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

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.

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.

The reporting requirements for the MIPS Quality component are to report six quality measures, including one outcome (which can include Patient-Reported Outcomes [PROs]) or high-priority measure, for at least 60 percent of the surgeon’s all-payer patients. This requirement applies to each eligible CPT code for each measure reported.

For the two measures reporting options (i.e. ACS Surgical Phases of Care Measures and ACS Trauma Specialty Measures) that are Qualified Clinical Data Registries (QCDRs), QCDRs allow eligible clinicians (ECs) to submit “QCDR” 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 difference in the manner it is reported by the QCDR. These QCDR measures provide surgeons with a wider range of options.

MIPS 2018 Improvement Activities through the SSR

For the MIPS 2018 performance year, eligible clinicians (ECs) may attest to and submit Improvement Activities data through the SSR for MIPS 2018 with 86 surgical relevant Improvement Activities to choose from.