CROSSWALK (Appendix A2): 2022 Qualified Registry Fact Sheet

Qualified Registry Self-Nomination Fact Sheet
CY 2021 Final versus CY 2022 Proposed
Burden impact: The changes to this self-nomination fact sheet reflect proposals in the CY2021
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program and result in an
estimated change of zero hours as the initial 2022 QCDR/Qualified Registry Fact Sheets were
published prior to the release of the CY2022 PFS Proposed Rule for the Quality Payment
Program. The 2022 QCDR/Qualified Registry Fact Sheets will be updated and republished after
the policies are finalized within the CY2022 PFS Final Rule for the Quality Payment Program.
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Change #1:
Location: Page 1
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
Section Header2021 Qualified Registry Fact Sheet
CY 2022 Proposed Rule text:
Section Header2022 Qualified Registry Fact Sheet
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Change #2:
Location: Page 1
Reason for Change:
Removal of versioning for the 2021 Qualified Registry Fact Sheet
CY 2021 Final Rule text:
Version 2
Updated on April 6, 2021
CY 2022 Proposed Rule text:
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Change #3:
Location: Page 1
Reason for Change:
Addition expanded terminology, along with acronym
CY 2021 Final Rule text:
A Qualified Registry is a data intermediary that collects MIPS data from MIPS eligible clinicians
and submits it to the Centers for Medicare & Medicaid Services (CMS) on their behalf.
Clinicians work directly with their chosen Qualified Registry to submit data on the selected
measures or activities they have selected.
CY 2022 Proposed Rule text:
A Qualified Registry is a data intermediary that collects Merit-based Incentive Payment System
(MIPS) data from MIPS eligible clinicians and submits it to the Centers for Medicare & Medicaid
Services (CMS) on their behalf. Clinicians work directly with their chosen Qualified Registry to
submit data on the selected measures or activities they have selected.

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Change #4:
Location: Page 1
Reason for Change:
Alignment with current year, removal of expanded form of MIPS and update to punctuation
CY 2021 Final Rule text:
1. Participants: You must have at least 25 participants by January 1 of the year prior to the
applicable performance period (January 1, 2020 for consideration for the 2021 Merit-based
Incentive Payment System (MIPS) performance period).4 These participants are not
required to use the Qualified Registry to report MIPS data to CMS, but they must submit
data to the Qualified Registry for quality improvement.5 Please note CMS expects
Qualified Registries would be up and running by January 1 of the performance period
to accept and retain data, to allow clinicians to begin their data collection on January
1 of the performance period.6 A system that is not “live” beginning with the start of the
performance period is considered non-compliant with this requirement.
CY 2022 Proposed Rule text:
1. Participants: You must have at least 25 participants by January 1 of the year prior to the
applicable performance period (January 1, 2021 for consideration for the 2022 MIPS
performance period).4 These participants are not required to use the Qualified Registry to
report MIPS data to CMS, but they must submit data to the Qualified Registry for quality
improvement.5 Please note CMS expects Qualified Registries would be up and running
by January 1 of the performance period to accept and retain data, to allow clinicians
to begin their data collection on January 1 of the performance period.6 A system that is
not “live”, beginning with the start of the performance period, is considered non-compliant
with this requirement.
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Change #5:
Location: Page 1
Reason for Change: Removal of text indicating Alternative Payment Model (APM)
Performance Pathway (APP) is a new data submission method starting in the 2021
performance period
CY 2021 Final Rule text:
3. Data Submission: You should submit data via a CMS-specified secure method for data
submission, such as a defined Quality Payment Program data format. Additional information
regarding data submission methodologies can be found in the Developer Tools section of the
Resource Section of the Quality Payment Program website: https://qpp.cms.gov/developers.
Note: the Alternative Payment Model (APM) Performance Pathway (APP) is a new data
submission method starting in the 2021 performance period. [Data submission is discussed in
more detail below]
CY 2022 Proposed Rule text:
3. Data Submission: You should submit data via a CMS-specified secure method for data
submission, such as a defined Quality Payment Program data format. Additional information
regarding data submission methodologies can be found in the Developer Tools section of the
Resource Section of the Quality Payment Program website: https://qpp.cms.gov/developers.
[Data submission is discussed in more detail below]

