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Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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ONLINE FIRST: What surgeons should know about…Quality Payment Program in 2021

Several finalized requirements for QPP participation in 2021 are identified, specifically the MIPS and APM pathways.

Haley Jeffcoat, MPH, Jill Sage, MPH

January 8, 2021

Editor’s note: This article is being posted electronically with the January Bulletin so that surgeons will have access to the important information it provides regarding changes in Medicare payment that took effect this month. Because of delays in the release of the final rule on the updates, this information was unavailable when the print version of the January Bulletin went to press, so the article will be published in the February 2021 print issue.

The Centers for Medicare & Medicaid Services (CMS) finalized several updates to meet the participation requirements for year five (2021) of the Quality Payment Program (QPP). The QPP comprises two pathways for participation—the Merit-based Incentive Payment System (MIPS) or sufficient participation in an Advanced Alternative Payment Model (APM). If you participate via MIPS, your score is calculated based on your performance in four categories: Quality, Improvement Activities (IA), Cost, and Promoting Interoperability (PI) (see sidebar). An estimated 228,000 clinicians will be eligible for MIPS in 2021.1,2

MIPS performance categories

  • Quality: This category uses MIPS measures that are intended to assess aspects of the quality of care delivered.
  • Improvement Activities: This category includes an inventory of activities that are intended to assess how clinicians improve care processes, enhance patient engagement in care, and increase access to care.
  • Cost: CMS automatically calculates the cost of aspects of care based on Medicare claims. MIPS uses cost measures in an effort to gauge the total cost of care during the year, during a hospital stay, or during a specific episode of care.2
  • Promoting Interoperability: This category focuses on how Certified Electronic Health Record Technology (CEHRT) is utilized, as defined by CMS and ONC, to manage patient engagement and the electronic exchange of health information.

It is important to note that the ACS believes the quality metrics used by CMS and other health insurers fail to drive improvement in surgical care because they are scattered measures, which payors use as a proxy for clinical quality programs so they can pay differentially. The unintended consequence of the payor’s action is that surgeons, other physicians, and hospitals caring for surgical patients may report individual sets of measures that hardly align with a patient’s care—which may help in meeting payment goals, but ends up disconnecting measures from quality as a program. Only by coincidence might the selected measures of the various surgical team members match up to align efforts for quality improvement. True surgical quality is a program that brings together all the aspects of care and informs the team of the structure, processes, and outcomes of their joint efforts.

The College has long advocated that the QPP measure erratic components of care discretely, assessing the individual surgeon separately from the hospital, separately from the anesthesiologist, separately from the pathologist, and so on. The College has advocated instead for an approach that replaces pieced-together measures with a quality program that focuses overarchingly on the care of the patient, including the goals and outcomes important to the patient, while also valuing the infrastructure, resources, and processes needed to deliver optimal care and improvement.

For 2021, are there changes to the MIPS program that I need to know about to avoid a penalty?

For the 2021 MIPS performance year, CMS increased the MIPS performance threshold from 45 points to 60 points. Eligible clinicians will receive a total MIPS final score based on their performance in the four performance categories identified earlier. This score is then benchmarked against a MIPS performance threshold to determine their payment adjustment.

MIPS performance in 2021 will determine your MIPS payment adjustment in 2023. Therefore, in 2021, you must achieve a total of at least 60 points through your performance in the four MIPS performance categories to avoid a negative payment adjustment in 2023. By statute, the maximum negative payment adjustment in 2023 is 9 percent.

When calculating total performance scores, CMS applies a specific weight to each performance category. Beginning in 2021, the Quality category weight will decrease five percentage points to 40 percent of the MIPS final score, and the Cost category will increase five percentage points to 20 percent of the MIPS final score.

The category weights for the PI and IA remain unchanged. In past years, clinicians could focus solely on the Quality category because it carried a higher weight and the overall MIPS performance threshold was lower. However, for the 2021 performance year, the Quality category can only provide clinicians with a maximum of 40 points toward their final MIPS score, which is insufficient to cross the performance threshold of 60 points and avoid a penalty. With the changes to the category weights and the increased performance threshold, it becomes increasingly important to strive to meet the reporting requirements in all three reportable MIPS categories (Quality, IA, and PI). Because CMS calculates your Cost score based on claims data, it is difficult to predict your Cost score for the performance period, but you can refer to past MIPS performance feedback reports to gain a better understanding of how you might score in 2021 (see Figure 1).

Is CMS making an effort to reduce the MIPS administrative burden and make participation more meaningful or relevant to surgical care?

The American College of Surgeons (ACS) and other medical societies are working with CMS to create a new way to participate in MIPS—the MIPS Value Pathways (MVPs). The intent of MVPs is to reduce the burden and complexity of selecting from a long list of MIPS measures and activities, and instead provide a more cohesive and meaningful reporting experience. MVPs will aim to connect activities and measures from the four MIPS performance categories that are relevant to a specific specialty, condition, or population. CMS anticipates that this effort will result in improved value, as well as the ability to provide clinicians and patients with more timely and relevant performance data, and help prepare clinicians for the transition from fee-for-service to alternative payment models (APMs).

