FAQs — Malnutrition Quality Measures for Reporting into a QCDR

These frequently asked questions are currently divided into two sections: General Questions and QCDR Participation. Two additional FAQ sections — Enrollment and Data Submission — will be added soon. If you have a question not addressed in the FAQ, you can submit it to the Academy. The list of questions below will be updated based on inquires related to reporting into a QCDR.

General Questions

  1. What is the difference between the four (4) malnutrition electronic Clinical Quality Measures (eCQMs) and the new malnutrition quality measures for reporting into a Qualified Clinical Data Registry (QCDR)?
  2. What is the Merit-based Incentive Payment System (MIPS)?
  3. How does MIPS impact eligible clinicians (including registered dietitians)?
  4. Is participation mandatory in MIPS?
  5. If choose to participate in MIPS reporting, how many measures need to be reported to meet the statutory requirement?
  6. What is a Qualified Clinical Data Registry (QCDR)?
  7. What is the benefit to eligible clinicians of participating in a QCDR as opposed to other reporting mechanisms?
  8. Why is the Academy partnering with two QCDRs?
  9. What measures stewarded by the Academy are available in the QCDR?

QCDR Participation

  1. Are all Academy members in the United States expected to participate?
  2. If not a member of the Academy, can credentialed nutrition and dietetics practitioners still participate in the Premier Clinician Performance Registry or the U.S. Wound Registry?
  3. What criteria should be used to select the best registry for practice needs?

Enrollment Questions

  1. What are the costs associated with QCDR participation?
  2. How to get started?
  3. What are the registration and payment deadlines for the QCDR?

Database Submission Questions

  1. What additional measures are available to report via the Premier Clinician Performance Registry and the U.S. Wound registry that are practice relevant?
  2. Will technical assistance be available to support participation in QCDR reporting for MIPS?
  3. What is the deadline for submission of performance data for the next performance period?
  4. What is the quality performance period that the QCDR will report to CMS for MIPS?
  5. Can the data reported be made publicly available?

1. What is the difference between the four (4) malnutrition electronic Clinical Quality Measures (eCQMs) and the new malnutrition quality measures for reporting into a Qualified Clinical Data Registry (QCDR)?

The new malnutrition quality measures for QCDR reporting are for large- and small-scale clinician practices and do not replace the four eCQMs and Global Malnutrition Composite Score measure (composite measure).

The four malnutrition eCQMs have been adopted by numerous health systems and hospitals throughout the nation as a part of the Malnutrition Quality Improvement Initiative (MQii) Learning Collaborative. The four malnutrition measures remain on the Centers for Medicare and Medicaid Services (CMS) Measures under Consideration List (MUC List).

The Academy continues to pursue the adoption of the composite measure into the CMS Inpatient Quality Reporting Program as well as seeking endorsement from the National Quality Forum (NQF).

View more information on the four eCQMs and the composite measure.

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2. What is the Merit-based Incentive Payment System (MIPS)?

The Merit-based Incentive Payment System (MIPS), is a Medicare system for value-based reimbursement that is track one of two tracks under the Quality Payment Program (QPP). The goal is to move Medicare Part B providers toward a performance-based payment system. The second track is the Advanced Payment Model (APM). The MIPS track (track one) was designed with the goal of promoting the ongoing improvement and innovation toward value-based care.

Every year, CMS changes MIPS reporting requirements, so it is important to periodically check the CMS website . Available measures, improvement activities, and scoring methodology change annually.

Clinicians select measures and improvement activities within each category that are applicable to their scope of practice and then report their performance rates to CMS after the end of the year.

Additional resources can be found on the Academy's Quality Payment Program page and the CMS website.

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3. How does MIPS impact eligible clinicians which includes registered dietitian nutritionists?

All Medicare providers, including registered dietitian nutritionists, that meet specific eligibility criteria are required to participate in the MIPS as of 2019. A nutrition/dietitian specialty measure set was included in the MIPS quality performance category for the first time as of January 2020. The Centers for Medicare and Medicaid Services (CMS) determines eligibility based on the following 3 low volume thresholds:

  • a provider's Medicare Part B charges
  • the number of Medicare patients seen by the Medicare provider
  • the number of Medicare services provided during a distinct "look-back" period

Eligible clinicians who are required to report to MIPS will be evaluated on 4 categories, contributing to an annual MIPS final score. A brief snap is represented below of the breakout by performance category.

MIPS 2020 Category Weights

MIPS category weights pie chart

For registered dietitian nutritionists, CMS decided to continue the reweighted scoring of only the Quality category and the Improvement Activities category.

