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 (replaced the Physician Quality Reporting System (PQRS) program)
  • Promoting Interoperability (PI) component (formerly known as the Advancing Care Information component; replaced the EHR Incentive Program a.k.a. Meaningful Use)
  • Improvement Activities (IA) component (new program)
  • Cost component (replaced the Value-based Payment Modifier (VM) program)

For the 2018 MIPS program 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 2018 performance year there are no reporting requirements for the Cost component.

To determine if you are eligible to participate in MIPS 2018, 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.

Overview of 2017 and 2018 MIPS Performance Years


2017 Program Year

2018 Program Year

Nonparticipation Penalty

Nonparticipation in the QPP in 2017 will result in a 4 percent Medicare Part B payment penalty in 2019.

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

MIPS Components

  • Quality
  • Advancing Care Information (ACI)
  • Improvement Activities (IA)
  • Quality
  • Promoting Interoperability (formerly ACI)
  • Improvement Activities (IA)
  • Cost

MIPS Performance Scoring

MIPS 2017 Components

MIPS 2018 Components

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