Crosswalk for Appendix C1 - 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template

QCDR Measure Submission Template
CY 2020 Final versus CY 2021 Proposed

Burden impact: The changes to this self-nomination fact sheet reflect proposals in the CY2021
Physician Fee Schedule (PFS) Proposed Rule for the Quality Payment Program. There is no
burden impact as a result of these changes.
*****
Change #1:
Location: Instructions Tab
Reason for Change:
Alignment with current year
CY 2020 Final Rule text:
Section- Cell A1:
Instructions for populating the 2020 MIPS Performance Period Self-Nomination QCDR
Measure Submission Template
CY 2021 Proposed Rule text:
Section-Cell A1:
Instructions for populating the 2021 Merit-Based Incentive Payment System (MIPS)
Performance Period Self-Nomination Qualified Clinical Data Registries (QCDR) Measure
Submission Template
*****
Change #2:
Location: Instructions Tab
Reason for Change:
Alignment with current year, edited for clarity
CY 2020 Final Rule text:
Section- Cell A3:
Disclaimer: The information noted with an asterisk (*) is subject to change based upon
what is finalized in the CY 2020 Physician Fee Schedule Final Rule for the Quality
Payment Program. If needed, this document will be updated to what is finalized in the
final rule and reposted accordingly.
CY 2021 Proposed Rule text:
Section-Cell A3:
Disclaimer: The information is subject to change based upon what is finalized in the
Calendar Year 2021 Physician Fee Schedule Final Rule for the Quality Payment
Program. If needed, this document will be updated to what is finalized in the final rule
and reposted accordingly.
*****
Change #3:
Location: Instructions Tab
Reason for Change:
Alignment with current year

CY 2020 Final Rule text:
Section- Cell A5:
The QCDR measure submission template should ONLY be filled out by QCDRs who
meet the 2020 definition of a QCDR and wish to submit QCDR measures for CMS
consideration.
CY 2021 Proposed Rule text:
Section-Cell A5:
The QCDR Measure Submission Template should ONLY be filled out by QCDRs who
meet the 2020 definition of a QCDR, are self-nominating as a QCDR for 2021, and wish
to submit QCDR measures for CMS consideration.
*****
Change #4:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section- Cell A6:
A QCDR may submit a maximum of 30 QCDR measures for review and approval by
CMS for reporting.
CY 2021 Proposed Rule text:
Section-Cell A6:
A QCDR may submit a maximum of 30 QCDR measures for review and approval by
CMS consideration for reporting.
*****
Change #5:
Location: Instructions Tab
Reason for Change:
Alignment with current year, edited for clarity
CY 2020 Final Rule text:
Section- Cell A7:
Complete the fields for each proposed 2020 MIPS Performance Period QCDR Measure.
Please ensure that the measure description and specifications are checked for grammar
and typographical errors before submission.
CY 2021 Proposed Rule text:
Section-Cell A7:
Complete the fields for each proposed 2021 MIPS Performance Period QCDR Measure.
(Note: If you do not own the measure, please provide your information in all unshaded
columns.) Please ensure that the QCDR measure specifications are checked for
grammar and typographical errors before submission.
*****
Change #6:
Location: Instructions Tab
Reason for Change:
Alignment with current year

CY 2020 Final Rule text:
Section- Cell A10:
1. Open the QCDR measure submission template and save it with your organization's
name (i.e.,2020 QCDR Measure Submission_QCDRName_vX). Please update the
version number, when an updated QCDR measure submission template is uploaded or
attached.
CY 2021 Proposed Rule text:
Section-Cell A10:
1. Open the QCDR Measure Submission Template and save it with your organization's
name (i.e., 2021 QCDR Measure Submission_QCDRName_vX). Please update the
version number, when an updated QCDR Measure Submission Template is uploaded or
attached.
*****
Change #7:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section- Cell A11:
2. Navigate to the "QCDR Information" tab. For existing QCDRs in good standing, please
update row 3 (Self-Nomination ticket #:) and row 4 (Number of QCDR Measures
submitted =). For new QCDRs, enter information for all the rows except for row 2 (QCDR
Vendor ID (if applicable) :). Your organization will be assigned a QCDR Vendor ID upon
approval.
CY 2021 Proposed Rule text:
Section-Cell A11:
2. Navigate to the "QCDR Information" tab. For existing QCDRs in good standing, please
update row 5 (Self-Nomination ticket #) and row 6 (Expected number of QCDR
measures to be submitted (to be entered by QCDR)). For new QCDRs, enter information
for all the rows except for row 4 (QCDR Vendor ID (if applicable)). Your organization will
be assigned a QCDR Vendor ID upon approval.
*****
Change #8:
Location: Instructions Tab
Reason for Change:
Alignment with current year, edited for clarity
CY 2020 Final Rule text:
Section- Cell A13:
4. Upload or attach the 2020 QCDR measure submission template to your organization's
2020 self-nomination form. Please note that the 2020 QCDR measure submission
template does not need to include all of the proposed QCDR measures to be uploaded
or attached to your organization's 2020 self-nomination form. You may upload or attach
an updated 2020 QCDR measure submission template with additional QCDR measures
prior to the end of the 2020 self-nomination period which ends at 8 pm ET on September
3rd.

