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pdf2025 Merit-Based Incentive
Payment System (MIPS)
Program: Self-Nomination
User Guide for Qualified
Clinical Data Registries
(QCDRs) and Qualified
Registries
June 2024
Table of Contents
Introduction ................................................................................................................................... 3
Purpose ..................................................................................................................................... 3
Background ............................................................................................................................... 3
Accessing the Quality Payment Program Website ....................................................................... 6
Sign Up for a Quality Payment Program Account ..................................................................... 6
Self-Nomination Form Tips ......................................................................................................... 16
Creating a Self-Nomination Form (prospective QCDRs/Qualified Registries) ............................ 17
Creating a Self-Nomination Form (existing QCDRs/Qualified Registries not in good standing) . 20
Populating the 2025 Self-Nomination Form ................................................................................ 22
Populating the 2025 Simplified Self-Nomination Form ............................................................... 24
Intermediary Contact Info ............................................................................................................ 24
Intermediary Details .................................................................................................................... 29
Qualified Posting Details ............................................................................................................. 33
Attestations ................................................................................................................................. 38
Improvement Activities ................................................................................................................ 42
Promoting Interoperability ........................................................................................................... 44
MIPS Clinical Quality Measures .................................................................................................. 46
MIPS electronic Clinical Quality Measures ................................................................................. 48
MIPS Value Pathways (MVPs) ................................................................................................... 50
Data Validation............................................................................................................................ 51
Populating Data Validation ...................................................................................................... 54
Benchmarking Capabilities(QCDR ONLY) .................................................................................. 57
QCDR Measures (QCDR ONLY) ................................................................................................ 58
Populating QCDR Measures ................................................................................................... 59
Pre-populated Existing QCDR Measures ............................................................................ 60
Self-Nominate QCDR Measures .......................................................................................... 61
Owned QCDR Measures ..................................................................................................... 62
Co-Owned by 2 or more QCDRs ......................................................................................... 63
Borrowed QCDR Measures ................................................................................................. 64
Measure Specification Fields .................................................................................................. 67
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Measure Info Section: .......................................................................................................... 67
Analytics Section: ................................................................................................................ 73
Testing Section: ................................................................................................................... 77
Supporting Documentation Section: .................................................................................... 84
QCDR Measure Permission Checklist .................................................................................... 89
Submission of the Self-Nomination Form ................................................................................... 89
Modifying a Self-Nomination Form .............................................................................................. 91
Withdrawing a Self-Nomination Form ......................................................................................... 91
Comments ................................................................................................................................... 92
How to View/Add Comment .................................................................................................... 92
Resources ................................................................................................................................... 94
Help with Self-Nomination ....................................................................................................... 94
Help with QCDR Measure Development................................................................................. 94
Version History Table .............................................................................................................. 95
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Introduction
Purpose
The 2025 Self-Nomination User Guide provides Qualified Clinical Data Registries (QCDRs) and
Qualified Registries with guidance on how to self-nominate for the 2025 performance period of
the Merit-based Incentive Payment System (MIPS) program. The intent of the guide is to
provide intermediaries with step-by-step instructions on the information needed to populate and
submit a completed Self-Nomination form for consideration by the Centers for Medicare &
Medicaid Services (CMS).
Background
The Self-Nomination form is available through the CMS Quality Payment Program (QPP) SelfNomination website and should be accessed, completed, and submitted by intermediaries
seeking to participate in the 2025 MIPS performance period as a QCDR and/or Qualified
Registry.
The QCDR and Qualified Registry Self-Nomination form contains the following tabs (please
note, you’re required to populate all required fields marked with an asterisk [*] and tabs prior to
submitting your Self-Nomination form for CMS review):
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Intermediary Contact Info tab – Intermediaries are required to enter their staff access
and contact information.
Intermediary Details tab – Intermediaries are required to enter their current and previous
MIPS program participation details.
Qualified Posting Details tab – A qualified posting is developed for the approved
QCDRs/Qualified Registries and is required to include:
o Cost information;
o Services included in cost;
o Last date to accept new clients;
o Reporting information/options supported;
o Data collection methods; and
o Performance categories supported.
The Qualified Posting is posted on the CMS QPP Resource Library.
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Attestations tab – Intermediaries are required to attest that they understand and are able
to meet the participation requirements for the 2025 MIPS performance period.
Improvement Activities tab – Intermediaries are required to select and support the
improvement activities supported for the 2025 MIPS performance period. For more
information, please see the MIPS Improvement Activities Requirements.
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Promoting Interoperability tab – Intermediaries are required to select and support the
Promoting Interoperability objectives and measures for the 2025 MIPS performance
period. For the Promoting Interoperability performance category, if the MIPS eligible
clinician, group, virtual group, or subgroup 1 is using certified electronic health record
technology (CEHRT), the third party intermediary may be excepted from this requirement if
ALL its MIPS eligible clinicians, groups, virtual groups, or subgroups fall under the
reweighting policies. Health Information Technology (IT) vendors are required to submit
data for at least one category. For more information, please see the MIPS Promoting
Interoperability Requirements.
MIPS Clinical Quality Measures (CQMs) tab – Intermediaries are required to select and
support the reporting of quality measures. The MIPS CQM is a collection type available to
intermediaries to support for the 2025 MIPS performance period. For traditional MIPS,
QCDRs and Qualified Registries must support at least 6 quality measures, with at least 1
outcome measure. If an outcome measure isn’t available, at least 1 other high-priority
measure should be used. For MVPs, QCDRs and Qualified Registries must support all
the MIPS quality measures (that require data submission) available in the MVP they intend
to support. Not all MIPS quality measure collection types within the MVP must be
supported. Some MIPS CQMs are also available as MIPS electronic Clinical Quality
Measures (eCQMs) and must be programmed and implemented as specified in the
technical measure specifications. Accountable Care Organizations (ACOs) participating in
the Medicare Shared Savings Program (Shared Savings Program) may report the 3
Medicare CQMs or a combination of eCQMs/MIPS CQMs/Medicare CQMs, to meet the
Shared Savings Program quality reporting requirement at § 425.510(b) and the quality
performance standard at § 425.512(a)(5). ACO Medicare CQMs are Quality Measures
001SSP, 134SSP, and 236SSP. Changes to the measure specifications or
implementation workflows by intermediaries aren’t permitted.
MIPS electronic Clinical Quality Measures (eCQMs) tab – Intermediaries may specify
the eCQMs supported for the 2025 MIPS performance period. Some MIPS eCQMs are
also available as MIPS CQMs and should be programmed and implemented as specified
in the technical measure specifications. Changes to the measure specifications or
implementation workflows by intermediaries aren’t permitted.
MIPS Value Pathways (MVPs) tab – Intermediaries may specify the MVPs and MIPS
quality measures and/or QCDR measures within the selected MVPs they’ll support for the
2025 MIPS performance period. The list of MVPs reflects what was finalized in the
Calendar Year (CY) 2024 Medicare Physician Fee Schedule (PFS) Final Rule. MVP
availability is subject to change, based upon what is finalized for inclusion and removal in
the CY 2025 Medicare PFS Final Rule. Intermediaries will be given the opportunity to
update the specified MVPs during the Qualified Posting review process after the CY 2025
Medicare PFS Final Rule has been published. In addition, voluntary and opt-in
participants, as well as virtual groups, are currently excluded from MVP reporting. If an
MVP is intended for reporting by multiple specialties, a QCDR or a Qualified Registry
Subgroup reporting isn’t available through traditional MIPS
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is required to report those measures pertinent to the specialty of its MIPS eligible
clinicians.
Data Validation tab – Intermediaries are required to specify the methodology that they’ll
use to validate the data submitted for the 2025 MIPS performance period.
Please refer to the 2025 QCDR Fact Sheet (PDF, 3MB) located in the QPP Resource Library for
additional information on the QCDR participation requirements. The 2025 QCDR Fact Sheet is
included in the 2025 Self-Nomination Toolkit.
Please refer to the 2025 Qualified Registry Fact Sheet (PDF, 3.4MB) located in the QPP
Resource Library for additional information on the Qualified Registry participation requirements.
The 2025 Qualified Registry Fact Sheet is included in the 2025 Self-Nomination Toolkit.
The QCDR Self-Nomination form contains the following additional tabs (you’re required to
populate all required fields marked with an asterisk [*] and tabs prior to submitting your SelfNomination form for CMS review):
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Benchmarking Capabilities tab (required) – Allows QCDRs to upload their
benchmarking methodology. CMS won’t use a QCDR’s benchmarking data to establish a
MIPS benchmark.
QCDR Measures tab (optional) – Allows QCDRs to provide QCDR measures and/or
supplemental QCDR measure documentation for consideration for the 2025 MIPS
performance period. To use the QCDR Measures tab, your intermediary must choose
‘Yes’ under the “Do you plan to submit QCDR Measures?” question on the Intermediary
Details tab to submit your QCDR measures. QCDRs who plan to submit QCDR measures
for CMS consideration must complete this tab.