MIPS 2020 Category Weights for RDNs

MIPS 2020 Category Weights for RDNs - Pie Chart

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4. Is participation mandatory in MIPS?

First time enrollees into Medicare are excluded from participating in MIPS. If this does not apply, start by entering your National Provider Identifier (NPI) in the QPP Participation Status Tool, then click on the "Check All Year"” button. Click on the "CY 2020" tab and to view the current associated practice(s). Click on the "expand" icon to see MIPS participation eligibility details, clinician and practice level information, and other factors that impact MIPS reporting. Possible eligibility determinations include:

  • Required to Participate: The clinician (NPI) must participate in MIPS if all 3 of the low volume thresholds are met or exceeded and report data associated with the performance period (first year available to registered dietitian nutritionists for example is 2019 performance data). If data is not reported, the clinician will incur a penalty of up to 7 percent for the 2019 performance period, increasing to 9 percent of all payments for the 2020 performance period (which is reported in 2021). The clinician can report data as an individual or combine data with others in the practice (report as a group).
  • Opt-in to MIPS: The clinician (NPI) does NOT need to report 2020 MIPS data if all 3 of the low volume thresholds are not met. The clinician will NOT incur a penalty for not reporting data. In this instance, the clinician can combine data with others in the practice (report as a group) or clinician can tell CMS they want to "opt-in" and report as an individual if one or two of the low volume thresholds are met or exceeded. The clinician may report data as an individual or combine data with others in the practice (report as a group).
  • Voluntarily Participate in MIPS: RDNs that are excluded from MIPS and choose not to Opt-in may choose to voluntarily participate in order to gain experience with the program and prepare for future participations with MIPS. RDNs that voluntarily participate will not be subject to positive or negative payment adjustments.

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5. If choose to participate in MIPS reporting, how many measures need to be reported to meet the statutory requirement?

An eligible clinician or practice group must submit data for at least six (6) quality measures or a complete specialty measure set. At least one of the measures must be an outcome or another high priority measure in the absence of an applicable outcome measure. Data must be collected for the full calendar year (January 1, 2020 - December 31, 2020).

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

A QCDR is a Centers for Medicare & Medicaid Services (CMS) approved vendor that collects data on behalf of clinicians for data submission. A QCDR submission differs from qualified registry submission in that QCDRs can submit non-MIPS measures, called QCDR measures, as well as, MIPS quality measures.

A QCDR may also submit data for the Promoting Interoperability and Improvement Activities on behalf of the clinician(s).

A QCDR may submit measures for CMS approval that are:

  • Not contained in the annual list of Quality Payment Program (QPP) measures
  • Have substantive differences in the population covered by an existing QPP measure
  • Have a different manner of submission of an existing QPP measure
  • Developed by the QCDR, specialty societies, or regional quality collaboratives
  • A National Quality Forum-endorsed measure that is not part of MIPS

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7. What is the benefit to eligible clinicians of participating in a QCDR as opposed to other reporting mechanisms?

CMS highlights "one of the ways QCDRs can help to improve the quality of care patients receive is by collecting clinical data from clinicians and reporting this data to CMS on their behalf for purposes of MIPS." The benefits of participating as an eligible clinician in either the Premier Clinician Performance Registry or the U.S. Wound Registry allows you to:

  • Gain access to benchmark and feedback reports and standardized performance data
  • Successfully participate in regulatory programs on Medicare Part B services
  • Enhance patient care and improve identification of patients at risk for malnutrition
  • Provide a one-stop-shop for submitting data for MIPS Quality, Improvement Activities, and Promoting Interoperability categories

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8. Why is the Academy collaborating with two QCDRs?

The Academy decided to collaborate with two established registries, the Premier Clinician Performance Registry and the U.S. Wound Registry, to ensure that registered dietitian nutritionists, physicians, and all other eligible clinicians who provide care to malnourished patients or those at risk of malnutrition had access to relevant measures and had more than one choice in a QCDR that could meet their needs.

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9. What measures stewarded by the Academy are available in the QCDR?(specific to the QCDR)

The following two measures are supported by the Premier Clinician Performance Registry and can be reported to CMS for MIPS:

  • Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist (RDN Measure): Percentage of patients age 18 years and older who are nutritionally at-risk that have documented nutrition intervention recommendations by a registered dietitian nutritionist or clinical qualified nutrition professional if identified with moderate or severe malnutrition as part of a nutrition assessment.
  • Appropriate Malnutrition Diagnosis (Physician Measure): Percentage of patients age 18 years and older who are found to be moderately or severely malnourished based on a nutrition assessment that have appropriate documentation in the medical record of a malnutrition diagnosis.

