Frequently asked questions

A clinical data registry records information about the health status of patients and the health care they receive over varying periods of time, and typically focus on patients who share a common reason for needing health care.

A QCDR is a CMS-approved entity 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.

CMS encourages specialty societies, such as APA and APA Services, Inc. (APASI), to develop their own registries to allow their members to report to the Merit-based Incentive Payment System (MIPS). This also allows psychology to take a leadership role in determining quality mental and behavioral health care.

The Advisory Committee for Measurement-Based Care and the Mental Behavioral Health Registry have developed specialty measures that are related to outcome measurement, psychotherapy, clinical research, and quality improvement. These quality measures can be submitted directly to the CMS. The MBHR is the only registry that includes measures to screen for anxiety disorders and report anxiety disorder treatment response. It also includes measures related to impaired functioning, such as sleep quality, pain interference, and social role functioning, and measures specifically for neuropsychology. This gives psychologists and other professionals who use our registry more flexibility in reporting patient-reported outcome measures in order to successfully participate in MIPS to receive reimbursement.

Psychologists were recognized as MIPS eligible cliniciansopens in new window starting in 2019. Those who are not exempt from MIPS via the low-volume threshold will be required to participate or will have their reimbursements penalized two years later. Psychologists can check their eligibility statusopens in new window on the CMS website.

Most psychologists who bill Medicare will be exempt from MIPS reporting under the Low Volume Threshold (LVT), which was created to ease the burden on small practices. If you bill for 200 or fewer beneficiaries, report $90,000 or less in allowed charges, or have fewer than 200 covered professional services under the Physician Fee Schedule (PFS), you fall under the LVT. More information on LVT eligibilityopens in new window can be found on the CMS website.

Yes, psychologists can report MIPS data as an opt-in eligible clinician, if they exceed one or more of the LVT options. For example, if billing 200 or more therapy sessions to Medicare in 2022, you would be eligible to opt-in and possibly receive a positive payment adjustment in 2024.

The MBHR allows practitioners to track quality outcomes on their clients and patients, providing rapid feedback on the progress of those they serve, while enabling benchmarking against practitioners doing similar work. The MBHR also provides resources related to clinical practice guidelines, evidence-based practices, and continuing education opportunities. It can also meet psychologists’ other data needs, such as meeting licensure renewal, credentialing or board certification requirements, and negotiating with quality-based reimbursement payment programs (pay-for-performance).

The MBHR includes 97 MIPS identified measures and 11 non-MIPS specialty measures, unique to the MBHR, that can be submitted directly to CMS. The MBHR is the only registry option that includes measures that enable professionals to screen for, and measure treatment progress for, anxiety disorders. Measures that are only available when using the MBHR include measures on anxiety, social role functioning, sleep quality, posttraumatic stress disorder, alcohol use, ADHD, and quality process measures specifically for neuropsychology. Measure identification is being steered by an advisory committee of experts in the field of outcome measurement, psychotherapy, clinical research, and quality improvement.

The MBHR specialty measures are evidence-based and designed to address gaps in care while fitting into your specialty and workflow. With that said, it is also important for providers to report on the MBHR measures specifically to help establish benchmarks for MIPS, which will potentially increase provider scores, and to ensure that the measures remain available in the future. CMS will not continue to approve specialty measures, like those in the MBHR, if measure adoption is low.

Quality measures that are in their first and second year of availability for reporting have an established minimum score of 5 or 7 points. In 2025, the following MBHR measures will yield at least 5 to 7 points:

• MBHR18 – Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan with Timely Transmission of Results
• MBHR19 – Trauma Screening and Re-Traumatization Prevention

There are multiple ways to upload data in the registry, so you do not need an EHR to use the registry; however, certain EHRs are compatible with the registry. For example, APA has partnered with Healthmonix and TherapyNotes, a popular EHR, to allow for seamless reporting to MIPS.

The MBHR team at Healthmonixopens in new window will guide you through entering data, outcome tracking, and reporting process. There are flexible and streamlined integration options to assist in entering data. For example, the data integration option allows providers to upload their data using a customized Excel spreadsheet.

Register or learn more about the MBHRopens in new window.

You can check your eligibility status on the CMS websiteopens in new window.

Psychologists in group practices can report MIPS measures as an individual provider or join the other clinicians in the practice to report as a group. A group practice includes two or more eligible clinicians. As of 2022, licensed clinical social workers are eligible clinicians in MIPS.

As individual providers, most psychologists will likely be exempt from MIPS reporting under the low-volume threshold. Psychologists reporting as a group have to include data for the clinicians who as individuals would have been exempt under the low-volume threshold.

The MBHR Advisory Committee recognizes that measures relevant to neuropsychologists is an important measurement gap and have worked to incorporate neuropsychologists and test technicians into the measurement development process.

For 2024, the MBHR features a suite of quality process measures specifically for neuropsychology that will yield a minimum of 5 to 7 points:

• MBHR18 Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan with Timely Transmission of Results

There are also standard MIPS quality measures that correspond to services typically billed by neuropsychologists:

• #130 Documentation of Current Medications in the Medical Record
• #134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
• #181 Elder Maltreatment Screen and Follow-Up Plan
• #282 Dementia: Functional Status Assessment
• #283 Dementia: Management of Neuropsychiatric Symptoms
• #286 Dementia: Counseling Regarding Safety Concerns
• #288 Dementia: Caretaker Education and Support

Eligible clinicians are expected to report on six quality measures. If, however, there are fewer than six quality measures available that fit your practice, then the number of possible points the clinician is expected to earn in the MIPS quality performance category will be lowered.

APA has partnered with a CMS-approved software company, Healthmonix, that specializes in developing health care-related data registries for specialty societies such as APA. They are responsible for securely housing the data and must adhere to strict compliance with the Health Insurance Portability and Accountability Act and other privacy laws. The privacy policy can be found on their websiteopens in new window.

The amount of time it takes depends on various factors, including the mode of data entry you use (uploaded Excel sheets, manual entry, electronic health records); how many patients you have and how many services you provide; how well you integrate data collection within your clinical work flow; and how often you enter data into the system. In addition, some measures only get reported once a year, while others may be collected once a quarter.

Yes. Psychologists and other providers can use the MBHR for their own personal practice without sending MIPS data to CMS. Pricing options are available on our website.