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"NPQR is a flexible, dynamic tool designed by us in the laboratory, for us. With NPQR, ASCP and our members will be able to improve the quality of what we do, demonstrate the value we add, and elevate the care we provide to our patients."
Alexandra Brown, MD, FASCP
Medical Director, National Pathology Quality Registry, ASCP
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  • NPQR

National Pathology Quality Registry

The National Pathology Quality Registry (NPQR) is a national quality and benchmarking program led by ASCP. The registry captures data that measure adherence to clinical practice guideline recommendations, quality and performance standards, and appropriate utilization of laboratory testing.

About NPQR
Information for Interested Laboratories
Measures and Reporting
2019 MIPS Reporting
Learn About NPQR

National Pathology Quality Registry

The National Pathology Quality Registry (NPQR) is a national quality and benchmarking program led by ASCP. The registry captures data that measure adherence to clinical practice guideline recommendations, quality and performance standards, and appropriate utilization of laboratory testing. NPQR has been granted Qualified Clinical Data Registry (QCDR) status for 2021 by the Centers for Medicare and Medicaid Services (CMS), meaning pathologists and laboratories can harness their laboratory data to both improve patient care and fulfill 2021 MIPS requirements. Download a list of the new measures developed specifically for ASCP’s NPQR and approved by CMS for 2021 reporting through a QCDR.

Download QCDR Measures Full Detail

Benefits of NPQR

NPQR helps laboratories optimize quality and performance and fulfill requirements in several key ways.

  • Monitoring appropriate utilization of laboratory testing.
  • Improving pre-analytical processes.
  • Optimizing turnaround time and critical value reporting.
  • Establishing best practices through national and peer group comparisons.
  • Assessing analytical and diagnostic accuracy.
  • Participating in pay-for-performance programs to meet CMS requirements

 

Quick NPQR Program Facts

  1. Developed as a tool for pathologists and laboratory professionals to promote best practices within laboratory medicine. This tool will also benefit our clinical colleagues and ultimately improve patient care.
  2. Designed with laboratory information system providers, the Registry supports integration with multiple LIS and includes quality and performance measures spanning the categories outlined in the link below.

Download  a brochure to see a sample of the quality and performance measures included in NPQR version 1.

Download Brochure

Learn more about how NPQR protects patient privacy, ensures data security, and complies with HIPAA regulations through our privacy and security white paper.

Download White Paper


The American Society for Clinical Pathology (ASCP) doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by ASCP directly or through a contractor or any other entity with which ASCP arranges to carry out its programs and activities. If needed to access the information on this website, ASCP will arrange to provide auxiliary aids and services including information in accessible formats such as Braille, large print, data/audio files, relay services and TTY communications, as appropriate under the circumstances. To request NPQR information in an accessible format email npqr@ascp.org.

Facts About NPQR Design

Why is NPQR Needed?

  • The NPQR planning process revealed that among laboratories and institutions, there is a need for a guidelines-driven, national quality measurement platform.
Who Participated in the design of NPQR?
  • NPQR is designed with guidance from your peers. An ASCP-appointed NPQR Steering Committee, along with input from several task forces focusing on specific clinical areas, has been designing the first version of the Registry. The planning phase of NPQR included interviews with stakeholders, surveys of ASCP membership priorities, and additional research.
What Reports and other features does NPQR include?
  • The Registry provides participants with standard reports as well as interactive dashboards that allow laboratories to analyze their performance across tests, responsible staff, and other dimensions.

 




     

Facts About NPQR Participation

Who can participate?

  • Any US-based laboratory can participate in NPQR, to include
    • Clinical pathology laboratories/laboratory medicine practices
    • Pathology laboratories/practices

    These entities can participate on an individual laboratory/practice basis, or as part of a hospital system, reference laboratory network, or other group entity.

How will the Registry benefit physicians who participate?

  • NPQR provides pathologists and laboratory professionals with guidelines-driven performance measurement, benchmarking, and quality improvement capabilities. It enables laboratories to identify areas for improvement, participate in government-required pay for performance programs, integrate results into educational programs, and measure adherence to appropriate utilization of laboratory testing. 

Do I need to manually enter data, or can I use automated feeds from my existing LIS?

