CROSSWALK (Appendix B2) 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet

Qualified Clinical Data Registry (QCDR) 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.
*****
Change #1:
Location: Page 1
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
Section Header2021 Qualified Clinical Data Registry (QCDR) Fact Sheet
CY 2022 Proposed Rule text:
Section Header2022 Qualified Clinical Data Registry (QCDR) Fact Sheet
*****
Change #2:
Location: Page 1
Reason for Change:
Removal of versioning for the 2021 Qualified Clinical Data Registry (QCDR) Fact Sheet
CY 2021 Final Rule text:
Version 2
Updated on April 6, 2021
CY 2022 Proposed Rule text:
*****
Change #3:
Location: Page 2
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
• Current 2021 MIPS Quality Measures.
CY 2022 Proposed Rule text:
• Current 2022 MIPS Quality Measures.
*****
Change #4:
Location: Page 2
Reason for Change:
Alignment with current year 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 MIPS
performance period).4 These participants are not required to use the QCDR to report MIPS

data to CMS, but they must submit data to the QCDR for quality improvement.5 Please note
CMS expects QCDRs 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 QCDR to report MIPS
data to CMS, but they must submit data to the QCDR for quality improvement.5 Please note
CMS expects QCDRs 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.
*****
Change #5:
Location: Page 3
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:
2. Data Submission: You should submit data via a CMS-specified secure method for data
submission, such as a defined Quality Payment Program data format.8 Additional information
regarding data submission methodologies can be found in the Developer Tools section of the
Resource Library 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. 8 Additional information
regarding data submission methodologies can be found in the Developer Tools section of the
Resource Library of the Quality Payment Program website: https://qpp.cms.gov/developers.
[Data submission is discussed in more detail below].
*****
Change #6:
Location: Page 3
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.

*****
Change #7:
Location: Page 3
Reason for Change:
Addition of new rule 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 #8:
Location: Page 4
Reason for Change:
Alignment with current year requirement and to use the singular form of
category
CY 2021 Final Rule text:
 Verification that only the MIPS quality measures and QCDR measures that are relevant for
the reporting periods will be used for MIPS submission. For the 2021 performance year,
this means:
• 2021 MIPS Clinical Quality Measures (CQMs), electronic CQMs (eCQMs) and/or
QCDR measures for the quality performance categories.
• 2021 Promoting Interoperability measures and objectives for the Promoting
Interoperability performance categories.
• 2021 improvement activities for the improvement activities performance categories.
CY 2022 Proposed Rule text:
 Verification that only the MIPS quality measures and QCDR measures that are relevant for
the reporting periods will be used for MIPS submission. For the 2022 performance year,
this means:
• 2022 MIPS Clinical Quality Measures (CQMs), electronic CQMs (eCQMs) and/or
QCDR measures 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.
*****
Change #9:
Location: Page 4
Reason for Change:
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.14 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 “detailed audit”) into the impact and root
cause of each such deficiency or data error for that MIPS payment year. 14 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.
*****
Change #10:
Location: Page 4
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.
CY 2022 Proposed Rule text:
5. 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.
*****
Change #11:
Location: Page 4
Reason for Change:
Correction of a citation footnote
CY 2021 Final Rule text:
§ 14.1400(b)(2)(v)(C)
CY 2022 Proposed Rule text:
§414.1400(b)(2)(v)(C)
*****
Change #12:
Location: Page 5
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
The 2021 Data Validation Execution Report with the results of your data
validation audit must be submitted to CMS by May 31, 2022.
CY 2022 Proposed Rule text:
The 2022 Data Validation Execution Report with the results of your data validation audit must be
submitted to CMS by May 31, 2023.
*****
Change #13:
Location: Page 5
Reason for Change:
Alignment with current year requirement, performance categories and to use the singular form
of category

CY 2021 Final Rule text:
 The 2021 Data Validation Execution Report must include:
o Name of QCDR
o Was data submitted for any of the performance categories for the 2021 MIPS
performance period?
o Overall Data Deficiency or Data Error Rate - (Number of Clinicians with a Data
Issue / Total Number of clinicians Supported)
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:
 The 2022 Data Validation Execution Report must include:
o Name of QCDR
o Was data submitted for any of the performance categories for the 2022 MIPS
performance period?
o Overall Data Deficiency or Data Error Rate - (Number of Clinicians with a Data
Issue / Total Number of clinicians Supported)
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, eCQMs and/or QCDR measures 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 and/or QCDR measure specifications (as applicable) were
implemented in the system?)

*****
Change #14:
Location: Page 5
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
 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:
 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.
*****
Change #15:
Location: Page 5
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
 Your report with the results of each targeted audit must include:
o the overall deficiency or data error rate;
o the types of deficiencies or data errors discovered,
o how and when the error or deficiency was corrected, and
o the percentage of your total clinicians impacted by the data error.
CY 2022 Proposed Rule text:
 Your report with the results of each targeted audit must include:
o the overall deficiency or data error rate;
o the types of deficiencies or data errors discovered;
o how and when the error or deficiency was corrected; and
o the percentage of your total clinicians impacted by the data error.

