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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Appendix L 2020 Partial QP Election Form	Form	Modified	Available
Form Appendix K 2022 MVP Candidates: Instructions and Template	Form and Instruction	Modified	Available
Form Appendix J 2021 Extreme and Uncontrollable Circumstances Application Form	Form	Modified	Available
Form Appendix I 2021 Hardship Exception Application Form	Form	Modified	Available
Form Appendix H Improvement Activities Performance Category, 2022 Call for Activities Submission Form	Form	Modified	Available
Form Appendix G Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form	Form	Modified	Available
Form Appendix F 2022 Peer Reviewed Journal Article Requirement Template	Form	Modified	Repair queued
Form Appendix E Data Template for Candidate Measures	Form	Modified	Available
Form Appendix D Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Form	Modified	Available
Form Appendix C Eligible Clinician Initiated Submission Form	Form	Modified	Repair queued
Form Appendix B Payer Initiated Submission Form	Form	Modified	Repair queued
Form Appendix A 2023 QCDR and Registry Self-nomination User Guide	Form and Instruction	Modified	Available
Form Appendix A CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	Repair queued
Form CMS-10621 Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)	Form and Instruction	Removed	Available
Form cms-10621 Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change)	Form and Instruction	Removed	Available
Form cms-10621 Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change)	Form and Instruction	Removed	Available
Form cms-10621 Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform)	Form and Instruction	Removed	Available
Form CMS-10621 Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New)	Form and Instruction	Removed	Available
Form CMS-10621 Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised)	Form and Instruction	Removed	Available
Form CMS-10621 Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised)	Form and Instruction	Removed	Available
Form CMS-10621 Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised)	Form and Instruction	Removed	Available
Form CMS-10621 Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised)	Form and Instruction	Removed	Available
Form CMS-10621 Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Appendix F1 (See Table 29): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Appendix E1 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submissi	Form and Instruction	Removed	Available
Form CMS-10621 Appendix D1 (See Table 27): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised)	Form and Instruction	Removed	Available
CMS-10621-Supporting Statement B (CMS-1770-P version 1).docx	Supporting Statement B	Uploaded 2022-08-05	Repair queued
CMS-10621 - Supporting Statement A (CMS-1770-P version 4).docx	Supporting Statement A	Uploaded 2022-08-05	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	2020 Partial QP Election Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	2022 MVP Candidates: Instructions and Template
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	2021 Extreme and Uncontrollable Circumstances Application Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	2021 Hardship Exception Application Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	Improvement Activities Performance Category, 2022 Call for Activities Submission Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	2022 Peer Reviewed Journal Article Requirement Template
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	Data Template for Candidate Measures
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	Eligible Clinician Initiated Submission Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	Payer Initiated Submission Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	2023 QCDR and Registry Self-nomination User Guide
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix F1 (See Table 29): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix E1 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submissi
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	Removed	Appendix D1 (See Table 27): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Other-Appendix A1 (See Table 3): 2022 Qualified Registry Fact Sh	Removed

ICR Details

OMB Control No: 0938-1314	ICR Reference No: 202208-0938-004
Status: Historical Inactive	Previous ICR Reference No: 202111-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 11/23/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/05/2022
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2025	36 Months From Approved	01/31/2025
Responses	633,021	0	633,021
Time Burden (Hours)	2,825,380	0	2,825,380
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS.

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Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014
  

Citations for New Statutory Requirements: US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU81	Proposed rulemaking	87 FR 45860	07/29/2022

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 45860	07/29/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	cms-10621, cms-10621, cms-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621	Appendix D1 (See Table 27): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised) ,   Appendix E1 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submissi ,   Appendix F1 (See Table 29): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised) ,   Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised) ,   Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised) ,   Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised) ,   Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised) ,   Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised) ,   Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New) ,   Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform) ,   Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change) ,   Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change) ,   Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)
CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Appendix A, Appendix B, Appendix C, Appendix D, Appendix E, Appendix F, Appendix G, Appendix H, Appendix I, Appendix J, Appendix K, Appendix L	2023 QCDR and Registry Self-nomination User Guide ,   Payer Initiated Submission Form ,   Eligible Clinician Initiated Submission Form ,   Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option ,   Data Template for Candidate Measures ,   2022 Peer Reviewed Journal Article Requirement Template ,   Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form ,   Improvement Activities Performance Category, 2022 Call for Activities Submission Form ,   2021 Hardship Exception Application Form ,   2021 Extreme and Uncontrollable Circumstances Application Form ,   2022 MVP Candidates: Instructions and Template ,   2020 Partial QP Election Form

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden associated with the policies and information collections for the CY 2022 performance period/CY 2024 MIPS payment year has been removed since the information will no longer be collected by or reported from clinicians for the Quality Payment Program in the CY 2023 performance period/2025 MIPS payment year. The currently approved burden estimate for the policies and information collections in the CY 2023 performance period/2025 MIPS payment year was set forth in the CY 2022 PFS final rule and have changed due to new statutes and program adjustments as set forth in this CY 2023 PFS proposed rule.

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Annual Cost to Federal Government: $181

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/05/2022

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