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Centers for Medicare & Medicaid Services Quality Payment Program
* Final Reminder: The 2025 Qualified Clinical Data Registry (QCDR) and Qualified Registry Self-Nomination Period Closes on September 3 [ #link_1 ]
* Reminder: Submit Comments on CMS Proposed Policy Changes for Quality Payment Program [ #link_2 ]
* The MIPS DVA will begin October 2024 for Performance Year (PY) 2023 [ #link_3 ]

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Final Reminder: The 2025 Qualified Clinical Data Registry (QCDR) and Qualified Registry Self-Nomination Period Closes on September 3

The Centers for Medicare & Medicaid Services (CMS) would like to remind you that the deadline for the 2025 Self-Nomination period for Qualified Clinical Data Registries (QCDRs) and Qualified Registries is today, September 3, 2024, at 8 p.m. ET. The Self-Nomination form on the Quality Payment Program (QPP) website [ https://qpp.cms.gov/ ] will lock at the deadline, and users won’t be able to make additional edits.

Please ensure that your 2025 QCDR or Qualified Registry Self-Nomination form is complete, and then click the Submit for Review button on the QPP website before the deadline.

You can only submit the Self-Nomination form for review after all required fields are complete on each tab. Each tab has a vertical progress indicator on the left side of the form. A green checkmark shows you’ve completed the tab, and the Submit for Review button becomes enabled when all the required fields are completed. Once you’ve selected the Submit for Review button, the Intermediary landing page will list your Self-Nomination form with the nomination status, “In Self-Nomination Review.”

Once submitted, check your application periodically for any follow-up questions regarding your Self-Nomination form, QCDR measures, and/or correspondence, as there’s a high volume of notifications from the MIPS QCDR/Registry Support Team (Practice Improvement and Measure Management Support (PIMMS) Team).

If you have a simplified Self-Nomination form, but are unable to access it, please contact the PIMMS Team at QCDRVendorSupport@gdit.com or RegistryVendorSupport@gdit.com. Don’t create and submit a new Self-Nomination form for your organization.

Sharing Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) account credentials with other users isn’t permitted and is considered a security violation. Ensure that a member of your organization has a HARP [ https://harp.cms.gov/register/profile-info ] account to sign in to the QPP website with the appropriate associated role at all times and that appropriate coverage is in place if the lead Self-Nomination contact person is out of the office. Each individual user must have their own HARP account to log in to the QPP website [ https://qpp.cms.gov/ ]. Unauthorized or improper use of this system is prohibited and may result in disciplinary action and/or civil and criminal penalties.

*For More Information*

Visit the QPP Resource Library [ https://qpp.cms.gov/resources/resource-library ] to download the 2025 Self-Nomination Toolkit for Qualified Clinical Data Registries (QCDRs) and Qualified Registries (ZIP, 15 MB) [ https://links-2.govdelivery.com/CL0/https:%2F%2Fqpp-cm-prod-content.s3.amazonaws.com%2Fuploads%2F2856%2F2025_Self-Nomination_Resources_Toolkit.zip/1/0101019199d4d138-e8bfb5cb-dd5b-4990-93e8-a28467ae3dda-000000/qePg6D-3_NcOiFJX30t0GEgoJSFcjGNaEnhVwDsh5Sc=368 ] and learn more about the QCDR and Qualified Registry Self-Nomination process.

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Reminder: Submit Comments on CMS Proposed Policy Changes for Quality Payment Program

*"Provide Feedback on Proposed Changes to the Quality Payment Program by September 9"*

The Centers for Medicare & Medicaid Services (CMS) recently issued its Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) Proposed Rule [ https://www.federalregister.gov/documents/2024/07/31/2024-14828/medicare-and-medicaid-programs-cy-2025-payment-policies-under-the-physician-fee-schedule-and-other ], which includes proposed policies for the Quality Payment Program (QPP).

The Notice of Proposed Rulemaking (NPRM) includes proposals for the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs), as well as several Requests for Information (RFIs).

