March 08, 2022

ACR QCDR Adds New Quality Measures for 2022 MIPS

The ACR National Radiology Data Registry (NRDR®) team is proud to announce that, once again, the ACR® has been approved as a Qualified Clinical Data Registry (QCDR) for the 2022 Merit-based Incentive Payment System (MIPS). The ACR QCDR will continue to offer MIPS measures as well as QCDR measures, with the notable addition of nine measures newly licensed from the MSN Healthcare Solutions QCDR:

  • MEDNAX55: Use of ASPECTS (Alberta Stroke Program Early CT Score) for Non-Contrast CT Head Performed for Suspected Acute Stroke.
  • MSN13: Screening Coronary Calcium Scoring for Cardiovascular Risk Assessment Including Coronary Artery Calcification Regional Distribution Scoring.
  • MSN15: Use of Thyroid Imaging Reporting & Data System (TI-RADS™) in Final Report to Stratify Thyroid Nodule Risk.
  • MSN16: Screening Abdominal Aortic Aneurysm Reporting with Recommendations.
  • QMM16: IVC Filter Management Confirmation.
  • QMM17: Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions Using the Ovarian-Adnexal Reporting and Data System (O-RADS™).
  • QMM18: Use of Breast Cancer Risk Score on Mammography.
  • QMM19: DEXA/DXA and Fracture Risk Assessment for Patients with Osteopenia.
  • QMM20: Opening Pressure in Lumbar Puncture.

These nine measures will be submitted via the MIPS portal using the same file template as the simplified GRID 2.0 measure templates. View the detailed QCDR measure specifications.

Measures Removed

While adding new quality measures for MIPS reporting, CMS is also removing a handful of measures used by some practices during previous MIPS years. The following measures will not be available for 2022 MIPS reporting:

  • ACRad 39: Use of Low-Dose CT Studies for Adults with Suspicion of Urolithiasis or Nephrolithiasis (Please note that ACRad 39 will continue to be available as a quality improvement metric in the General Radiology Improvement Database registry and could eventually return as a QCDR measure if utilization increases.).
  • MIPS 21: Perioperative Care: Selection of Prophylactic Antibiotic — First OR Second Generation Cephalosporin.
  • MIPS 23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients).
  • MIPS 154: Falls: Risk Assessment.
  • MIPS 195: Radiology: Stenosis Measurement in Carotid Imaging Reports.
  • MIPS 225: Radiology: Reminder System for Screening Mammograms.

For users unable to reach these six measures for 2022 MIPS, the ACR advises submitting via a Qualified Registry (QR) rather than a QCDR. If CMS determines that a group or individual has not submitted the required six measures but has reported all measures available to them, their quality score will be adjusted accordingly using the CMS Eligible Measure Applicability process.

Please visit the ACR QCDR webpage for more information. If you have any questions about 2022 MIPS, please contact Zach Smith, Senior Quality Programs Specialist.