CY 2021 Proposed Rule text:
Section-Cell A13:
4. Upload or attach the 2021 QCDR Measure Submission Template to your
organization's 2021 Self-Nomination form. Please note that the 2021 QCDR Measure
Submission Template does not need to include all of the proposed QCDR measures to
be uploaded or attached to your organization's 2021 Self-Nomination form. You may
upload or attach an updated 2021 QCDR Measure Submission Template with additional
QCDR measures prior to the end of the 2021 Self-Nomination period which ends at 8
p.m. Eastern Time (ET) on September 1st.
*****
Change #9:
Location: Instructions Tab
Reason for Change:
Process improvement
CY 2020 Final Rule text:
Location: N/A
CY 2021 Proposed Rule text:
Section-Cell B19, C19, D19:
Column Header: Measure ID: Measure Title (Reference only)
Required/Optional? N/A
Instructions: This is a locked autofilled cell that gives a reference point of Measure ID and
Measure Title.
*****
Change #10:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section- Cell B25
Column header: Measure Submission Status
CY 2021 Proposed Rule text:
Section- Cell B20
Column header: Measure Ready for PIMMS Review?
*****
Change #11:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell D26
Instructions: Enter "Yes", "No" or "Co-owned" for this field. By selecting "No" you are
attesting that you currently have the appropriate documentation (i.e., email, letter) giving
your organization permission from the QCDR measure owner/steward to use the QCDR
measure. Documentation to support permission will be verified.

*If your answer is no, you do not own the measure, please fill out Columns E, F, G, and
H. For remaining columns, please enter "See owner specs".
CY 2021 Proposed Rule text:
Section-Cell: D21
Instructions: Enter "Yes", "No" or "Co-owned by 2 or more QCDRs" for this field. By
selecting "No" you are attesting that you do not own or co-own the measure and currently
have the appropriate documentation (i.e., email, letter) giving your organization
permission from the QCDR measure owner/steward to use the QCDR measure.
Documentation to support permission will be verified. Please provide information in all
unshaded columns. Please note that the QCDR who owns the measure must be an active
and approved QCDR for the given self-nomination period.
*****
Change #12:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell B27, D27
Column Header: If you do not own or co-own this measure with another QCDR(s),
please indicate the owner or co-owners
Instructions: Provide the name of the QCDR that owns this measure or the QCDR(s) that
co-own this measure.
Example: Centers for Medicare & Medicaid Services
CY 2021 Proposed Rule text:
Section-Cell B22, D22
Column Header: If you answered "No" or "Co-owned by 2 or more QCDRs”, please
indicate the approved owner or co-owners
Instructions: Provide the name of the active and approved QCDR(s) that own or co-own
the QCDR measure.
Example: XXX QCDR
*****
Change #13:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell B38, D38
Column Header: QCDR Measure Type
Instructions: Select the measure type from the drop down list that describes the measure
submitted for review.
CY 2021 Proposed Rule text:
Section-Cell B23, D23
Column Header: Program Submission Status
Instructions: Select the measure submission status from the drop down list that
describes the measure submitted for review. (New or existing measure with/without
changes). If you select ‘Existing Approved QCDR Measure With No Changes’, all cells