  • In order to minimize manual data entry, ASCP is working with laboratory systems vendors to integrate the Registry directly in their products. Additionally, laboratories that wish to connect their lab systems using their existing information technology capabilities are also allowed to certify for Registry submission.

Is the data my lab provides secure and/or anonymous?

  • Yes.  NPQR is compliant with the Health Information Portability and Accountability Act of 1996 (HIPPA) and Health Information Technology for Economic and Clinical Health (HITECH) Act.







 

How to Participate

Interest Form

Interested laboratories should complete the NPQR Interest Form below to be included in NPQR updates.

 

Contact for More Information

To learn more about the National Pathology Quality Registry, please contact Ali Brown, MD, FASCP, Chief Officer, Medical Quality, ASCP, and the ASCP NPQR team at NPQR@ascp.org.

Measures and Reporting

About NPQR Measures and Reporting 

The National Pathology Quality Registry is a member-driven initiative that will allow participants to collect and disseminate data critical to quality improvement in the laboratory. NPQR measures were created by pathologists and laboratory professionals to provide a trusted source for best practices and benchmarking. This interactive resource applies data aggregation and visualization tools to data from your lab’s LIS to help you develop projects to improve patient care and reduce costs.

 

What NPQR Offers

NPQR offers 14 CMS-approved QCDR measures, 30 NPQR-exclusive performance measures, and 5 Quality Payment Program measures, as well as a variety of Improvement Activities for MIPS reporting. While NPQR’s primary focus is as a practical improvement tool, participation can also be utilized to satisfy requirements for pathologists participating in MIPS. NPQR measures were developed to apply to a wide variety of pathology specialties and practices.

NPQR Quality Payment Program (QPP) Measures

These measures are part of the QPP pathology specialty measures set and can be reported through NPQR, billing/claims, or other registries. They are largely the former Physician Quality Reporting System (PQRS) measures.

 

Measure Descriptions

Click the measures listed below to view the associated descriptions. Measures with an asterisk (*) are outcome or high priority measures. Use the button below to download a PDF with additional details about each measure.

Download QPP Measures

QPP 249: Barrett’s Esophagus Pathology Reporting 

Measure Description: Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia
Registry and Claims Specifications

QPP 250: Radical Prostatectomy Pathology Reporting

Measure Description: Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status
Registry and Claims Specifications

QPP 395: Lung Cancer Reporting (Biopsy/Cytology Specimens)*

Measure Description: Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report
Registry and Claims Specifications

QPP 396: Lung Cancer Reporting (Resection Specimens)*

Measure Description: Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type
Registry and Claims Specifications

QPP 397: Melanoma Reporting

Measure Description: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate
Registry and Claims Specifications

NPQR 2020 Qualified Clinical Data Registry (QCDR) Measures

These measures are exclusive to NPQR, and can be utilized for benchmarking and quality improvement practices in the laboratory. They can also be used to satisfy MIPS requirements. These measures can be reported to CMS only through NPQR. Laboratories can choose to provide data on any or all of these measures, as they relate to their particular practice.

Measure Descriptions

Click the measures listed below to view the associated descriptions. Measures with an asterisk (*) are outcome or high priority measures. Use the buttons below to download a PDF with additional details about each measure or an Excel document with the full details for all measures.

Download QCDR Measures
Download QCDR Measures Full Detail

NPQR1. Notification to the Ordering Provider Requesting Myoglobin or CK-MB in the Diagnosis of Suspected Acute Myocardial Infarction (AMI)

Measure Description: Percentage of ordering providers who have ordered a myoglobin or CK-MB for greater than 10% of the patients who have a diagnosis of suspected AMI, that were informed by the laboratory these tests are not beneficial for patients with a diagnosis of suspected AMI.

NPQR2. Notification to the Ordering Provider Requesting Thyroid Screening Tests Other Than Only a Thyroid Stimulating Hormone (TSH) in the Initial Screening of a Patient With a Suspected Thyroid Disorder

Measure Description: Percentage of ordering providers who ordered thyroid screening tests other than a TSH in greater than 10% of their patients for the evaluation of a patient with suspected non-neoplastic thyroid disease, who were informed by the laboratory these tests are not beneficial for the initial diagnosis of thyroid disease.