To be considered for the 2025 MIPS performance period, QCDRs and/or Qualified Registries
will be required to submit their complete Self-Nomination form, inclusive of QCDR measures
(QCDRs only), by 8 p.m. ET on September 3, 2024. Intermediaries who intend to participate in
MIPS as a QCDR and/or Qualified Registry must complete and submit a Self-Nomination
form for each intermediary type for the 2025 MIPS performance period. CMS will only
approve the organization for the intermediary type identified within the Self-Nomination form.
Applicants won’t be able to update or submit their Self-Nomination after the deadline. CMS
won’t review late submissions.
Failure to meet participation requirements and/or falsifying any information provided during SelfNomination may result in remedial action being taken against the QCDR and/or Qualified
Registry or termination as a QCDR and/or Qualified Registry in the current and future MIPS
program years.
CMS will post 2 Qualified Postings for the 2025 MIPS performance period (one for approved
QCDRs and a second for approved Qualified Registries). MIPS eligible clinicians, groups, virtual
groups, subgroups, or Alternative Payment Model (APM) Entities, including Shared Savings
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Program ACOs, inclusive of voluntary and opt-in participants or MVP participants, may use the
Qualified Postings to select a CMS-approved QCDR or Qualified Registry as their method of
data submission for MIPS reporting.
Additional resources regarding the 2025 MIPS performance period are on the QPP website.
Accessing the Quality Payment Program Website
Sign Up for a Quality Payment Program Account
If you don’t have a user account, you must create a user account.
1. Review the QPP Access User Guide (ZIP, 4.2MB) that contains these files:
a. QPP Access at-a-Glance - Gives an overview of what you need to do to sign in to
the QPP website and how you’ll manage access to organizations to self-nominate.
b. Register for a Health Care Quality Information Systems (HCQIS) Access Roles
and Profile (HARP) Account - Gives step-by-step instructions with screenshots for
new users (those who have never signed in to the QPP website) to create an
account.
c. Connect to an Organization - Gives step-by-step instructions with screenshots for
any user to request authorization for an organization. Follow these steps if you
need to self-nominate for an organization that’s currently submitting data on the
QPP website. This includes organizations that qualify for the simplified SelfNomination form. You may need to connect to the organizations that you need to
self-nominate.
d. Security Officials: Manage Access - Gives step-by-step instructions with
screenshots for a small group of users (those with a Security Official role) to
approve requests to access their organization. Follow these steps if you need to
self-nominate for an organization that’s currently submitting data on the QPP
website. This includes organizations that qualify for the simplified Self-Nomination
form. You may need to request the Security Official role for the organizations that
you need to self-nominate.
2. Navigate to the QPP website.
3. Click on Register.
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4. Click on ‘Register with HARP’ to create your account. This process could take 5-15
minutes depending on how quickly your data is verified. HARP uses a third-party service
provided by Experian to verify your identity. This may require your Social Security
number. Please select the ‘Security Official’ role.
5. If you’re self-nominating for a new intermediary that isn’t currently active on the QPP
website, then you’re done.
6. If you’re self-nominating for an existing intermediary that’s active on the QPP website,
then you’ll need to connect to that organization and request the “Security Official” role.
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7. Once you’ve created an account and logged in, you’ll land on the Manage Access page
in the QPP website and will see the ‘Registry/QCDR Self-Nomination’ link to access the
Self-Nomination form for QCDRs/Qualified Registries. You’ll see the organizations that
you’re connected to listed on the Manage Access page. If you aren’t seeing an existing
intermediary that’s active on the QPP website that you need to self-nominate, then you’ll
need to click on ‘CONNECT TO ORGANIZATION and connect to that organization and
request the ‘Security Official’ role.
8. Log in to the QPP website.
9. Select ‘Sign in’.
10. Enter your User Identifier (ID) and Password, check the “Yes, I agree” box, and click the
‘Sign in’ button.
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You must have the ‘Security Official’ role assigned to access, complete, and submit the SelfNomination form for your organization(s). If you don’t have the ‘Security Official’ role, please
submit a request to your organization’s ‘Security Official’ via the QPP website. If you’re the
‘Security Official’ for your organization, you may add this role to the appropriate staff via the
QPP website. Users can request access as a ‘Security Official’ on the Manage Access page by
clicking the ‘CONNECT TO ORGANIZATION’ link. You’ll be able to identify the
QCDRs/Qualified Registries where the ‘Security Official’ role has been approved as they’re
listed on the Manage Access page. The list of organizations that you can self-nominate will
match the list of organizations displayed on the Manage Access page under the Registry option
(QCDR/Qualified Registry intermediaries). If you know the organization that you need to selfnominate is active on the QPP website and it’s missing from this list, then you need to follow the
steps above to ’CONNECT TO ORGANIZATION’ in the ‘Security Official’ role.
Sharing HARP account credentials with other users isn’t permitted and is considered a
security violation. Each individual user must have their own HARP account to log in to
the QPP website. Unauthorized or improper use of this system is prohibited and may
result in disciplinary action and/or civil and criminal penalties.
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Self-Nomination Form Tips
Please consider the following tips as you prepare to self-nominate:
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Please contact the MIPS QCDR/Registry Support Team (Practice Improvement and
Measures Management Support [PIMMS] Team) at [email protected]
or [email protected], if you can’t find your simplified SelfNomination form (instead of creating and submitting a new Self-Nomination form
for your organization).
QCDRs and Qualified Registries must enter and maintain a Health Insurance Portability
and Accountable Act (HIPAA)-compliant Business Associate Agreement (BAA) with its
participating MIPS eligible clinicians, groups, virtual groups, subgroups, or APM Entities,
including Shared Savings Program ACOs, inclusive of voluntary and opt-in participants,
that provides for receipt of patient-specific data. The BAA must account for the disclosure
of quality measure results, numerator and denominator data, and/or patient-specific data
on Medicare and non-Medicare patients on behalf of MIPS eligible clinicians, groups,
virtual groups, subgroups, or APM Entities, including Shared Savings Program ACOs,
inclusive of voluntary, opt-in participants, and MVP participants.
All QCDRs and Qualified Registries must complete and submit their Self-Nomination form
via the QPP website. No other Self-Nomination form submission methods will be
accepted.
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Prepare the information needed to complete the Self-Nomination form and data validation
in advance of the attempt to self-nominate via the QPP website. The system will log you
out after 30 minutes of inactivity.
A third party intermediary’s principal place of business and retention of associated CMS
data must be within the U.S. CMS policy prohibits non-U.S. citizens from accessing CMS
IT systems.
The time required to complete this information collection is estimated to average 2.5 hours
per Self-Nomination form, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the Self-Nomination form.
All fields marked with a red asterisk (*) are required.
You won’t be able to successfully submit a Self-Nomination unless all the required fields of
all tabs have been filled out. However, once submitted, you may go back and edit your
submission until 8 p.m. ET on September 3, 2024. Don’t click ‘SUBMIT FOR REVIEW’
until all the required fields of all tabs have been completed.
Comment functionality is available in the Self-Nomination tool. It may be used for
specifying any updates or informing CMS about any changes that have been applied to
the Self-Nomination or QCDR measures. Refer to the ‘Comments’ section of this user
guide for additional information.
Please ensure that a member of your organization has a QPP account with the
appropriate associated role at all times and that appropriate coverage is in place if the
lead Self-Nomination contact person is out of the office.
If an error message is generated while in the QPP Self-Nomination website, you should try
refreshing the page and/or clearing your cache.
If you have questions about the 2024 Self-Nomination form, please contact the QPP
Service Center by email at [email protected], by creating a QPP Service Center ticket,
or by phone at 1-866-288-8292 (Monday through Friday from 8 a.m. to 8 p.m. ET). People
who are deaf or hard of hearing can dial 711 to be connected to a Telecommunications
Relay Services (TRS) Communications Assistant.
Creating a Self-Nomination Form (prospective
QCDRs/Qualified Registries)
1. Click ’Registry/QCDR Self-Nomination’ under Manage Access.
2. Click ’Add New Intermediary’.
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3. Enter your intermediary name (to be displayed on the Qualified Posting) and indicate your
QCDR’s or Qualified Registry’s intermediary type. Please ensure you’ve selected the correct
intermediary type, as this may affect your application. If you would like to self-nominate to
become both a QCDR and Qualified Registry, you must complete an application for each
intermediary type.
4. Click ‘Save & Continue’.
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5. Add ‘Watchers’ to monitor the status of your Self-Nomination form. This feature allows
intermediaries to create a list of users who should receive email notifications when comments
and/or status changes are provided. Make sure the ‘watcher(s)’ you provide are kept current
to prevent delays with your Self-Nomination.
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Creating a Self-Nomination Form (existing
QCDRs/Qualified Registries not in good
standing)
Find your intermediary name in the list on the Intermediary landing page with the SelfNomination Form ‘Partially Renewed’ status.
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If you aren’t seeing an intermediary that you know is active on the QPP website, please refer to
the Intermediary Not Listed link for instructions on how to connect to that organization via the
Manage Access page.
1. Click on the ‘INTERMEDIARY NOT LISTED’ button.
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2. Follow the directions provided in the “Intermediary Not Listed?” pop-up window.
