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:

  • Quality component (PQRS)
  • Promoting Interoperability (PI) component (formerly Advancing Care Information)
  • Improvement Activities (IA) component
  • Cost component

For the 2019 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 2019 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 2019 data if you are ineligible. To determine if you are eligible to participate in MIPS 2019, 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 2019 is your “Initial Eligibility” for the MIPS 2019 performance year. Verify your MIPS 2019 “Final Eligibility” in November 2019 again, which is when eligibility data is finalized by CMS.

Overview of 2018 and 2019 MIPS Performance Years


2018 Performance Year

2019 Performance Year

Nonparticipation Penalty

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

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

MIPS Performance Scoring

MIPS 2017 Components

MIPS 2018 Components

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