that should not be changed will be shaded. Please ONLY update the cells that are
unshaded.
*****
Change #14:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell D28
Instructions: Provide the QCDR measure ID assigned to the 2017/2018/2019 MIPS
performance period approved measure included in the QCDR measure specifications.
Enter "N/A" if not applicable.
Example: ABC55
CY 2021 Proposed Rule text:
Section-Cell D24
Instructions: Please enter the most recent CMS assigned QCDR measure ID if the
QCDR measure was included in any MIPS performance period as an approved
measure. Enter "N/A" if not applicable. Please do NOT self-assign a QCDR measure ID.
CMS is responsible for assigning QCDR measure IDs.
*****
Change #15:
Location: Instructions Tab
Reason for Change:
Process improvement
CY 2020 Final Rule text:
Section-Cell B39, D39, B39, D40
Column Header: If this is an existing measure with changes, do the changes impact the
intent of the measure?
Instructions: If yes, indicate if the variance is within your registry and/or from another
source. If another source, please cite the source.
Column Header: Please indicate what has changed to the existing measure and how the
change impacts the intent of the previous version.
Instructions: "Provide details regarding the measure changes and how the changes
impact the previous version of the QCDR measure.
Example: 10% improvement in depression symptoms has been added to the numerator.
The measure can no longer be benchmarked against the previous year. "
CY 2021 Proposed Rule text:
Section-Cell B25, D25
Column Header: If existing measure with changes, please indicate what has changed to
the existing measure
Instructions: Provide a detailed explanation of what changes were made to the measure.
Example: Denominator exclusion added

*****
Change #16:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell D41
Instructions: Enter "Yes" or "No" for this field.
CY 2021 Proposed Rule text:
Section-Cell D26
Instructions: Enter "Yes" or "No" to indicate if the benchmark from prior years is able to
be used for comparison.
*****
Change #17:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell B42, D42
Column Header: If applicable, please Indicate why the previous benchmark cannot be
used.
Instructions: Provide details regarding why the previous benchmark cannot be used.
Example: The improvement addition to the numerator will make this measure an
Outcome measure and therefore cannot be compared to the measure from last year.
CY 2021 Proposed Rule text:
Section-Cell B27, D27
Column Header: If applicable, please provide details why the previous benchmark can or
cannot be used
Instructions: Provide details regarding why the previous benchmark can or cannot be
used in response to the changes to the existing measure.
Example: The improvement addition to the numerator will make this measure an
Outcome measure and therefore cannot be compared to the measure from last year.
*****
Change #18:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell B36, D36
Column Header: Data Source Used for the Measure
Instructions: Indicate the data source(s) used for the measure. This may include but is
not limited to administrative claims data, facility discharge data, chronic condition data
warehouse (CCW), claims, CROWNWeb, EHR (enter relevant parts), Hybrid, IRF-PAI,
LTCH CARE data set, National Healthcare Safety Network (NHSN), OASIS-C1, paper
medical record, Prescription Drug Event Data Elements, PROMIS, record review,
Registry (enter which Registry), Survey, Other (describe source).

CY 2021 Proposed Rule text
Section-Cell B35, D35
Column Header: Primary Data Source Used for Abstraction
Instructions: Indicate the primary data source used for the measure. This may include
but is not limited to administrative claims data, facility discharge data, chronic condition
data warehouse (CCW), claims, CROWNWeb, EHR (enter relevant parts), Hybrid, IRFPAI, LTCH CARE data set, National Healthcare Safety Network (NHSN), OASIS-C1,
paper medical record, Prescription Drug Event Data Elements, PROMIS, record review,
Registry (enter which Registry), Survey, Other (describe source).
*****
Change #19:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell D37
Instructions: Provide additional information when "Registry" and/or "Other" is selected.
Example: ABC Registry
CY 2021 Proposed Rule text
Section-Cell D36
Instructions: Provide additional information when "Registry" and/or "Other" is selected.
Example: ABC Registry
You may list additional data sources used in addition to the primary data source.
*****
Change #20:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell B44
Column Header: Is the QCDR measure a high priority measure?
CY 2021 Proposed Rule text
Section-Cell B38
Column Header: High Priority Measure?
*****
Change #21:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell D48
Instructions: Select which care setting(s) are included within the measure.