NPQR3. Notification to the Ordering Provider Requesting Amylase Testing in the Diagnosis of Suspected Acute Pancreatitis

Measure Description: Percentage of ordering providers who ordered an amylase test in greater than 10% of their patients for the evaluation of a patient with acute pancreatitis, who were informed by the laboratory this test is not beneficial for the diagnosis of pancreatitis.

NPQR4. Time Interval: Critical Value Reporting for Chemistry*

Measure Description: Measurement of the time interval beginning with the time results are verified for any of the following Sodium, Potassium, Chloride, Calcium-total, Bicarbonate – CO2, Ammonia, Total Bilirubin – Newborn, Arterial Blood Gases – pH, PO2, PCO2, Glucose, Glucose – Newborn tests until the critical value is reported by the laboratory. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received, this should be considered as performance not met.

NPQR5. Time Interval: Critical Value Reporting for Cerebrospinal Fluid - White Blood Cells (CSF - WBC)*

Measure Description: Measurement of the time interval beginning with the time results are verified until the critical value is reported by the laboratory for CSF-WBC. Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through the Laboratory Information System, the Electronic Health Record, or email with read receipt functionality. When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.

NPQR6. Time Interval: Critical Value Reporting for Toxicology*

Measure Description: Measurement of the time interval beginning with the time results are verified until the critical value is reported by the laboratory for carbamazepine, phenobarbital, and acetaminophen toxicology tests. Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through the Laboratory Information System, the Electronic Health Record, or email with read receipt functionality. When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.

NPQR7. Time Interval: Critical Value Reporting for Troponin*

Measure Description: Measurement of the time interval beginning with the time results are verified for troponin until the critical value is reported by the laboratory. Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through the Laboratory Information System, the Electronic Health Record, or email with read receipt functionality. When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.

NPQR11. Rate of Communicating Results of an Amended Report with a Major Discrepancy to the Responsible Provider*

Measure Description: Rate of communicating to the responsible provider the results of diagnostic reports that were amended due to a major discrepancy.

NPQR13. Rate of Notification to Clinical Provider of a New Diagnosis of Malignancy*

Measure Description: The rate of reporting to a responsible clinical provider from the pathologist when there is a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin) from a pathology specimen.

NPQR15. Non-small Cell Lung Carcinoma (NSCLC) Ancillary Biomarker Testing Status and Turnaround Time From Point of Specimen Accession Date to Ancillary Testing Completion and Reporting Date Should Be ≤10 days

Measure Description: Percentage of lung cytopathology or pathology specimen cases with non-small cell lung carcinoma (NSCLC) that address presence or absence of actionable targets through ancillary biomarker testing AND meet the maximum 10-day turnaround time (TAT) requirement (report date of ancillary biomarker testing – accession date = ≤ 10 days).

NPQR16. Notification to the Provider Ordering Repeat Blood Chemistry Panels in Clinically Stable Patients Within Four Days.

Measure Description: Percentage of providers who ordered a repeat blood chemistry panel within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.

NPQR17. Notification to the Provider Ordering Repeat C. difficile Stool Toxin Testing Within Seven Days.

Measure Description: Percentage of providers who ordered repeat C. difficile stool toxin testing within seven days on an individual patient, who were notified by the laboratory that repeat testing is not beneficial, and can lead to increased false positive test results.

NPQR18. Notification to the Provider Ordering Repeat Complete Blood Counts (CBCs) in Clinically Stable Patients Within Four Days.

Measure Description: Percentage of providers who ordered a repeat CBC within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.

NPQR19. Notification to the Provider Ordering Repeat Hepatitis C Serology Testing on a Patient With Previously Positive Results.

Measure Description: Percentage of providers who ordered repeat Hepatitis C serology testing on a patient with previously positive results, who were notified by the laboratory that repeat testing is not beneficial.

NPQR Performance Measures

These measures are exclusive to NPQR and can be utilized for benchmarking and quality improvement practices in the laboratory. They are not used for CMS reporting to satisfy MIPS. Laboratories can choose to provide data on any or all of these measures, as they relate to their particular practice.

Measure Descriptions

Click the measure categories below to view the related measures and their descriptions. Use the button below to download a PDF with additional details about each measure.

