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

MIPS 2020 Quality Options through the SSR–Qualified Registry Clinical Quality Measures Option

The 2020 Qualified Registry – Clinical Quality Measures option consists of 15 MIPS Clinical Quality Measures (CQMs) to choose from, and provides options to general and plastic surgeons. Of those 15 measures, 4 are outcome measures and 10 are high-priority measures.

Furthermore, the 15 available MIPS CQMs comprise two different CMS "Specialty Measure Sets" for surgeons to report on:

  • General Surgery Specialty Measures Set (comprised of all 15 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.

Reporting Requirements for 2020 Quality

  • Surgeons are expected to report on a minimum of six measures, including one outcome measure (a high-priority measure may be substituted if an outcome measure is not applicable) for the duration of the performance year (12 months).
  • In 2020, to receive a performance score on a measure, Report quality data for 70 percent of all patients to which each measure is applicable, regardless of payor, over the course of the 2020 calendar year.
  • To achieve full credit for this category, you will need to earn 60 Quality measure points. Each Quality measure is worth a maximum of 10 points, but there are many situations where the points available for reporting a measure are capped below 10 points, making it extremely difficult to achieve 60 points for this category.

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

Yes

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

47

Advance 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 MIPS 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 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