Federal Reporting
Learn more about federal reporting with The PINNACLE Registry and the Diabetes Collaborative Registry.
The following information is provided for educational purposes only and should not be regarded as clinical or legal advice. Veradigm does not ensure the accuracy of this information and does not guarantee that following this information will result in receiving any government payment. It is the attesting healthcare providers responsibility to comply with all program requirements.
Medicaid Eligible Professional (EP) Promoting Interoperability (PI) Program
The voluntary Medicaid EP PI program is administered by states and territories as approved by the Centers of Medicare and Medicaid Services (CMS). The Medicaid EP PI program is separate and in addition to the QPP requirements. Eligible Professionals (EP) that participate in the Medicaid EP Promoting Interoperability program attest directly to the state. Providers opting to report must have begun reporting in 2016, qualify for the Medicaid patient volume threshold and must not have yet received all six available EHR incentive payments. The last year for achieving Medicaid EP EHR Incentive Payments is 2021. The last attestation submission date for 2021 is September 30th 2021 or earlier as required by the state Medicaid EP entitiy.
The PINNACLE Registry and the Diabetes Collaborative Registry are both considered registries under the Clinical Data Registry Reporting measure of Objective 8: Public Health and Clinical Data Registry Reporting.
Click here for the 2021 Medicaid EP detailed specification sheet for Objective 8: Public Health and Clinical Data Registry Reporting.
Quality Payment Program (QPP)
The PINNACLE Registry® and the Diabetes Collaborative Registry® captures valuable data on coronary artery disease, hypertension, heart failure, atrial fibrillation and diabetes in the outpatient setting to provide clinical insights to practices. The registries have been approved as a single Qualified Clinical Data Registry (QCDR) for the 2021 Merit-based Incentive Payment System (MIPS) Program Year, offering eligible participating practices a free and easy solution to report MIPS data in 2021.
Practices must be currently submitting data via System Integration (SI) or Secure File Transfer Protocol (SFTP) to have the registries submit MIPS data to CMS on their behalf.
Benefits of reporting via the PINNACLE and Diabetes Collaborative QCDR:
- Reporting MIPS data to CMS is a FREE benefit to eligible practices submitting data through the registries
- Interoperability with most electronic health record (EHR) systems
- Flexibility to select your six Quality measures, Promoting Interoperability measures and Improvement Activities that are specific to your practice through an easy to use interactive MIPS Dashboard
- Practices have the option of reporting as individual providers or at the group practice level (>2 clinicians who have reassigned their Medicare billing rights to a single TIN)
- When a practice reports as a group, their data is scored by CMS at the practice level. Group practice reporting also means that performance data on Care Compare is posted at the group level, not individual provider level.
- Frequent feedback and monitoring: Participants receive access to quality improvement tools and clinical support, as well as monthly benchmarking reports that include registry and CMS benchmarks for comparison purposes.
Quality Measures
Measures indicated as available for public reporting on Care Compare are required to meet certain standards set by CMS. These measures must be statistically valid, reliable, accurate, comparable across submission mechanisms and meet the minimum reliability threshold to be included in the Provider Data Catalog. The measures are posted publicly in plain language, making them easier to understand. Measures in their first two years, measures with fewer than 20 reporters, non-risk adjusted QCDR outcome and non-proportional measures are not available for public reporting.
2021 Program Year
Details on the CMS approved 2021 QPP and QCDR measures for the PINNACLE and Diabetes Collaborative QCDR are below:
2021 Clinical Data Registry QPP Timeline
Requesting use of the Registries for Reporting
Eligible clinicians who are actively submitting data to the PINNACLE Registry or the The Diabetes Collaborative Registry can request that we report their 2021 MIPS data on their behalf to CMS via the PINNACLE and Diabetes Collaborative QCDR. To initiate this, clinicians must complete an electronic data release consent form (eDRCF). Groups reporting with the registries will only need to sign one eDRCF while individual providers are required to submit one eDRCF for each provider reporting.
The eDRCF collects clinician and group consent. This is an annual requirement by CMS that allows the QCDR to release data to CMS on the clinicians’ or groups’ behalf. Only data for eligible clinicians and groups will be submitted to CMS if the QCDR receives a completed eDRCF by the specified deadline.
For more information, see our MIPS Frequently Asked Questions.
Additional Information
- 2021 QPP Final Rule Fact Sheet
- 2021 QPP Final Rule External FAQs
- 2021 MIPS Checklist
- If you have questions about the Clinical Data Registries and participating in MIPS, contact the Registry Support Team at (800) 257-4737 or ncdr@acc.org
- If you have an inquiry regarding the reporting requirements, payment adjustments and performance feedback reports please contact CMS, available Monday - Friday 8:00 a.m. - 8:00 p.m. ET by phone 1-866-288-8912 (TRS:711) or email at QPP@cms.hhs.gov.
- For more information about MIPS and how to get started please visit https://qpp.cms.gov/
- To maximize use of the ACC tools, we recommend you review the available clinical tool kits. You can access these tools by registering for an ACC.org account at https://cvquality.acc.org/Register.