Populating the 2025 Self-Nomination Form
Disclaimer: A majority of the screenshots used in this section of the user guide were taken from
the QCDR Self-Nomination form. Corresponding fields of the Qualified Registry Self-Nomination
form may slightly differ.
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The ‘Populating the 2025 Self-Nomination Form’ process should be completed by prospective
QCDRs/Qualified Registries or existing QCDRs/Qualified Registries that currently aren’t in good
standing (i.e., remedial action was taken against the intermediary). Existing QCDRs/Qualified
Registries in good standing may refer to the ’Populating the 2025 Simplified Self-Nomination
form’ section of this user guide for information on self-nominating for the 2025 MIPS
performance period. Existing QCDRs/Qualified Registries in good standing should contact the
MIPS QCDR/Registry Support Team (PIMMS Team) at [email protected] or
[email protected] if they can’t find or access the simplified Self-Nomination
form (instead of submitting a new Self-Nomination form).
All input placed into the form is automatically saved when you move to the next field. If you can’t
complete the Self-Nomination form in one session, you may click the ‘Save & Close’ button on
the Self-Nomination form and come back to it later.
You may navigate between the Self-Nomination form tabs by clicking the appropriate tab on the
left-hand side of the screen or at the bottom of the screen.
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Populating the 2025 Simplified Self-Nomination
Form
A Simplified Self-Nomination form is available to reduce the burden of Self-Nomination for those
existing QCDRs/Qualified Registries that have previously participated in MIPS and are in good
standing (remedial action hasn’t been taken against the intermediary). Existing
QCDRs/Qualified Registries in good standing should contact the MIPS QCDR/Registry Support
Team (PIMMS Team) at [email protected] and
[email protected] if they can’t find or access the Simplified Self-Nomination
form (instead of submitting a new Self-Nomination form).
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QCDR/Qualified Registry with substantive changes – existing QCDRs/Qualified
Registries in good standing may also submit, for CMS review and approval, updates to a
QCDR’s/Qualified Registry’s data validation, or a change in the organizational structure
that would impact any aspect of the QCDR/Qualified Registry. Substantive changes
impacting the organizational structure should be communicated to CMS as soon as
possible. Suggestions for new MIPS quality measures should go through the Annual Call
for Measures process and updates to the existing MIPS quality measures should be
submitted to the existing measure’s steward. QCDRs/Qualified Registries aren’t allowed to
submit or create new MIPS quality measures during Self-Nomination. Significant
changes such as new collaborations may require a new Self-Nomination form.
You may begin your 2025 Simplified Self-Nomination form by clicking ‘Get Started’ on the SelfNomination landing page. Existing QCDRs and Qualified Registries that are eligible for the
Simplified Self-Nomination form will see a nomination status of ’Renewed’.
The new fields in the 2025 Self-Nomination form (fields that are now required or include
validation for a specific format [i.e., telephone number]) will need to be populated or updated for
the Self-Nomination form to pass validation and be successfully submitted.
Intermediary Contact Info
1. Enter the name of your QCDR or Qualified Registry (if different from the intermediary name)
and your organization’s Taxpayer Identification Number (TIN). The intermediary name will be
used as your QCDR or Qualified Registry name for CMS purposes. Please include the
external organization that you’re partnering or collaborating with as part of your intermediary
name. Please indicate if your organization will be participating as both intermediary types (i.e.,
QCDR/Qualified Registry) for the 2025 MIPS performance period. The ‘Intermediary Staff
Access’ field will ONLY be seen if the Self-Nomination form is for a new intermediary. List
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email addresses for any additional staff at your organization who need to have access to the
Self-Nomination form. To access an existing intermediary’s Self-Nomination form, additional
users must be connected to that organization as a ‘Security Official’ role.
2. Enter the mailing address for your QCDR or Qualified Registry.
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3. Enter the QCDR’s or Qualified Registry’s contact information (i.e., Phone Number and
Website). The ’Phone Number’ field should be populated as (XXX) XXX-XXXX.
4. Enter information for a program, clinical, and technical contact. You’re required to provide
3 unique points of contact (POCs) for these 3 fields. Entering only 1 POC or different email
addresses for the same POC (i.e., the same name is entered for the program and clinical
contact with 2 different email addresses) isn’t acceptable. If you would like to add
additional POCs to be included in the email distribution to receive program
announcements and support call information (if approved), please add the email
address(es) in the ‘Additional Contact Email(s)’ field.
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This contact information will only be used in relation to your potential participation in the
program. To ensure notices are received, please have these contacts add the QPP email to
their safe/approved senders list.
Intermediary Details
1. Click the Intermediary Details tab.
2. Indicate your QCDR’s or Qualified Registry’s intermediary type. If ‘Health IT Vendor’ or ‘Other’
is selected, please specify.
3. Indicate if this is a new or existing QCDR or Qualified Registry that participated under MIPS
and the Physician Quality Reporting System (PQRS). Select all the applicable years your
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QCDR or Qualified Registry participated in MIPS and/or PQRS as a QCDR or Qualified
Registry. If you change intermediary type, your organization is considered as ‘new’ for the
given MIPS performance period. If you’re an existing intermediary, you’ll be required to
answer the next question regarding your participation during the last 2 performance periods
and the submission of MIPS data.
4. Indicate whether or not your intermediary has participated as a QCDR or Qualified Registry
during the last 2 MIPS performance periods by selecting ‘Yes’ or ‘No’.
5. If ‘Yes’ is selected for the question above, did your intermediary not submit any MIPS data for
either of the 2 years preceding the applicable Self-Nomination period on behalf of clinicians,
groups, virtual groups, subgroups, or APM Entities, including Shared Savings Program ACOs,
inclusive of voluntary, opt-in, and/or MVP participants? If ‘No’ is selected, no further
information is needed. If ‘Yes’ is selected, provide a detailed Self-Nomination participation
plan on how your intermediary plans to encourage clinicians, groups, virtual groups,
subgroups, or APM Entities, including Shared Savings Program ACOs, inclusive of voluntary,
opt-in, and/or MVP participants, to submit MIPS data to CMS and why you should still be able
to participate as a qualified intermediary going forward.
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6. Enter any other aliases or acronyms your QCDR or Qualified Registry currently uses or has
used for participation as a QCDR or Qualified Registry in previous performance periods.
7. Please indicate your QCDR’s or Qualified Registry’s related clinical specialty(ies).
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8. Does the QCDR plan to submit QCDR measures? Please select ‘Yes’ or ‘No’ (QCDRs only).
To populate the QCDR Measures tab, your intermediary must choose ‘Yes’ under the “Do you
plan to submit QCDR Measures?” question to submit your QCDR measures for CMS
consideration.
9. Describe how your QCDR meets the definition of a QCDR. Reiterating CMS’ definition of a
QCDR doesn’t suffice as justification as to how your QCDR meets the definition. Please
describe in detail your QCDR’s clinical expertise and quality measure development
experience, partnerships or collaborations, patient and/or disease tracking capability,
method(s) used to foster quality improvement, and evidence of meeting the identified
deficiencies to meet the definition of a QCDR (if applicable) (QCDRs Only).
Please refer to the 2025 QCDR Self-Nomination Fact Sheet for more detailed information on
what’s required.
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Qualified Posting Details
1. Click the Qualified Posting Details tab.
2. Indicate the cost information as well as the type of services your QCDR or Qualified Registry
provides. If approved, this information will be included in the QCDR’s or Qualified Registry’s
Qualified Posting. Please include frequency (monthly, annual, per submission), if the cost is
per provider/practice, and if there’s a different cost for supporting traditional MIPS compared to
MVPs. Make sure to provide in detail the differences in cost/services in each Self-Nomination
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form, if you’re an intermediary that selected ‘Yes’ to self-nominate as both a QCDR and
Qualified Registry in the Intermediary Contact Info tab.
3. Indicate the latest date your QCDR or Qualified Registry can accept new clients. Please add
the date as MM/DD/YYYY. The performance period starts January 1, 2025, and ends
December 31, 2025. As a reminder, data submissions begin January 2, 2026, and end on
March 31, 2026.
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Indicate the data collection method(s) your QCDR or Qualified Registry supports, select
the performance category(ies) you’ll be supporting, and which reporting options you’ll
support. If ‘Other’ is selected, please specify the data collection method in the
corresponding field. The quality and improvement activities performance categories are
grayed out as your QCDR or Qualified Registry must support quality and improvement
activities. QCDRs and Qualified Registries that submit data are REQUIRED to
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support the quality, Promoting Interoperability and improvement activities
performance categories. A third party intermediary could be exempted from
Promoting Interoperability if ALL its MIPS eligible clinicians, groups, virtual groups,
and/or subgroups, fall under the reweighting policies. For more information, please
see the MIPS Promoting Interoperability Requirements.
Indicate which reporting options and participation options you’ll support for your MIPS
eligible clinicians to participate as individual clinicians, groups, virtual groups, subgroups or
APM Entities, including Shared Savings Program ACOs, inclusive of voluntary, opt-in,
and/or MVP participants. QCDRs and Qualified Registries must support MVPs that are
relevant to the specialties supported. An intermediary may be excepted from
supporting MVPs if none of the approved MVPs for the given MIPS performance period
are relevant to the specialties supported. QCDRs and Qualified Registries may also
support the APM Performance Pathway (APP).