*****
Change #16:
Location: Page 6
Reason for Change:
Addition expanded terminology, along with acronym
CY 2021 Final Rule text:
6. Performance Category Feedback Reports: QCDRs 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 AMP Entities who have submitted data on a given measure.

CY 2022 Proposed Rule text:
6. Performance Category Feedback Reports: QCDRs 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 AMP Entities who have submitted data on a
given measure.
*****
Change #17:
Location: Page 6
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
7. Attest that you understand the QCDR qualification criteria and program requirements, and
will meet all program requirements.
CY 2022 Proposed Rule text:
7. Attest that you understand the QCDR qualification criteria and program requirements and
will meet all program requirements.
*****
Change #18:
Location: Page 7
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).
*****
Change #19:
Location: Page 8
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, QCDR 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, QCDR would be up and
running by January 1 of the given performance period, etc.).
*****
Change #20:
Location: Page 8
Reason for Change:
Update to punctuation

CY 2021 Final Rule text:
CMS will further evaluate the QCDR to determine if any additional inaccurate, unusable or
otherwise compromised data has been submitted. Data inaccuracies may lead to remedial
action/termination of the QCDR for future program year(s) based on CMS discretion.
CY 2022 Proposed Rule text:
CMS will further evaluate the QCDR to determine if any additional inaccurate, unusable, or
otherwise compromised data has been submitted. Data inaccuracies may lead to remedial
action/termination of the QCDR for future program year(s) based on CMS discretion.
*****
Change #21:
Location: Page 9
Reason for Change:
Update to punctuation
CY 2021 Final Rule text:
• The Qualified Posting is developed for the approved QCDRs and include organization
type, specialty, previous participation in MIPS (if applicable), program status (remedial
action taken against the QCDR or terminated as a third part 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
QCDRs are included in the Qualified Posting that is posted on the CMS Quality Payment
Program Resource Library.
CY 2022 Proposed Rule text:
• The Qualified Posting is developed for the approved QCDRs and include organization
type, specialty, previous participation in MIPS (if applicable), program status [remedial
action taken against the QCDR or terminated as a third part 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
QCDRs are included in the Qualified Posting that is posted on the CMS Quality Payment
Program Resource Library.
.
*****
Change #22:
Location: Page 10
Reason for Change:
Alignment with current year and addition of a hyperlink
CY 2021 Final Rule text:
The list of CMS-approved QCDRs that have been approved to submit data to CMS as a QCDR
for the 2021 MIPS performance period will be posted in the 2021 QCDR Qualified Posting on
the Resource Library of the CMS Quality Payment Program website.
CY 2022 Proposed Rule text:
The list of CMS-approved QCDRs that have been approved to submit data to CMS as a QCDR
for the 2022 MIPS performance period will be posted in the 2022 QCDR Qualified Posting on
the Resource Library of the CMS Quality Payment Program website.

*****
Change #23:
Location: Page 10
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.
*****
Change #24:
Location: Page 11
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 #25:
Location: Page 11
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.

*****
Change #26:
Location: Page 11
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 #27:
Location: Page 11
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?
*****
Change #28:
Location: Page 11
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 #29:
Location: Page 11
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.
*****
Change #30:
Location: Page 11
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 #31:
Location: Page 12
Reason for Change:
Removal of QCDR measure concept preview calls
CY 2021 Final Rule text:
• Take advantage of QCDR measure concept preview calls available until June 30, 2020.
These preview calls allow CMS, the MIPS QCDR/Registry Support Team, and the QCDR
to collaboratively discuss and provide feedback regarding new and existing QCDR
measure(s) prior to self-nomination. This may also provide an opportunity to discuss
current provisionally approved QCDR measures with suggested revisions or measure
duplications. CMS may provide preliminary input that may be useful to revise QCDR
measures. Please note, that final measure decisions will not be made during the call. To
schedule a meeting, contact the [email protected] by 5 p.m. ET on June
12, 2020. QCDR measure concepts and specifications to be discussed at the meeting
must be sent at least one week prior to the scheduled meeting in a single Word or Excel
document. If information is not received at least one week prior to the scheduled meeting,
the meeting is subject to be rescheduled. In addition, a QCDR measure concept preview
call does not signify that a prospective QCDR has meet the QCDR definition for a given
self-nomination period.
CY 2022 Proposed Rule text:
•
*****
Change #32:
Location: Page 12
Reason for Change:
Removal of QCDR measure concept preview calls
CY 2021 Final Rule text:
• Be face valid for 2022 due to an incremental approach being finalized for measure
testing.
CY 2022 Proposed Rule text:
• Be face valid for 2022 performance period/2024 MIPS payment year. To be approved for
the 2023 performance period/2025 MIPS payment year and future years, a QCDR
measure must be face valid for the initial MIPS payment year for which it is approved
and fully tested with complete testing results at the clinician level, prior to submitting the
QCDR measure at the time of self-nomination for any subsequent MIPS payment year
for which it is approved.
*****
Change #33:
Location: Page 15
Reason for Change:
Removal of reference to 2021 MIPS performance period

