CCACO

Quality Reporting FAQ

PY2026 Quality Reporting Overview

CCACO will continue quality reporting under the APP Plus quality measure set for Medicare Shared Savings Program ACOs. Practices may be asked to support reporting through EHR registry reports, QRDA files, Medicare CQM reports, MIPS CQM reports, or manual entry through the CCACO Quality Portal when additional patient-level information is needed.

What's Changing in PY2026?

PY2026 is an important transition year for ACO quality reporting. CMS allows ACOs to report APP Plus measures using eCQMs, MIPS CQMs, or Medicare CQMs. However, PY2026 is expected to be the final year that MIPS CQMs remain available for ACO quality reporting.

The biggest new provider-facing clinical reporting addition for PY2026 is Colorectal Cancer Screening, which includes colonoscopy and other accepted colorectal cancer screening methods.

eCQMs – electronic Clinical Quality Measures reported from certified EHR systems using all-payer data.
MIPS CQMs – registry or EHR-based CQM reporting, available for PY2026 as a transition option.
Medicare CQMs – Medicare patient population reporting option for ACO quality submission.
Manual Portal Entry – used by CCACO when EHR reports are incomplete or patient-level follow-up is needed.

Transition to the APP Plus Quality Measure Set

CMS requires Shared Savings Program ACOs to report under the APP Plus quality measure set. The measure set includes chronic condition management, preventive screening, patient experience, and CMS-calculated claims-based quality measures.

For PY2026, CCACO’s provider-facing reporting focus will include Diabetes, Controlling High Blood Pressure, Depression Screening and Follow-Up, Breast Cancer Screening, and the newly added Colorectal Cancer Screening measure.

What’s New for Providers?

Colorectal Cancer Screening is now part of the PY2026 APP Plus reporting workflow.
Practices should ensure colonoscopy and other colorectal screening results are documented in structured EHR fields when possible.
Blood pressure, HbA1c, depression screening, breast cancer screening, and colorectal screening data should be captured throughout the year.
CCACO may request EHR reports, QRDA files, registry exports, or manual portal entry depending on each practice’s EHR capability.
Measures are scored collectively across the ACO, so complete and accurate documentation from each practice is important.

Overview of Reporting Methods

Feature	eCQMs	MIPS CQMs	Medicare CQMs
Data Source	Certified EHRs using structured electronic data	EHR or registry reports	Medicare patient population data, registry files, or manual abstraction
Submission Support	QRDA files or certified EHR/data aggregator export	Registry, EHR report, or CQM export	CCACO portal, registry export, or manual patient-level reporting
Automation Level	Mostly automated when EHR data is structured correctly	Partially automated depending on EHR/reporting vendor	May require manual abstraction and follow-up for missing data
Data Format	Standardized electronic format such as QRDA I	EHR registry report, registry file, CSV, or vendor output	Flexible templates, CSVs, portal entry, or CCACO-requested format
Population	All-payer data	Eligible patients captured through the EHR or registry workflow	Medicare population used for ACO quality reporting

Submitting Quality Data: Your Role

CCACO makes it easy to participate in quality reporting. Your practice can contribute in 3 simple steps:

Pull Your EHR or Registry Report
Download the available quality report from your EHR or registry. Reports should include required patient information such as patient name, date of birth, provider NPI, measure status, service dates, and result values when available.
Upload to the CCACO Quality Portal
Log in to the CCACO Quality Portal and upload the requested file securely. CCACO will review the file and follow up if additional formatting or patient-level details are needed.
Review Flagged Patients
CCACO may notify your practice if patients are missing required data, appear non-compliant, or need manual confirmation. These patients may need chart review or manual entry through the portal.

What Happens Behind the Scenes

CCACO validates and merges submitted data with claims and attribution files.
Measure results are reviewed and attributed to the appropriate practice/provider.
Missing or inconsistent data is flagged for follow-up when needed.
Final quality files are prepared for CMS submission.

Measures Reported by CCACO (PY2026)

These are the main provider-reported clinical quality measures CCACO is collecting for PY2026 under the APP Plus framework:

CMS122 – Diabetes: Glycemic Status Assessment Greater than 9%
Previously: Diabetes: Hemoglobin A1c Poor Control
Description: Percentage of patients 18–75 with diabetes whose most recent glycemic status assessment is greater than 9%.
Documentation Focus: Most recent HbA1c/glycemic status result and result date should be documented in a structured EHR field when possible.
Goal: Lower is better — controlled patients should have HbA1c/glycemic status below the poor-control threshold.
CMS165 – Controlling High Blood Pressure (Quality ID 236)
Description: Percentage of patients 18–85 with a diagnosis of hypertension whose blood pressure was adequately controlled during the measurement period.
Numerator: Most recent blood pressure reading less than 140/90 mmHg.
Documentation Focus: Blood pressure readings should be entered in structured vitals fields, not only in free-text notes.
Goal: Higher is better — indicates better blood pressure control.
CMS2 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Previously: Depression Screening with Follow-Up
Description: Percentage of patients 12 years and older screened for depression with a documented follow-up plan when required.
Documentation Focus: Screening result, screening tool, service date, and follow-up plan should be captured when applicable.
Goal: Early detection and appropriate follow-up.
CMS125 – Breast Cancer Screening
Description: Percentage of women in the eligible age range who had appropriate breast cancer screening.
Documentation Focus: Mammogram completion date and result should be documented or provided to CCACO when requested.
Goal: Higher is better — ensure mammogram results are captured in the EHR or reporting file.
CMS130 – Colorectal Cancer Screening (Quality ID 113)
Description: Percentage of adults 45–75 years of age who had appropriate screening for colorectal cancer.
Accepted Screening Methods: Fecal occult blood test/FIT, stool DNA with FIT, flexible sigmoidoscopy, CT colonography, or colonoscopy.
Documentation Focus: Screening type, result date, and completion status should be documented clearly in the EHR or submitted to CCACO when requested.
Goal: Higher is better — ensure completed colorectal cancer screenings, including colonoscopies, are captured for reporting.

Additional PY2026 Quality Components

In addition to the provider-reported clinical quality measures above, the APP Plus framework also includes patient experience and CMS-calculated claims-based measures. These measures may not require direct chart upload from each practice, but they still reflect the overall quality and coordination of care across the ACO.

Patient Experience

CAHPS for MIPS Survey:
Measures patient experience, communication, access, and care coordination.

Claims-Based Measures

Hospital-Wide Readmission:
CMS-calculated measure based on unplanned readmissions.
Multiple Chronic Conditions Admissions:
CMS-calculated measure related to hospital admission rates for patients with multiple chronic conditions.

Provider Documentation Focus

Structured blood pressure readings
HbA1c/glycemic status results
Depression screening and follow-up plan
Breast cancer screening results
Colorectal cancer screening results, including colonoscopy

Provider Checklist for PY2026

Confirm your practice’s EHR system and available quality reporting options with CCACO.
Enter blood pressure readings in structured vitals fields.
Enter HbA1c/glycemic status results with result dates.
Document depression screening results and follow-up plans when applicable.
Capture mammogram completion dates for eligible patients.
Capture colorectal cancer screening type and completion date, including colonoscopy when performed.
Upload requested EHR reports, registry files, QRDA files, or templates to the CCACO Quality Portal.
Review any patient lists or follow-up requests sent by CCACO.

Source: CMS Shared Savings Program Guidance & Specifications and QPP APP Quality Reporting Requirements

Need Assistance?

For questions, contact ghu@ccaco.org or call 212-965-0222.