2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)

Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

OMB: 0938-1314

IC ID: 221782

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Document Name Document Type
Appendix A1 2021 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf Instruction
Appendix A1 2021 MIPS Qualified Registry Self-Nomination Fact Sheet_Updated.docx Instruction
Appendix B1 2021 MIPS QCDR Self-Nomination Fact Sheet.pdf Instruction
Appendix B1 2021 MIPS QCDR Self-Nomination Fact Sheet_Updated.docx Instruction
CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Sub Appendix C1 2021 QCDR Measure Submission Template.xlsx Form
CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Sub Appendix C1 2021 QCDR Measure Submission Template.xlsx Form
Appendix A2 2021 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf Crosswalk to Appendix A1 - 2021 Qualified Registry Fact Sheet IC Document
Appendix A2 2021 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk_Updated.docx Crosswalk to Appendix A1 - 2021 Qualified Registry Fact Sheet IC Document
Appendix B2 2021 MIPS QCDR Self-Nomination Fact Sheet Crosswalk.pdf Crosswalk for Appendix B1 - 2021 Qualified Clinical Data Registry (QCDR) Fact Sheet IC Document
Appendix B2 2021 MIPS QCDR Self-Nomination Fact Sheet Crosswalk_Updated.docx Crosswalk for Appendix B1 - 2021 Qualified Clinical Data Registry (QCDR) Fact Sheet IC Document
Appendix C2 2021 QCDR Measure Submission Template Crosswalk.pdf Crosswalk for Appendix C1 - 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template IC Document
Appendix C2 2021 QCDR Measure Submission Template Crosswalk.pdf Crosswalk for Appendix C1 - 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1400

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Appendix A1 2021 MIPS Qualified Registry Self-Nomination Fact Sheet_Updated.docx	Yes	Yes	Printable Only
Instruction			Appendix B1 2021 MIPS QCDR Self-Nomination Fact Sheet_Updated.docx	Yes	Yes	Printable Only
Form	CMS-10621	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Appendix C1 2021 QCDR Measure Submission Template.xlsx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Quality Payment Program (QPP), System No. 09–70– 0539	FR Citation: 83 FR 6587

Number of Respondents: 265	Number of Respondents for Small Entity: 229

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	265	0	10	26	229
Annual IC Time Burden (Hours)	1,965	730	30	138	1,067
Annual IC Cost Burden (Dollars)	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk to Appendix A1 - 2021 Qualified Registry Fact Sheet	Appendix A2 2021 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk_Updated.docx	05/07/2021
Crosswalk for Appendix B1 - 2021 Qualified Clinical Data Registry (QCDR) Fact Sheet	Appendix B2 2021 MIPS QCDR Self-Nomination Fact Sheet Crosswalk_Updated.docx	05/07/2021
Crosswalk for Appendix C1 - 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Appendix C2 2021 QCDR Measure Submission Template Crosswalk.pdf	01/05/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.