CY 2021 Proposed Rule text
Section-Cell D42
Instructions: Select which care setting is included within the measure. If multiple care
settings apply, select the option "Multiple Care Settings" and enter them in the next cell.
*****
Change #22:
Location: Instructions Tab
Reason for Change:
Process improvement
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell B43, C43, D43
Columns Header: If Multiple Care Settings selected, list Care Settings here
Require/Optional? Optional
Instructions: If "Multiple Care Settings" was selected, enter all Care Settings that apply.
*****
Change #23:
Location: Instructions Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell B44, C44, D44
Columns Header: Includes Telehealth?
Require/Optional? Required
Instructions: Please answer "Yes" or "No" if the QCDR measure’s denominator includes
services provided via telehealth. (Please review the quality action to ensure that it is
appropriate via telehealth.)
*****
Change #24:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell D55
Instructions: If not a continuous variable and/or ratio measure enter N/A.
Example: 0-100%
CY 2021 Proposed Rule text
Section-Cell D51
Instructions: Please provide a defined range of performance. If it is not a continuous
variable and/or ratio measure, enter "N/A".
Example: 0-250 minutes

*****
Change #25:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell B58, D58
Column Header: Indicate an Overall Performance Rate if more than 1 performance rate
is submitted
Instructions: Specify which of the submitted rates will represent an overall performance
rate for the measure or how an overall performance rate could be calculated based on
the data submitted [for example, simple average of the performance rates submitted or
weighted average (sum of the numerators divided by the sum of the denominators), etc.
CY 2021 Proposed Rule text
Section-Cell B54, D54
Column Header: Indicate an Overall Performance Rate
Instructions: Specify which of the submitted rates will represent an overall performance
rate for the measure or how an overall performance rate could be calculated based on
the data submitted (for example, simple average of the performance rates submitted) or
weighted average (sum of the numerators divided by the sum of the denominators), etc.
If only 1 performance rate is being submitted, enter 1st performance rate.
*****
Change #26:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell B59
Column Header: Risk-Adjusted
CY 2021 Proposed Rule text
Section-Cell B55
Column Header: Risk-Adjusted Status?
*****
Change #27:
Location: Instructions Tab
Reason for Change:
Edited for clarity, updated to align with program requirements
CY 2020 Final Rule text:
Section-Cell D61
Instructions: Please attest that the measure element can be abstracted and is feasible.
CY 2021 Proposed Rule text
Section-Cell D57
Instructions: Please attest that the measure element can be abstracted and is feasible. If
borrowing the measure, it is expected that the ability to abstract the data according to
the QCDR measure owner’s specifications is a condition of self-nominating the QCDR

measure. Withdrawing of the QCDR measure during an active performance period is
not acceptable.
*****
Change #28:
Location: Instructions Tab
Reason for Change:
Edited for clarity, updated to align with program requirements
CY 2020 Final Rule text:
Section-Cell B62, D62
Column Header: Please provide any test data on reliability/validity
Instructions: If test data on reliability/validity is not available enter N/A.
CY 2021 Proposed Rule text
Section-Cell B59, D59
Column Header: Validity Testing Summary
Instructions: Provide validity testing summary if available.

*****
Change #29:
Location: Instructions Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell B58, C58, D58
Column Header: Was the QCDR measure tested at the individual clinician level?
Required/Optional? Optional
Instructions: Enter "Yes" or "No" to indicate if the QCDR measure was tested at the
individual clinician level.
*****
Change #30:
Location: Instructions Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell B60, C60, D60
Column Header: Feasibility Testing Summary
Required/Optional? Optional
Instructions: Provide feasibility testing summary if available.

*****
Change #31:
Location: Instructions Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell B61, C61, D61
Column Header: Reliability Testing Summary
Required/Optional? Optional
Instructions: Provide reliability testing summary if available.
*****
Change #32:
Location: Instructions Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell B62, C62, D62
Column Header: Describe Link to Cost Measure/Improvement Activity
Required/Optional? Required
Instructions: Describe the link between the QCDR measure, cost measure, and an
improvement activity. Please document "no link identified", if there is no link to a cost
measure or an improvement activity. In cases where a QCDR measure does not have a
clear link to a cost measure and an improvement activity, we would consider exceptions
if the potential QCDR measure otherwise meets the QCDR measure requirements and
considerations.
*****
Change #33:
Location: Instructions Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
Section- Cell B65, D65
Column Header: Provide measure performance data and variance rate, if available
Instructions: Provide measure performance data and variance rate, if available. CMS
provided provisional approval with the expectation that evidence of a performance gap
would be provided. Please provide the average performance rate, variance range and
the number of eligible clinicians and/or TINs submitting the measure within your selfnomination.
Provisionally approved QCDR measures that do not have performance data or
performance data does not support a gap, the measure will likely not be approved for

