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

Reporting for Quality

MIPS 2018 Quality ComponentAssuming that a clinician or group is scored under all four performance categories, the Quality component is worth 50 percent of the MIPS final score. For 2018, a clinician is expected to report on a minimum of six measures, including one outcome measure (a high-priority measure may be substituted if an outcome measure is not available). In order to receive a performance score on a measure, the clinician or group must report quality data for 60 percent of all patients for which each measure is applicable over the course of 12 months. Surgeons can choose from numerous MIPS measures, including CMS’ general surgery specialty measure set or use a QCDR such as the ACS Surgeon Specific Registry (SSR), which includes additional quality measures beyond the traditional MIPS quality measures.

For 2018, providers can choose from the following data submission mechanisms for the Quality component:

  • Claims
  • QCDR
  • Qualified registry
  • EHR
  • CMS web interface (groups of 25 or more)
  • CMS-approved survey vendor for CAHPS for MIPS (must be reported in conjunction with another data submission mechanism)

One major, noteworthy change for 2018 is the data completeness criteria. In 2018, providers who report via claims must submit data on 60 percent of Medicare patients in order to meet the data completeness criteria.

Those who report via other mechanisms need to report on 60 percent of all patients regardless of payer (including no-pay patients). It is important to understand that measures that do not meet these data completeness thresholds will only earn one point out of 10 potential points (three out of 10 points for small practices). In addition to the points earned through the clinical quality measures, providers can earn bonus points for reporting additional outcome and high-priority measures, as well as a bonus for end- to-end electronic reporting of quality measures via CEHRT.

The MIPS performance threshold (15 points) is the minimum number of final score points that must be earned in order to avoid a payment penalty in 2020. While there are multiple ways to achieve 15 points, one way is through full participation in the Quality performance category. For example, a provider can earn at least 15 points by only submitting all six required quality measures as long as they meet the necessary data completeness criteria detailed above. The bar is even lower for providers in small practices consisting of 15 or fewer providers. Providers in small practices can report on each of the six measures for a single patient and still earn 15 points and avoid a penalty. This is because providers in small practices will earn three points (as opposed to non-small practice providers who earn one point) for measures that do not meet the data completeness criteria. Under these scenarios in 2018, the provider would not have to report on any other MIPS performance categories to avoid a penalty.