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Attestations
1. Click the Attestations tab.
2. Review the ’Participation’ statement and enter your name to attest that your QCDR or
Qualified Registry meets the participation requirements. In addition, please review and answer
the Self-Nomination attestation questions and indicate if your QCDR or Qualified Registry is
able to meet these program requirements. To be considered, a QCDR or Qualified Registry
must attest ’Yes’ to all the Self-Nomination attestations.
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These attestations include the acceptance of data exports directly from an Electronic Health
Record (EHR) or other data sources. If you become aware that any submitted information isn’t
true, accurate, and complete, you’ll correct such issues promptly prior to submission or refrain
from submitting it.
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Improvement Activities
1. Click the Improvements Activities tab.
2. You may select ‘All’ or ‘Some’. The list of supported improvement activities will appear if
‘Some’ is selected. For more information, please see the 2024 Improvement Activities
Requirements. Improvement activities availability is subject to change, based upon what’s
finalized for inclusion and removal in the CY 2025 Medicare PFS Final Rule
3. You may select each improvement activity you’ll support from the list of all the improvement
activities. A list will display and update after each individual improvement activity is selected.
Select ’All’, instead of selecting each improvement activity from the drop down, if you’ll support
all the improvement activities.
4. You may remove a selected individual improvement activity by clicking the ‘X’ next to each
selected improvement activity or click ‘Clear all’ to remove all the selected improvement
activities. In addition, you may use the ‘Search’ function to look up specific improvement
activities.
5. To edit your improvement activities, refer to the ‘Modifying a Self-Nomination’ section of this
user guide.
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Promoting Interoperability
1. Click the Promoting Interoperability tab.
2. You may select ‘All’, ‘Some’, or ‘None’. The list of supported Promoting Interoperability
objectives and measures will appear if ‘Some’ is selected. Promoting Interoperability
objectives and measures availability is subject to change, based upon what’s finalized for
inclusion and removal in the CY 2025 Medicare PFS Final Rule. A third party intermediary
could be excepted from Promoting Interoperability if ALL its MIPS eligible clinicians, groups,
virtual groups, or subgroups fall under the reweighting policies. If you select ‘None’, please
make sure you uncheck ‘Promoting Interoperability’ under the Reporting Options section on
the Qualified Posting Details tab. A field will display for your intermediary to provide an
attestation of the exception criteria. For more information, please see the MIPS Promoting
Interoperability Requirements.You may select each Promoting Interoperability measure
you’ll support from the list of all the Promoting Interoperability objectives and measures.
Each individual objective or measure selected will show after each objective or measure is
selected. Select ‘All’, instead of selecting each Promoting Interoperability objective and
measure from the drop down if you’ll support all the Promoting Interoperability objectives
and measures.
3. You may remove a selected objective or measure by clicking the ’X’ next to each selected
objective or measure or click ‘Clear all’ to remove all the selected objectives or measures.
In addition, you may use the ‘Search’ function to look up specific objectives or measures.
4. To edit your objectives or measures, refer to the ‘Modifying a Self-Nomination’ section of
this user guide.
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MIPS Clinical Quality Measures
1. Click the MIPS Clinical Quality Measures (CQMs) tab.
2. You may select ‘All’, ‘Some’, or ‘None’. The list of individual MIPS CQMs will appear if
‘Some’ is selected. The MIPS CQM must be used as specified. Measure specification
changes aren’t permitted. MIPS CQM availability is subject to change, based upon what’s
finalized for inclusion and removal in the CY 2025 Medicare PFS Final Rule.
3. You may select each MIPS CQM you’ll support from the list of all the MIPS CQMs. Each
MIPS CQM selected will show after each measure is selected. Select ‘All’, instead of
selecting each MIPS CQM from the drop down if you’ll support all the MIPS CQMs. ACOs
participating in the Medicare Shared Savings Program may report the 3 Medicare CQMs,
or a combination of eCQMs/MIPS CQMs/Medicare CQMs, to meet the Shared Savings
Program quality reporting requirement at § 425.510(b) and the quality performance
standard at § 425.512(a)(5).The Medicare CQMs are Quality Measures 001SSP, 134SSP,
and 236SSP.
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4. You may remove a selected MIPS CQM by clicking the ‘X’ next to each selected measure
or click ‘Clear all’ to remove all the selected measures. In addition, you may use the
‘Search’ function to look up specific measures.
5. To edit your individual MIPS CQMs, refer to the ‘Modifying a Self-Nomination’ section of
this user guide.
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MIPS electronic Clinical Quality Measures
1. Click the MIPS electronic Clinical Quality Measures (eCQMs) tab.
2. You may select ‘All’, ‘Some’, or ’None’. The list of individual eCQMs will appear if ‘Some’ is
selected. The eCQM must be used as specified. Measure specification changes aren’t
permitted. eCQM availability is subject to change, based upon what’s finalized for inclusion
and removal in the CY 2025 Medicare PFS Final Rule
3. You may select each eCQM you’ll support from the list of all the eCQMs. Each eCQM
selected will show after each measure is selected. Select ‘All’, instead of selecting each
eCQM from the drop down if you’ll support all the eCQMs.
4. You may remove a selected eCQM by clicking the ’X’ next to each selected measure or
click ‘Clear all’ to remove all the selected measures. In addition, you may use the ‘Search’
function to look up specific measures.
5. To edit your individual eCQMs, refer to the ‘Modifying a Self-Nomination’ section of this
user guide.
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MIPS Value Pathways (MVPs)
1. Click the MIPS Value Pathways (MVPs) tab.
2. You may select ‘All’, ’Some’, or ‘None’. The list of individual MVPs will appear if ‘Some’ is
selected. The list of MVPs reflects what’s finalized in the CY 2024 Medicare PFS Final
Rule. MVP availability is subject to change, based upon what’s finalized for inclusion and
removal in the CY 2025 Medicare PFS Final Rule. Intermediaries will be given the
opportunity to update the specified MVPs after the CY 2025 Medicare PFS Final Rule has
been published.
3. You may select each MVP and the MIPS quality measures and/or QCDR measures within
the selected MVPs you’ll support from the list of all currently available MVPs. Each MVP
selected will show after one is selected. Select ‘All’, instead of selecting each individual
MVP from the drop down if you’ll support all the MVPs. Intermediaries are expected to
support all MIPS quality measures, improvement activities, Promoting Interoperability
objectives and measures within an MVP but not all the collection types or QCDR
measures. QCDRs should obtain permission to borrow the QCDR measure(s) from the
applicable QCDR measure owner(s). A QCDR and Qualified Registry must support all
measures and improvement activities available in the MVP with 2 finalized exceptions:
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a. If an MVP includes several specialties, then a QCDR or Qualified Registry is only
expected to support the measures that are pertinent to the specialty of their
clinicians.
b. QCDR measures are only required to be reported by the QCDR measure owner. In
instances where a QCDR doesn’t own the QCDR measures in the MVP, the
QCDR may only support the QCDR measures if they have the appropriate
permissions.
4. You may remove a selected MVP by clicking the ‘X’ next to each selected MVP or click
‘Clear all’ to remove all the selected MVPs. In addition, you may use the ‘Search’ function
to look up specific MVPs.
5. To edit your individual MVPs, refer to the ‘Modifying a Self-Nomination’ section of this user
guide.
Data Validation
On this tab, you’ll be asked to specify the methodology your QCDR, or Qualified Registry will
use for validating the data being submitted to CMS for traditional MIPS, MVPs, and the APP
reporting. All fields are required to be populated. The data validation strategy must be
populated into the pre-formulated fields in the Self-Nomination form. CMS will only review the
information populated in the pre-formulated fields for purposes of satisfying the data
validation strategy. Execution of your data validation strategy must be completed prior to
the 2025 data submission period for all performance categories supported, so errors can
be corrected prior to data submission for the 2025 MIPS performance period. All data
that’s eligible to be submitted for the MIPS program (traditional MIPS, MVPs reporting, or the
APP) is subject to validation, regardless of whether they’re MIPS eligible clinicians, groups,
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virtual groups, subgroups, or APM Entities, including Shared Savings Program ACOs, inclusive
of voluntary, opt-in, and/or MVP participants. Voluntary, opt-ins, and virtual groups are currently
excluded from MVPs reporting.
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Populating Data Validation
1. Describe how your QCDR or Qualified Registry will verify MIPS eligibility for each clinician,
group, virtual group, subgroup, or APM Entity, including any Shared Savings Program
ACO, inclusive of voluntary, opt-in, and/or MVP participant (i.e., verify all participation
categories meet the eligibility thresholds). A MIPS eligible clinician, group, virtual
group, subgroup, or APM Entity, including any Shared Savings Program ACO,
inclusive of voluntary, opt-in, and/or MVP participants’ self-attestation, doesn’t
suffice.
