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 quality data to earn a performance-based adjustment on their Medicare payments. There are four components/categories of MIPS:

For the 2020 MIPS performance year, the SSR is supporting the Quality and Improvement Activities components for ECs to participate in, and reporting these components through the SSR is considered registry-based reporting.

The PI component can only be fulfilled through the use of a Certified EHR Technology (CEHRT) system, and for the 2020 performance year there are no reporting requirements for the Cost component.

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.

Check Your MIPS Eligibility Before You Report

You might not be required to report MIPS 2020 data if you are ineligible. To determine if you are eligible to participate in MIPS 2020, visit the CMS QPP website and use the “check your participation status” tool by entering your National Provider Identifier (NPI) number. Your eligibility prior to November 2020 is your “Initial Eligibility” for the MIPS 2020 performance year. Verify your MIPS 2020 “Final Eligibility” in November 2020 again, which is when eligibility data is finalized by CMS.

Changes from 2019 to 2020 MIPS Performance Years

 

2019 Performance Year

2020 Performance Year

Nonparticipation Penalty

Nonparticipation in the QPP in 2019 will result in a 7 percent Medicare Part B payment penalty in 2021.

Nonparticipation in the QPP in 2020 will result in a 9 percent Medicare Part B payment penalty in 2022.

MIPS 2020 Participation through the SSR

For the 2020 MIPS performance year, the SSR is supporting the Quality and Improvement Activities components of for surgeons to participate in, and reporting these components through the SSR is considered registry-based reporting.

MIPS 2020 Quality Options through the SSR

The SSR has been approved by CMS to provide MIPS Quality participation through registry-based reporting for the 2020 performance year.

The following is a reporting option* that surgeons have to participate in MIPS Quality through the SSR.

For all other 2020 MIPS Quality reporting options and available MIPS Clinical Quality Measures (CQMs), refer to CMS.

MIPS 2020 Improvement Activities through the SSR

For the MIPS 2020 performance year, surgeons may attest to and submit Improvement Activities data through the SSR for MIPS 2020 with 83 surgically relevant Improvement Activities to choose from.