October 23, 2020

Showcasing Most Popular ACEP (QCDR) Measures for 2019

The American College of Emergency Physicians (ACEP) has taken an active role in helping emergency physicians successfully participate in the Merit-based Incentive Payment System (MIPS)—the main reporting program for physicians in Medicare. One major way that ACEP has aided physicians is by developing a qualified clinical data registry (QCDR) that emergency physicians can use to report measures under MIPS. ACEP’s QCDR, the Clinical Emergency Data Registry (CEDR), has been approved by CMS as a mechanism for MIPS reporting every year since the start of the program.

CEDR provides a single platform for meeting all four of the MIPS performance categories – Quality, Cost, Improvement Activities, and Promoting Interoperability.

For years, CEDR has developed quality measures—called QCDR measures—that are meaningful to emergency physicians and help drive improvement in the quality of emergency care that patients receive. All QCDR measures must be approved by CMS every year to ensure that they are still clinically relevant. The process of developing these measures requires a significant amount of work and dedication from volunteer emergency physicians (supported by ACEP staff) from the conceptualization of a measure to receiving CMS approval for use in MIPS.

In 2019, CEDR consisted of 12 ACEP-developed measures and 22 Quality Payment Program (QPP) measures that are available to all clinicians in MIPS. A total of 1,373 hospitals, which were part of 298 tax identification numbers (TINs), used CEDR to meet MIPS requirements. Of the 298 TINS, 238 received an additional MIPS bonus for exceptional performance. Twenty-two TINs received a perfect score of 100.

TIN Reporting Frequency by ACEP Measures


Of the 12 ACEP-developed measures, ACEP 50 and ACEP 51 were by far the most popular in 2019, with 231 and 229 TINs reporting these measures, respectively. These are the outcome measures that capture the time patients spend in the emergency department (ED) from the time they arrive to when they are discharged.

ACEP 50 - Time (in minutes) from ED arrival to ED departure for discharged patients for Adult Patients

ACEP 51 - Time (in minutes) from ED arrival to ED departure for discharged patients for Pediatric Patients

The measures are meant to help reduce the time patients remain in the ED, which in turn can lead to improved access to treatment and higher quality care. The measures exclude transfers, psychiatric, and expired patients—which all could account for longer ED visits. The performance is calculated through a “Z score” (as defined by CMS). Each group scores 2 bonus points for submitting the measures.

ACEP 21 was another popular measure in 2019, with 151 TINs reporting this measure.

ACEP 21 - Coagulation studies in patients presenting with chest pain with no coagulopathy or bleeding

The measure works on the rationale that coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient. The measure refinement process that goes along with submitting the measure helps guide emergency physicians in making any necessary changes to their ED practice that they would need to be successful. The “High Priority” status of the measure allows emergency physicians to receive a bonus point for submitting the measure.

Among the QPP measures, QPP 65, 91, 116 and 331 were the most submitted measures. CEDR provides the capability to electronically capture and map these measures in unity with CMS billing codes.


TIN Reporting Frequency by QPP Measures

QPP 65 - Appropriate Treatment for Children with Upper Respiratory Infection (URI)

QPP 91 - Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.

QPP 116 - The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription

QPP 331 - Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms

In all, CEDR is an ever-evolving QCDR which keeps abreast with the constant change in policies and strives to provide the absolute best platform for emergency physicians to participate in MIPS and improve the quality of care they provide to their patients.