For many years, the ACS has raised concerns about CMS’ quality metrics, which have failed to drive improvements in surgical care because they are disconnected from the health care delivery process and sporadic in nature. Therefore, the College has advised the agency to develop a surgical MVP that considers the comprehensiveness of a quality program, including the infrastructure, resources, and processes needed to deliver optimal care. Examples of this are the ACS Trauma, Bariatric, and Geriatric Surgery quality programs. The College also advocates that it is critical for a surgical MVP to align clinician efforts at the facility level for a patient-centric quality program approach.

However, as a result of the coronavirus 2019 (COVID-19) public health emergency (PHE), CMS has decided to delay the implementation of MVPs until at least 2022. Instead, the agency has further developed guiding principles and other requirements for stakeholders to consider when collaborating with CMS on the development of MVPs.

Will CMS provide relief for surgeons who have patients or practices that are affected by COVID-19?

CMS designated the COVID-19 pandemic as a qualifying event for the Extreme and Uncontrollable Circumstances Hardship Exception during the PHE. If that pandemic or another hardship is disrupting your practice in 2021, you may continue to apply for an Extreme and Uncontrollable Circumstance Hardship Exception, requesting that CMS reweight up to all four MIPS performance categories.

If approved for reweighting of all four performance categories, you will receive a neutral payment adjustment in 2023, based on the 2021 performance year. It is important to note, however, that data submission will override any reweightings approved through this application on a category-by-category basis, which means you will be scored on those categories. Because these hardship applications, as well as MIPS data, can be submitted at the individual clinician, group practice, and/or APM entity level, it is important to check with these other stakeholders to see what actions they plan to take. Note that APM Entities may only request to be reweighted on all four categories of MIPS, rather than category-by-category.

Do I need to know about any changes to the Certified Electronic Health Record Technology (CEHRT) I use to participate in the MIPS PI category?

The PI category focuses on how clinicians use CEHRT to manage patient engagement and the electronic exchange of health information. To receive a score in PI, you are required to use technology that is considered certified by the Office of the National Coordinator (ONC) for Health IT’s Certification Program. The current version required for participation in the PI category is the 2015 edition. However, to better promote interoperability, the ONC recently finalized updated 2015 edition certification criteria through its 21st Century Cures Act final rule, www.healthit.gov/curesrule/.3 Because health information technology (IT) developers have until December 31, 2022, to make technology certified to the updated criteria available to their customers, MIPS participants may use technology certified to either the existing 2015 Edition or updated 2015 Edition Cures Update certification criteria until December 31, 2022. Beginning in the 2023 MIPS performance year, you will be required to use technology that is certified to match the updated 2015 Edition criteria.

In recent years, the ACS has advocated for CMS to transition the PI program beyond electronic health record (EHR)-centric data exchange toward true interoperability. With the rapid pace at which health care technology is advancing, the College believes that CMS should begin considering rewards for how clinicians include knowledge sharing and knowledge engineering digital services, instead of focusing solely on measuring the functionality of EHRs.

What is the easiest way to report MIPS data to meet the 60-point performance threshold and avoid a penalty?

With the increase in the performance threshold to 60 points, it will be necessary to meet the reporting requirements for all three MIPS performance categories. CMS calculates cost scores using claims data, so it is not necessary to submit data for this category, but you should review your past MIPS performance feedback reports to predict how you might perform in 2021.

In past years, the ACS has recommended that you fully report in all MIPS performance categories to achieve maximum scores, but it was possible to avoid a payment penalty by partially submitting data or only reporting one or two categories. Because of the increased performance threshold and adjustments to the percentages of the category weights, you no longer can avoid a payment penalty through partial reporting.

What is required to achieve the maximum score in the Quality category?

As in previous years, surgeons are expected to report on at least six MIPS quality measures, including one outcome measure (a high-priority measure may be substituted if an outcome measure is not available)4 for the duration of the performance year. To receive a performance score on a measure, you must report quality data for at least 70 percent of all applicable patients (regardless of payor) over the course of the 2021 calendar year.

To achieve full credit for this category, you will need to earn 60 Quality measure points. Each Quality measure is worth up to 10 points, but there are multiple situations where the points available for a measure are capped below 10 points (for example, if the measure lacks a benchmark or is classified by as “topped out” because of high performance rates), making it more challenging to achieve 60 points for this category. However, there are various ways to earn bonus points in the Quality category, which are outlined in the CMS quality reporting fact sheet. You also can earn up to 10 additional percentage points on your Quality score if your 2021 category performance has improved as compared to 2020.

What is required to achieve the maximum score in the IA performance category?

To receive full credit (15 points toward your final MIPS score), most surgeons must select and attest to having completed up to four activities over at least 90 consecutive days in the 12-month performance period for a total of 40 points. Improvement activities are classified by medium or high weights. A medium-weighted activity generally accounts for 10 points and a high-weighted activity accounts for 20 points (small practices can earn more points for IAs and thus, attest to fewer).