Download Performance Measures

Appropriate Use of Laboratory Testing

  • Notification to the Ordering Provider Requesting 25-OH-Vitamin D Testing 
    Measure Description: Percentage of ordering providers who ordered a 25-OH-Vitamin D, who were informed by the laboratory this test is not beneficial for patients who do not have suspected osteoporosis, chronic kidney disease, malabsorption or obesity

    Or follow practice patterns without the need for clinician notification with:

    Don’t Order Population Based Screening For 25-OH-Vitamin Deficiency
     Measure Description: Percentage of patients who have a 25-OH-Vitamin D performed
  • Test for Troponin I or T in the Diagnosis of Acute Myocardial Infarction (AMI). Don’t Use Myoglobin or CK-MB.
    Measure Description: Percentage of patients who have a diagnosis of AMI, that have a troponin I or T test performed
  • In the Initial Screening of a Patient with a Suspected Thyroid Disorder Perform only a Thyroid Stimulating Hormone (TSH) Test, and if Abnormal, Follow up with Additional Evaluation Depending on Findings
    Measure Description: Percentage of patients who have only a Thyroid Stimulating Hormone (TSH) performed in the evaluation of non-neoplastic thyroid disease
  • In Cases of Suspected Acute Pancreatitis Test for Lipase. Do Not Test for Amylase.
     Measure Description: Percentage of patients who have lipase testing performed when suspecting acute pancreatitis
  • Notification to the Provider Ordering Repeat Blood Chemistry Panels in Clinically Stable Patients Within Four Days.
     Measure Description: Percentage of providers who ordered a repeat blood chemistry panel within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.
  • Notification to the Provider Ordering Repeat C. difficile Stool Toxin Testing Within Seven Days.
     Measure Description: Percentage of providers who ordered repeat C. difficile stool toxin testing within seven days on an individual patient, who were notified by the laboratory that repeat testing is not beneficial, and can lead to increased false positive test results.
  • Notification to the Provider Ordering Repeat Complete Blood Counts (CBCs) in Clinically Stable Patients Within Four Days.
     Measure Description: Percentage of providers who ordered a repeat CBC within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.
  • Notification to the Provider Ordering Repeat Hepatitis C Serology Testing on a Patient With Previously Positive Results.
     Measure Description: Percentage of providers who ordered repeat Hepatitis C serology testing on a patient with previously positive results, who were notified by the laboratory that repeat testing is not beneficial.

 

Improving Pre-Analytical Processes

  • Test Not Performed or Results Canceled
     Measure Description: The percentage of tests that were not performed or results not available due to any of the following reasons: inadequate container, inappropriate volume, compromised sample, sample contamination, improper storage or transport; or any combination of these reasons
  • Test Not Reordered after Cancellation Due to Pre-Analytical Issue or Error (Within 24 Hours Inpatient)
     Measure Description: Percentage of tests that were reordered as a result of that test not being performed or results not available due to any of the following reasons: inadequate container, inappropriate volume, compromised sample, contamination, improper storage or transport; or any combination of these reasons
  • Test Not Reordered after Cancellation Due to Pre-Analytical Issue or Error (Within 60 days Outpatient)
     Measure Description: Percentage of tests that were reordered as a result of that test not being performed or results not available due to any of the following reasons: inadequate container, inappropriate volume, compromised sample, contamination, improper storage or transport; or any combination of these reasons

 