use in the 2020 performance period of MIPS. CMS provided provisional approval with
the expectation that evidence of a performance gap would be provided.
Example: 2019 Performance data shows 150 individual submissions with a mean rate of
performance 71.2%
CY 2021 Proposed Rule text
Section-Cell B65, D65
Column Header: Provide measure performance data (# months data collected, average
performance rate, performance range, and number of clinicians or groups)
Instructions: Please provide the # of months the data was collected, average
performance rate, performance range and the number of eligible clinicians and/or TINs
submitting the measure within your self-nomination.
Example: 12 months, Average performance rate 75%, range 52-89%, 112 Clinicians
submitting data
*****
Change #34:
Location: Instructions Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell B67, C67, D67
Column Header: If applicable, provide a Participation Plan if QCDR measure has low
adoption by clinicians
Required/Optional? Optional
Instructions: If a QCDR measure fails to meet benchmarking thresholds for 2
consecutive performance periods (i.e. the data submitted is insufficient in meeting the
case minimum and volume thresholds required for benchmarking), the QCDR may
submit a participation plan for CMS consideration if is believed that the measure is
important and relevant to a specialist’s practice.
Participation Plan requirements:
Detailed plan and methods to encourage eligible clinicians and groups to increase
QCDR measure adoption.
As examples, a QCDR measure participation plan could include one or more of the
following: Development of an education and communication plan; update the QCDR
measure’s specification with changes to encourage broader participation; require
reporting on the QCDR measure as a condition of reporting through the QCDR.
*****
Change #36:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:

Section- Cell D67
Instructions: Indicate the specialty/specialties the measure applies to (i.e.,
Anesthesiology, Neurology, Urology, etc.).
Example: Mental/Behavioral Health
CY 2021 Proposed Rule text
Section-Cell D68
Instructions: Indicate the specialty/specialties the measure applies to.
Example: Anesthesiology, Neurology, and Urology
*****
Change #37:
Location: Instructions Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section- Cell D68
Instructions: Please provide a preferred clinical or specialty category (i.e., Diabetes,
Substance Use/Management). Please note that if a preferred measure published clinical
category is not provided, one will be assigned to the measure by CMS.
Example: Mental/Behavioral Health
CY 2021 Proposed Rule text
Section-Cell D69
Instructions: Please provide a preferred clinical or specialty category. Please note that if
a preferred measure published clinical category is not provided, one will be assigned to
the measure by CMS.
Example: Diabetes and Substance Use/Management
*****
Change #38:
Location: QCDR Information Tab
Reason for Change:
Process improvement- Table created
CY 2020 Final Rule text:
Section-Cell A1-A4:
QCDR Organization Name:
QCDR Vendor ID (if applicable):
Self-Nomination ticket #:
Number of QCDR Measures submitted =
CY 2021 Proposed Rule text
Section-Cell A2-10:
Column Title: QCDR Information Fields:
QCDR Organization Name:
QCDR Vendor ID (if applicable):
Self-Nomination ticket #:
Expected number of QCDR measures to be submitted (to be entered by QCDR):

Total number of QCDR measures entered in 2021 QCDR Measure Submission
Template:
Total number of QCDR measures "Ready for PIMMS Review" status in 2021 QCDR
Measure Submission Template:
Total number of QCDR measures in "Work in Progress" status in 2021 QCDR Measure
Submission Template:
Total number of QCDR measures in missing required information:
Section-Cell B2:
Column Title: QCDR Information Entries
Section-Cell C2-C10:
Column Title: Instructions/Notes
To be completed by the QCDR.
To be completed by the QCDR, if a Vendor ID has been assigned.
To be completed by the QCDR, once a self-nomination ticket is available in the QPP
Self-Nomination Portal.
To be completed by the QCDR. Should include the number of QCDR measures the
QCDR plans to submit for the 2021 self-nomination period.
For reference only. Count allows check against expected number of QCDR measures to
be submitted.
For reference only. Allows confirmation that all expected QCDR measures are ready for
PIMMS review at time of submission.
For reference only. Allows confirmation that all expected QCDR measures are no longer
in a work in progress status at time of submission.
For reference only. Allows confirmation of the number of QCDR measures missing
required information.
*****
Change #39:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Process improvement
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Cell Column D
Column title: Measure ID: Measure Title (Reference only)
*****
Change #40:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section- Cell Column D
Column title: Measure Submission Status*

