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

MIPS 2018 Quality Options through the SSR – ACS Surgical Phases of Care Measures QCDR Option

The ACS Surgical Phases of Care Measures provides 11 non-MIPS measures and one MIPS measure for a Quality reporting option. Of the total 12 measures available, three are outcome measures, and one is a Patient-Reported Outcome (PRO) measure.

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.) ACS23

Unplanned Hospital Readmission within 30 Days of Principal Procedure

Outcome

Non-MIPS

10.) ACS25

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 Surgical Phases of Care Measures QCDR—Appendix: Eligible CPT Codes