2. Indicate the method your QCDR or Qualified Registry will use to verify the accuracy of
TINs and/or National Provider Identifiers (NPIs) intended for submission (i.e., CMS
National Plan and Provider Enumeration System (NPPES), CMS claims, and/or tax
documentation). Each MIPS eligible clinician, group, virtual group, subgroup, or APM
Entity, including any Shared Savings Program ACO, inclusive of voluntary, opt-in,
and/or MVP participants’ self-attestation, doesn’t suffice.
3. Describe the method your QCDR or Qualified Registry will use to accurately calculate
reporting and performance rates (i.e., formulas included in the quality measure
specifications).
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4. Describe the system your QCDR or Qualified Registry will use to verify that only 2025
versions of MIPS quality measures, QCDR measures, Medicare CQMs for ACOs, MVPs,
improvement activities, and Promoting Interoperability measures are reported for MIPS
submission.
5. Describe the process used to complete the data validation audit of a subset of data prior to
the submission to CMS. Periodic examinations may be completed to compare patient
record data with submitted data and/or ensure the MIPS measures were accurately
reported based on the appropriate measure specifications (that is, accuracy of numerator,
denominator, and exclusion criteria). The QCDR/Qualified Registry must provide their
sampling methodology that would be used to conduct the audits. The QCDR or Qualified
Registry, at a minimum, must meet the following sampling methodology to meet
participation requirements:
• Sample size of at least 3% of a combination of individual clinicians, groups, virtual
groups, subgroups, and APM Entities, including Shared Savings Program ACOs,
submitted to CMS, except that the sample size must have a minimum of 10 individual
clinicians, groups, virtual groups, subgroups, and APM Entities, including Shared
Savings Program ACOs, but the sample size doesn’t need to include more than 50
individual clinicians, groups, virtual groups, subgroups, and APM Entities, including
Shared Savings Program ACOs;
• Sample size that includes at least 25% of the patients of each individual clinician,
group, virtual group, subgroup, and APM Entity, including any Shared Savings
Program ACO, except that the sample size for each individual clinician, group, virtual
group, subgroup, and APM Entity, including any Shared Savings Program ACO, must
have a minimum of 5 patients but doesn’t need to include more than 50 patients.
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The data validation audit and targeted audit aren’t the same audit. See further details in
the targeted audit section.
6. Describe the process used to complete a targeted audit if data validation inaccuracies are
identified during the data validation audit. A targeted audit and data validation audit aren’t
the same type of audit. A targeted audit is only required if the data validation audit
identifies deficiencies or data errors.The targeted audit should include a description of the
root cause analysis, how the deficiency or data error was corrected, and the percentage of
your total MIPS eligible clinicians, groups, virtual groups, subgroups, or APM Entities,
including Shared Savings Program ACOs, inclusive of voluntary, opt-in, and MVP
participants, that were impacted by the deficiency or data error. The sample used for
auditing in the targeted audit can’t include data used for the data validation audit in which
the deficiency or data error was identified (i.e., select an additional 3% of the sample in
addition to the MIPS eligible clinicians, groups, virtual groups, subgroups, or APM Entities,
including Shared Savings Program ACOs, inclusive of voluntary, opt-in, and/or MVP
participants, that were impacted by the identified deficiency or data error). The aspect of
the audit that’s considered ‘the detail’ is the specific deficiency or data error for which
you’re auditing.
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Benchmarking Capabilities(QCDR ONLY)
This tab is optional and should ONLY be used by QCDRs for CMS consideration.
1. Indicate whether you have benchmarking capability (QCDR only). Upload your
benchmarking plan in the ‘file uploads’ section if ‘Yes’ is selected. Don’t upload the
attachment in the comment section.
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QCDR Measures (QCDR ONLY)
This tab is optional and should ONLY be used by QCDRs if they’re submitting QCDR
measures for CMS consideration.
QCDR measures are required to be submitted using the QCDR Measures tab. This tab should
ONLY be filled out by QCDRs who meet the definition of a QCDR, are self-nominating as a
QCDR for 2025, and want to self-nominate QCDR measures for CMS consideration.
Each QCDR may self-nominate a maximum of 30 QCDR measures for CMS consideration.
Existing QCDRs (in good standing) will be provided a pre-populated QCDR Measures tab
which includes their 2024 MIPS performance period approved QCDR measure specifications.
The pre-populated QCDR measures (for existing QCDRs in good standing only) will be
added to each existing QCDR’s respective 2025 Simplified Self-Nomination form in the
QPP website. Please note, pre-populated QCDR measures will need to be updated to
include information for the ‘new’ required fields.
In addition, any updates to previously approved QCDR measure specifications from the 2024
MIPS performance period will need to be included in the QCDR measure submission for CMS
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consideration. Furthermore, QCDRs in good standing may also submit new QCDR measures
for CMS consideration for the 2025 MIPS performance period.
In instances where a QCDR believes a low-reported QCDR measure that didn’t meet
benchmarking thresholds is still important and relevant to a specialist’s practice, the QCDR may
develop and submit a QCDR measure participation plan for CMS consideration. This QCDR
measure participation plan must include the QCDR’s detailed plans and changes that will
encourage MIPS eligible clinicians and groups to submit data on the low-reported QCDR
measure for MIPS program purposes.
As examples, a QCDR measure participation plan could include one or more of the following:
• Development of an education and communication plan.
• Update the QCDR measure’s specification with changes to encourage broader
participation.
• Require reporting on the QCDR measure as a condition of reporting through the QCDR.
Populating QCDR Measures
All fields denoted with an asterisk (*) are required. The QCDR Measures tab has built in
validation to ensure that all required fields are completed. Please ensure that all fields
are checked for grammar and typographical errors. A complete list of fields with
instructions is at the end of this section.
Select the QCDR Measures tab to begin the QCDR measure submission process:
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Pre-populated Existing QCDR Measures
The QCDR measures are pre-populated in the ‘DRAFTS’ section under the QCDR Measures
tab as part of the Simplified Self-Nomination form process for QCDRs in good standing from the
previous MIPS performance period.
To view your pre-populated existing QCDR measures:
1. Click ‘DRAFTS’.
2. Click the down arrow in the ‘DRAFTS’ box.
3. Click the ‘Edit Details’ button of the QCDR measure to be completed.
4. Complete all required fields. Required fields will vary depending on the QCDR measure
owner status, measure adoption, and new versus existing QCDR measure status.
5. When all required fields are completed and ready for CMS submission, click the ‘Submit to
CMS’ button located at the bottom of your screen. If the button is grayed out, please
review and complete the missing required fields.
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Self-Nominate QCDR Measures
These QCDR measures can be new or existing QCDR measures that the QCDR would like to
submit for CMS consideration. This would include existing QCDR measures that didn’t meet the
criteria to be in the pre-populated form (i.e., a QCDR measure borrowed from another QCDR or
a QCDR measure that wasn’t approved for the prior year but had previously been in the
program).
To submit a QCDR measure for CMS consideration:
1. Click on ‘+ Add QCDR Measure’.
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2. Indicate the measure owner status. Select ‘Yes’, ‘No’, or ‘Co-owned by 2 or more QCDRs’
for this field.
a. By selecting ‘Yes’, you’re attesting that you own or co-own the QCDR measure.
b. By selecting ‘No’, you’re attesting that you don’t own or co-own the QCDR
measure and currently have written permission from the QCDR measure owner to
use the QCDR measure. The QCDR who owns the QCDR measure must be an
active and approved QCDR for the given Self-Nomination period. CMS/the MIPS
QCDR/Registry Support Team (PIMMS Team) will confirm that the appropriate
permission has been given by the QCDR measure owner as part of the QCDR
measure review process.
i. During the measure specification process, the QCDR measure owner will
verify that all QCDRs attesting to borrowing their QCDR measure have
permission to do so.
ii. Each QCDR measure owner will be provided with names of other QCDRs
that have attested to borrowing their QCDR measure.
c. By selecting ‘Co-owned by 2 or more QCDRs’, you’re attesting that you’re a coowner of the QCDR measure.
d. “Are you the primary steward?” field:
i. This field needs to be answered ‘Yes’ by the co-owner taking primary
responsibility for the QCDR measure. The purpose of assigning a primary
steward is to aid in determining appropriate measure specifications if
there’s conflicting information between QCDR measure owners.
Owned QCDR Measures
1. “Do you own this measure?” field:
a. Select ‘Yes’ and click continue.
2. Complete all required fields. Required fields will vary depending on the QCDR measure
owner status.
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3. When all required fields are completed and ready for CMS submission, click on the
’Submit to CMS’ button located at the bottom of your screen. If the button is grayed out,
please review and complete the missing required fields.
Co-Owned by 2 or more QCDRs
1. “Do you own this measure?” field:
a. Select ‘Co-owned by 2 or more QCDRs’.
2. “Has this measure been previously approved by CMS?” field:
a. Select ‘Yes’ or ‘No’ and then the ‘Continue’ button located at the bottom of your
screen.
3. If ‘No’ was selected:
a. Populate the required fields that are present.
4. If ‘Yes’ was selected:
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a. Type in the ‘Assigned Measure ID’. Any QCDR measure that was approved for the
previous MIPS performance period can be entered.
b. Click on ’Find Measure’. If the correct QCDR measure information appears, select
the ’Continue’ button located at the bottom of your screen.
