningful for individuals and groups.
An internal improvement measure in 2020, CPOM felt that the changes made to the measure in 2020 allowed for the measure to be promoted to a QCDR measure this year. As indicated, ePreop31 was amended to remove MAC anesthesia and include regional and neuraxial anesthesia. In addition, denominator exclusions were expanded to include ASA physical status 1 and intentional hypotension. Last, the hypotension measure risk adjustment was changed to take into more clear consideration of surgical complexity. For information on how to start reporting this new QCDR measure, visit https://www.provationmedical.com/ioh/.
The other four measures, indicated by AQI69, AQI70, AQI71, and AQI72, were developed by CPOM during the 2019-2020 governance year. In 2020, CPOM released its report that detailed how the measures were developed and the public comments that the measures received. That report is available on the ASA website for member reference. ASA and AQI worked closely with our QCDR partners to gather preliminary data on these measures.
Although these measures have been approved for 2021, CMS requires that a minimum number of physicians and groups report the measures each year for the measures to remain in the program. Groups wishing to diversify their scoring in the MIPS performance category may wish to test and/or report these measures for the 2021 reporting year. Quality benchmarks on the four new measures will be based upon data submitted for the 2021 performance year.
Contact ASA Quality and Regulatory Affairs (QRA) at qra@asahq.org for questions on reporting these measures.