American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

How to Participate in Quality

MIPS Scoring Components

Quality, based off of the former Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS), is worth 60 percent of the Merit-based Incentive Payment System (MIPS) final score. Because this program has the highest weight, it will have the biggest impact on providers’ scores. To maximize performance on the Quality score, providers can report on 50 percent of all patients seen (for all payors, except those who report by claims) for at least 90 consecutive days on a minimum of six measures, including one outcome measure or one high-priority measure if an outcome measure is not available. Providers who submit using claims reporting must report on 50 percent of their Medicare patients. Providers who participate through group reporting can continue to report via the CMS web interface or the Consumer Assessment of Healthcare Providers and Systems for MIPS.

For 2017 only, physicians can avoid a penalty for MIPS by reporting a single measure for a single patient. Physicians who report the MIPS components for 90 days or up to a full calendar year may earn an incentive payment based on performance. Learn more about the Pick Your Pace reporting options for 2017.

Quality Measures Available for Reporting

Measures can be chosen from the following sources:

Qualified Clinical Data Registry (QCDR)

Physicians who report using a QCDR can choose both MIPS and non-MIPS measures. The ACS has two registries which have been approved by CMS. The ACS Surgeon Specific Registry (SSR)  is a qualified registry as well as a QCDR and can be used to report the Quality component of MIPS. The ACS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a QCDR that can also be used for MIPS reporting.

MIPS Measures List

To the full list of MIPS Quality measures, visit the CMS QPP Quality web page.

MIPS Specialty-Specific Measure Set

Physicians who choose to report using a specialty-specific measure set can review measures found on the CMS QPP Quality web page and filter according to specialty. If there are less than six measures within the specialty-specific measure set that apply to a physician’s practice, they are able to report on less than six measures without being subjected to a penalty. The ACS is awaiting CMS’ approval to use the SSR to offer surgeons the ability to report the General Surgery Specialty-Specific Measure Set for 2017.

The ACS SSR includes the general surgery measures specialty set along with the ACS-developed QCDR measures known as the Surgical Phases of Care Measures. For more information on these measures offered via the SSR, please view the MIPS 2017 Quality Options through the SSR webpage.

Data must be submitted via a QCDR, a qualified registry, an electronic health record system, or through claims reporting.

Group Reporting

CMS has provided physicians who report MIPS as a group two additional reporting options. Groups of 25 or more clinicians can use the CMS Web Interface—a secure, internet-based data submission option. Learn more about the CMS Web Interface reporting option, visit the CMS website. Groups of two or more providers also have the option of reporting via the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey that measures the patients’ experience of care. Learn more about the CAHPS for MIPS reporting option, visit the CMS website.

For more information, visit the CMS QPP Quality web page or contact Bobby Kopp at or 202-672-1506.