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

MIPS 2018 Participation

MIPS 2018 Participation through the SSR

For the 2018 MIPS performance year, the SSR is supporting the Quality and Improvement Activities (IA) components for surgeons to participate in, and reporting these components through the SSR is considered registry-based reporting.

Table of Contents

  • Overview of 2017 and 2018 MIPS Performance Years
  • MIPS 2017 Quality Options
  • MIPS 2017 Improvement Activities

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
  • Advancing Care Information (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)

MIPS 2018 Quality Options through the SSR

The SSR has been approved by CMS to provide MIPS Quality participation through registry-based reporting for the 2018 performance year.

The following are three options* that surgeons have to participate in MIPS Quality through the SSR. Please note that only one Quality option noted below is required to participate in 2018 MIPS Quality through the SSR.

  • General Surgery Specialty Measures Set includes options for general surgeons (MIPS-Qualified Registry)
  • ACS Surgical Phases of Care Measures includes options for a wide range of surgical specialties (MIPS-Qualified Clinical Data Registry (QCDR))
  • Trauma Measures includes options for trauma surgeons (MIPS-Qualified Clinical Data Registry (QCDR))

MIPS – Qualified Registry

For MIPS Quality measure reporting, Quality measures have been grouped together according to ‘specialty measure set’ as defined by CMS. For the 2018 MIPS performance year, the SSR is supporting the General Surgery Specialty Measures Set.

General Surgery Specialty Measures Set Option

The 2018 General Surgery Specialty Measures Set consists of 15 MIPS Quality measures to choose from. Of those 15 measures, 4 are outcome measures and 10 are high-priority measures.

Quality ID#

Measure Title and Description

Measure Type

High-Priority Measure

21

Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin

Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis.

Process

No

23

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.

Process

Yes

46

Medication Reconciliation Post-Discharge

The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.

This measure is reported as three rates stratified by age group:

  • Submission Criteria 1: 18-64 years of age
  • Submission Criteria 2: 65 years and older
  • Total Rate: All patients 18 years of age and older

Process

Yes

47

Care Plan

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

Process

Yes

128

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.

Normal Parameters:

Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

Process

No

130

Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

Process

Yes

226

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.

Process

No

317

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.

Process

No

354

Anastomotic Leak Intervention

Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery

Outcome

Yes

355

Unplanned Reoperation within the 30 Day Postoperative Period

Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period

Outcome

Yes

356

Unplanned Hospital Readmission within 30 Days of Principal Procedure

Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure

Outcome

Yes

357

Surgical Site Infection (SSI)

Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

Outcome

Yes

358

Patient-Centered Surgical Risk Assessment and Communication

Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

Process

Yes

374

Closing the Referral Loop: Receipt of Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Process

Yes

402

Tobacco Use and Help with Quitting Among Adolescents

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

Process

No

MIPS-Qualified Clinical Data Registry

The SSR also provides the MIPS Quality option—Qualified Clinical Data Registry (QCDR)—to leverage new specialty-specific measures developed by the ACS for 2018 MIPS Quality reporting. QCDRs allow eligible clinicians (ECs) to submit non-MIPS measures, which are measures that are not contained in the MIPS-approved measure set for the applicable reporting period, or a measure that may be in the MIPS measure set but has substantive differences in the manner it is reported by the QCDR. These non-MIPS measures provide surgeons with a wider range of options. Two QCDR options are available for 2018 MIPS Quality reporting:

  • ACS Surgical Phases of Care Measures QCDR
  • ACS Trauma Measures QCDR

ACS Surgical Phases of Care Measures QCDR Option

Surgical Phase of Care

CMS Measure 
ID #

Measure Title

Measure Type

MIPS/
Non-MIPS

Preoperative / Perioperative

1.) ACS15

Preoperative Composite

Composite

Non-MIPS

2.) ACS18

Patient Frailty Evaluation

Process

Non-MIPS

3.) ACS16

Preventive Care and Screening: Tobacco Screening and Cessation Intervention

Process

Non-MIPS

4.) ACS17

Preoperative Key Medications Review for Anticoagulation Medication

Process

Non-MIPS

QPP 358

Patient-Centered Surgical Risk Assessment and Communication

Process

MIPS

Intraoperative

5.) ACS19

Intraoperative Composite

Composite

Non-MIPS

Postoperative

6.) ACS20

Optimal Postoperative Communication and Plan and Patient Care Coordination Composite

