Information Collection

CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary

IC 250662 under ICR 202301-0938-017 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Appendix A1 2022 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf Other-Appendix A1 (See Table 3): 202
Appendix A1 2022 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf Other-Appendix A1 (See Table 3): 202
Appendix B1 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet.pdf Other-Appendix B1 (See Table 4): 202
Appendix B1 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet.pdf Other-Appendix B1 (See Table 4): 202
CMS-10621 Appendix D1 (See Table 27): 2022 Submission Form for Oth Appendix D1 2022 Payer Initiated Submission Form.pdf Form and Instruction
CMS-10621 Appendix D1 (See Table 27): 2022 Submission Form for Oth Appendix D1 2022 Payer Initiated Submission Form.pdf Form and Instruction
CMS-10621 Appendix E1 (See Table 28): 2022 Submission Form for Eli Appendix E1 2022 Clinician Initiated Submission Form.pdf Form and Instruction
CMS-10621 Appendix E1 (See Table 28): 2022 Submission Form for Eli Appendix E1 2022 Clinician Initiated Submission Form.pdf Form and Instruction
CMS-10621 Appendix F1 (See Table 29): 2022 Submission Form for Req Appendix F1 2022 All-Payer QP Data Submission Form.pdf Form and Instruction
CMS-10621 Appendix F1 (See Table 29): 2022 Submission Form for Req Appendix F1 2022 All-Payer QP Data Submission Form.pdf Form and Instruction
CMS-10621 Appendix G1 (See Table 15): Measures under Consideration Appendix G1 2021 MUC Data Template.pdf Form and Instruction
CMS-10621 Appendix G1 (See Table 15): Measures under Consideration Appendix G1 2021 MUC Data Template.pdf Form and Instruction
CMS-10621 Appendix H1 (See Table 15): 2022 Peer Reviewed Journal A Appendix H1 2022 MIPS Peer Reviewed Template .pdf Form and Instruction
CMS-10621 Appendix H1 (See Table 15): 2022 Peer Reviewed Journal A Appendix H1 2022 MIPS Peer Reviewed Template .pdf Form and Instruction
CMS-10621 Appendix I1 (See Table 20): Promoting Interoperability P Appendix I1 2022 PI Call for Measures Submission Form.pdf Form and Instruction
CMS-10621 Appendix I1 (See Table 20): Promoting Interoperability P Appendix I1 2022 PI Call for Measures Submission Form.pdf Form and Instruction
CMS-10621 Appendix J1 (See Table 24): Improvement Activities Perfo Appendix J1 2022 IA Call for Activities Submission Form.pdf Form and Instruction
CMS-10621 Appendix J1 (See Table 24): Improvement Activities Perfo Appendix J1 2022 IA Call for Activities Submission Form.pdf Form and Instruction
CMS-10621 Appendix M1 (See Table 25): 2022 MVP Candidates: Instruc Appendix M1 2022 MVP Development Standardized Template v2.pdf Form and Instruction
CMS-10621 Appendix M1 (See Table 25): 2022 MVP Candidates: Instruc Appendix M1 2022 MVP Development Standardized Template v2.pdf Form and Instruction
CMS-10621 Appendix O1 (See Table 26): 2020 Partial QP Election For Appendix O Partial QP Submission Form.pdf Form and Instruction
CMS-10621 Appendix O1 (See Table 26): 2020 Partial QP Election For Appendix O Partial QP Submission Form.pdf Form and Instruction
cms-10621 Appendix C1 (Table 4): 2022 Qualified Clinical Data Regi Appendix C1 2022 Qualified Clinical Data Registry (QCDR) measure submission template v4.0.xlsx Form and Instruction
cms-10621 Appendix C1 (Table 4): 2022 Qualified Clinical Data Regi Appendix C1 2022 Qualified Clinical Data Registry (QCDR) measure submission template v4.0.xlsx Form and Instruction
cms-10621 Appendix K1 (See Table 16): 2021 Hardship Exception Appl Appendix K1 2021 Promoting Interoperability Hardship Exception Application.pdf Form and Instruction
cms-10621 Appendix K1 (See Table 16): 2021 Hardship Exception Appl Appendix K1 2021 Promoting Interoperability Hardship Exception Application.pdf Form and Instruction
cms-10621 Appendix L1 (See Table 16): 2021 Extreme and Uncontrolla Appendix L1 2021 Extreme and Uncontrollable Circumstances Reweighting Application.pdf Form and Instruction
cms-10621 Appendix L1 (See Table 16): 2021 Extreme and Uncontrolla Appendix L1 2021 Extreme and Uncontrollable Circumstances Reweighting Application.pdf Form and Instruction
CMS-10621 Appendix N1 (See Table 13): 2021 CMS Web Interface and C Appendix N1 2022 CMS Web Interface and CAHPS for MIPS Registration Guide.pdf Form and Instruction
CMS-10621 Appendix N1 (See Table 13): 2021 CMS Web Interface and C Appendix N1 2022 CMS Web Interface and CAHPS for MIPS Registration Guide.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Appendix A1 (See Table 3): 2022 Qualified Registry Fact Sheet (Revised)			Appendix A1 2022 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf	Yes	No	Printable Only
Other-Appendix B1 (See Table 4): 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet (Revised)			Appendix B1 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet.pdf	Yes	No	Printable Only
Form and Instruction	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 D1 2022 Payer Initiated Submission Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	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	Appendix E1 2022 Clinician Initiated Submission Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	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)	Appendix F1 2022 All-Payer QP Data Submission Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10621	Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised)	Appendix G1 2021 MUC Data Template.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10621	Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised)	Appendix H1 2022 MIPS Peer Reviewed Template .pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10621	Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised)	Appendix I1 2022 PI Call for Measures Submission Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10621	Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised)	Appendix J1 2022 IA Call for Activities Submission Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10621	Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised)	Appendix M1 2022 MVP Development Standardized Template v2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10621	Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New)	Appendix O Partial QP Submission Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	cms-10621	Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform)	Appendix C1 2022 Qualified Clinical Data Registry (QCDR) measure submission template v4.0.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	cms-10621	Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change)	Appendix K1 2021 Promoting Interoperability Hardship Exception Application.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	cms-10621	Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change)	Appendix L1 2021 Extreme and Uncontrollable Circumstances Reweighting Application.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10621	Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)	Appendix N1 2022 CMS Web Interface and CAHPS for MIPS Registration Guide.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 119,890	Number of Respondents for Small Entity: 119,890

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

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-310,051	310,051
Annual IC Time Burden (Hours)	-1,435,361	1,435,361
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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