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

The Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) is the default pathway of the Quality Payment Program (QPP) where eligible clinicians (ECs) submit evidence-based and practice-specific quality data to receive a performance-based payment adjustment on their Physician Fee Schedule (PFS) payments. There are four components of MIPS:

  • Quality component (replaces the Physician Quality Reporting System (PQRS))
  • Advancing Care Information (ACI) component (replaces the EHR Incentive Program and Meaningful Use)
  • Improvement Activities (IA) component (new program)
  • Cost (replaces the Value-based Payment Modifier (VM))

For the 2017 MIPS program year, the SSR is supporting the Quality and IA components for ECs to participate in, and reporting these components through the SSR is considered registry-based reporting. The ACI component can only be fulfilled through the use of a Certified EHR Technology (CEHRT) system, and for the 2017 program year only there is no reporting requirement for the Cost component.

To determine if you are eligible to participate in MIPS 2017, visit the CMS QPP website and use the “check your participation status” tool by entering your National Provider Identifier (NPI) number.

For more information about QPP and MIPS as it relates to surgeons, visit the ACS Division of Advocacy and Health Policy’s QPP Resource Center.

Please note that 2017 MIPS participation through the SSR is not yet available.

  • The SSR MIPS-Qualified Registry, which includes the Quality (General Surgery Measures Specialty Set) and IA components, is anticipated to be available in the SSR in July 2017.
  • The SSR MIPS-Qualified Clinical Data Registry, which includes the Quality (ACS SSR Surgical Phases of Care QCDR) and IA components, is anticipated to be available in September 2017.