Frequently Asked Questions for 2017 QCDR

What is the Quality Payment Program (QPP)?

In 2016, the Department of Health and Human Services (HHS) issued its final rule with comment period implementing the Quality Payment Program that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Quality Payment Program’s purpose is to provide new tools and resources to help you give your patients the best possible, highest-value care.

What is the Merit Based Incentive Program (MIPS)?

The Merit-based Incentive Payment System is a track under the Quality Payment Program. If you successfully participate in MIPS, you will earn a performance-based payment adjustment to your Medicare payment. The Society will participate as a QCDR in the Quality performance component of MIPS.

What is a Qualified Clinical Data Registry (QCDR)?

Qualified Clinical Data Registry is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.

What are the requirements to be eligible for the Quality Payment Program?

Each Eligible Physician will need to bill Medicare more than $30,000 AND provide care for more than 100 Medicare patients in 2017.

Why what are the requirements to successfully participate in the Quality Performance Program of MIPS under QPP?

Report up to 6 quality measures across 3 NQS domains, including an outcome measure, for a minimum of 90 days. Notwithstanding the foregoing, participation in the Mastery of Breast Surgery Program’s QCDR requires reporting on each measure for all patients to which the measure applies.

What are the National Quality Strategy Domains?

The 6 NQS domains are:

  1. Person and Caregiver-Centered Experience Outcomes
  2. Patient Safety
  3. Care Coordination
  4. Population/Public Health
  5. Efficient Use of Healthcare Resources
  6. Effective Clinical Care

What quality measures are available for reporting through Society’s 2017 QCDR?

For 2017, the Society’s QCDR is qualified to report on the following PQRS and non-PQRS (Society endorsed) measures:

Non-MIPS (Society endorsed) measures:

Ways to successfully report for MIPS?

Pick Your Pace in MIPS

Reminder- we only submit for the Quality component of MIPS.

Here is a chart of how you can submit the other three components. 

MIPS Data Submission Mechanisms

2017 MIPS Performance

Are you subject to a penalty if you don’t participate in MIPS?

Yes, a 2019 negative payment adjustment (-0.4%).

Where can I find my data for the 2017 QCDR?

Login to Mastery>My Reports>QCDR/PQRS Measures (2017).

Where can I find my incomplete reports?

Login to Mastery>My Reports>QCDR/PQRS Measures (2017)>Incomplete under each quality measure.

Can I participate in the Society’s QCDR program if I am part of a GPRO (Group Practice Reporting Option)?

No, the Society does not submit for GPRO’s.

What if I don’t know whether or not my TIN is associated to a GPRO?

You can ask your hospital or group practice whether they participate in GPRO before participating in the Mastery’s QCDR program.  You can still use Mastery for Maintenance of Certification even if you don’t participate in QCDR.

How are the 3% of participants chosen for the audit and can I be chosen two consecutive years?

Participants are randomly chosen, and participants from the previous year are excluded from the pool.

What if I have answered all the quality measures, yet I am receiving an incomplete report or my performance rate is null or 0?

For example, if you have 10 patients and you chose exceptions, exclusions, or ‘not mets’ for all 10 patients, then your performance rate will be null or 0.  You need to have at least 1 ‘met’ in order to have a performance rate of above 0%.  A null means that your denominator is 0 or that you don’t have any “mets” in the denominator.

When does the society submit my 2017 QCDR data to CMS and what is the deadline to have all my data entered for 2017?

We submit data to CMS by March 31, 2018.

The deadline to have all your data updated in the Mastery is February 1, 2018.

We will send monthly reminders to anyone with incomplete data for the two outcome measures because both 2017 QCDR quality measures (Surgical Site Infection and Unplanned 30 Day Re-operation After Mastectomy) require participants to update patient information 30 days after the procedure.

There will be a $100 non-refundable fee at the time of confirmation form submission.


If you have additonal questions, please contact us at

The American Society of Breast Surgeons
10330 Old Columbia Road, Suite 100
Columbia, MD 21046
Telephone: 410-381-9500
Or (toll free) /877-992-5470 Fax: 410-381-9512