The GIQuIC 2023 Qualified Clinical Data Registry (QCDR) is approved to report for individual eligible providers, groups, and virtual groups to the CMS Merit-based Incentive Payment System (MIPS), specifically the Quality, Promoting Interoperability, and Improvement Activities performance categories.
If you are considering using the GIQuIC QCDR to report to CMS’ MIPS program for the 2023 reporting year, please watch the following two webinars. They outline the steps you need to take now in order to report to MIPS through GIQuIC in 2023.
- Click here for GIQuIC 2023 MIPS Action Plan webinar
- Click here for GIQuIC 2023 MIPS Action Plan slides
- Click here for MIPS 2023 GIQuIC QCDR Reporting: Planning and Execution webinar
- Click here for MIPS 2023 GIQuIC QCDR Reporting: Planning and Execution slides
If a physician is MIPS-eligible in 2023:
- They must submit data for three performance categories, including:
- CMS will collect and calculate data for the Cost Performance Category – 30% of MIPS score
- Individual eligible providers, groups, and virtual groups can report to the Quality, Promoting Interoperability, and Improvement Activities performance categories via the GIQuIC 2023 QCDR
- A final MIPS score of 0 to 100 points will be calculated according to performance across the four MIPS performance categories
- The final score determines whether a physician or group receives a negative, neutral, or positive MIPS payment adjustment; 75 points overall is needed to avoid a negative payment adjustment
- A MIPS payment adjustment that reflects performance during 2023 will be applied to payments for covered professional services in 2025
- Click here for CMS’ 2023 MIPS Quick Start Guide
MIPS Performance Categories
Quality Performance Category
The Quality Performance Category uses measures to evaluate clinician performance reflecting the quality of healthcare that is being provided to patients and accounts for 30% of the final MIPS score. Reporting GI-specific quality measures is a key benefit of participating in GIQuIC and reporting to CMS’ MIPS program via the GIQuIC 2023 QCDR.
2023 GIQuIC QCDR Measures
|GIQIC25||Screening Colonoscopy Adenoma Detection Rate – Female||Outcome|
|GIQIC24||Screening Colonoscopy Adenoma Detection Rate – Male||Outcome|
|GIQIC23||Appropriate follow-up interval based on pathology findings in screening colonoscopy||High-Priority|
|NHCR4||Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation||High-Priority|
|QPP185||Colonoscopy Interval for Patients with a History of Adenomatous Polyps — Avoidance of Inappropriate Use||High-Priority|
|QPP320||Appropriate follow-up interval for normal colonoscopy in average risk patients||High-Priority|
|QPP439||Age Appropriate Screening Colonoscopy||High-Priority|
|GIQIC10||Appropriate management of anticoagulation in the peri-procedural period rate – EGD||High-Priority|
Click here for complete numerator/denominator descriptions of each of the 2023 GIQuIC QCDR measures.
Getting Started with Quality
Click here for CMS’ 2023 MIPS Quick Start Guide.
Then, put together your Quality Plan of Action:
CMS requires physicians to review their performance at least four times throughout the
2023 performance year.
For more information about the Quality Performance Category for the 2023 Performance Year, please visit: https://qpp.cms.gov/mips/quality-requirements.
Improvement Activities Performance Category
The Improvement Activities performance category rewards participants for activities that improve clinical practice and accounts for 15% of the final MIPS score. There is a list of activities that are weighted as either medium (worth 10 points each) or high (worth 20 points each). To earn full credit in this category, participants must submit one of the following combinations of activities:
- 2 high-weighted activities
- 1 high-weighted activity and 2 medium-weighted activities, or
- 4 medium-weighted activities
Small practices and practices in rural areas complete two medium-weight activities or one high-weight activity for maximum score.
CMS provides a list of more than 100 suggested activities in their Improvement Activities Inventory so you can select those that best fit your practice to improve patient engagement, safety, and care. A PDF of the 2023 Improvement Activities Inventory is available for download here.
In addition, there are CMS-approved Improvement Activities that are specific to QCDRs, as noted in the inventory.
GIQuIC Registry Favorite Improvement Activities
A clinician or group may report any improvement activity listed on the CMS inventory. Following are popular improvement activities reported via the GIQuIC CQDR.
|IA_PSPA_17||Implementation of analytic capabilities to manage total cost of care for practice population|
|IA_PSPA_18||Measurement and improvement at the practice and panel level|
|IA_PSPA_28||Completion of an Accredited Safety or Quality Improvement Program|
|IA_PSPA_28||Participation in MOC Part IV|
|IA_PSPA_7||Use of QCDR data for ongoing practice assessment and improvements|
|IA_PM_7||Use of QCDR for feedback reports that incorporate population health|
Getting Started with Improvement Activities
Click here for CMS’ 2023 Improvement Activities Performance Category Quick Start Guide.
Then, put together your Improvement Activities Plan of Action:
For more information about the Improvement Activities Performance Category for the 2022 Performance Year, please visit: https://qpp.cms.gov/mips/improvement-activities.
Promoting Interoperability Performance Category
The Promoting Interoperability Performance Category emphasizes the use of certified electronic health record technology (CEHRT) to facilitate the exchange of information between clinicians, pharmacies, and patients to improve outcomes. It accounts for 25% of the final MIPS score.
Getting Started with Promoting Interoperability
For a full list of the current objectives and measures of the Promoting Interoperability performance category, please refer to CMS’ 2023 Promoting Interoperability Performance Category Quick Start Guide by clicking here.
Then, put together your Promoting Interoperability Plan of Action:
For more information about the Promoting Interoperability Performance Category for the 2023 Performance Year, please visit: https://qpp.cms.gov/mips/promoting-interoperability.