Additionally, the Premier Clinician Performance Registry supports two measures that are not submitted to CMS for MIPS reporting, but that your health system, practice, or you can use for internal quality improvement. These two measures are:

  • Completion of a Screening for Malnutrition Risk and Follow-Up Referral to a Registered Dietitian Nutritionist for At-Risk Patients: Percentage of patients aged 18 years and older who have a completed malnutrition screening to determine their risk for malnutrition and for whom there is a referral to a registered dietitian nutritionist for nutrition assessment documented in the medical record.
  • Nutrition Care Plan Communicated to Post-Discharge Provider: Percentage of patients age 18 years and older at the date of the encounter who have a diagnosis of moderate or severe malnutrition and a nutrition care plan that includes recommended nutrition interventions for which a continuing care plan inclusive of nutrition is provided to the next level of care clinician or entity.

View the measure specifications.

The following two measures are supported by the U.S. Wound Registry and can be reported to CMS for MIPS:

  • Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist (RDN Measure): Percentage of patients age 18 years and older who are nutritionally at-risk that have documented nutrition intervention recommendations by a registered dietitian nutritionist or clinical qualified nutrition professional if identified with moderate or severe malnutrition as part of a nutrition assessment.
  • Obtaining Preoperative Nutritional Recommendations from a Registered Dietitian Nutritionist (RDN) in Nutritionally At-Risk Surgical Patients (Physician Measure): Percentage of patients age 18 years and older who have undergone a surgical procedure and were identified to be at-risk for malnutrition based on a malnutrition screening OR who were referred to a registered dietitian nutritionist or clinically qualified nutrition professional and have a preoperative nutrition assessment which was documented in the medical record along with documentation of any recommended nutrition interventions.

Additionally, the U.S. Wound Registry supports two measures that are not submitted to CMS for MIPS reporting, but that you or your practice can use for internal quality improvement. These two measures are:

  • Completion of a Screening for Malnutrition Risk and Referral to Registered Dietitian Nutritionist for At-Risk Patients (Quality Improvement Activities Measure): Percentage of patients aged 18 years and older who have a completed malnutrition screening to determine their risk for malnutrition and for whom there is a referral to a registered dietitian nutritionist for nutrition assessment documented in the medical record.
  • Appropriate Malnutrition Diagnosis: Percentage of patients age 18 years and older who are found to be moderately or severely malnourished based on a nutrition assessment that have appropriate documentation in the medical record of a malnutrition diagnosis.

View the measure specifications.

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Participation Questions

1. Are all Academy members in the United States expected to participate?

Participation in either the Premier Clinician Performance Registry or U.S. Wound Registry is not an Academy member requirement, however, all Academy members are encouraged to consider using either of these two QCDRs to report on relevant measures to CMS in order to meet the MIPS reporting requirements. Participation will help improve the quality of care provided by the clinician, individual practices, or the health care system for those patients who are at risk for malnutrition.

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2. If not a member of the Academy, can credentialed nutrition and dietetics practitioners still participate in the Premier Clinician Performance Registry or the U.S. Wound Registry?

Yes, all registered dietitian nutritionists may participate in either QCDR Registry based on eligibility criteria noted in FAQs questions 3 and 4 and in the Microlearning Series.

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3. What criteria should be used to select the best registry for practice needs?

It is suggested to use the following to determine which QCDR may be appropriate.

  • Eligible clinicians that are part of a health system, are part of a medium to large practice, or provide inpatient care, may want to consider the Premier Clinician Performance Registry
  • Eligible clinicians or those belonging to a small practice, ambulatory surgical centers, or who provide care in the ambulatory setting may want to consider participating in the U.S. Wound Registry
  • Eligible clinicians or practices may also want to consider which measures they are interested in reporting and whether they are currently collecting all the necessary data elements for each performance measure. To see which measures are reported by each registry, view the list of QCDR Registries
  • Eligible clinicians may also want to consider what other measures they may be able to report to meet the six (6) measures requirement.

The Academy can provide you with additional support in determining which QCDR may be right for you; Email quality@eatright.org.