It is important to note that the requirements differ based on practice size and/or location. For small practices or rural practices to achieve full credit, only one high-weighted activity (worth 40 points) or two medium-weighted activities (worth 20 points each) are required. CMS defines small practices as those consisting of 15 or fewer eligible clinicians. CMS defines rural practices as those where more than 75 percent of the National Provider Identifiers billing under the individual Merit-based Incentive Payment System-eligible clinician or group’s Taxpayer Identification Number (TIN) are designated in a ZIP code as a rural area or health professional shortage areas—based on the most recent Health Resources and Services Administration Area Health Resource File data set.

If you are participating in MIPS as a group (that is, TIN-level), you may only attest to an improvement activity if at least 50 percent of the clinicians in the group or virtual group complete the same activity during any continuous 90-day period in the performance year.

What is required to achieve the maximum score in the MIPS PI performance category?

To receive credit for the PI category in 2021, you must:

  • Use the CEHRT 2015 edition or the updated 2015 edition discussed previously
  • Report performance for 90 continuous days or more
  • Respond “yes” to completing the Prevention of Information Blocking attestations
  • Respond “yes” to ONC Direct Review Attestation (if applicable)
  • Respond “yes” to completing the Security Risk Analysis measure
  • Report data for all measures under each of the 4 objectives, or claim an exclusion, if applicable

Reporting in the PI category is “all or nothing,” meaning that you must report a numerator and denominator for all objectives to qualify for a score in this category.

I participate in MIPS through my employer, but in previous years I was not required to report surgical measures. Does the 2021 rule change this expectation?

Each year, you should determine your MIPS eligibility status, regardless of how you participated (or didn’t participate) in previous years. To check your eligibility, use your National Provider Identification (NPI) numbers in the QPP Participation Lookup tool. After determining your eligibility, be sure you understand how your employer or group plans to participate and how this may have changed since previous years.

Because clinicians may participate in MIPS at the TIN-level, surgeons who are part of a larger group or employed by a larger institution may have previously satisfied QPP requirements without even knowing it or taking any action. Some larger groups rely on the CMS Web Interface to report quality measures, which allows groups to submit a specified set of quality measures (mostly primary care-focused) on a sample of their patients.

Although the Web Interface remains an option for large groups in 2021, CMS has decided to retire it in 2022, which means that groups that have relied on it in the past will need to select a different reporting strategy. You should consult with your group practice administrator to determine whether and how the group will report on your behalf in 2021 and beyond.

Am I required to participate in MIPS if I am part of an APM?

Qualifying Participants (QPs) in an Advanced APM are clinicians that participate sufficiently in an APM, and are therefore exempt from MIPS and qualify for a 5 percent lump sum incentive payment. Note that the thresholds for qualifying for QP status have been raised for 2021, which means that clinicians who were exempt from MIPS in the past might have to participate in 2021.

If you participate in a MIPS APM, but not at a volume to achieve QP status, you still must participate in MIPS to avoid a penalty. Until 2020, these clinicians generally scored at the APM Entity level under what was known as the APM Scoring Standard. This scoring standard provided scoring accommodations, such as a reweighting of the Cost category to 0 percent, that accounted for value-focused efforts already being made through the APM.

Starting in 2021, CMS is retiring the APM Scoring Standard but offering a new APM Performance Pathway (APP). Clinicians in MIPS APMs may participate in the APP or traditional MIPS at the individual, group, virtual group, or APM Entity level in 2021. However, reporting requirements and scoring accommodations will depend on which track is selected. Those opting to participate through the APP will be required to report on a specific APP measures set, but will automatically get full credit for Improvement Activities in 2021 and their Cost category will be reweighted to 0 percent. For clinicians in MIPS APMs who do not use the APP, those reporting at the APM Entity level will have cost reweighted to 0 percent, but those reporting at the individual and group level still will be scored on Cost. MIPS APM participants not using the APP also will not receive automatic full credit for IA, but they will still be eligible for the 50 percent IA credit granted by the statute. Note that Shared Savings Program ACOs must report through the APP but may report on the Web Interface set in place of certain APP measures for 2021 only.

It is important to check the QPP Participation Lookup tool  to determine whether you are considered a qualifying provider or are required to participate in MIPS in 2021.


  1. Centers for Medicare and Medicaid Services. Physician fee schedule. CY 2021 Medicare Physician Fee Schedule Final Rule. Available at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched. Accessed December 17, 2020.
  2. Centers for Medicare and Medicaid Services. Quality Payment Program. MIPS overview. Available at: https://qpp.cms.gov/mips/overview. Accessed December 17, 2020.
  3. The Office of the National Coordinator for Health Information Technology. ONC’s Cures Act Final Rule supports seamless and secure access, exchange, and use of electronic health information. Available at: www.healthit.gov/curesrule/. Accessed December 17, 2020.
  4. Centers for Medicare and Medicaid Services. Quality Payment Program. Quality Measures Requirements. Available at: https://qpp.cms.gov/mips/quality-measures. Accessed December 17, 2020.