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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Appendix L1 2022 Partial QP Election Form (for submission in CY 2023)	Form and Instruction	Modified	Available
Form Appendix K1 2023 MVP Candidates: Instructions and Template	Form and Instruction	Modified	Available
Form Appendix J 2022 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide (for submission in CY2023	Form and Instruction	Modified	Available
Form Appendix I 2022 MIPS Promoting Interoperability Hardship Exception Application Guide (for submission in CY 2023)	Form and Instruction	Modified	Available
Form Appendix H1 Improvement Activities Performance Category, 2023 Call for Activities Submission Form	Form and Instruction	Modified	Available
Form Appendix G1 Promoting Interoperability Performance Category, 2023 Call for Measures Submission Form	Form and Instruction	Modified	Available
Form Appendix F1 2023 Peer Reviewed Journal Article Requirement Template	Form and Instruction	Modified	Available
Form Appendix E1 Measures under Consideration 2022 (for the 2024 performance period), Data Template for Candidate Measures	Form and Instruction	Modified	Available
Form Appendix D1 2023 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Form and Instruction	Modified	Available
Form Appendix C1 2023 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)	Form and Instruction	Modified	Available
Form Appendix B1 2023 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Form	Modified	Available
Form Appendix A Self-Nomination User Guide for Qualified Clinical Data Registries (QCDRs) and Qualified Registries	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	Available
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	Available
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 A (CMS-1770-F Version 2).docx	Supporting Statement A	Uploaded 2023-01-25	Repair queued
Comment Response Document.docx	Supplementary Document	Uploaded 2023-01-25	Repair queued
CMS-10621-Supporting Statement B (CMS-1770-F)Version1_clean[1].docx	Supporting Statement B	Uploaded 2023-01-25	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 and Instruction	Modified	2022 Partial QP Election Form (for submission in CY 2023)
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	2023 MVP Candidates: Instructions and Template
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	2022 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide (for submission in CY2023
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	2022 MIPS Promoting Interoperability Hardship Exception Application Guide (for submission in CY 2023)
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	Improvement Activities Performance Category, 2023 Call for Activities Submission Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	Promoting Interoperability Performance Category, 2023 Call for Measures Submission Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	2023 Peer Reviewed Journal Article Requirement Template
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	Measures under Consideration 2022 (for the 2024 performance period), Data Template for Candidate Measures
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	2023 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 and Instruction	Modified	2023 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form	Modified	2023 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction	Modified	Self-Nomination User Guide for Qualified Clinical Data Registries (QCDRs) and Qualified Registries
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: 202301-0938-017
Status: Historical Active	Previous ICR Reference No: 202111-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Quality Payment Program (QPP)/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: Approved without change	Conclusion Date: 04/18/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/26/2023
Terms of Clearance:

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	159,528	0	633,021
Time Burden (Hours)	713,860	0	2,825,380
Cost Burden (Dollars)	0	0	0

---

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.

---

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

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU81	Final or interim final rulemaking	87 FR 69404	11/18/2022

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 45860	07/29/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 69404	11/18/2022
Did the Agency receive public comments on this ICR? Yes

---

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 B1, Appendix A, Appendix D1, Appendix E1, Appendix F1, Appendix G1, Appendix H1, Appendix K1, Appendix L1, Appendix C1, Appendix I, Appendix J	Self-Nomination User Guide for Qualified Clinical Data Registries (QCDRs) and Qualified Registries ,   2023 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) ,   2023 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form) ,   2023 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option ,   Measures under Consideration 2022 (for the 2024 performance period), Data Template for Candidate Measures ,   2023 Peer Reviewed Journal Article Requirement Template ,   Promoting Interoperability Performance Category, 2023 Call for Measures Submission Form ,   Improvement Activities Performance Category, 2023 Call for Activities Submission Form ,   2022 MIPS Promoting Interoperability Hardship Exception Application Guide (for submission in CY 2023) ,   2022 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide (for submission in CY2023 ,   2023 MVP Candidates: Instructions and Template ,   2022 Partial QP Election Form (for submission in CY 2023)

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	159,528	633,021	1,285	0	-474,778	0
Annual Time Burden (Hours)	713,860	2,825,380	-3,708	0	-2,107,812	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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 changes in this CY 2023 collection of information request are associated with our November 18, 2022 (87 FR 69404) final rule (CMS-1770-F, RIN 0938-AU81). Where updated data and assumptions were available for the CY 2023 PFS final rule, we have adjusted the applicable ICRs. In aggregate, we estimate that the finalized policies will result in a net decrease in burden for the CY 2023 performance period/2025 MIPS payment year due to updated data and assumptions as well as finalized policies. As discussed in sections 12 and 15 of this Supporting Statement, the finalized policies in the CY 2023 PFS final rule will result in a decrease in burden for the ICRs related to the data submission via the Medicare Part B Claims, MIPS CQM QCDR, and eCQM collection types for the quality performance category. The policies will also result in an increase in the burden for the ICR related to the MVP quality performance category. We also estimate that the finalized policies in the CY 2023 PFS final rule will result in an increase in burden for the ICRs related to MVP registration, MVP quality submission, and data submission for the Promoting Interoperability performance category. The remaining changes to our currently approved burden estimates are adjustments due to the use of updated data sources and assumptions. We are also requesting to add one new ICR to capture the estimated burden for third party intermediary plan audits. We added the new ICR to distinctly capture the capture the burden for collection of information related to: (1) QCDR and qualified registry targeted audits as established under the conditions for approval at § 414.1400(b)(3)(vi) through (viii); and (2) all the requirements for remedial action and termination at § 414.1400(e). For simplicity, we capture the estimated burden for third party intermediaries to submit additional requirements for compliance with both the conditions of approval and remedial action and termination criteria under one ICR. We note that the addition of this ICR is not due to finalized policy changes in this rule, but rather it is a change in our approach to representing the estimated burden for third party intermediaries in the CY 2022 PFS final rule (86 FR 65569 through 65576).

---

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

---

Common Form ICR:  No

---

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: 01/26/2023

---