Optimizing Turnaround Time and Critical Value Reporting

  • Time Interval: Sample Collection to Results Verified
     Measure Description: Time interval of tests recorded from sample collection until results are verified (Clinical Pathology)
  • Time Interval: Sample Collection to Sample Received
     Measure Description: Time interval of tests recorded from sample collection time until sample is received in the laboratory (Anatomic and Clinical Pathology)
  • Time Interval: Sample Received to Results Verified / Case Signed Out
    Measure Description: Time interval of tests recorded from the time a sample is received in the laboratory until results are verified (Clinical Pathology)
  • Time Interval: Critical Value Reporting
     Measure Description: Measurement of the time interval beginning when results are verified until the critical value is reported (Clinical Pathology)
  • Rate of Critical Value Reporting for Cerebrospinal Fluid - White Blood Cell (CSF-WBC) 
     Measure Description: The percentage of CSF-WBC tests reported by a laboratory back to the ordering provider as critical when the CSF-WBC test results in a critical value
  • Rate of Critical Value Reporting for Chemistry Tests
     Measure Description: The percentage of chemistry tests; Sodium, Potassium, Chloride, Calcium, Bicarbonate, Ammonia, Total Bilirubin – Newborn, Arterial Blood Gases – pH, PO2, PCO2, Glucose, Glucose – Newborn, reported by a laboratory back to the ordering provider as critical when a chemistry test results in a critical value
  • Rate of Critical Value Reporting for Troponin
     Measure Description: The percentage of troponin tests reported by a laboratory back to the ordering provider as critical when a troponin test results in a critical value
  • Rate of Critical Value Reporting for Toxicology
     Measure Description: The percentage of carbamazepine, phenobarbital, acetaminophen toxicology tests reported by a laboratory back to the ordering provider as critical when the test results in a critical value

 

Assessing Diagnostic Accuracy

  • Total Discrepancies Overall Rate
     Measure Description: Rate of major and minor discrepancies per overall cases evaluated
  • Major Discrepancy Rate   
     Measure Description: Rate of major discrepancies per overall cases evaluated
  • Misidentified Cases
     Measure Description: Rate of cases with incorrect patient demographics and/or anatomic location
  • Non-Diagnostic Error Rate
    Measure Description: Rate of cases in which there is missing or incorrect information or typographical inaccuracies are present
  • All Specimen Defects Rate
     Measure Description: Rate of cases in which any specimen defect occurs
  • Major (Only) Specimen Defects Rate
    Measure Description: Rate of cases in which a major defect in specimen processing occurs
  • Rate of Major Discrepancy in Diagnosis between Frozen Section and Final Diagnosis
     Measure Description: Rate of major discrepancies when comparing diagnosis from a frozen section to the final diagnosis
  • Rate of Surgical Anatomic Pathology Case Review
     Measure Description: Rate of retrospective review of all surgical pathology cases
  • Rate of Preliminary Autopsy Diagnosis (PAD) Sign Out
     Measure Description: Rate of autopsy preliminary anatomic diagnoses (PAD) signed out in less than two business days
  • Rate of Review of Pap Test Samples Interpreted as Negative
     Measure Description: Rate of Pap test samples interpreted as negative by the cytotechnologist that are reevaluated by a pathologist or a qualified supervisory cytotechnologist prior to reporting
  • Non-small Cell Lung Carcinoma (NSCLC) Ancillary Biomarker Testing Status and Turnaround Time From Point of Specimen Accession Date to Ancillary Testing Completion and Reporting Date Should Be ≤10 days
     Measure Description: Percentage of lung cytopathology or pathology specimen cases with non-small cell lung carcinoma (NSCLC) that address presence or absence of actionable targets through ancillary biomarker testing AND meet the maximum 10-day turnaround time (TAT) requirement (report date of ancillary biomarker testing – accession date = ≤ 10 days).

Reporting Improvement Activities for Pathologists in MIPS

In 2015, the Medicare Access and Chip Reauthorization Act, known as MACRA, created the Quality Payment Program (QPP) that attempts to shift healthcare delivery from fee-for-service to pay-for-performance. The QPP consists of two tracks, with the Merit-based Incentive Payment System (MIPS) being the QPP option that most pathologists will likely be participating in. 

In 2019, pathologists must attest to two medium-weighted or one high-weighted improvement activity to earn the minimum amount of points in this category. For more information, please see the CMS’ Quality Payment Program webpage.

 

Resources for Reporting Improvement Activities

Click below to download a table describing Improvement Activities that are applicable to pathologists for reporting in the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS). The document shows examples of qualifying activities in italics, including National Pathology Quality Registry (NPQR) participation options.

Download Improvement Activities

2019 MIPS Reporting

About MIPS Reporting

In 2015, the Medicare Access and CHIP Reauthorization Act, known as MACRA, created the Quality Payment Program (QPP) that attempts to shift healthcare delivery from fee-for-service to pay-for-performance. Former Medicare reporting programs (the Physician Quality Reporting System, Value-based Modifier, and Meaningful Use) have been consolidated into the QPP, which rewards value over volume of services delivered. The QPP option in which most pathologists will likely participate is the Merit-based Incentive Payment System (MIPS). For 2019 and subsequent years, clinicians will receive positive or negative payment adjustments based on their performance relative to scores of their peers.

