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

Qualified Clinical Data Registry

The Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) Data Registry is a qualified clinical data registry (QCDR) for the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS).

The CMS approved the MBSAQIP Data Registry as a QCDR for the CMS 2014, 2015, and 2016 Physician Quality Reporting System (PQRS) program. In 2017, the MBSAQIP Data Registry has been approved as a Quality Payment Program (QPP) MIPS Qualified Entity for the 2017 and 2018 performance period of MIPS.

MBSAQIP participants have the opportunity to elect that their MBSAQIP QCDR quality measures results be submitted to CMS for MIPS (formerly PQRS) participation. One benefit of using the MBSAQIP QCDR is that data are already being collected as part of participation in the MBSAQIP. To be considered a QCDR for MIPS, the MBSAQIP must self-nominate each year and meet CMS requirements specified in annual Physician Fee Schedule (PFS) final rule.


The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 introduced the new QPP with two tracks for surgeons to participate: the MIPS and Advanced Alternative Payment Models (APMs). MIPS is the QPP track most physicians will (initially) participate in.

What Is MIPS?

MIPS is a new payment mechanism that will provide payment adjustments to Medicare Part B payments two years after the performance year. Three previous programs (EHR Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Modifier (VM)) were consolidated into the new Merit-Based Incentive Payment System (MIPS) program. Payment adjustments will begin in 2019, based on 2017 performance.

MIPS graphic

Overview of 2017 and 2018 Program Year


2017 Program Year

2018 Program Year

Nonparticipation penalty

Nonparticipation in the QPP in 2017 will result in a 4 percent Medicare Part B payment penalty in 2019.

Nonparticipation in the QPP in 2018 will result in a 5 percent Medicare Part B payment penalty in 2020.


Check if you are eligible to participate in MIPS 2017 by visiting the CMS QPP website and by entering your National Provider Identifier (NPI) number(s).

Eligibility look-up for MIPS 2018 will be available at a later date

MIPS Components

Quality (formerly PQRS)
Advancing Care Information (ACI) (formerly EHR meaningful use)
Improvement Activities (IA) (new in 2017)

MIPS performance period final score

MIPS 2017 Components

MIPS 2018 Components


Changes from 2017 program year:
Quality: 50% (instead of 60% in 2017)
Cost: 10% (instead of 0% in 2017)


The following 2017 and 2018 MIPS components will be available for surgeons to fulfill through the MBSAQIP QCDR:


2017 Program Year

2018 Program Year

General Resources