2020 Quality Payment Program Extreme and Uncontrollable Circumstances Exception
March 5, 2021
NACOR News

2020 Quality Payment Program Extreme and Uncontrollable Circumstances Exception

Practices that have been approved by CMS for an Extreme and Uncontrollable Circumstances Exception for Covid-19 or a natural disaster (e.g. wildfires or hurricanes) and are registered to submit Quality Data to CMS through NACOR must notify AQI no later than Friday, March 19.

To notify AQI of your practice's exemption status, submit a ticket by emailing nacorsupport@asahq.org.

If AQI does not receive notification through a support ticket, AQI will follow customary procedures for sending your practice's data to CMS. If CMS receives data from a group or individual that has a hardship exemption, CMS will score the data submitted.

To see if your practice has been approved for an Exception, check the Quality Payment Program Website using the QPP Participation Status Tool.

2021 MIPS highlights

The following changes to MIPS quality reporting are effective in 2021:

  • Report at least six quality measures (1 Outcome or High Priority if Outcome not available) for 70% of the eligible cases per measure for the full calendar year.
  • Achieve a MIPS Final Score of 60 points to avoid a possible payment adjustment. (The threshold was 45 points for 2020.)
  • Negative payment adjustment of up to 9% in 2023.
  • When attesting to an Improvement Activity, at least 50% of the practice's providers are required to participate in the activity for a consecutive 90-day period during the PY.
  • MIPS Value Pathways were postponed until the 2022 PY.

For more information, visit the ASA Website or email AskAQI@asahq.org.

2021 measures available

AQI is supporting 32 measures for the 2021 reporting year (16 QCDR and 16 MIPS). The 2021 AQI/NACOR QCDR measures were approved by CMS and are available here.

Please note the following quality measures have been retired by CMS and are not available for 2021 submission:

  • MIPS 408 – Opioid Therapy Follow-up Evaluation
  • MIPS 412 – Documentation of Signed Opioid Treatment Agreement
  • MIPS 414 – Evaluation or Interview for Risk of Opioid Misuse
  • AQI58 – Infection Control Practices for Open Interventional Pain Procedures
  • AQI61 – Ambulatory Post-Discharge Patient Follow-Up

The following quality measures are new for the 2021 MIPS Performance Year:

  • AQI69 – Intraoperative Antibiotic Redosing
  • AQI70 – Prevention of Arterial Line Related Bloodstream Infections
  • AQI71 – Ambulatory Glucose Management
  • AQI72 – Perioperative Anemia Management
  • EPREOP31 – Intraoperative Hypotension among Non-Emergent Noncardiac Surgical Cases

The 2021 Internal Improvement Measures will be available in early 2nd quarter 2021.

If you have any questions email askaqi@asahq.org or qra@asahq.org.

Register for 2021 NACOR reporting

Quality reporting practices can now begin the enrollment process for Anesthesia Quality Institute's (AQI) 2021 NACOR Quality Reporting by completing the new online order form. NACOR is a designated QR and QCDR for the Centers for Medicare & Medicaid Services Quality Payment Program.

AQI's NACOR quality reporting options include the following offerings in 2021 to ensure that NACOR remains the leader in anesthesiology: Quality Concierge, NACOR Quality Reporting, NACOR Benchmarking, and NACOR Basic.

All practices re-enrolling in NACOR Quality Reporting, Benchmarking, or Basic should complete a new order form for 2021. Practices enrolled in Quality Concierge are not required to complete the form.

2020 Reporting Deadlines

NACOR Registration: October 1, 2021

January through November 2021 data submission: January 31, 2022

Individual Quality Reporting Consent Submission: January 31, 2022

Improvement Activity Attestation: January 31, 2022

CMS Opt-Out for Individual Reporting: January 31, 2022

TIN/NPI Reconciliation: January 31, 2022

All data submissions: February 15, 2022

Contact AQI

Register: qcdr@asahq.org

NACOR Dashboard support: NACORSupport@asahq.org

Ask AQI: AskAQI@asahq.org



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