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

Quality 45%

Assuming that a clinician or group is scored under all four performance categories, the Quality performance category will be worth 45 percent of the Merit-based Incentive Payment System (MIPS) final score in 2020; the category's weight was not changed between 2019 and 2020.

Quality Reporting Requirements

  • As in previous years, surgeons 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) for the duration of the performance year (12 months).
  • In 2020, to receive a performance score on a measure, clinicians or groups must report quality data for 70 percent of all patients to which each measure is applicable, regardless of payor, over the course of the 2020 calendar year.
  • To achieve full credit for this category, you will need to earn 60 Quality measure points. Each Quality measure is worth a maximum of 10 points, but there are many situations where the points available for reporting a measure are capped below 10 points, making it extremely difficult to achieve 60 points for this category.

Ways to Report Quality Data

Centers for Medicare and Medicaid Services (CMS) offers numerous quality measures for MIPS reporting, and has organized some of these measures into specialty measure sets. For example, general surgeons can utilize the General Surgery specialty measure set to determine which MIPS measures might fit best with the care they provide. Surgeons can choose from the below Quality data submission mechanisms .

  • Claims (Claims reporting is only available to surgeons in small groups)
  • Qualified Clinical Data Registry (QCDR)
  • Qualified Registry (such as the ACS Surgeon Specific Registry [SSR])
  • 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)

How Are Quality Measures Scored?  

Surgeons will receive between 3 and 10 points for quality measures submitted during the 2020 performance period when they report at least 20 cases and meet the 70 percent data completeness threshold.
Quality measures are scored based on the following categories:

  • 3 to 10 points—A surgeon 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
  • Key Scoring Change for 2020—While clinicians could receive 1 point in 2019 for reporting a measure that does not meet the data completeness criteria, beginning in 2020, measures that do not meet the data completeness criteria will earn 0 points.
    • Providers in small practice will still receive 3 points, even if they do not meet the data completeness criteria on a measure.

Additional Factors That Can Affect Quality Measure Scoring

  • Many measures that are most relevant to surgeons are considered "topped-out" in 2020. This makes it extremely hard to earn 60 points in Quality, because many of these measures are subject to scoring caps where the highest achievable score for the measure is 7 points.
  • MIPS measures can also be subject to scoring caps if they do not have a benchmark for all 10 deciles. This happens when about 10 percent to 60 percent or more of clinicians performed at the maximum achievable performance rate. In these situations, performance scores lower than 100 percent are capped at the specified level. In the example below, if a clinician's performance is anything less than 100 percent, he/she can only earn up to 3 points on the measure:





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


MIPS Clinical Quality Measure (CQM)









Bonus Points

  • Two bonus points can be earned for reporting additional outcome measures and one bonus point can be earned for reporting additional high-priority measures, beyond what is required for full Quality reporting. CMS will only provide performance scores for a physician's top six performing measures, but reporting additional outcome and high priority measures beyond those six are eligible for bonus points and should be considered a way to boost your Quality category score.
  • Small practices will receive a 6-point bonus added to their Quality performance score when they submit data on at least 1 quality measure.
  • Surgeons can also receive up to 10 bonus points in Quality for demonstrating improvement in the category, overall, from year to year.

How to Achieve the 2020 MIPS Performance Threshold and Avoid a Payment Penalty

In the 2020 MIPS performance year, surgeons must earn 45 MIPS overall points to meet the performance threshold and avoid a payment penalty in 2022. There are multiple ways to earn 45 points, but with some of the scoring caps on Quality measures and the increase in the performance threshold, it is more difficult to achieve the performance threshold than in past years. When planning for 2020 MIPS reporting, it is recommended that surgeons report fully in all performance categories to give them the best chance to avoid a negative adjustment for 2022.

Scoring Example 1

  • Fully report 6 measures under the quality performance category and achieve an average performance score of 70 percent across all measures, which would contribute 31.5 points towards the MIPS final score


  • Fully participate in the Improvement Activities category, which would contribute 15 points towards the MIPS final score.

Scoring Example 2

  • Fully report 6 measures under the quality performance category and achieve an average score of 85 percent across all measures, which would contribute 38.25 points towards the MIPS final score


  • Receive half credit in the Improvement Activities category, which would contribute 7.5 points towards the MIPS final score.

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 2020.