NACOR Quality Reporting Options and Mechanisms

Quality Payment Program Reporting Options

The Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR) offers two reporting options for individuals and group's participating in the Quality Payment Program (QPP) - the Qualified Registry (QR) and the Qualified Clinical Data Registry (QCDR). Participants may choose either reporting option and report as individuals or groups to participate in the Merit-based Incentive Payment System (MIPS).

Group Practice Reporting

A practice can report as a group when two or more ECs reassign their billing rights to a single TIN. Groups are assessed collectively at the TIN level across all MIPS categories and payment adjustments will be applied across the group. To participate as a group, the group must report data for all clinicians, including those that would have been exempt as individuals. The low volume threshold for groups is defined as practices with less than or equal to $90,000 in allowed charges, less than or equal to 200 Medicare patients and less than 200 covered professional services under the Physician Fee Schedule. Groups that meet some, but not all, of these criteria can choose to opt in to MIPS reporting. If a practice chooses to report via group, then all clinicians in the group must report. 

Individual

ECs reporting at the individual level will be assessed based upon their National Provider Identifier (NPI)/Tax Identification Number (TIN) combination. Payment adjustments are based on performance across all MIPS categories and will be applied to the individual EC’s Medicare Part B Fee-for-Service payments in the correlating payment year. If a clinician does not meet the minimum threshold for MIPS they are exempt from reporting MIPS at the individual level. The low volume threshold for individuals is defined as clinicians with less than or equal to $90,000 in allowed charges, less than or equal to 200 Medicare patients and less than 200 covered professional services under the Physician Fee Schedule. Individuals that meet some, but not all, of these criteria can still choose to opt in to MIPS reporting beginning in 2019.

Qualified Clinical Data Registry (QCDR) and Qualified Registry (QR)

The QCDR and QR options offered by AQI NACOR for reporting 2020 MIPS is for the MIPS quality and improvement activity performance categories only. ECs and groups wishing to report the Promoting Interoperability (PI) performance category should consider other vendors. 

The only difference between reporting via a QCDR versus reporting via a QR is in the MIPS quality performance category. Reporting via a QCDR allows participants to choose both QCDR and MIPS measures to achieve the six measure minimum reporting threshold. Qualified Registry participants may only report MIPS measures and may not need to report six measures. Instead, they must report as many MIPS measures that apply to their patient population and group.

Criteria for attesting to improvement activities is the same regardless of QCDR or QR use.

2020 MIPS Quality Performance Category Reporting QR QCDR:

  Qualified Registry (QR) Qualified Clinical Data Registry (QCDR)
Selection of quality measures to report Applicable MIPS measures only Available MIPS and QCDR measures
* See the CMS Anesthesiology Specialty Measure Set * See the CMS Anesthesiology Specialty Measure Set
  * See AQI NACOR QCDR Measure Set
Report six quality measures Yes; however CMS will recognize if less than six measures apply to the patient population or group and readjust the score appropriately. Yes
Report an outcome or high priority measure Yes Yes
Report on 70% of the eligible cases for all payers (Medicare and non-Medicare) Yes Yes
AQI NACOR Measure compliance reports available for viewing  Yes  Yes

Enrollment

To enroll in QCDR or QR you must first become a NACOR participant. If you are already a member of NACOR you must sign up for QCDR or QR as well.

2020 Deadlines

Deadline Opens Closes
2020 Registration *January 1, 2020 October 30, 2020
January 1, 2020 – November 2020 Data Submission   January 29, 2021 
December 2020 Data Submission and corrected files January 1, 2021 January 31, 2021
Data submitted to CMS may be posted on Physician Compare Yes Yes