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Change #6:
Location: Page 2
Reason for Change:
Addition expanded terminology, along with acronym
CY 2021 Final Rule text:
Except as provided in the Final Rule, QCDRs, qualified registries, and health information
technology (IT) vendors must be able to submit data for all of the following MIPS performance
categories:
CY 2022 Proposed Rule text:
Except as provided in the Final Rule, Quality Clinical Data Registries (QCDRs), qualified
registries, and health information technology (IT) vendors must be able to submit data for all of
the following MIPS performance categories:
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Change #7:
Location: Page 2
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
4. Data Validation and Targeted Audits: You must conduct Data Validation for the 2021
performance year prior to any data submission for the 2021 performance period.
CY 2022 Proposed Rule text:
4. Data Validation and Targeted Audits: You must conduct Data Validation for the 2022
performance year prior to any data submission for the 2022 performance period.
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Change #8:
Location: Page 2
Reason for Change:
Change to use the plural form of the term
CY 2021 Final Rule text:
 Verification of the accuracy of tax identification numbers (TINs) and National Provider
Identifier (NPIs)
CY 2022 Proposed Rule text:
 Verification of the accuracy of tax identification numbers (TINs) and National Provider
Identifiers (NPIs)
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Change #9:
Location: Page 2
Reason for Change:
Alignment with current year requirement and to use the singular form of category
CY 2021 Final Rule text:
 Verification that only MIPS quality measures that are relevant for the reporting periods
will be used for MIPS submission. For the 2021 performance year, this means:
o 2021 MIPS Clinical Quality Measures (CQMs) and/or electronic CQMs (eCQMs)
for the Quality performance categories.
o 2021 Promoting Interoperability measures and objectives for the Promoting
Interoperability performance categories.

CY 2022 Proposed Rule text:
 Verification that only MIPS quality measures that are relevant for the reporting periods
will be used for MIPS submission. For the 2022 performance year, this means:
o 2022 MIPS Clinical Quality Measures (CQMs) and/or electronic CQMs (eCQMs)
for the quality performance category.
o 2022 Promoting Interoperability measures and objectives for the Promoting
Interoperability performance category.
o 2022 improvement activities for the improvement activities performance category.
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Change #10:
Location: Page 2
Reason for Change:
Addition of new citation footnote
CY 2021 Final Rule text:
N/A
CY 2022 Proposed Rule text:
§414.1380(c)(2)(i)(A)(4) or (5) or §414.1380(c)(2)(i)(C)(1) through (7) or
§414.1380(c)(2)(i)(C)(9)
Change #11:
Location: Page 3
Reason for Change:
Update to punctuation, grammar, and alignment with current year
CY 2021 Final Rule text:
Targeted Audits: If a data validation audit identifies one or more deficiency or data error, you
must also conduct a targeted audit (formerly known as “detailed audit”) into the impact and root
cause of each such deficiency or data error for that MIPS payment year. Any required targeted
audits for the 2021 performance year and correction of any deficiencies or data errors identified
through such audit must be completed prior to the submission of data for the 2021 performance
year.
CY 2022 Proposed Rule text:
Targeted Audits. If a data validation audit identifies one or more deficiency or data error, you
must also conduct a targeted audit (formerly known as a “detailed audit”) into the impact and root
cause of each such deficiency or data error for that MIPS payment year. Any required targeted
audits for the 2022 performance year and correction of any deficiencies or data errors identified
through such audit must be completed prior to the submission of data for the 2022 performance
year.
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Change #12:
Location: Page 3
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
5. Data Validation Execution Report (DVER) and Targeted Audits: You must execute your
2021 Data Validation and any required targeted audits prior to the submission of data for
the 2021 MIPS performance period.
 The 2021 Data Validation Execution Report that includes the results of your data
validation audit, must be submitted to CMS by May 31, 2022.

