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

MIPS General Surgery Measures

The Centers for Medicare and Medicaid (CMS) offers specialty measure sets that include focused Merit-based Incentive Payment System (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. 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 2020?

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 5.

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 5.

Advance Care 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 7.

Preventative Care and 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 7.

Documentation of Current Medications in the Medical Record

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.

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

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 7.

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 5.

Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

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 7.

Anastomotic Leak Intervention

No

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 Reoperation within the 30-Day Postoperative period

No

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 7.

Unplanned Hospital Readmission within 30 Days of Principal Procedure

No

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 7.

Surgical Site Infection (SSI)

No

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.

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

Yes

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 6.

Tobacco Use and Help with Quitting Among Adolescents

Yes

Yes

Yes, if you do not receive a perfect score (which would receive 10 points) on this measure, the greatest number of points available is 7.