CMS Approves ACEP’s Clinical Emergency Data Registry for MIPS Participation

A list of approved qualified clinical data registries (QCDRs) was finally released late last month, five months into the first reporting period for the Centers for Medicare and Medicaid Services’ (CMS) Merit-based Incentive Payment System (MIPS). Among the list of approved QCDRs was the American College of Emergency Physicians’ (ACEP) Clinical Emergency Data Registry (CEDR).

CEDR was approved for reporting all three MIPS categories in effect for the 2017 reporting year: Advancing Care Information, Improvement Activities, and Quality. CEDR also is available for both individual and group reporting.

In submitting their QCDR for approval by CMS, ACEP said they are “offering the ACEP MIPS Registry to emergency physicians and emergency clinicians to promote the highest quality of emergency care.” The cost of using CEDR for the 2017 reporting year, according to the CMS announcement listing the various approved QCDRs, is $0.25 per visit plus a $100 annual participant fees for ACEP nonmembers.

CEDR supports the following MIPS quality measures, which also are included as part of the MIPS Emergency Medicine specialty care set:

• Q066 Appropriate Testing for Children with Pharyngitis,
• Q091 Acute Otitis Externa (AOE): Topical Therapy,
• Q093 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use,
• Q116 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis,
• Q254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain,
• Q255 Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure,
• Q317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented,
• Q415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older, and
• Q416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years.

A few other MIPS quality measures, which are not part of the Emergency Medicine specialty care set, are supported by CEDR:

• Q076 Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections,
• Q187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy,
• Q326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy, and
• Q419 Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered.

Important to note, a few MIPS quality measures which are included in the MIPS Emergency Medicine specialty care set are not supported by CEDR:

• Q047 Care Plan,
• Q374 Closing the Referral Loop: Receipt of Specialist Report,
• Q130 Documentation of Current Medications in the Medical Record,
• Q226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention,
• Q431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling, and
• Q402 Tobacco Use and Help with Quitting Among Adolescents.

Among the many benefits of reporting MIPS via a QCDR are the additional quality measures each QCDR supports that are not included in the MIPS quality measure set. These measures are developed by the QCDR and approved by CMS for inclusion in the program. Many specialty-specific QCDRs, like CEDR, believe their non-MIPS measures provide more meaningful information for members of their specialty than the standard MIPS measures do. Also, unlike other reporting options, QCDRs collect data on all patients, not just Medicare patients, which also makes the data more meaningful to providers.

For 2017, CEDR supports the following non-MIPS measures:

• ACEP 21 – Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding,
• ACEP 22 – Appropriate Emergency Department Utilization of CT for Pulmonary Embolism,
• ACEP 24 – Pregnancy Test for Female Abdominal Pain Patients,
• ACEP 25 – Tobacco Use: Screening and Cessation Intervention,
• ACEP 26 – Sepsis Management: Septic Shock: Lactate Level Measurement,
• ACEP QI01 – Sepsis Management: Septic Shock: Blood Cultures Ordered,
• ACEP 27 – Sepsis Management: Septic Shock: Antibiotics Ordered,
• ACEP 28 – Sepsis Management: Septic Shock: Fluid Resuscitation,
• ACEP 29 – Sepsis Management: Septic Shock: Repeat Lactate Level Measurement,
• ACEP 30 – Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 10%,
• ACEP 31 – Emergency Medicine: Appropriate Foley Catheter Use in the Emergency Department,
• ACEP 32 – ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients,
• ACEP 33 – ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80k +),
• ACEP 35 – ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k- 79,999),
• ACEP 36 – ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k- 59,999),
• ACEP 37 – ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999),
• ACEP 38 – ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less),
• ACEP 39 – ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding EDs,
• ACEP 40 – ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients,
• ACEP 41 – ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Supercenter EDs (80k +),
• ACEP 43 – ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in High Volume EDs (60k-79,999),
• ACEP 44 – ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Average Volume EDs (40k- 59,999),
• ACEP 45 – ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Moderate Volume EDs (20k-39,999),
• ACEP 46 – ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Low Volume EDs (19,999 and less),
• ACEP 47 – ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Freestanding Eds, and
• ACEP QI02 – Emergency Medicine: Appropriate Use of Imaging for Recurrent Renal Colic.

For more information about the various QCDRs approved by CMS for 2017, review the recently released Merit-Based Incentive Payment System (MIPS): 2017 CMS-Approved Qualified Clinical Data Registries (QCDRs) from the Quality Payment Program (QPP) website. Also, learn more about CEDR at ACEP’s website (NOTE: as of the time of publication, the CEDR page has not been updated to reflect the new MIPS program guidelines).

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