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

MIPS 2017 Quality Options through the SSR

The Surgeon Specific Registry (SSR) has been approved by the Centers for Medicare & Medicaid Services (CMS) to provide Merit-based Incentive Payment System (MIPS) Quality participation through registry-based reporting for the 2017 program year.

The following are two 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 2017 MIPS Quality through the SSR.

*Please note that for any other 2017 MIPS Quality reporting options, please refer to CMS.

MIPS-Qualified Registry

For MIPS Quality measure reporting, Quality measures have been grouped together according to ‘measure specialty set’. For the 2017 MIPS program year, the SSR is supporting the General Surgery Measures Specialty Set. In addition to the familiar general surgery measures developed by the ACS, other Quality measures have been included in this measures specialty set, which will provide surgeons with a more robust selection of measures to choose from.

General Surgery Measures Specialty Set Option

Individual eligible clinicians (ECs) may submit 2017 MIPS Quality General Surgery Measures Specialty Set data through the SSR. ECs must report on a minimum of six measures, including one outcome or high-priority measure, for at least 50% of all-payor patients. Should the EC select the 2017 General Surgery Measures Specialty Set, a minimum of 20 patients must be reported for each of the six measures chosen by the EC.

The 2017 General Surgery Measures Specialty Set consists of 13 MIPS Quality measures to choose from. To access any of the measures specifications, click on any of the measures in the table below.

Quality
ID #

Measure Name

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

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 or documentation 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 six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter

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 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 within24 months AND who received cessation counseling intervention if identified as a tobacco user

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 reporting 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

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

MIPS-Qualified Clinical Data Registry

The SSR also provides the MIPS Quality option—Qualified Clinical Data Registry (QCDR)—to leverage new measures developed by the ACS known as the Surgical Phases of Care for 2017 MIPS Quality reporting. QCDRs allow eligible clinicians (ECs) to submit non-MIPS measures, which are measure 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 differences in the manner it is reported by the QCDR. These non-MIPS measures provide surgeons with a wider range of options based on this new framework measuring surgical care across the care continuum of phases identified by the ACS. The ACS Surgical Phases of Care Measures were designed to be inclusive of all surgical specialties, and are clinically relevant and meaningful.

ACS SSR Surgical Phases of Care Measures QCDR Option

The ACS SSR Surgical Phases of Care Measures QCDR option provides 10 non-MIPS measures and one MIPS measure for a reporting option. ECs must report on a minimum of six measures, including one outcome or high-priority measure, for at least 50% of all-payor patients. Should the EC select the 2017 ACS Surgical Phases of Care Measures QCDR, a minimum of 20 patients must be reported for each of the six measures chosen by the EC.

To access the measures specifications, including eligible CPT® codes, for the 10 non-MIPS Surgical Phases of Care measures, download the 2017 Surgical Phases of Care Measures Specifications Manual. For information on the MIPS measure available in the ACS SSR Surgical Phases of Care QCDR (#358 – Patient-Centered Surgical Risk Assessment and Communication), click on the measure in the table below. A 2017 Surgical Phases of Care Measures Quick Guide is another available resource and provides a list of all required data fields, variables, and qualifying questions that pertain to each measure.

Surgical Phase of Care

Measure
ID #

Measure Name

Measure Type

MIPS/
Non-MIPS

Preoperative / Perioperative

SPC 1

Preoperative Composite

Composite

Non-MIPS

SPC 2

Patient Frailty Evaluation

Process

Non-MIPS

SPC 3

Preventive Care and Screening: Tobacco Screening and Cessation Intervention

Process

Non-MIPS

SPC 4

Preoperative Key Medications Review for Anticoagulation Medication

Process

Non-MIPS

QPP 358

Patient-Centered Surgical Risk Assessment and Communication

Process

MIPS

Intraoperative

SPC 5

Intraoperative Composite

Composite

Non-MIPS

Postoperative

SPC 6

Optimal Postoperative Communication and Plan and Patient Care Coordination Composite

 

Non-MIPS

Post-Discharge

SPC 7

Post-Acute Recovery Composite

Composite

Non-MIPS

SPC 8

Unplanned Reoperation within the 30 Day Postoperative Period

Outcome

Non-MIPS

SPC 9

Unplanned Hospital Readmission within 30 Days of Principal Procedure

Outcome

Non-MIPS

SPC 10

Surgical Site Infection (SSI)

Outcome

Non-MIPS