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The Pathologists Quality Registry improves practice performance by benchmarking against other pathology practices and makes it easier to qualify for bonuses under Medicare's Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) track. This registry, developed by the College of American Pathologists (CAP), will be the first pathologist-specific registry and powered by FIGmd, a leading provider of clinical data registries.
The Pathologists Quality Registry will be available to pathologists for use in collecting medical and/or clinical data to foster improvement in the quality of care provided to patients in addition to MIPS reporting. Designed specifically for the practice of pathology by pathologists, the registry will ensure pathologists have a mechanism for quality improvement against the CAP’s established standards, optimal opportunity for positive payment adjustments under MIPS, and compliance with requirements under the Medicare QPP program.
The CAP has partnered in the development of the Pathologists Quality Registry with FIGmd, a company that specializes in developing clinical registries and integrating data from multiple sources into those registries. FIGmd has developed and maintained registries for several specialty societies, including the American College of Cardiology, American Society for Clinical Oncology, American Academy of Dermatology, American College of Emergency Physicians, American Academy of Neurology, American Academy of Ophthalmology, American Academy of Otolaryngology – Head and Neck Surgery, American College of Rheumatology, and American Urological Association.
The Pathologists Quality Registry helps reduce the burden of reporting on pathologists by offering MIPS reporting for Quality Performance and Improvement Activities categories, which are the only two needed by non-patient-facing pathologists in 2018.
Pathologists Quality Registry instead of claims-based reporting for several reasons:
- Claims-based reporting does not support reporting for all categories of MIPS.
- Claims-based reporting is only available for a subset of measures that can be found in the Pathologists Quality Registry.
- Claims-based reporting is only based on Medicare patients, not all of your applicable patients.
- The Centers for Medicare and Medicaid Services (CMS) data suggests that clinicians’ performance is higher when reporting through a registry due to the availability of additional clinical data to support measures.
In addition, registry participants may choose to report as a group or individually. The complex claims-based reporting can only be used for individual reporting. The Pathologists Quality Registry will improve practice performance and identify opportunities to further enhance patient care with quarterly benchmarking reports against other pathology practices.
The Pathologists Quality Registry is a CMS-approved, qualified clinical data registry (QCDR). The Pathologists Quality Registry has successfully completed a qualification process that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.
With the CMS QCDR designation, the Pathologsits Quality Registry can help by submitting your Medicare data to the CMS in order to comply the CMS latest Medicare payment program QPP.
The advantages of using a CMS approved QCDR are that:
- Multiple MIPS categories can be submitted through one mechanism
- Group reporting is allowed, as claims reporting is only for individuals
- Allows participants to track reporting progress throughout the year and provides benchmarking information for quality improvement
Since the Pathologists Quality Registry is a CMS-approved QCDR, participants may submit information on both the CMS QPP measures (eight for pathology) and on six nonQPP/QCDR pathology specific measures, which are only available within the Pathologists Quality Registry. The CMS allows up to 30 additional non-QPP/QCDR measures, and the CAP plans to add additional measures in the future. A QCDR gives a better picture of the overall quality of care provided, because QCDRs collect and report quality information on patients from all payers, not just Medicare patients. The CMS awards QCDR status on an annual basis. The CAP will re-apply next year in order to maintain QCDR status for the Pathologists Quality Registry.
The cost for the Pathologists Quality Registry is $299 per CAP member per year. This price includes access to dashboards and standard reports, plus submission to the CMS for your MIPS reporting. Non-members may also enroll in the Pathologists Quality Registry at a cost of $799 per pathologist per year at the point of Registry purchase to receive the member discount. For a practice, the total costs for participating in the registry will be the sum of the price for each practicing pathologist in the group.
The Pathologists Quality Registry includes dashboards that provide you with access to everything from performance measurements and comparisons to basic analytics. Interactive tools increase usability and flexibility and put pertinent and actionable metrics at your fingertips. You can generate reports and measure your performance results against the registry as a whole. If your practice has multiple locations, you can benchmark each location separately.
Yes. A group is a practice of two or more Eligible Clinicians (EC’s) that would like to combine their measures and encounters under one tax identification number (TIN) for submission of the program. You will not have to register with the CMS to report as a GPRO. You will indicate your submission preference (Individual vs. GPRO) when requested via FIGmd, and/or at the end of the year within the MIPS Submission Module on your dashboard.
The CAP is the only pathologists’ medical specialty society to offer the only the CMS approved Pathologists Quality Registry on the market designed by pathologists for pathologists. With over 50 years of experience in collecting data for peer comparison, quality improvement and regulatory compliance, the CAP has the expertise and track record, the relationships with the CMS to help pathologists comply with MIPS quality reporting requirements.