 The 2021 Data Validation Execution Report must include:
o Name of Qualified Registry
o Was data submitted for any of the performance categories for the 2021 MIPS
performance period?
CY 2022 Proposed Rule text:
6. Data Validation Execution Report (DVER) and Targeted Audits: You must execute your
2022 Data Validation and any required targeted audits prior to the submission of data for
the 2022 MIPS performance period.
 The 2022 Data Validation Execution Report that includes the results of your data
validation audit, must be submitted to CMS by May 31, 2023.
 The 2022 Data Validation Execution Report must include:
o Name of Qualified Registry
o Was data submitted for any of the performance categories for the 2022 MIPS
performance period?
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Change #13:
Location: Page 4
Reason for Change:
Alignment with current year, updates to performance categories, changing to use of singular
verbiage.
CY 2021 Final Rule text:
o For each type of deficiencies or data errors discovered you must provide (1) description and
examples of the deficiency/error; (2) the percentage of clinicians impacted by the
deficiency/error and (3) when and how each deficiency/error was corrected. Types of
deficiencies or data errors include, but are not limited to, the following:
 Errors or deficiencies related to verifying MIPS eligibility of clinicians, groups, and
virtual groups.
 Errors or deficiencies related to verifying the accuracy of TINs and NPIs.
 Errors or deficiencies related to use of 2021 MIPS measures and activities were
utilized for submission, namely
 2021 MIPS CQMs, eCQMs and/or QCDR measures for the Quality
performance categories.
 2021 Promoting Interoperability measures and objectives for the Quality
performance categories.
 2021 Improvement Activities for the Improvement Activities performance
categories.
 Errors or deficiencies in calculating data completeness and performance rates
(i.e., were any issues identified with how the MIPS quality measure specifications
and/or QCDR measure specifications (as applicable) were implemented in the
system?)
CY 2022 Proposed Rule text:
o For each type of deficiencies or data errors discovered you must provide (1) description and
examples of the deficiency/error; (2) the percentage of clinicians impacted by the
deficiency/error and (3) when and how each deficiency/error was corrected. Types of
deficiencies or data errors include, but are not limited to, the following:
 Errors or deficiencies related to verifying MIPS eligibility of clinicians, groups, and
virtual groups.
 Errors or deficiencies related to verifying the accuracy of TINs and NPIs.





Errors or deficiencies related to use of 2022 MIPS measures and activities were
utilized for submission, namely
 2022 MIPS CQMs and/or eCQMs for the quality performance category.
 2022 Promoting Interoperability measures and objectives for the
Promoting Interoperability performance category.
 2022 improvement activities for the improvement activities performance
category.
Errors or deficiencies in calculating data completeness and performance rates
(i.e., were any issues identified with how the MIPS quality measure specifications
(as applicable) were implemented in the system?)

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Change #14:
Location: Page 4
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
o If you are required to conduct any targeted audits for performance year 2021, the
corresponding 2021 Targeted Audit results should also be submitted to CMS by May 31,
2022.
CY 2022 Proposed Rule text:
o If you are required to conduct any targeted audits for performance year 2022, the
corresponding 2022 Targeted Audit results should also be submitted to CMS by May 31,
2023.
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Change #15:
Location: Page 5
Reason for Change:
Addition expanded terminology, along with acronym
CY 2021 Proposed Rule text:
6. Performance Category Feedback Reports: Qualified Registries are required to provide
performance category feedback at least four times a year, and provide specific feedback to all
clinicians, groups, virtual groups, and APM Entities on how they compare to other clinicians,
groups, virtual groups, and APM Entities who have submitted data on a given measure.
CY 2022 Final Rule text:
6. Performance Category Feedback Reports: Qualified Registries are required to provide
performance category feedback at least four times a year, and provide specific feedback to all
clinicians, groups, virtual groups, and Alternative Payment Model (APM) Entities on how they
compare to other clinicians, groups, virtual groups, and APM Entities who have submitted data
on a given measure.
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Change #16:
Location: Page 5
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
7. Attest that you understand the Qualified Registry qualification criteria and program
requirements, and will meet all program requirements.

