Quality - QCDR

Are you struggling with submitting MIPS data to CMS?  We can help. MPOG is an approved Qualified Clinical Data Registry (QCDR). With this designation, MPOG can report approved quality measures to CMS (Center for Medicare and Medicaid Services)  on behalf of eligible professionals (EPs) and group practices for participation in the MIPS (Merit-based Incentive Payment System).

For 2018, MPOG can submit information in the Quality and Improvement Activities categories.  For more information about the MPOG QCDR program, please refer to the Participation Guide. If your site is interested in participating, please contact Katie Buehler and provide the following information:

a) Reporting option: Group or individual

b) MIPS categories MPOG will be submitting: Quality, Improvement Activites, or Both

c) Estimated number of providers and provider type (Attendings, CRNAs, or Both)

d) Formal practice business name and address

e) Contact information for Practice QCDR Administrator

Only MPOG sites submitting the the Minimum Data Requirement on a monthly basis are eligible to participate.

Please note:

Approved Measures for QCDR Reporting- 2018


QCDR Measure MPOG Measure Abbreviation Measure Description Measure Domain
ASPIRE2 NMB 01 Train of four monitor documented after last dose of non-depolarizing neuromuscular blocker Effective Clinical Care
ASPIRE6* PUL 01 Application of Lung-Protective Ventilation during General Anesthesia Patient Safety
ASPIRE18* CARD 02 Avoiding myocardial injury Effective Clinical Care
ASPIRE19* AKI 01 Avoiding acute kidney injury Effective Clinical Care
MIPS 424* TEMP 03 Perioperative temperature management Patient Safety
MIPS 426* TOC 02 Post-anesthetic transfer of care measure: procedure room to a PACU Communication and Care Coordination
MIPS 427* TOC 03 Post-anesthetic transfer of care measure: procedure room to a ICU Communication and Care Coordination
MIPS 430* PONV 01 Prevention of postoperative nausea and vomiting (PONV)- combination therapy Patient Safety
MIPS 463* PONV 02 Prevention of postoperative nausea and vomiting (PONV)- combination therapy (pediatrics) Patient Safety

For complete measure specifications, please go to the Quality Measures Webpage.

*Those measures with an (*) are considered High Priority measures per CMS.

Bold: Risk adjusted outcome measures. Risk adjustment methodology provided by the MPOG statistics team.


MPOG recommends that you review the list of improvement activities posted on the CMS website: https://qpp.cms.gov/mips/improvement-activities and select the activities most applicable to your providers.

Anesthesia providers are required to attest to performing 2 medium-weighted or 1 high-weighted activity for 90 consecutive days for 2018.  There are 13 activities related to QCDR activity however, the five (5) activities listed below are most relevant to your participation in MPOG.  As we near the submission deadline, MPOG will send a form to each site to request information about the activities selected/performed.

  1. IA_BE_8: Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive (Medium)
  2. IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements (Medium)
  3. IA_PM_7: Use of QCDR for feedback reports that incorporate population health (High)
  4. IA_CC_6: Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination (Medium)
  5. IA_BE_2: Use of QCDR to support clinical decision making (Medium)

Contact Katie Buehler with any questions regarding MPOG QCDR.