Frequently Asked Questions for 2018 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 (QPP) 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 and to provide Medicare payment updates based on those activities.

What is the Merit Based Incentive Program (MIPS)?

The Merit-based Incentive Payment System (MIPS) is a track under the Quality Payment Program, which aims to streamline the reporting requirements and performance calculations of legacy programs such as the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VM), and EHR Incentive Program (i.e., Meaningful Use). If you are required to participate in MIPS, your Medicare payments will be subject to a performance-based adjustment. In order to assist with requirements under the Quality Performance Category, the Society offers a Qualified Clinical Data Registry (QCDR), which provides breast surgeons with a more relevant set of measures.

What is a Qualified Clinical Data Registry (QCDR)?

Qualified Clinical Data Registry (QCDRs) 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. QCDRs tend to offer more relevant reporting options for specialists under the MIPS Quality Performance Category.

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

Eligible physicians who bill Medicare more than $90,000 AND provide care for more than 200 Medicare patients are subject to MIPS. For those who choose to report as a group, groups are held to the same eligibility threshold. In other words, groups who bill Medicare more than $90,000 AND provide care for more than 200 Medicare patients are subject to MIPS.

You can look up your eligibility here:

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

Report up to 6 quality measures including an outcome measure or a high priority measure if an outcome measure isn't available. To be eligible to be scored on the performance of these measures in 2018, you must report these measures on at least 60% of the patients to which these measures are applicable over the course of the calendar year. Participation in the Master of Breast Surgery Program's QCDR helps to meet these Quality Performance Reporting requirements by offering a sufficient number of measures and requiring that measures be reported for all patients.

How is my final score calculated?

2018 MIPS performance year final score: • Performance category weight: Quality 50%, Cost 10%, Improvement Activities 15%, and Advancing Care Information 25%.

The Society's QCDR only submits for the Quality component of the MIPS score. Data submission under the Improvement Activities Performance Category and Advancing Care Information Performance Category can be done via the CMS Data Submission System. Clinicians are not required to submit any data related to the Cost Category. CMS will calculate these measures and determine applicability based on claims data.

Small practice bonus: 5 points will be added to the final MIPS Composite Score for any MIPS eligible clinician or small group who's in a small practice (defined as 15 or fewer eligible clinicians), as long as the MIPS eligible clinician or group submits data on at least 1 performance category in an applicable performance period. To find out if CMS has defined you as eligible for the small practice bonus, go to the MIPS look-up tool and enter your NPI; under the "Special Status" heading, look to see if you are designated as a Small Practice.

What quality measures are available for reporting through Society’s 2018 QCDR?

For 2018, the Society's QCDR is qualified to report on the following MIPS and non-MIPS (Society developed and endorsed) measures:

Non-MIPS (Society endorsed) measures:

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

Yes, if you are found eligible to participate in MIPS, but do not meet the minimum reporting requirements, your 2020 Medicare Part B payments will subject to a -5.0% adjustment. Depending on a clinician or group’s performance, the payment adjustment for the 2020 payment year could range from - 5% to + (5% x scaling factor not to exceed 3) as required by law. (The scaling factor is determined in a way so that budget neutrality is achieved.)

Where can I find my data for the 2018 QCDR?

Login to Mastery>My Reports>QCDR/PQRS Measures (2018).

Where can I find my incomplete reports?

Login to Mastery>My Reports>QCDR/PQRS Measures (2018)>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)?

The Society’s QCDR facilitates reporting under the Quality Performance Category for those eligible clinicians who have decided to participate in MIPS as an “individual.” For those who choose to participate in MIPS as a “group” (defined as all providers listed under your Tax ID Number (TIN), there are other reporting options available other than the Society’s QCDR.

How do I know if I am associated with a TIN for which participation is being handled for me under the group?

First, contact your hospital or group practice to see whether it has developed a MIPS reporting strategy for your group.  If you choose to use Mastery as a QCDR to submit MIPS Quality Performance Category data as an individual, but your group also submits quality data via a different mechanism, CMS will evaluate your performance across all 4 MIPS categories-- at both the individual and group level-- and assign you the most favorable score for purposes of your payment adjustment.

Also keep in mind that you can still use Mastery for Maintenance of Certification, even if you are not participating in the QCDR program. Note that MOC participation is one of the activities recognized under the Improvement Activities category in 2018

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 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 2018 QCDR data to CMS and what is the deadline to have all my data entered for 2018?

The deadline to have all your data updated in the Mastery is February 1, 2019. We will submit 2018 data to CMS by March 31, 2019.

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