CY 2022 Proposed Rule text:
7. Attest that you understand the Qualified Registry qualification criteria and program
requirements and will meet all program requirements.
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Change #17:
Location: Page 6
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
 Signed verification of clinician names, contact information, services provided, costs
charged to clinicians, quality measures or specialty-specific measure sets (if applicable).
CY 2022 Proposed Rule text:
 Signed verification of clinician names, contact information, services provided, costs
charged to clinicians, quality measures, or specialty-specific measure sets (if applicable).
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Change #18:
Location: Page 5
Reason for Change:
Addition expanded terminology, along with acronym
CY 2021 Final Rule text:
 Business associate agreements must comply with HIPAA Privacy and Security Rules (82
FR 53812).
CY 2022 Proposed Rule text:
 Business associate agreements must comply with Health Insurance Portability and
Accountability Act (HIPAA) Privacy and Security Rules (82 FR 53812).
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Change #19:
Location: Page 7
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
 Participation requirements (for example, and not limited to: conducting data validation and
submitting required reports, performance feedback to clinicians, Qualified Registry would
be up and running by January 1 of the given performance period, etc.).
CY 2022 Proposed Rule text:
 Participation requirements (for example, and not limited to conducting data validation and
submitting required reports, performance feedback to clinicians, Qualified Registry would
be up and running by January 1 of the given performance period, etc.).
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Change #20:
Location: Page 7
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
CMS will further evaluate the Qualified Registry to determine if any additional inaccurate,
unusable or otherwise compromised data has been submitted. Data inaccuracies may lead to

remedial action/termination of the Qualified Registry for future program year(s) based on CMS
discretion.
CY 2022 Proposed Rule text:
CMS will further evaluate the Qualified Registry to determine if any additional inaccurate,
unusable, or otherwise compromised data has been submitted. Data inaccuracies may lead to
remedial action/termination of the Qualified Registry for future program year(s) based on CMS
discretion.
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Change #21:
Location: Page 8
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
• If the self-nomination form and MIPS Quality Measures are approved, a Qualified Posting is
developed for the approved Qualified Registry and include organization type, specialty,
previous participation in MIPS (if applicable), program status (remedial action taken against
the Qualified Registry or terminated as a third party intermediary (if applicable)), contact
information, last date to accept new clients, virtual groups specialty parameters (if
applicable), the approved quality measures, reporting options supported, performance
categories supported, services offered, and costs incurred by clients. All approved Qualified
Registries are included in the Qualified Posting that is posted on the CMS Quality Payment
Program Resource Library.
CY 2022 Proposed Rule text:
• If the self-nomination form and MIPS Quality Measures are approved, a Qualified Posting is
developed for the approved Qualified Registry and include organization type, specialty,
previous participation in MIPS [(if applicable), program status (remedial action taken against
the Qualified Registry or terminated as a third party intermediary (if applicable)], contact
information, last date to accept new clients, virtual groups specialty parameters (if
applicable), the approved quality measures, reporting options supported, performance
categories supported, services offered, and costs incurred by clients. All approved Qualified
Registries are included in the Qualified Posting that is posted on the CMS Quality Payment
Program Resource Library.
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Change #22:
Location: Page 8
Reason for Change:
Alignment with current year and addition of hyperlink
CY 2021 Final Rule text:
The list of CMS-approved Qualified Registries that have been approved to submit data to CMS
as a Qualified Registry for the 2021 MIPS performance period will be posted in the 2021
Qualified Registry Qualified Posting on the Resource Library of the CMS Quality Payment
Program website.
CY 2022 Proposed Rule text:
The list of CMS-approved Qualified Registries that have been approved to submit data to CMS
as a Qualified Registry for the 2022 MIPS performance period will be posted in the 2022
Qualified Registry Qualified Posting on the Resource Library of the CMS Quality Payment
Program website.