5. Complete all required fields. Required fields will vary depending on the QCDR measure
owner status.
6. When all required fields are completed and ready for CMS submission, click the ‘Submit to
CMS’ button located at the bottom of your screen. If the button is grayed out, please
review and complete the missing required fields.
Borrowed QCDR Measures
The QCDR who owns the QCDR measure must be an active and approved QCDR for the given
Self-Nomination period. CMS/the MIPS QCDR/Registry Support Team (PIMMS Team) will
confirm that the appropriate permission has been given by the QCDR measure owner as part of
the QCDR measure review process.
1. “Do you own this measure?” field:
a. Select ‘No’.
2. “Has this measure been previously approved by CMS?” field:
a. Select ‘Yes’ or ’No’ and the ‘Continue’ button located at the bottom of your screen.
b. If ’No’ is selected:
i. Populate the required fields.
1. When uploading the written permission documentation from the
QCDR measure owner to use the QCDR measure, please include
the date of the upload in the file name.
a. Note: The required fields are limited to fields that a
borrowing QCDR needs to complete, and these fields differ
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from the QCDR measure owner fields. The remaining
QCDR measure specifications will be collected from the
QCDR measure owner.
2. When all required fields are completed and ready for CMS
submission, click the ‘Submit to CMS’ button located at the bottom
of your screen. If the button is grayed out, please review the
submission for missing required fields.
c. If ‘Yes’ is selected:
i. Type in the ‘Assigned Measure ID’ for the given QCDR measure. Any
QCDR measure that was approved for the prior MIPS performance period
can be entered.
ii. Click ‘Find Measure’. If the correct QCDR measure information appears,
select ‘Continue’ located at the bottom of your screen.
1. If an incorrect Assigned Measure ID is entered, you won’t be able to
continue until an existing Measure ID is entered (don’t use spaces,
see example below). Please ensure the QCDR measure you’re
attempting to locate was approved for the previous MIPS
performance period.
iii. Populate the required fields.
1. Note: The required fields are limited to fields that a borrowing
QCDR needs to complete, and these fields differ from the QCDR
measure owner fields. The remaining QCDR measure
specifications will be collected from the QCDR measure owner.
2. When all required fields are completed and ready for CMS
submission, click the ‘Submit to CMS’ button located at the bottom
of your screen. If the button is grayed out, please review the
submission for missing required fields.
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Submitting QCDR Measures for CMS Consideration
Please ensure that all QCDR measures are in the ‘Submitted to CMS’ status before the close of
the Self-Nomination period (8 p.m. ET on September 3, 2024). QCDR measures that are in a
‘Draft’ or ‘Non-active’ status won’t go through the CMS consideration process for use by the selfnominating QCDR. Please ensure that any QCDR measures in ‘Draft’ status are moved into ‘Nonactive’ or ‘Submitted’ or the Self-Nomination form can’t be submitted for CMS consideration.
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Measure Specification Fields
The following section provides detailed information on each QCDR measure specification field.
Required fields will vary depending on the QCDR measure owner’s status, measure adoption,
and a QCDR measure’s ‘new’ versus ‘existing’ status.
Measure Info Section:
•
•
Measure Title* – Provide the measure title, which should begin with a clinical condition of
focus, followed by a brief description of action. Example: Preventive Care and Screening:
Screening for Depression and Follow-Up Plan.
Measure Description* – Describe the measure in full detail. Example: Percentage of
patients aged 12 years and older screened for depression on the date of the encounter or
up to 14 days prior to the date of the encounter using an age-appropriate standardized
depression screening tool AND, if positive, a follow-up plan is documented on the date of
or up to 2 days after the date of the qualifying encounter.
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•
•
•
Denominator* – Describe the eligible patient population to be counted to meet the
measures’ inclusion requirements. Example: All patients aged 12 years and older at the
beginning of the performance period with at least one qualifying encounter during the
performance period.
Numerator* – Provide the clinical action that meets the requirements of the measure.
Example: Patients screened for depression on the date of the encounter or up to 14
days prior to the date of the encounter using an age-appropriate standardized tool AND,
if positive, a follow-up plan is documented on the date of or up to 2 days after the date of
the qualifying encounter.
Denominator Exclusions* – Provide a denominator exclusion that would remove the
patient, procedure, or unit of measurement from the denominator. Enter ‘N/A’ if not
applicable. Example: Documentation stating the patient has had a diagnosis of bipolar
disorder.
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•
•
•
•
Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy
or for whom there’s evidence of a right and a left unilateral mastectomy.
Denominator Exceptions* – Provide the denominator exception that would allow for the
exercise of clinical judgement. Applied after the numerator calculation and only if the
numerator conditions aren’t met. Enter ‘N/A’ if not applicable. Examples: Medical
Reason(s) for not screening the patient for depression: Patient is in an urgent or
emergent situation where time is of the essence and to delay treatment would jeopardize
the patient’s health status.
Numerator Exclusions* – Provide a numerator exclusion that would remove the
patient, procedure, or unit of measurement from the numerator (used only in ratio
measures). Applied before the numerator calculation. Enter ‘N/A’ if not applicable.
Example: If the number of central line blood stream infections per 1,000 catheter days
were to exclude infections with a specific bacterium, that bacterium would be listed as a
numerator exclusion.
Primary Data Source Used for Abstraction* – Select all applicable primary data
sources used for the QCDR measure. This may include, but isn’t limited to,
administrative claims data, facility discharge data, chronic condition data warehouse
(CCW), claims, CROWNWeb, EHR (enter relevant parts), Hybrid, Inpatient
Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI), Long-term Care
Hospital (LTCH) CARE data set, National Healthcare Safety Network (NHSN),
Outcomes and Assessment Information Set (OASIS-C1), paper medical record,
Prescription Drug Event Data Elements, Patient-Reported Outcomes Measurement
Information System (PROMIS), record review, Registry (enter which Registry), Survey,
and/or Other (describe source).
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o
If applicable, please enter additional information regarding the data source used
– Provide additional information when ’EHR’, ‘Registry’ and/or "Other" is selected
in the text box that appears as needed. You may list data sources used in
addition to the primary data source. Example: ABC Registry.
•
Consensus-Based Entity (CBE) ID (Identifier) Number (if applicable) –
o Provide the assigned CBE ID number, if the submitted QCDR measure
fully aligns with the CBE endorsed version of the measure. If no CBE ID
number, enter ‘0000’. Examples: 0418, 0000.
•
High-Priority Measure?* – Enter ‘Yes’ or ’No’ to indicate if the measure is a high-priority
measure.
High-Priority Type* – If ’Yes’ is selected for “High-Priority Measure?”, select the most
appropriate high-priority measure type from the drop-down list.
•
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•
Measure Type* – Select which measure type applies to the QCDR measure from the
drop-down list.
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•
Care Setting* – Select all applicable care settings that are included within the QCDR
measure. If “Other” is selected, a text box will appear for free text to be entered.
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•
Includes Telehealth?* – Please answer ‘Yes’ or ’No’ if the QCDR measure’s denominator
includes services that are able to be provided via telehealth. (Please review the quality
action to ensure it’s appropriate via telehealth.)
Analytics Section:
•
Measure Calculation Type* – Indicate the calculation type of the QCDR measure. If
“Continuous Variable” or “Ratio” is chosen, provide a defined range of scores and the
topics it describes in the text box that appears. Example: 0-250 minutes
o Inverse Measure – This is a measure where a lower calculated performance
rate for this type of measure would indicate better clinical care or control and
is represented by the ‘Performance Not Met’ numerator option. Submitting
that numerator option will produce a performance rate that trends closer to
0%, as quality increases.
o Proportional Measure – This is a measure where the score is derived by
dividing the number of cases that meet a criterion for quality (the numerator)
by the number of eligible cases within a given time frame (the denominator).
The numerator cases are a subset of the denominator cases. Example:
Percentage of patients 18-75 years of age with diabetes who had hemoglobin
A1c > 9.0% during the measurement period.
o Continuous Variable Measure – This is a measure where the measure score
for each individual value for the measure can fall anywhere along a
continuous scale and can be aggregated using a variety of methods, such as
the calculation of a mean or median. Example: Mean time to thrombolytics
which aggregates the time in minutes from a case presenting with chest pain
to the time of administration of thrombolytics.
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CMS encourages QCDRs to construct the numerators to be
proportional by establishing an expected benchmark based on
guidelines or national performance data. Applying MIPS scoring
methodology has proven to be challenging for non-proportional
measures because variability in the data points makes decile creation
based on a mathematical analysis very unpredictable.
o Ratio Measure – Indicate if the measure is a ratio measure. This is a
measure where a score that may have a value of zero or greater (derived by
dividing a count of one type of data by a count of another type of data). The
key to the definition of a ratio is that the numerator isn’t in the denominator.
Example: The number of patients with central lines who develop infection
divided by the number of central line days). Rates closer to one represent the
expected outcome.
• Number of performance rates to be calculated and submitted* – Indicate the
number of performance rates required to be submitted for the measure.
