December 10, 2019

QCDR Update: New Quality Measures Potentially Available for Reporting

The ACR National Radiology Data Registry (NRDR®) is awaiting final approval as a CMS-approved Qualified Clinical Data Registry (QCDR) for the Merit-Based Incentive Payment System (MIPS) in 2020 for MIPS reporting. While ACR does expect CMS approval for its sixth year as a QCDR for 2020, final approval is still pending.

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 in order to fulfill reporting requirements for the Quality category under MIPS. Participants can also use the QCDR to select activities for the Improvement Activities category.

Potential New QCDR Measures

In 2020, we expect the NRDR QCDR to include 49 MIPS measures and 14 QCDR measures spanning multiple NRDR data registries. Seven new QCDR measures were proposed to CMS for reporting through the ACR General Radiology Improvement Database (GRID) in NRDR:

  • Interpretation of 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 existing measures from ACR’s NRDR 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 as follows:

  • 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 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 Computed Tomography (CT) Imaging for Incidentally-Detected Pulmonary Nodules According to Recommended Guidelines (Existing MIPS measure #364)
  • Recommended Follow-up for Imaging Findings

How to Participate

Find out how to use the ACR QCDR to participate in MIPS reporting and access a QCDR toolkit. Get started »