March 06, 2023

MIPS Measure Changes in 2023

The ACR National Radiology Data Registry (NRDR®) is a CMS-approved Qualified Clinical Data Registry (QCDR) for the Merit-based Incentive Payment System (MIPS) for 2023. Thirteen QCDR measures spanning two NRDR data registries and nine additional licensed measures have been approved for inclusion in the QCDR, along with 38 MIPS measures.

QCDR participants can report a combination of QCDR and MIPS measures to fulfill reporting requirements for the Quality category. Participants can also use the QCDR to select activities for the Improvement Activities category.
Below are highlights of the measure changes in 2023:

Scoring Changes

  • Score threshold stays the same (75 points).
  • Category weights stays the same (30% quality, 30% cost, 25% PI, 15% IA).
  • Quality measure deciles now 1–10 instead of 3–10.
  • Non-benchmarked measures older than two years default to 0 points.
  • Quality measure data completeness now 75% (up from 70%).

Removed Measures

  • #76: Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections.
  • #110: Preventive Care and Screening: Influenza Immunization.
  • #111: Pneumococcal Vaccination Status for Older Adults.
  • #265: Biopsy Follow-Up.
  • #323: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI).

Measure Changes

  • #145: Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy. Numerator no longer accepts exposure time and number of images; must include radiation dose indices (reference air kerma, kerma-area product, or peak skin dose).