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Change #23:
Location: Page 8
Reason for Change:
Alignment with current year, updates to terminology and verb tense
CY 2021 Final Rule text:
July 1 – September 1 of the year prior to the applicable performance period. For the 2021
performance period, the self-nomination period was open at 10 a.m. (Eastern Time) ET on July
1st and closed at 8 p.m. ET on September 1, 2020. Self-Nominations submitted after the deadline
were not considered.
CY 2022 Proposed Rule text:
July 1 – September 1 of the year prior to the applicable performance period. For the 2022
performance period, the self-nomination period will promptly open at 10 a.m. (Eastern Time) ET
on July 1st and close at 8 p.m. ET on September 1, 2021. Self-Nominations submitted after the
deadline were not considered.
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Change #24:
Location: Page 11
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
• Qualified Registry Support Calls - CMS will hold mandatory joint support calls for
Qualified Registries and QCDRs that are approved to participate in the 2021
performance period. These support calls will be held approximately once a month, with
the kick-off meeting (in-person or virtually) being the first of the monthly calls. The
support calls address reporting requirements, steps for successful submission, and allow
for a question and answer session. The monthly support calls are limited to only
approved 2021 performance period Qualified Registries. Each Qualified Registry must
attend both the webinar and audio portion via computer or phone to receive credit for
attending the support call. One representative, from an entity supporting multiple
Qualified Registries, will NOT be counted as attendance for multiple Qualified Registries.
CY 2022 Proposed Rule text:
• Qualified Registry Support Calls - CMS will hold mandatory joint support calls for
Qualified Registries and QCDRs that are approved to participate in the 2022
performance period. These support calls will be held approximately once a month, with
the kick-off meeting (in-person or virtually) being the first of the monthly calls. The
support calls address reporting requirements, steps for successful submission, and allow
for a question and answer session. The monthly support calls are limited to only
approved 2022 performance period Qualified Registries. Each Qualified Registry must
attend both the webinar and audio portion via computer or phone to receive credit for
attending the support call. One representative, from an entity supporting multiple
Qualified Registries, will NOT be counted as attendance for multiple Qualified Registries.
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Change #25:
Location: Page 9
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
Your Qualified Registry’s entity name

CY 2022 Proposed Rule text:
Your Qualified Registry’s entity name.
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Change #26:
Location: Page 9
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
 Are you supporting MIPS CQMs? Please note that the reporting of MIPS CQMs must
utilize the current measure specification for the performance period in which they will be
used, and must be used as specified. Third party intermediaries are not permitted to
alter or modify measure specifications.
CY 2022 Proposed Rule text:
 Are you supporting MIPS CQMs? Please note that the reporting of MIPS CQMs must
utilize the current measure specification for the performance period in which they will be
used and must be used as specified. Third party intermediaries are not permitted to alter
or modify measure specifications.
*****
Change #27:
Location: Page 9
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
 Are you supporting MIPS eCQMs? Please note that the reporting of MIPS eCQM must
utilize the current measure specification for the performance period in which they will be
used, and must be used as specified. Third party intermediaries are not permitted to
alter or modify measure specifications.
CY 2022 Proposed Rule text:
 Are you supporting MIPS eCQMs? Please note that the reporting of MIPS eCQM must
utilize the current measure specification for the performance period in which they will be
used and must be used as specified. Third party intermediaries are not permitted to alter
or modify measure specifications.
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Change #28:
Location: Page 10
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
 Which 2021 improvement activities are you supporting?
CY 2022 Proposed Rule text:
 Which 2022 improvement activities are you supporting?
*****
Change #29:
Location: Page 10
Reason for Change:
Alignment with current year