Composite

Non-MIPS

Post-Discharge

7.) ACS21

Post-Acute Recovery Composite

Composite

Non-MIPS

8.) ACS22

Unplanned Reoperation within the 30 Day Postoperative Period

Outcome

Non-MIPS

9.) ACS 23

Unplanned Hospital Readmission within 30 Days of Principal Procedure

Outcome

Non-MIPS

10.) Pinc51

Surgical Site Infection (SSI)

Outcome

Non-MIPS

All Phases

11.) ACS24

Surgical Phases of Care Patient-Reported Outcome Composite

Patient-Reported Outcome (PRO)

Non-MIPS

 

ACS Trauma Measures QCDR Option

CMS Measure 
ID #

Measure Title

Measure Type

MIPS/
Non-MIPS

1.) ACSTrauma1

Trauma Initial Assessment Composite

Process

Non-MIPS

2.) ACSTrauma5

Optimal Timing of Surgical or Procedural Intervention for Hemorrhage in Trauma

Process

Non-MIPS

3.) ACSTrauma6

Optimal Ratio of Blood Product Transfusion

Process

Non-MIPS

4.) ACSTrauma7

Timely Initiation of VTE Prophylaxis in Trauma Patients

Process

Non-MIPS

5.) ACSTrauma4

Splenic Salvage Rate

Outcome

Non-MIPS

6.) ACSTrauma2

Mortality Rate Following Blunt Traumatic Injury to the Chest and/or Abdomen

Outcome

Non-MIPS

7.) ACSTrauma3

Mortality Rate Following Penetrating Traumatic Injury to the Chest and/or Abdomen

Outcome

Non-MIPS

ACS Trauma Measures QCDR - Appendices

Appendix 1 – Inclusion Criteria

Appendix 2 – TQIP/NTDB Eligible ICD-10 Injury Diagnoses

MIPS 2018 Improvement Activities Options through the SSR

The Surgeon Specific Registry (SSR) has been approved by the CMS to provide MIPS Improvement Activities (IA) through registry-based reporting for the 2018 performance year. Eligible clinicians** (ECs) may attest to and submit IA data through the SSR for 2018 MIPS with 86 surgically relevant IAs to choose from.

Each IA must be attested to for a minimum of 90 days to earn full credit. To earn the maximum score for the IA component of MIPS, an EC must attest to 40 points worth of IAs, and each IA is assigned one of two weightings:

  • High (20–40 points)
  • Medium (10–20 points)

How many IAs an individual EC must attest to and the amount of points an IA is worth is then dependent on the size of the group for which the EC is a part of:

  • Individual ECs in groups with more than 15 clinicians must select from one of the following combinations (high-weighted activities = 20 points; medium-weighted activities = 10 points):
    • 2 high-weighted activities
    • 1 high-weighted activity and 2 medium-weighted activities
    • Up to 4 medium-weighted activities
  • Individual ECs in groups with 15 or fewer clinicians, in a small practice or a rural setting, must select from one of the following combinations (high-weighted activities = 40 points; medium-weighted activities = 20 points):
    • 1 high-weighted activity
    • 2 medium-weighted activities

Download the full list of MIPS 2018 Improvement Activities available through the SSR.

**For the 2017 and 2018 MIPS performance periods, the following clinician types can participate in MIPS: [hysicians; physician assistants (PAs); nurse practitioners (NPs); clinical nurse specialists; certified registered nurse anesthetics; and any clinician group that includes one of the professionals listed above.