Specifically, we’re proposing policies that:


* Continue the development and maintenance of MVPs
* Establish the APM Performance Pathway (APP) Plus quality measure set
* Update the MIPS measure/activity inventories and scoring methodologies

Finally, we’re proposing a small number of policies intended to maintain stability within the MIPS program through the established performance threshold and data completeness criteria.

*2025 Policy Highlights*

Key QPP policies that we are proposing in the 2025 PFS Proposed Rule include:


* Introducing 6 new MVPs for the 2025 performance period that are related to ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care
* Creating APP Plus, an additional quality measure set under the APP, which would include the 6 measures currently in the APP quality measure set and incrementally incorporate the remaining 5 Adult Universal Foundation quality measures for a total of 11 measures by the 2028 performance period/2030 payment year
* Maintaining the current performance threshold policies, leaving the performance threshold set at 75 points for the 2025 performance period
* Keeping the 75% data completeness criteria through the 2028 performance period

*Submit a Formal Comment by September 9*

You must officially submit your comments in one of the following ways [ https://www.federalregister.gov/documents/2024/07/31/2024-14828/medicare-and-medicaid-programs-cy-2025-payment-policies-under-the-physician-fee-schedule-and-other#open-comment ]:


* Electronically, through Regulations.gov [ https://www.regulations.gov/commenton/CMS-2024-0256-0045 ]
* Regular mail
* Express or overnight mail

Comments are due no later than* 5:00 p.m. ET on September 9, 2024.*

*For More Information*

Learn more about the QPP proposals by reviewing the following 2025 QPP Proposed Rule Resources:


* 2025 Quality Payment Program Proposed Rule Fact Sheet and Policy Comparison Table (PDF, 596KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2876/2025-QPP-Proposed-Rule-Fact-Sheet-and-Policy-Comparison-Table.pdf ]
* 2025 Proposed and Modified MVPs Guide (PDF, 948KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2877/2025-Proposed-and-Modified-MVPs-Guide.pdf ]

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The MIPS DVA will begin October 2024 for Performance Year (PY) 2023

The Centers for Medicare & Medicaid Services (CMS) has contracted with Guidehouse to conduct data validation and audits (DVAs) of MIPS eligible clinicians or groups in accordance with the legislative authority set forth in 42 CFR 414.1390(a)-(d) [ https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-414/subpart-O/section-414.1390 ]. This regulation requires MIPS eligible clinicians or groups to comply with data sharing requests, providing all data as requested by CMS. Data validation and audits are designed and conducted to confirm the accuracy and completeness of reported results of the MIPS program.

If you are selected for the MIPS DVA, an email will be sent to the Security Official in your Health Care Quality Information Systems Access, Roles, and Profile (HARP) account. Please review that the contact information is up to date in the HARP system. The email will be sent from Guidehouse (MIPS_DVA_Request@guidehouse.com).

MIPS eligible clinicians selected for DVA can expect notification of selection and initial requests for information starting October 2024 through April 2025. There may also be ad hoc DVA work that is conducted through 2025. You will have 45 days from the date of the notice to provide the requested information of substantive, primary source documents.  These documents may include: copies of claims, medical records for applicable patients, or other resources used in the data calculations for MIPS measures, objectives, and activities. Primary source documentation also may include verification of records for Medicare and non-Medicare patients where applicable. 

Please note, failure to provide the requested information for the DVA could result in a payment adjustment in accordance with the legislative authority set forth in §§ 405.980 [ https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFR70fab268832aef1 ] through 405.986 [ https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFR70fab268832aef1 ]. It may also increase the possibility that you will be selected for future DVA. If a third-party is used for MIPS data submission, MIPS eligible clinicians are accountable to ensure that all requested audit documentation is provided in a complete and timely manner.

Please refer to the Merit-based Incentive Payment System (MIPS) Data Validation and Audit (DVA) Factsheet for PY 2023 for additional information at MIPS DVA Fact Sheet PY 2023 (PDF, 306KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2992/MIPS-DVA-Fact-Sheet-PY-2023.pdf ]. If you have questions pertaining to the DVA, please contact Guidehouse at MIPS_DVA@guidehouse.com.

QPP Footer 2023 [ https://qpp.cms.gov/resources/help-and-support ]


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