CY 2021 Final Rule text:
 Which 2021 Promoting Interoperability objectives and measures are you supporting?
CY 2022 Proposed Rule text:
 Which 2022 Promoting Interoperability objectives and measures are you supporting?
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Change #30:
Location: Page 10
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
 Confirm you will conduct your 2021 data validation audits and any required targeted
audits and correct any deficiencies or data errors identified through such audits prior to
the submission of data for the MIPS payment year.
CY 2022 Proposed Rule text:
 Confirm you will conduct your 2022 data validation audits and any required targeted
audits and correct any deficiencies or data errors identified through such audits prior to
the submission of data for the MIPS payment year.
*****
Change #31:
Location: Page 10
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
 Confirm you will submit reports with the results of each 2021 performance period Data
Validation audit and targeted audit by the deadline of May 31, 2022.
CY 2022 Proposed Rule text:
 Confirm you will submit reports with the results of each 2022 performance period Data
Validation audit and targeted audit by the deadline of May 31, 2023.
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Change #32:
Location: Page 10
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
 Specify the Cost (frequency (monthly, annual, per submission)) and if the Cost is per
provider/practice) and Services Included in Cost.
CY 2022 Proposed Rule text:
 Specify the Cost [(frequency (monthly, annual, per submission)] and if the Cost is per
provider/practice) and Services Included in Cost.
*****
Change #33:
Location: Page 10
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
CMS has the authority to impose remedial action or termination based on its determination that
a third-party intermediary is non-compliant with one or more applicable criteria for approval, has

submitted a false certification or has submitted data that is inaccurate, unusable, or otherwise
compromised.
CY 2022 Proposed Rule text:
CMS has the authority to impose remedial action or termination based on its determination that
a third party intermediary is non-compliant with one or more applicable criteria for approval, has
submitted a false certification or has submitted data that is inaccurate, unusable, or otherwise
compromised.
*****
Change #34:
Location: Page 11
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
• Qualified Registry Support Calls - CMS will hold mandatory joint support calls for
Qualified Registries and QCDRs that are approved to participate in the 2021
performance period. These support calls will be held approximately once a month, with
the kick-off meeting (in-person or virtually) being the first of the monthly calls. The
support calls address reporting requirements, steps for successful submission, and allow
for a question and answer session. The monthly support calls are limited to only
approved 2021 performance period Qualified Registries. Each Qualified Registry must
attend both the webinar and audio portion via computer or phone to receive credit for
attending the support call. One representative, from an entity supporting multiple
Qualified Registries, will NOT be counted as attendance for multiple Qualified Registries.
CY 2022 Proposed Rule text:
• Qualified Registry Support Calls - CMS will hold mandatory joint support calls for
Qualified Registries and QCDRs that are approved to participate in the 2022
performance period. These support calls will be held approximately once a month, with
the kick-off meeting (in-person or virtually) being the first of the monthly calls. The
support calls address reporting requirements, steps for successful submission, and allow
for a question and answer session. The monthly support calls are limited to only
approved 2022 performance period Qualified Registries. Each Qualified Registry must
attend both the webinar and audio portion via computer or phone to receive credit for
attending the support call. One representative, from an entity supporting multiple
Qualified Registries, will NOT be counted as attendance for multiple Qualified Registries.
*****
Change #35:
Location: Page 11
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
Quality Payment Program – For additional questions related to the Quality
performance category, please contact the Quality Payment Program Service
Center at [email protected] or 1-866-288-8292 (Monday – Friday, 8 a.m. –
8 p.m. ET).
CY 2022 Proposed Rule text:
Quality Payment Program - For additional questions related to the Quality performance
category, please contact the Quality Payment Program Service Center at [email protected] or
1-866-288-8292 (Monday – Friday, 8 a.m. – 8 p.m. ET).

*****
Change #36:
Location: Page 12
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
• The Self-Nomination User Guide - This guide provides step-by-step instructions for
entities looking to become an approved Qualified Registry for the 2021 performance
period of MIPS.
CY 2022 Proposed Rule text:
• The Self-Nomination User Guide - This guide provides step-by-step instructions for
entities looking to become an approved Qualified Registry for the 2022 performance
period of MIPS.