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 2019 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.

MACRA and QPP

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 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 2021, based on 2019 performance.

MIPS graphic

About MIPS 2019

  • Nonparticipation penalty: Nonparticipation in the QPP in 2019 will result in a 7 percent Medicare Part B payment penalty in 2021.
  • Eligibility: Check if you are eligible to participate in MIPS 2019 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
    • Quality: 45 percent
    • Promoting Interoperability: 25 percent
    • Improvement Activities: 15 percent
    • Cost: 15 percent

Changes from 2018 program year:
Quality: 45 percent (instead of 50 percent in 2018)
Cost: 15 percent (instead of 10 percent in 2018)

The following 2019 MIPS categories will be available for surgeons to fulfill through the MBSAQIP QCDR:

Resources

2019 Program Year

2018 Program Year

General Resources