Under MIPS, a clinician’s payment adjustments are based on a composite performance score. For pathologists and other non-patient facing clinicians, this score is calculated by adding up points earned in two categories: Quality and Improvement Activities, and comparing those scores against a group of like-providers. A composite score in 2019 will determine payment adjustments in 2021. Based on a clinician’s score, they will either receive up to a 7% bonus or down to a 7% penalty.

How to Confirm Your Eligibility

  1. Confirm your eligibility status by visiting https://qpp.cms.gov/participation-lookup.
  2. Determine whether CMS classifies you as being in an Advanced Alternative Payment Model (APM), as participation in an APM takes precedence over participation in MIPS.
  3. Check to make sure you are classified by CMS as a non-patient facing clinician – this special status means you only need to report in two (of the four) MIPS performance categories:
    1. Quality
    2. Improvement Activities

You are not eligible for the MIPS program if you meet one of the following criteria:

  • You are already participating in an APM.
  • You are below the low-volume threshold, meaning one of the following applies to you:
    • You billed $90,000 or less in Medicare Part B.
    • You have 200 or fewer Medicare Part B patients.
    • You have 200 or fewer covered professional services under the Physician Fee Schedule. (When CMS uses the term “service”, they are equating one professional claim line with positive allowed charges to one professional service.)
  • You are new to the Medicare Program (i.e., this is your first year as a Medicare provider).

Additional Resources

CMS QPP Resource Library

How to Report Data

Reporting Individually

  • An individual is defined as a single clinician, identified by their individual National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN).
  • Enter your NPI into the Quality Payment Program Look-Up Tool to see if you are eligible as an individual or as part of a group.

Reporting as Part of a Group

  • A group is defined as a single TIN with 2 or more clinicians (at least one clinician within the group must be MIPS eligible) as identified by their NPI, who have reassigned their Medicare billing rights to a single TIN.
  • Enter your organization’s Tax Identification Number (TIN) number after logging in to the Quality Payment Program website with your user account to determine if you qualify for group reporting.

To decide whether reporting individually or as a group makes more sense for you, consider the following:

  • Group reporting is advantageous as it gives increased opportunity to report on a more varied set of measures, but keep in mind that all clinicians under a TIN are included, not just those that are MIPS-eligible.
  • Group reporting applies to both the Quality category and the Improvement Activities category. (You can’t report as a group for one and individually for the other.)

Reporting Methods

  • Qualified Clinical Data Registry (QCDR) - The National Pathology Quality Registry (NPQR) has 14 NPQR-exclusive quality measures, which broadly apply to many labs/pathologists. Groups and individuals can submit data through a QCDR, which then submits the data to CMS on your behalf.  
  • Medicare Part B Claims - If you are in a practice of 15 or fewer clinicians, your billing company can report Quality Measures using claims data.
  • Other Qualified Registries

How to Score Points in MIPS

You must score 30 points (up from 15 points in 2018) to get a neutral payment adjustment and avoid a penalty.

If a score is 7.5 points or below, the maximum negative 7% penalty will be assessed.

If a score is above 75 points, a clinician will receive an additional payment adjustment for exceptional performance.

Pathologists are assessed on their performance in two categories:

  1. Quality (85% of final score)
  2. Improvement Activities (15% of final score)

To avoid the negative payment adjustment and score 30 points, complete the following:

  1. Submit Improvement Activity data for at least a continuous 90-day period on one high-weighted or two medium-weighted activities (see ASCP-recommended list of activities here). Retain related documentation for ten years.
  2. Submit Quality data for a 12-month period on at least 6 measures that meet the 20 case minimum to be eligible for the maximum amount of points in this category. One of the 6 measures should be an outcome measure, if available; if there are no applicable outcome measures, you can submit another high priority measure instead. CMS will calculate your score based on only the highest scoring measures, so it’s best to submit data on as many measures as you can.

Discover How NPQR Ensures Privacy and Security

Learn more about how NPQR protects patient privacy, ensures data security, and complies with HIPAA regulations through our privacy and security white paper.


Read More
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