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

MIPS 2019 Quality Options through the SSR – ACS Surgical Phases of Care Measures QCDR Option

The ACS Surgical Phases of Care (SPC) Measures provides eight QCDR measures and one MIPS measure for a Quality reporting option. Of the total nine measures available, three are outcome measures, and one is a Patient-Reported Outcome (PRO) measure. Download the full measures specifications document for the Surgical Phases of Care Measures QCDR.

Surgical Phase of Care

CMS Measure 
ID #

Measure Title

Measure Type

MIPS/
QCDR

Preoperative / Perioperative

ACS18

Patient Frailty Evaluation

Process

QCDR

ACS16

Preventive Care and Screening: Tobacco Screening and Cessation Intervention

Process

QCDR

QPP 358

Patient-Centered Surgical Risk Assessment and Communication

Process

MIPS

Postoperative

ACS20

Optimal Postoperative Communication and Plan and Patient Care Coordination Composite

Composite

QCDR

Post-Discharge

ACS21

Post-Acute Recovery Composite

Composite

QCDR

ACS22

Unplanned Reoperation within the 30-Day Postoperative Period

Outcome

QCDR

ACS23

Unplanned Hospital Readmission within 30 Days of Principal Procedure

Outcome

QCDR

ACS25

Surgical Site Infection (SSI)

Outcome

QCDR

ACS24

Surgical Phases of Care Patient-Reported Outcome Composite

Patient-Reported Outcome (PRO)

QCDR

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