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

Reporting for Quality

Quality 45%

Assuming that a clinician or group is scored under all four performance categories, the Quality component will be worth 45 percent of the Merit-based Incentive Payment System (MIPS) final score in 2019, a 5 percent decrease from previous years. Unchanged from 2018, clinicians are 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 to which each measure is applicable over the course of the 2019 calendar year. Surgeons can choose from numerous MIPS measures, including the Center for Medicare and Medicaid Services (CMS) general surgery specialty measure set or use a Quality Clinical Data Registry (QCDR) such as the ACS Surgeon Specific Registry (SSR) and Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) Data Registry, which include additional quality measures beyond the traditional MIPS quality measures.

Providers can choose from the following data submission mechanisms for the Quality component:

  • Claims (New in 2019, claims reporting is only available to clinicians in small groups)
  • QCDR
  • Qualified registry
  • Electronic Health Record (EHR)
  • CMS web interface (groups of 25 or more)
  • CMS-approved survey vendor for  Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS (must be reported in conjunction with another data submission mechanism)

To meet the data completeness criteria, providers who report via claims must submit data on at least 60 percent of Medicare patients in order to meet the data completeness criteria. Those who report via other mechanisms need to report on at least 60 percent of all patients regardless of payer (including no-pay patients). Clinicians will receive between 1 and 10 points for quality measures submitted during the 2019 performance period. Quality measures are scored based on the following categories:

  • 3 to 10 points—A clinician will receive 3 to 10 points based on performance compared to a historical or performance year benchmark as long as the measure meets the data completeness criteria, has a benchmark, and has a sufficient number of cases (>20 cases for most measures)
  • 3 points—A clinician will receive 3 points if they meet the data completeness criteria, but either (1) the measure doesn’t have a benchmark and/or (2) the volume of cases is insufficient
  • 1 point—A clinician will receive 1 point if the measure does not meet the data completeness criteria
    • Providers in small practice will still receive 3 points, even if they do not meet the data completeness criteria.
  • Topped out measures—It is important to understand that many measures are considered “topped-out” in 2019. This means that the highest achievable score for these measures is capped at 7-points. Also note that some MIPS measures applicable to surgeons are subject to scoring caps due to a benchmark that does not have benchmarks for all ten deciles.   This happens when about 10% to 60% or more of clinicians performed at the maximum achievable performance rate. Although these measures are not yet topped out, they are usually close.  In these situations, performance scores lower than 100% are capped at the specified level.  In the example below, if a clinician’s performance is anything less than 100%, he/she can only earn up to 3 points on the measure:

Measure

#

Submission

Ave.

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10

Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin

21

Registry/ QCDR

94.6

98.67 - 99.99

--

--

--

--

--

--

100

MIPS General Surgery Measures

CMS offers specialty measure sets that include focused MIPS quality measures specific to certain specialties, such as the general surgery measure listed in the table below. These measures and others relevant to surgical care are available via the SSR. Surgeons can choose to report 6 measures from this group to fulfill the reporting requirements for the quality category, but if 6 measures are not applicable to their practice, they are only required to report the measures that apply. The table below shows the MIPS General Surgery Measure set, explains which measures are topped out, and the points available.

<

Is the measure topped-out in 2019?

Is the measure subject to a 7-point scoring cap?

Is the measure capped based on the benchmark?  

Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin

Yes

Yes

Yes, if you do not receive a perfect score (which would receive 7 points) on this measure, the greatest number of points available is 3.

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When indicated in ALL Patients)

Yes

Yes

Yes, if you do not receive a perfect score (which would receive 7 points) on this measure, the greatest number of points available is 3.

Medication Reconciliation Post-Discharge

Yes

Yes

Yes, if you do not receive a perfect score (which would receive 7 points) on this measure, the greatest number of points available is 5.

Care Plan

No

No

No

Preventative Care & Screening: Body Mass Index (BMI) Screening and Follow-up plan

No

No

Yes, if you do not receive a perfect score (which would receive 7 points) on this measure, the greatest number of points available is 8.

Documentation of Current Medications in the Medical Record

Yes

Yes

No

Preventative Care & Screening: Tobacco Use: Screening and Cessation Intervention

No

No

No

Sentinel Lymph Node Biopsy for Invasive Breast Cancer

Yes

Yes

Yes, if you do not receive a perfect score (which would receive 7 points) on this measure, the greatest number of points available is 4.

Preventative Care & Screening: Screening for High Blood Pressure and Follow-up documented

No

No

No

Unplanned Reoperation within the 30 Day post-operative period

Yes

No

Yes, if you do not receive a perfect score (which would receive 10 points) on this measure, the greatest number of points available is 6.

Unplanned Hospital Readmission within 30 Days of Principal Procedure

Yes

No

Yes, if you do not receive a perfect score (which would receive 10 points) on this measure, the greatest number of points available is 5.

Surgical Site Infection (SSI)

Yes

No

Yes, if you do not receive a perfect score (which would receive 10 points) on this measure, the greatest number of points available is 5.

Patient-Centered Surgical Risk Assessment and Communication

Yes

Yes

Yes, if you do not receive a perfect score (which would receive 7 points) on this measure, the greatest number of points available is 6.

Closing the Referral Loop: Receipt of Specialist Report

No

No

No

Tobacco Use and Help with Quitting Among Adolescents

Yes

No

Yes, if you do not receive a perfect score (which would receive 10 points) on this measure, the greatest number of points available is 8.

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 Certified Electronic Health Record Technologo. New in 2019, small practices will receive a 6-point bonus added to their Quality performance score when they submit data on at least 1 quality measure. This replaces that 5-bonus points that were applied to a small practice’s MIPS final score in previous years. 

In 2019, clinicians also will have the opportunity to earn additional Quality category points based on their rate of improvement from their Quality category score in Year 2 (2018) of the program.

The MIPS performance threshold (30 points) is the minimum number of final score points that must be earned in order to avoid a payment penalty in 2021. While there are multiple ways to achieve 30 points, one way is through full participation in the Quality performance category. For example, a surgeon would have to receive at least 41quality measure achievement points to receive approximately 30 points for the Quality performance category. However, achieving 41 points may still be difficult due to the large number of surgical measures that are topped-out or subject to scoring caps. Coupling performance in Quality with another category, such as Improvement activities, could make the 30-point threshold more attainable. See the example below: 

  • Fully participate in the Improvement Activities category, to earn 15 points towards the MIPS final score AND
  • Fully report 6 measures under the Quality performance category and achieve an average performance score of 35% across all measures, which would earn a total of 15.75 MIPS points

CMS also offers many resources on their Quality Payment Program website, and is a great resource for learning about and selecting Quality measures, Promoting Interoperability measures, and Improvement Activities for reporting in 2019.