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Enrollment Questions

1. What are the costs associated with QCDR participation?

  • Premier Clinician Performance Registry
    The price for participation in the Premier Clinician Performance Registry is $19,750 for up to 50 providers, with a cost of $225 for each additional provider. Additionally, there is a fee of $100 for each provider associated with the data submission to CMS. All costs are annual and are not eligible to be prorated.
  • U.S. Wound Registry
    The U.S. Wound Registry annual costs range from $150 to $699 per provider based on the services selected. To obtain exact pricing please start the enrollment process. Once enrolled, the U.S. Wound Registry will email a username and password to log into the registry. Then select the MIPS package that is most applicable and view the package price.

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2. How to get started?

  1. Eligible clinicians should first determine if participation in MIPS is required for mandatory reporting or decide to opt-in to MIPS. Read more information on possible eligibility determinations.
  2. For more information on MIPS basics, review the CMS Quick Start Guide.
  3. If participation in MIPS is required or the choice is to opt-in, review the malnutrition quality measure specifications for both registries, the Premier Clinical Performance Registry and the U.S. Wound Registry, to determine if the measures are relevant.
  4. Review other measures included in MIPS that can be reported to ensure the 6-measure reporting requirement can be met. A complete list of the measures offered for the Premier Clinician Performance Registry and the U.S. Wound Registry can be found on their respective websites.
  5. Ensure that all the data elements are currently being collected to meet the malnutrition quality measures as well as the additional measures selected to report for MIPS participation.
  6. Contact the registry and work with the assigned staff to ensure that necessary data for the MIPS measures is transmitted appropriately and begin the enrollment process.

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3. What are the registration and payment deadlines for the QCDR?

  • Premier Clinician Performance Registry
    The deadline to complete contracting with Premier is September 30, 2020. The payment terms are 50% upon contract execution, with the remaining balance invoiced in March or April 2021.
  • U.S. Wound Registry
    Registration and payment deadline for the U.S. Wound registry are February 28, 2021.

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Database Submission Questions

1. What additional measures are available to report via the Premier Clinician Performance Registry and the U.S. Wound registry that are practice relevant?

To meet MIPS reporting requirements for the quality category, the eligible clinician must report at least six quality measures, including at least one outcome measure for a 12-month period (Note: if an applicable outcome measure is not available, select one other high priority measure).

While each clinician, practice, or health system should determine which measures are practice relevant, the Academy has identified the following list of measures which may be of interest and based on the Centers for Medicare & Medicaid Services (CMS), HHS. Final Rule. Federal Register, Vol. 84, No. 221, Friday, November 15, 2019, Pages 63379-63380.

  • #001: Diabetes - Hemoglobin A1c Poor Control (>9)
  • #128: Preventive Care and Screening - Body Mass Index (BMI) Screening and Follow-Up Plan
  • #130: Documentation of Current Medications in the Medical Record - High Priority
  • #181: Elder Maltreatment Screening and Follow-Up Plan
  • #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • #374: Closing the Referral Loop: Receipt of Specialist Report
  • #239: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
  • #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

View the full list of CMS MIPS Measures.

  • Premier Clinician Performance Registry
    The Premier Clinician Performance Registry supports all MIPS electronic clinical quality measures (eCQMs). Additionally, the registry supports several QCDR measures.
  • U.S. Wound Registry
    The U.S. Wound Registry supports all MIPS electronic clinical quality measures. Additionally, the registry supports several QCDR measures which can be accessed here.

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2. Will technical assistance be available to support participation in QCDR reporting for MIPS?

All technical assistance is provided directly by either the Premier Registry or U.S. Wound Care Registry. Please note, technical support from registries may be associated with additional costs or fees. Eligible clinicians should first work with their internal staff who are responsible for regulatory reporting to determine feasibility of MIPS reporting.

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3. What is the deadline for submission of performance data for the next performance period?

  • Premier Clinician Performance Registry
    The deadline for submission of the performance data for the next period is early February 2021. The deadline to select measures that should be submitted by Premier to CMS is in early March 2021.
  • U.S. Wound Registry
    The deadline for submission of the performance data for the next performance period is February 15, 2021. As soon as the U.S. Wound Registry submits the data to CMS through the API, same day feedback from CMS is received and these preliminary results from CMS are forwarded to the clinician within 3 to 4 days. CMS final results are not available until July 2021 for the 2020 MIPS Reporting Period.

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4. What is the quality performance period that the QCDR will report to CMS for MIPS?

For the Quality Performance Category, 12 months of quality data will need to be reported for the 2020 performance period (January 1 – December 31, 2020).

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5. Can the data reported be made publicly available?

Yes, the measures reported as part of the MIPS program may be publicly reported on the Physician Compare website if selected by CMS.

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