Documentation requirements for reporting measures to NACOR
April 16, 2021

Documentation requirements for reporting measures to NACOR

During the 2020 MIPS performance year, AQI conducted practice audits where data submitted to NACOR was compared to the supporting medical documentation. As a result of our findings, we have developed some questions and tips practices should review when choosing measures to report.

As with all quality measures, groups are only allowed to report on measures where all the data elements of the denominator are completed and documented, and where a clinical quality action or outcome (numerator) is completed and documented.

Although an individual or group may collect and report on any measure, not all measures are applicable to all patients or physicians.

  • Do you have access to all elements of the denominator?
  • Can you capture and document all the elements of the denominator?
  • Are you billing the CPT codes found in the denominator?
  • Can you capture the denominator exclusions to the measure?
  • Are you objectively tracking the numerator actions or outcomes?
    • (NOTE: a pre-filled checkbox is NOT appropriate)
  • Are you documenting denominator exceptions as they occur?

When the measure does NOT apply:

  • You do not capture or cannot document one or more elements of the denominator.
  • You do not have access to or cannot document or substantiate the denominator was fulfilled or the numerator actions occurred.
  • Only a general policy exists but individual elements of the denominator or number are not captured.
  • Unless otherwise stated, you do not complete the clinical action or are not responsible for the outcome measure.
  • You cannot maintain documentation on the measure for six years.

AQI and CMS may conduct audits on your measure data. To prepare for a possible audit:

  • Read the measure closely.
  • Ensure that your numerator choice (performance met versus performance not met) is appropriately chosen.
  • Make sure that you have access to documents that substantiate the measure.
  • Ensure that policies are supported by clinical documentation that a process or outcome occurred.
  • Record appropriate time stamps (especially for Perioperative Temperature Management).
  • Work with your technology vendors.
  • Keep documentation for at least six years.

If you have any questions email

Measure overview: AQI 71 Ambulatory Glucose Management

Measure AQI 71 is new for the 2021 reporting period. If your practice has elected to report this measure, please review the following:

Reporting Denominator definition (all): office-based and ambulatory surgery is defined as a therapeutic or diagnostic procedure performed in a healthcare facility that does not require an overnight stay (fewer than 24 hours of care).

Denominator Exclusions (all): procedure fewer than 30 minutes in duration (case will not count for the measure).

  • Each measure should be reported, as appropriate, for each time a patient undergoes a procedure in an office-based or ambulatory setting during the reporting period.
  • This measure has four sub-metrics which are used to calculate the total composite score.
  • All sub-metrics are required to be reported during the performance period.
  • To be scored on this measure, clinicians must have at least one eligible case reported for AQI71a, AQI71b, AQI71c, and AQI71d.
  • It is anticipated that qualified anesthesia providers and eligible clinicians who provide denominator-eligible services will submit this measure.

Numerator Note for AQI71d: to meet this measure, the anesthesiologist or other member of the care team must provide both oral and written education. Provision of written materials alone is not sufficient. The education that was provided should be documented in the medical record.

Questions? Email

2021 Improvement Activities for MIPS

For the 2021 MIPS performance year AQI is supporting Improvement Activities for Anesthesiologists and Pain Medicine Physicians. To attest to Improvement Activities in the NACOR Dashboard, practices should select IAs from the supported list. The data validation requirements for the IAs are available in the Quality Payment Program Resource Library.

Each individual improvement activity is assigned a weight of either medium or high. Medium weighted activities receive 10 points and high weighted activities receive 20 points. To receive full credit, eligible clinicians and groups must receive a score of 40 points. For group practices reporting in 2021, CMS requires 50% of the group’s National Provider Identifier (NPI) clinicians to perform the same improvement activity during any continuous 90-day period within the same performance year.

Small practices, rural practices, or practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS eligible clinicians will have their medium weighted activities count for 20 points and their high-weighted activities count for 40 points. They will still be required to reach 40 points to receive full credit for this component.

2021 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

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