• Performance Rate Description(s) – Provide a brief description for each performance
rate to be calculated and submitted. This is required for a QCDR measure that has more
than 1 performance rate. Example: This measure will be calculated with 7 performance
rates:
o Rate 1: Overall Percentage for patients (ages 5-50) with well-controlled
asthma, without elevated risk of exacerbation
o Rate 2: Percentage of pediatric patients (ages 5-17) with well-controlled
asthma, without elevated risk of exacerbation
o Rate 3: Percentage of adult patients (ages 18-50) with well-controlled
asthma, without elevated risk of exacerbation
o Rate 4: Asthma well-controlled (submit the most recent specified asthma
control tool result) for patients (ages 5-17) with Asthma.
o Rate 5: Asthma well-controlled (submit the most recent specified asthma
control tool result) for patients (ages 18-50) with Asthma.
o Rate 6: Patient not at elevated risk of exacerbation for patients (ages 5-17)
with Asthma
o Rate 7: Patient not at elevated risk of exacerbation for patients (ages 18-50)
with Asthma
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•
Indicate an Overall Performance Rate* – Select from the drop-down list which
submitted rates will represent an overall performance rate for the measure or how an
overall performance rate could be calculated based on the data submitted (for example,
simple average of the performance rates submitted) or weighted average (sum of the
numerators divided by the sum of the denominators), etc. If only one performance rate
is being submitted, enter ‘1st Performance Rate’.
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•
•
•
Risk-Adjusted Status* – Indicate if the measure is risk-adjusted.
o If risk-adjusted, indicate which score is risk-adjusted* – Indicate if a specific
stratum, the overall score, or a performance rate is risk-adjusted for the measure.
If social determinants of health are built into the risk adjustment model, please
specify.
Is the QCDR Measure able to be abstracted?* – Please attest the measure elements
can be abstracted and are feasible. If borrowing the QCDR measure, it’s expected that
the ability to abstract the data according to the QCDR measure owner’s specifications is
confirmed prior to self-nominating the QCDR measure. Withdrawing the QCDR measure
during an active performance period isn’t acceptable.
Disclosure: Does this measure require the use of proprietary software, devices,
etc.?* – Indicate if the QCDR measure requires the use of a proprietary software,
device, survey, etc. that a clinician, group, virtual group, or subgroup would have to
purchase or pay to use.
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Testing Section:
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Was the QCDR measure tested using an appropriate data set? – Select ‘Yes’ or ‘No’
to indicate if the QCDR measure was tested using data collected at the MIPS eligible
clinician level.
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Face validity* – Face validity testing, at a minimum, is required for all new QCDR
measures for the initial MIPS performance period for which it’s approved. This is intended
to assess whether face validity testing was conducted on the final performance measure
and isn’t intended to assess whether patient-reported surveys or tools have face validity.
Testing Level of Analysis – Indicate if a vote was conducted among experts and
patients/caregivers on whether the final performance measure scores can be used to
differentiate good from poor quality of care.
Sample Size – Indicate the number of experts and patients/caregivers who voted on
face validity (specifically, whether the measure could differentiate good from poor quality
care).
Results – If votes were conducted using a scale, sum all responses in agreement with the
statement. If more than one question was asked of the experts and patients/caregivers,
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only provide results from the question relating to the ability of the final performance
measure to differentiate good from poor quality of care.
Interpretation – Briefly explain the interpretation of the result, including any disagreement
with the face validity of the performance measure.
Empirical Validity* – Empirical validity testing is required for all existing QCDR
measures after their first MIPS performance period for which it’s approved. Indicate
whether empirical validity testing was conducted for the performance measure score(s)
using data collected at the accountable entity level. For more information on empirical
validity testing, refer to the Blueprint content on the CMS Measures Management
System (MMS) Hub.
Type of Analysis/Statistic Name – Provide the name for the type of analysis or statistic
for which empirical validity testing was conducted.
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Testing Level of Analysis – Provide the level of analysis at which the empirical validity
analysis was conducted.
Sample size – Provide the number of accountable entities sampled to test the final
performance measure score(s). Note that this field is intended to capture the number of
measured entities and not the number of individual patients or cases included in the
sample.
Results – Describe the methods used to assess empirical validity. Describe the
comparison groups or constructs used to verify the validity of the measure score(s),
including hypothesized relationships (for example, expected to be positively or
negatively correlated). Describe your findings for each analysis conducted, including the
statistical results and the strongest and weakest results across analyses. If applicable,
include the precision of the statistical result(s) (for example, 95% confidence interval)
and/or an assessment of statistical significance (for example, p-value).
Interpretation – Briefly describe the interpretation of the result, indicating whether the
statistical result affirmed the hypothesized relationship for the analysis conducted.
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Reliability* – Reliability testing is required for all QCDR measures after their first MIPS
performance period for which it was approved. Indicate whether reliability testing was
conducted for the performance measure score(s) using data collected at the accountable
entity level. For more information on reliability testing, refer to the Blueprint content on the
CMS MMS Hub.
Type of Analysis/Statistic Name – Provide the name for the type of analysis or statistic
for which reliability testing was conducted.
Testing Level of Analysis – Provide the level of analysis at which the reliability testing
was conducted.
Sample Size – Provide the number of accountable entities sampled to test the final
performance measure score(s). Note that this field is intended to capture the number of
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measured entities and not the number of individual patients or cases included in the
sample.
Results – Describe the statistical result for the analysis used to assess reliability.
Interpretation – Briefly describe the interpretation of the results.
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Patient/Encounter-Level Data Element* – Patient/encounter-level data element
testing is required for all QCDR measures after their first MIPS performance period
for which it was approved. Indicate whether patient/encounter-level testing of the
individual data elements within the final performance measure was conducted. Prior
studies of the same data elements may be submitted. If data elements are tested for
validity, then reliability testing of data elements isn’t required. For more information
on patient/encounter-level data element reliability testing, refer to the Blueprint
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content on the CMS MMS Hub. For more information on patient/encounter-level data
element validity testing, refer to the Blueprint content on the CMS MMS Hub.
Type of Analysis/Statistic Name – Indicate the statistic used to determine that data
elements are reliable and/or valid (for example, percent agreement, kappa, positive
predictive value). If more than one type of statistic was calculated, list the one that
best depicts the reliability and/or validity of the data elements in your measure. Other
statistics and results should be included.
Testing Level of Analysis – Provide the level of analysis at which the data element
testing was conducted.
Sample Size – Provide the number of patients/encounters sampled.
Results – Describe the statistical result for the analysis used to assess
patient/encounter-level data element testing. If providing kappa or a correlation
coefficient, results should be between -1 and 1. If providing percent agreement,
sensitivity, or positive predictive value, results should be between 0% and 100%.
Interpretation – Briefly describe the interpretation of results. This may include a list
of all data elements tested including their frequency and statistical results, as
applicable. If any data element has low reliability or validity, describe the anticipated
impact and whether it could introduce bias to the measure score(s).
Feasibility* – Provide a feasibility testing summary of the extent that the specified data
elements are available in electronically defined fields. Examples of extent:
o ALL data elements are in defined fields in administrative claims.
o ALL data elements are in defined fields in EHRs.
o ALL data elements are in defined fields in electronic clinical data (for example,
clinical registry, nursing home minimum data set, or MDS, home health Outcome
and Assessment Information Set (OASIS)).
o ALL data elements are in defined fields in a combination of electronic sources.
o SOME data elements are in defined fields in electronic sources.
o NO data elements are in defined fields in electronic sources.
Feasibility testing is required for all existing QCDR measures.
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Supporting Documentation Section:
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Describe Link to Cost Measure/Improvement Activity* – Describe the link between
the QCDR measure, cost measure, and an improvement activity. Please document “No
Link Identified” if there’s no link to a cost measure or an improvement activity. In cases
where a QCDR measure doesn’t have a clear link to a cost measure and an
improvement activity, we would consider exceptions if the potential QCDR measure
otherwise meets the QCDR measure requirements and considerations.
QCDR Measure Reporting Options* – Please indicate if the QCDR measure has been
finalized in a CMS-approved MVP for the given MIPS performance period or if it will be
used in traditional MIPS.
Clinical Recommendation Statement* – Provide a concise statement regarding the
clinical recommendation for this QCDR measure including the current clinical guideline
for which the measure is derived. Please list the type of evidence that was used to
support the measure such as clinical guidelines, USPSTF (U.S. Preventive Services
Task Force) guidelines, systematic review, empirical data, or define any other type of
evidence. Specify the grade of the guidelines/systematic review, if available. Example:
Adolescent Recommendation (ages 12-18) “The USPSTF recommends screening for
major depressive disorder (MDD) in adolescents ages 12 to 18. Screening should be
implemented with adequate systems in place to ensure accurate diagnosis, effective
treatment, and appropriate follow-up (B recommendation)” (Sui, A. and USPSTF, 2016,
p. 360).
