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

MIPS 2019 Quality Options through the SSR–Qualified Registry Clinical Quality Measures Option

The 2019 Qualified Registry – Clinical Quality Measures option consists of 16 MIPS Clinical Quality Measures (CQMs) to choose from, and provides options to general and plastic surgeons. Of those 16 measures, 4 are outcome measures and 10 are high-priority measures.

Furthermore, the 16 available MIPS CQMs comprise two different CMS “Specialty Measure Sets” for surgeons to report on:

  • General Surgery Specialty Measures Set (comprised of all 16 CQMs listed below)
  • Plastic Surgery Specialty Measures Set (comprised of Quality ID#’s 21, 23, 130, 226, 317, 355, 356, 357, 358)

You do need to report all measures in a set. Surgeons and practices can choose to submit a specialty or subspecialty measure set. In doing so, they must submit data on at least 6 measures within that set.

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

264

Sentinel Lymph Node Biopsy for Invasive Breast Cancer

The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.

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 12–20 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