CY 2021 Proposed Rule text
Section-Cell Column E
Column title: Measure Ready for PIMMS Review? *
*****
Change #41:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Cell Column F
Column title: If you do not own or co-own this measure with another QCDR(s), please
indicate the owner or co-owners
CY 2021 Proposed Rule text
Section- Cell Column G
Column title: If you answered "No" or "Co-owned by 2 or more QCDRs”, please indicate
the approved owner or co-owners
*****
Change #42:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Column Q
Column title: QCDR Measure Type*
CY 2021 Proposed Rule text
Section-Column H
Column title: Program Submission Status*
*****
Change #43:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Column Q
Column title: QCDR Measure Type*
CY 2021 Proposed Rule text
Section-Column H
Column title: Program Submission Status*
*****
Change #44:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity

CY 2020 Final Rule text:
Section-Column R, Column S
Column title: If this is an existing measure with changes, do the changes impact the
intent of the measure?
Column title: Please indicate what has changed to the existing measure and how the
change impacts the intent of the previous version
CY 2021 Proposed Rule text
Section-Column J
Column title: If existing measure with changes, please indicate what has changed to the
existing measure
*****
Change #45:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Column U
Column title: If applicable, please Indicate why the previous benchmark cannot be used
CY 2021 Proposed Rule text
Section-Column L
Column title: If applicable, please provide details why the previous benchmark can or
cannot be used
*****
Change #46:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Column O
Column title: Data Source Used for the Measure*
CY 2021 Proposed Rule text
Section-Column T
Column title: Primary Data Source Used for Abstraction*
*****
Change #47:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Column W
Column title: Is the QCDR measure a high priority measure? *
CY 2021 Proposed Rule text
Section-Column W
Column title: High Priority Measure? *

*****
Change #48:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Process improvement
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Column AB
Column title: If Multiple Care Settings selected, list Care Settings here
*****
Change #49:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Process improvement
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Column AC
Column title: Includes Telehealth? *
*****
Change #50:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Column AK
Column Title: Indicate an Overall Performance Rate if more than 1 performance rate is
submitted*
CY 2021 Proposed Rule text
Section-Column AM
Column title: Indicate an Overall Performance Rate*
*****
Change #51:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Process improvement
CY 2020 Final Rule text:
Section-Column AL
Column Title: Risk-Adjusted*
CY 2021 Proposed Rule text
Section-Column AN
Column title: Risk-Adjusted Status? *

*****
Change #52:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Column AQ
Column title: Was the QCDR measure tested at the individual clinician level?
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Change #53:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
Section-Column AO
Column title: Please provide any test data on reliability/validity
CY 2021 Proposed Rule text
Section-Column AR
Column title: Validity Testing Summary
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Change #54:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Column AS
Column title: Feasibility Testing Summary
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Change #55:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Column AT
Column title: Reliability Testing Summary

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Change #56
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A
CY 2021 Proposed Rule text
Section-Column AU
Column title: Describe Link to Cost Measure/Improvement Activity*
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Change #57:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity, updated to align with program requirements
CY 2020 Final Rule text:
Section-Column AR
Column title: Provide measure performance data and variance range, if available*
CY 2021 Proposed Rule text
Section-Column AX
Column title: Provide measure performance data (# months data collected, average
performance rate, performance range, and number of clinicians or groups)
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Change #58:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section-Column AS
Column title: Provide the study citation to support performance gap for the measure, if
measure performance data is not available
CY 2021 Proposed Rule text
Section-Column AY
Column title: If applicable, provide the study citation to support performance gap for the
measure
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Change #59:
Location: 2021 QCDR Measure Subm Template Tab
Reason for Change:
Updated to align with program requirements
CY 2020 Final Rule text:
N/A