In the past Medicare payment was based on just reporting measures; now, Medicare payment is based on how you perform on the measures, compared to your peers. Pathologists have the opportunity to report, and potentially receive incentive payments by demonstrating the highest quality care. The CAP wants to reduce the administrative burden of reporting, while helping pathologists maximize their performance and MIPS revenue.
Enrollment in the registry will be for the MIPS 2018 reporting year. This means you would need to identify an alternate methodology for the MIPS 2017 reporting period. With 2017 being denoted a transitional year by the CMS, you can still report data via claims, so depending on the processes in place with your practice, you may be able to continue with that process. We have a claims-based reporting fact sheet that can guide reporting for 2017.
Sign-up and Enrollment for the registry opens October 8, 2017. The initial launch of the registry is for 2018 manual data entry. To complete the one-time sign-up and enrollment, go to registry.cap.org, and you will see instructions on the information you will need to have ready to complete the enrollment. Enrollment includes completing basic information about you and your practice, providing your NPI and TIN, providing additional information about your practice and different locations, if applicable, signing standard legal agreements, and providing payment. We estimate that it will take you less than 30 minutes to complete the one-time sign-up and enrollment in the registry.
After you complete sign up, enrollment, and payment, you will have access to the webbased manual data entry portal starting January 2, 2018 so you can start entering manual data at the beginning of the year. Prior to entering any manual data, practices must complete the sign up portal, and sign legal agreements to complete enrollment. For manual data entry, practices must complete the enrollment process no later than October 1, 2018 in order to be eligible to submit 2018 MIPS through the registry, and in order to start entering data to meet the MIPS 2018 reporting deadline of March 2019.
The CAP is currently pilot testing LIS-billing system and EHR-facilitated data entry into the registry. The initial launch of the registry is for manual data entry only, as data integration testing and integration is refined. The CAP will release information on successful integration and key dates once the pilot testing is completed.
Technical and Logistical Questions
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In order to enroll in the Pathologists Quality Registry you will need to provide all of the information included in the enrollment checklist available at cap.org. The enrollment checklist details all the information required to enroll in the Pathologists Quality Registry.
To complete the enrollment paperwork (one time only) will take multiple steps.
Step 1: Enter all of your site’s pertinent information including the physician details (e.g. TIN and NPI). For small practices (e.g. 4 physicians) this can be completed in less than 30 min, however, the time increased based on the volume of pathologists in your practice.
Step 2: Sign legal documents. The agreement with CAP will be processed immediately, however the FIGmd agreement will be submitted for signature, there will be a lag time associated with this.
Step 3: Once the FIGmd contract is signed, you will then be able to return to the system to process your payment.
Step 4: Within 3-5 business days, a FIGmd account representative will reach out to your site administrator to schedule an introductory call.
The CAP is working to enable automated data entry, however manual data entry will be available immediately. Use of the web-based forms to enter data into the Registry will require a staff person to manually enter your data.
Yes. You can use the manual data entry option for submitting data.
The CAP is working with APLIS/LIS vendors as we launch the Pathologists Quality Registry. The CAP will publish and maintain a list of vendors whom FIGmd has successfully integrated with the CAP registry. Additionally, web data entry forms are an option for practices where integration is not feasible.
Once enrolled in the Pathologists Quality Registry, your practice will select the data submission methodology that works best for your practice. One option is a web interface for manual entry of case data elements for the quality measures or an automated data submission. Depending on what works for your practice you can either have the data pulled directly from your LIS or have a file pushed to the registry. Our registry partner, FIGmd, will work with your practice on the mapping of required data elements from your APLIS/LIS or other system that houses the needed data. The registry also supports attestation for improvement activities.
Data Security and Privacy Questions
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Only authorized practice managers will have access to practice level data that includes individual pathologist dashboards. Pathologists can only see their own identifiable individual information. Data collected from other registry participants will be rolled up into the aggregate and appear as the registry benchmark.
The data submitted by practices is only used for reporting to the CMS on behalf of the practice. The CAP will not analyze, report, or sell patient or provider identifiable data. The individual patient data submitted by a practice remain the exclusive property of the practice.
Registered users are welcome to use their data to help improve and promote their practice. Data can’t be shared across practices except at the aggregate level for benchmarking purposes.
Physician access is restricted to their own individual identifiable data. Authorized practice managers can view data for any of the individual pathologists in the practice as well as the practice level.
Data security was a critical factor in the selection of a registry platform. The vendor that the CAP selected is accredited under EHNAC Data Registry Accreditation Program (DRAP) and Cloud Enabled Accreditation Program (CEAP). The vendor has additional relevant certifications ensuring the security of the data in the registry.