Rationale for the QCDR measure* – Provide a concise statement regarding the
rationale for the QCDR measure. Example: Depression is a serious medical illness
associated with higher rates of chronic disease, increased health care utilization, and
impaired functioning (Pratt, Brody 2014). 2014 U.S. survey data indicate that 2.8 million
(11.4%) adolescents ages 12 to 17 had a major depressive episode (MDE) in the past
year and that 15.7 million (6.6%) adults ages 18 or older had at least one MDE in the
past year, with 10.2 million adults (4.3%) having one MDE with severe impairment in the
past year (Center for Behavioral Health Statistics and Quality, 2015).
Provide measure performance data (# months data collected, average
performance rate, performance range, and number of clinicians or groups)* –
Please provide the number of months the data was collected, average performance rate,
standard deviation, performance range, and the number of eligible clinicians and/or TINs
submitting the measure.
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Can the measure be benchmarked against the previous performance period data?
Enter ‘Yes’ or ‘No’ to indicate if the benchmark from prior years can be used for
comparison. If this is an existing measure, an answer is required.
If applicable, please provide details outlining why the previous benchmark can or
cannot be used. Provide details regarding why the previous benchmark can or can’t be
used in response to the changes to the existing measure. Example: The improvement
addition to the numerator will make this measure an outcome measure; therefore, it can’t
be compared to the measure from last year.
If applicable, provide the study citation to support performance gap for the
measure – Citations should be the most current available or within 5 years. Example:
Negative outcomes associated with depression make it crucial to screen, identify, and
treat depression in its early stages. While Primary Care Providers (PCPs) serve as the
first line of defense in the detection of depression, studies show that PCPs fail to
recognize up to 50% of depressed patients (Borner, 2010, p. 948).
If applicable, provide a Participation Plan if QCDR measure has low adoption by
clinicians – If a QCDR measure fails to meet benchmarking thresholds for 2
consecutive performance periods (i.e., the data submitted is insufficient in meeting the
case minimum requirements and volume thresholds required for benchmarking), the
QCDR may submit a participation plan for CMS consideration if the QCDR believes that
the measure is important and relevant to a specialist’s practice.
o Participation Plan requirements:
Detailed plan and methods to encourage eligible clinicians and groups
to increase QCDR measure adoption.
Example: A QCDR measure participation plan could include 1 or
more of the following:
• Development of an education and communication plan
• Update the QCDR measure’s specification with changes (to
encourage broader participation)
• Require reporting on the QCDR measure as a condition of
reporting through the QCDR
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Please indicate applicable specialty/specialties* – Select 1 or more applicable
specialties. Multiple specialties can be selected. If “Other” is selected, please enter free
text in the “Other Specialties” text box that appears.
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Preferred measure published clinical category* – Please provide a preferred clinical
or specialty category. If a preferred measure published clinical category isn’t provided, 1
will be assigned to the measure by CMS. Example: Diabetes and Substance
Use/Management.
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QCDR Notes – Provide any additional notes that would assist in the review or clarification
of the QCDR measure.
•
If existing measure with changes, please indicate what has changed to the existing
measure. (Optional) – Please provide information on what changes were made to the
existing measure(s).
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QCDR Measure Permission Checklist
If a QCDR has been granted permission to use a QCDR measure owned by another active and
approved QCDR, the permission must be obtained prior to self-nominating the borrowed QCDR
measure for each MIPS performance period. It’s expected that the ability to abstract the
data according to the QCDR measure owner’s specifications is a condition of selfnominating the QCDR measure. Withdrawal of a QCDR measure mid-performance period
isn’t acceptable and may lead to remedial action, up to and including termination. The
following is a QCDR measure permission checklist:
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Identify the QCDR measure(s) your QCDR will request permission to use.
Contact the QCDR measure owner to request permission to use their QCDR
measure(s).
The QCDR Qualified Posting and QCDR Measure Specifications located on the CMS
QPP Resource Library may be used to identify the appropriate point of contact.
Obtain written permission from the QCDR measure owner to use their QCDR
measure(s).
Upload the documentation at the time of Self-Nomination for CMS reference. Please
use the ‘Documentation of Approval from other QCDR’ section to upload your
supporting documentation.
o CMS doesn’t provide agreement templates and defers to the QCDRs regarding
the appropriate content to include in such an agreement.
Submission of the Self-Nomination Form
1. Once the required fields of all tabs are completed, the Self-Nomination status will update
to “Draft Complete”. You won’t be able to successfully submit a Self-Nomination form
unless all the required fields, marked with a red asterisk (*), of all tabs have been
populated.
2. Once the form is filled out in its entirety and all edits are finalized, you’ll need to click on
the ‘Submit For Review’ button to save the entire Self-Nomination form and complete the
submission process. The ‘Submit For Review’ button is located at the bottom of the leftside of the page under the Self-Nomination form tabs, as well as on the Self-Nomination
landing page.
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3. You’ll receive a confirmation email with your Self-Nomination number. Please save the
email for future reference.
4. We recommend you print a copy of your approved Self-Nomination form for your records.
5. Add ‘Watchers’ to monitor the status of your Self-Nomination form. This feature allows
intermediaries to create a list of users who should receive an email notification when
comments are added.
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Modifying a Self-Nomination Form
To review or modify your Self-Nomination form, click ‘EDIT’ on the Self-Nomination landing
page. As a reminder, you won’t be able to modify your submission after 8 p.m. ET on
September 3, 2024.
If you have any questions about the 2024 QPP Self-Nomination form, please contact the QPP
Service Center by email at [email protected], by creating a QPP Service Center ticket, or by
phone at 1-866-288-8292 (Monday through Friday from 8 a.m. to 8 p.m. ET). People who are
deaf or hard of hearing can dial 711 to be connected to a Telecommunications Relay Services
(TRS) Communications Assistant.
Withdrawing a Self-Nomination Form
If you want to withdraw an entire Self-Nomination form (that has already been submitted) from
consideration to participate in MIPS as a QCDR or Qualified Registry, click on the ’Withdraw’
button. The ’Withdraw’ button is on the Self-Nomination landing page or within the SelfNomination form.
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Comments
How to View/Add Comment
Please periodically monitor for comments posted, as there are instances where email
notifications are delayed or blocked by your email.
1. Click on ‘VIEW/ADD COMMENTS’ to view, respond, or add a comment.
2. Click ‘ADD COMMENT’.
3. Please make sure to indicate the correct subject in the ‘Select Subject’ dropdown that
coordinates with the topic. For example, if you’re submitting/responding to a comment on
your Self-Nomination form, choose the ‘Self-Nomination’ category from the ‘Select Subject’
dropdown.
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4. When you’re ready to submit your comment, click ‘Send’.
5. Once a comment has been submitted, all ‘watchers’ will receive an email notification.
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Resources
Help with Self-Nomination
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Refer to the 2025 QCDR Self-Nomination Fact Sheet (PDF, 3MB) and 2025 Qualified
Registry Self-Nomination Fact Sheet (PDF, 3.4MB) located in the 2025 Self-Nomination
Resources Toolkit (ZIP, 11MB). In addition, lists with the criteria used to audit and validate
data submitted in each of the MIPS performance categories will be available on the
website.
For assistance with completing the Self-Nomination form, the comment box may be used
to ask questions about populating form fields or submitting additional information. Refer to
the ‘Comments’ section of the user guide for additional information.
For additional assistance regarding Self-Nomination criteria, contact the QPP Service
Centerby email at [email protected], by creating a QPP Service Center ticket, or by
phone at 1-866-288-8292 (Monday through Friday from 8 a.m. to 8 p.m. ET). People who
are deaf or hard of hearing can dial 711 to be connected to a Telecommunications Relay
Services (TRS) Communications Assistant. To avoid security violations, don’t include
personally identifiable information (PII) or protected health information (PHI), such
as a Social Security number or TIN, in email inquiries to QPP.
Help with QCDR Measure Development
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Blueprint content on the CMS Measures Management System (MMS) Hub - Provides a
standardized system for developing and maintaining the quality measures used in CMS’
various quality initiatives and programs. This provides guidance to measure developers to
help them produce high-caliber healthcare quality measures and also documents the core
set of business processes and decision criteria when developing, implementing, and
maintaining measures.
Measure Development Plan – This is a focused framework to help CMS build and improve
quality measures that MIPS eligible clinicians, groups, virtual groups, APM Entities,
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voluntary participants, and/or opt-in participants could report under MIPS and as
participants in APM Entities (collectively known as QPP).
QCDR Measure Development Handbook - Provides guidance and suggestions to QCDR
measure developers on QCDR measure structure, analytics, and types. It also includes a
QCDR measure development checklist, resources for QCDR measure development and
definitions used by CMS to communicate QCDR measure review decisions. The QCDR
measure development handbook is found in the Self-Nomination form under ’Resources’.
Version History Table
Date
06/01/2024
Change Description
Original Version
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1314 (Expiration date: 01/31/2025). The time
required to complete this information collection varies per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not
be reviewed, forwarded, or retained. If you have questions or concerns regarding where to
submit your documents, please contact QPP at [email protected].
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| File Type | application/pdf |
| File Title | 2025 MIPS QCDR/Qualified Registry Self-Nomination User Guide |
| Subject | Self-Nomination User Guide |
| Author | CMS @ GDIT |
| File Modified | 2024-05-30 |
| File Created | 2024-05-30 |