January 09, 2020

NRDR Approved as Qualified Data Registry for MIPS Reporting in 2020

The American College of Radiology® (ACR®) National Radiology Data Registry (NRDR®) has been approved as a Centers for Medicare and Medicaid Service (CMS)-approved Qualified Clinical Data Registry (QCDR) for the Merit-Based Incentive Payment System (MIPS) in 2020 for MIPS reporting.

Under CMS regulations, eligible clinicians can meet MIPS quality reporting requirements by participating in a QCDR. By using a QCDR to report on the required number of MIPS measures, physicians and group practices can potentially be better placed to obtain a positive adjustment and also avoid negative payment adjustments, which can result from nonreporting or underreporting.

QCDR participants can report a combination of QCDR measures and MIPS measures to fulfill reporting requirements for the Quality category under MIPS. Participants can also use the QCDR to select activities for the Improvement Activities category.

In 2020, the QCDR will include 49 MIPS measures and 14 QCDR measures spanning multiple NRDR data registries. Seven new QCDR measures have been added for reporting through the ACR General Radiology Improvement Database (GRID):

  • Interpretation of Computed Tomography (CT) Pulmonary Angiography for Pulmonary Embolism
  • Incidental Coronary Artery Calcification Reported on Chest CT
  • Use of Structured Reporting in Prostate MRI
  • Surveillance Imaging for Liver Nodules <10mm in Patients at Risk for Hepatocellular Carcinoma
  • Use of Quantitative Criteria for Oncologic FDG PET Imaging
  • Use of Low-Dose Cranial CT or MRI Examinations for Patients with Ventricular Shunts
  • Use of Low-Dose CT Studies for Adults with Suspicion of Urolithiasis or Nephrolithiasis

Many of these measures focus on collecting data for recommended follow-up of incidental findings and other detailed information in the radiology report.

CMS has also elected to remove five measures from the ACR QCDR. The CT Colonography Registry, Interventional Radiology Registry and National Mammography Database will no longer have measures available for QCDR reporting beginning in 2020. The removed measures are:

  • ACRad 1: CT Colonography True Positive Rate
  • ACRad 26: Appropriate Venous Access for Hemodialysis
  • ACRad 29: Rate of Percutaneous Nephrostomy Tube Replacement Within 30 Days Secondary to Dislodgement
  • ACRad 30: Rate of Inadequate Percutaneous Image-Guided Biopsy
  • ACRad 35: Screening Mammography Early Cancer Detection Rate

Additionally, the GRID Registry has also added four other new exam-level measures, three of which are applicable to two MIPS measures:

  • Follow-up Recommendations for Incidental Findings of Simple-Appearing Cystic Renal Masses (Existing MIPS measure #405)
  • Appropriate Follow-up Imaging for Benign Adrenal Masses (Existing MIPS measure #405)
  • Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines (Existing MIPS measure #364)
  • Recommended Follow-up for Imaging Findings

Refer to the MIPS Qualified Clinical Data Registry Page on the ACR website to learn more about the changes to the ACR for 2020 and how to participate in MIPS reporting and gain access to the QCDR toolkit.