CY 2021 Final Rule text:
QCDR measures are generally approved annually for one performance period. Beginning with
the 2021 MIPS performance period, QCDR measures may be approved for 2 years, at CMS
discretion. Upon annual review, CMS may revoke QCDR measure second year approval, if the
QCDR measure is found to be: topped out; duplicative of a more robust measure; reflects an
outdated clinical guideline; or if the QCDR that is nominating the QCDR measure is no longer in
good standing.
CY 2022 Proposed Rule text:
QCDR measures are generally approved annually for one performance period. QCDR
measures may be approved for 2 years, at CMS discretion. Upon annual review, CMS may
revoke QCDR measure second year approval, if the QCDR measure is found to be: topped out;
duplicative of a more robust measure; reflects an outdated clinical guideline; or if the QCDR that
is nominating the QCDR measure is no longer in good standing.
*****
Change #34:
Location: Page 16
Reason for Change:
Clarification added for QCDR measure specifications requirements
CY 2021 Final Rule text:
For QCDR Measures, QCDR measure specifications include:
• Measure Title
• Description
• QCDR measure ID for previously approved CMS measure
• Denominator and numerator statements
• Descriptions of the denominator exceptions, denominator exclusions, and numerator
exclusions
• National Quality Strategy (NQS) domain
• Care setting
• Meaningful measure area
• Meaningful measure area rationale
• Measure type
• If the QCDR measure is a high priority measure and priority type (if applicable)
• Primary data source used for abstraction
• Concise summary of evidence to support performance gap
• Performance data on the QCDR measure (number of months collected, average performance
rate, performance range, and number of clinicians reporting the QCDR measure)
• Measure owner, please note that permission to use another QCDR’s measure should be
obtained prior to the QCDR measure being submitted for CMS consideration
• National Quality Forum (NQF) ID number, if applicable
• Number of performance rates required for QCDR measure
• Overall performance rate information, if more than one is required
• Clinical recommendation statements which summarize the clinical recommendation based on
best practices
• QCDR measure rationale which provides a brief statement describing the evidence base
and/or intent for the measure
• Traditional vs Inverse measure
• Proportional, continuous variable, ratio measure indicator
• If the QCDR measure is risk-adjusted and which score is risk-adjusted

• Risk adjustment variables, and risk adjustment algorithms, when applicable
• Indicate if the QCDR measure was tested at the individual clinician level
• Describe link to Cost measure/Improvement Activity
• Indicate which specialty/specialties apply to the QCDR measure
• Preferred measure clinical category
• Attestation of the feasibility of the QCDR measure at the time of self-nomination
CY 2022 Proposed Rule text:
For QCDR Measures, QCDR measure specifications include:
• Measure Title
• Description
• QCDR measure ID for previously approved CMS measure
• Denominator and numerator statements
• Descriptions of the denominator exceptions, denominator exclusions, and numerator
exclusions
• National Quality Strategy (NQS) domain
• Care setting
• Includes Telehealth
• Meaningful measure area
• Meaningful measure area rationale
• Measure type
• If the QCDR measure is a high priority measure and priority type (if applicable)
• Primary data source used for abstraction
• Concise summary of evidence to support performance gap
• Performance data on the QCDR measure (number of months collected, average performance
rate, performance range, and number of clinicians reporting the QCDR measure)
• Measure owner, please note that permission to use another QCDR’s measure should be
obtained prior to the QCDR measure being submitted for CMS consideration
• National Quality Forum (NQF) ID number, if applicable
• Number of performance rates required for QCDR measure
• Overall performance rate information, if more than one is required
• Clinical recommendation statements which summarize the clinical recommendation based on
best practices
• QCDR measure rationale which provides a brief statement describing the evidence base
and/or intent for the measure
• Traditional vs Inverse measure
• Proportional, continuous variable, ratio measure indicator
• If the QCDR measure is risk-adjusted and which score is risk-adjusted
• Risk adjustment variables, and risk adjustment algorithms, when applicable
• Indicate if the QCDR measure was tested at the individual clinician level
• Describe link to Cost measure/Improvement Activity
• Indicate which specialty/specialties apply to the QCDR measure
• Preferred measure published clinical category
• Attestation of the feasibility of the QCDR measure at the time of self-nomination
• Validity, Feasibility, and Reliability testing summary
• Participation Plan if QCDR measure has low adoption by clinicians

*****
Change #35:
Location: Page 17
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 #36:
Location: Page 17
Reason for Change:
Alignment with current year
CY 2021 Final Rule text:
• QCDR Support Calls - CMS will hold mandatory joint support calls for QCDRs and
Qualified Registries 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 QCDRs. Each QCDR 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 QCDRs, will NOT be counted as
attendance for multiple QCDRs.
CY 2022 Proposed Rule text:
• QCDR Support Calls - CMS will hold mandatory joint support calls for QCDRs and
Qualified Registries 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 include approved 2022
performance period QCDRs. Each QCDR 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 QCDRs, will NOT be counted as
attendance for multiple QCDRs.

*****
Change #37:
Location: Page 18
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 QCDR 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 QCDR for the 2022 performance period of
MIPS.