CMS Approves AQI NACOR as a Qualified Registry for 2017

On Friday, March 17, the Centers for Medicare & Medicaid Services (CMS) approved the Anesthesia Quality Institute’s (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) application to participate in the Merit-based Incentive Payment System (MIPS) as a Qualified Registry in 2017.

Physician anesthesiologists and other eligible clinicians (ECs) reporting to MIPS can choose from more than thirty MIPS measures offered in the ASA’s Qualified Registry to fulfill requirements in the MIPS Quality component, including those in the CMS recommended Anesthesiology Specialty Measure Set. The Qualified Registry will also support attestation for the MIPS Improvement Activities Component.

For the MIPS Quality Component, reporting via Qualified Registry requires ECs and groups to report six MIPS measures for at least 50 percent of all patients, both Medicare and non-Medicare patients. One of these six measures must be an outcome measure or one high-priority measure as specified by CMS, if an outcome measure does not apply. If six measures are not applicable, the EC or group must report all applicable measures. Practices are reminded to use the 2017 measure specifications for all measures.

Anesthesiology Specialty Measure Set
MIPS #44: CABG: Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
MIPS #76: Prevention of CVC-Related Bloodstream Infections*
MIPS #130: Documentation of Current Medications in the Medical Record
MIPS #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
MIPS #404: Anesthesiology Smoking Abstinence*
MIPS #424: Perioperative Temperature Management*
MIPS #426: Post-Anesthetic Transfer of Care Measure: Procedure Room to PACU*
MIPS #427: Post-Anesthetic Transfer of Care Measure: Procedure Room to ICU*
MIPS #430: Prevention of PONV - Combination Therapy*
* designates a proposed "high priority measure" 

The MIPS Improvement Activities Component, requires ECs and groups reporting via Qualified Registry to attest to a combination of activities aimed at clinical practice improvement. Improvement Activities must meet the 40-point threshold designated by CMS. ASA and AQI expect to release more information on our websites in the weeks ahead. According to the MACRA Final Rule, practices should maintain documentation of such activities for at least 10 years. 

AQI NACOR is currently awaiting approval from CMS on its application to participate in MIPS as a Qualified Clinical Data Registry (QCDR) in 2017. More information, including QCDR measure specifications will be released following approval from CMS. 

To learn more about reporting requirements please review ASA MACRA resources. Learn more about MIPS and download full measure specifications at the CMS Quality Payment Program website. For additional information, please contact the ASA Department of Quality and Regulatory Affairs (QRA) at (202) 289-2222 or via e-mail at [email protected].