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 2018 MIPS performance year. The MBSAQIP Data Registry has been approved by CMS as a QCDR since 2014.

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 2020, based on 2018 performance.

MIPS graphic

About MIPS 2018

  • Nonparticipation penalty: Nonparticipation in the QPP in 2018 will result in a 5 percent Medicare Part B payment penalty in 2020.
  • Eligibility: 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).
  • MIPS Components:
    • Quality (formerly PQRS)
    • Promoting Interoperability (formerly Advancing Care Information)
    • Improvement Activities (IA)
    • Cost
  • Scoring

MIPS 2018 Components

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

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


2018 Program Year

General Resources