August 2017
Colorado QPP Coalition: August Fast Facts

1. What is a Qualified Registry?
 A qualified registry is an entity that collects clinical and non-clinical data from an individual clinician or group practice that is participating in the merit-based incentive payment system (MIPS) and submits it to the Centers for Medicare and Medicaid Services on behalf of the clinicians. Clinicians work directly with a chosen CMS-approved registry to submit data on the selected measures or specialty set of measures. For a list of the 2017 approved qualified registries, click here .

2. What is a Qualified Clinical Data Registry (QCDR)?

A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission directly to CMS for MIPS reporting. A clinical data registry records information about the health status of patients and the health care they receive in an organized system. QCDRs give a picture of the overall quality of care provided because QCDRs collect and report quality information on patients from all payers, not just Medicare patients. For the official list of the 2017 CMS-approved QCDRs that lists each measure collected (248 pages) click here .

3. What is the difference between a Qualified Registry and a QCDR?

The QCDR reporting option is different from a qualified registry because it isn't limited to measures within the Quality Payment Program (QPP). The QCDR can host "non-MIPS" measures approved by CMS for reporting. Measures submitted by a QCDR might include measures from one or more of the following categories, with a maximum of 30 non-MIPS measures allowed per QCDR:
  • Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CAHPS), which must be reported via a CAHPS certified vendor
  • National Quality Forum (NQF) endorsed measures
  • Current 2017 MIPS measures
  • Measures used by boards or specialty societies
  • Measures used by regional quality collaborations
  • Other approved CMS measures
4. Need a user friendly search tool for your Qualified Registry or QCDR research?

Click here  for a tool developed by the American Medical Association to search for a QCDR or registry approved by CMS for submitting QPP measures. This tool provides easy navigation and filtering options.
5. Where can I go to learn more about these reporting options?

The QPP website offers excellent resources and education. Please click here to go to the resource library on this site.

Stay tuned for the upcoming September webinar hosted by the Colorado QPP Coalition on "How to report for the 2017 QPP Performance Year." For more information and to register for this webinar, please check the coalition webpage,
Now available: Electronic transaction complaints report

Individuals and organizations can now file complaints against a HIPAA-covered entity for non-compliance with standards for transaction formats, code sets, unique identifiers, and operating rules through the Administrative Simplification Enforcement and Testing Tool (ASETT).
The Centers for Medicare & Medicaid Services (federal CMS) recently released a   report on complaints submitted from January to July 2017. The report includes information about the number, type, and status of complaints submitted to ASETT.

Use ASETT to electronically file your transaction complaints and test your transactions for compliance. Visit the Administrative Simplification website for more information on filing complaints and enforcement and compliance, or view this fact sheet.
Opportunity to comment on E/M change

As part of Medicare's proposed rule for 2018, the Centers for Medicare and Medicaid Services is requesting comments on possible revisions to the E/M documentation guidelines. The Association of Health Care Auditors and Educators has been asked by the federal CMS to submit comments as an organization and the association is seeking input from all Colorado physicians, providers and stakeholders.
Click here to view the proposed rule. Page 129 of the proposed rule is where the start of the E/M services discussion for providers begins. Page 130 is where you will find information for comment request. Here's a key excerpt:
"We are seeking comment on whether clinicians and other stakeholders believe removing the documentation requirements for the history and physical exam would be a good approach. While we believe MDM guidelines may also need to be updated, we believe in the nearer term it may be possible to eliminate the current focus on details of history and physical exam, and allow MDM and/or time to serve as the key determinant of E/M visit level. We are seeking public comment on this approach."
Comments on other sections of the proposed rule are also welcome for submission. Proposed RVU changes for both malpractice and practice expense and excel file access are located here.
Please submit comments and input by Sept. 5, 2017 to Robin Linkler, Executive director of operations for the Association of Health Care Auditors and Educators at The association will collectively compile and submit the information prior to the stated Federal Register deadline of Sept. 11, 2017. 
Free small provider HIPAA training

The U.S. Department of Health and Human Services, Office for Civil Rights (OCR), Rocky Mountain Region, will be presenting FREE training in Grand Junction and Denver in August and September. The purpose of the presentation - titled "Privacy, Security, and Breach Notification Rules: HIPAA for the Small Provider" - is to help small health care providers that are covered entities understand their regulatory obligations under HIPAA. OCR will cover a number of topics such as an individual's right of access, safeguarding protected health information, the business associate agreement requirement, and risk analysis/risk management.
Grand Junction
Aug. 25, 2017, 8 a.m. - 12 p.m.
Wayne Aspinall Federal Bldg
Conference Room
400 Rood Avenue
Grand Junction, CO
Sept. 8, 2017, 8 a.m. - 12 p.m.
Byron Rogers Federal Bldg
Aspen/Pine Room, Floor 16
1961 Stout Street
Denver, CO
Space is limited; registration is required and is first-come, first-served. Register by emailing Scott Grayson at or Hyla Schreurs at Please indicate the location of the presentation you will attend as other programs will be held in Wyoming, Utah, North Dakota, South Dakota, and Montana. 

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Take Credit Cards? Is Your Practice Ready for the Oct. 15 EMV Deadline?

Important! What your practice needs to know about switching to EMV: Click here.

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