2018 MIPS PARTICIPATION GUIDE

The American College of Surgeons (ACS) Surgeon Specific Registry (SSR) has been approved by the Centers for Medicare & Medicaid Services (CMS) as both a Qualified Registry and a Qualified Clinical Data Registry (QCDR) for the 2018 MIPS Performance Year.

facs.org/quality-programs/ssr/mips

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Table of Contents I.) CMS QPP MIPS Overview ............................................................................................................... 2

1.1.) What is the CMS Quality Payment Program (QPP)? ........................................................................ 2

1.2.) What is MIPS? .................................................................................................................................. 2

1.3.) MIPS Final Score and Payment Adjustments ................................................................................... 3

1.4.) Does MIPS Apply to Me (i.e. Do I need to report)? ......................................................................... 4

1.5.) MIPS 2018 | Summary of Key Facts ................................................................................................. 5

II.) MIPS 2018 Participation Options via the SSR ................................................................................. 6

2.1.) Which MIPS 2018 Categories does the SSR Support? ..................................................................... 6

2.2.) MIPS 2018 Quality Measures Reporting Options ............................................................................ 6

2.2.1.) Quality Measures – MIPS Performance Category Requirements ............................................. 6

2.3.) MIPS 2018 Improvement Activities Options .................................................................................... 7

2.3.1.) Improvement Activities – MIPS Performance Category Requirements ................................... 7

III.) Using the SSR to Report MIPS 2018 Data ...................................................................................... 8

3.1.) Signing up for (consenting to) MIPS 2018 Participation .................................................................. 8

3.1.1.) Selecting your MIPS Quality Measures Option and Measures ............................................... 11

3.1.2.) Selecting your MIPS Improvement Activities ......................................................................... 12

3.1.3.) Reviewing and Saving your MIPS 2018 Consent and Selections in the SSR ........................... 13

3.2.) Entering Cases for MIPS 2018 Quality Measures in the SSR .......................................................... 14

3.2.1.) Important Information about Measure Attestation ............................................................... 17

3.3.) Reviewing your MIPS 2018 Data with the MIPS Measures Reports .............................................. 18

3.3.1.) Accessing the MIPS Measures Reports ................................................................................... 18

3.3.2.) Using the MIPS Measures Reports ......................................................................................... 19

3.4.) Approving your MIPS 2018 Data Submission (REQUIRED) ............................................................ 23

3.4.1.) Un-Approving your MIPS Data Submission for Editing or Cancelling Participation ............... 27

Appendix 1 – Reporting MIPS 2018 through the SSR – Participation Checklist ................................... 28

Appendix 2 – MIPS 2018 Quality Measures Details ............................................................................ 29

General Surgery Specialty Measures Set ............................................................................................... 29

ACS Surgical Phases of Care Measures .................................................................................................. 32

ACS Trauma Quality Measures ............................................................................................................... 36

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I.) CMS QPP MIPS Overview

1.1) What is the CMS Quality Payment Program (QPP)?

The CMS QPP is the operationalization of the Medicare Access & CHIP Reauthorization Act (MACRA) legislation of 2015. The QPP took effect on January 1, 2017. There are two participation tracks to choose from in the QPP based on your practice size, specialty, location, or patient population:

• Merit-based Incentive Payment System (MIPS) or • Advanced Alternative Payment Models (APMs)

1.2.) What is MIPS? MIPS is the default track of the CMS QPP where eligible clinicians (ECs) submit quality data to earn a performance-based adjustment on their Medicare payments. The MIPS program is comprised of four performance categories:

• Quality • Promoting Interoperability (PI) (formerly known as Advancing Care Information (ACI)) • Improvement Activities (IA) • Cost

For the 2018 MIPS performance year, the SSR is supporting the Quality and Improvement Activities categories. Currently the PI category can only be fulfilled through the use of a Certified EHR Technology (CEHRT) system, and for the 2018 performance year there are no reporting requirements for the Cost category.

MIPS began measuring performance in 2017. The data reported in 2017 will be used to adjust payments in 2019. The data reported in calendar year 2018 will be used to adjust payments in 2020. MIPS combined the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VM), and the EHR Incentive Program commonly referred to as Meaningful Use (MU), added the new component Improvement Activities, and combined them to derive a composite MIPS Final Score.

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1.3.) The MIPS Final Score and Payment Adjustments

In 2018, participants in MIPS will report data that will result in payment adjustments (positive, negative, or neutral) in 2020. Payment adjustments are applied two years after the performance year. The data reported to CMS in various categories (Quality, PI, IA, and Cost) will be combined into a single MIPS Final Score, which will be compared with a threshold to determine each provider’s update.

Category Weights For the 2018 performance year, Quality, PI, IA, and Cost will account for 50, 25, 15, and 10 percent of the total MIPS Final Score, respectively. (See figure below).

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1.4.) Does MIPS Apply to Me (i.e. Do I need to report)? For 2018, CMS estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers, particularly those who are employed or are in large group practices, will have data submitted on their behalf by their group, institution, or employer. Therefore, it is imperative that as a first step, all surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, surgeons should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for them by their group, institution, or employer.

For 2018, CMS increased the low-volume threshold. It is now set at less than or equal to $90,000 in Medicare Part B allowable charges OR 200 or fewer Medicare Part B patients seen during the period selected by CMS. Because this represents an increase compared to 2017, it will result in even more providers being exempted from participating in MIPS. If EITHER of these thresholds is NOT met, it is sufficient to exclude one from reporting MIPS data in 2018.

To determine if you have met either of the above thresholds and therefore determine whether you are eligible to participate in MIPS, it is highly recommended that you utilize “Check Participation Status” tool on the CMS QPP website, which uses your NPI number to lookup your status by performance year.

https://qpp.cms.gov/participation-lookup

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1.5) MIPS 2018 | Summary of Key Facts

2018 Performance Year

MIPS 2018 Categories • Quality • Promoting Interoperability (PI) • Improvement Activities (IA) • Cost

Nonparticipation Penalty Nonparticipation in the QPP in 2018 will result in a 5 percent Medicare Part B payment penalty in 2020.

MIPS Performance Scoring

Neutral Payment Adjustment Threshold

A 2018 MIPS final score of 15 points will earn you a neutral payment adjustment in calendar year 2020.

Changes from 2017 Performance Year

-Quality: 50% (instead of 60% in 2017). -Cost: 10% (instead of 0% in 2017). -Advancing Care Information (ACI) has been renamed to Promoting Interoperability (PI). -Partial-year reporting is not allowed in MIPS 2018 Data Submissions.

MIPS Eligibility Enter your NPI number into the “Check Participation Status” tool on the CMS QPP website to determine if you are eligible (i.e. expected) to report MIPS 2018 data to CMS. https://qpp.cms.gov/participation-lookup

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II.) MIPS 2018 Participation Options via the SSR

2.1.) Which MIPS 2018 Categories does the SSR Support? For the 2018 MIPS performance year, the SSR supports the Quality and Improvement Activities (IAs) components for surgeons to participate in. Reporting MIPS through the SSR is considered registry-based reporting. The SSR does not currently support data submission on the Promoting Interoperability or Cost components. For information on how to submit compliant data on these components, please visit the ACS Advocacy’s QPP Resource Center at https://www.facs.org/advocacy/qpp/2018. 2.2.) MIPS 2018 Quality Measures Reporting Options 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. • General Surgery Specialty Measures Set includes options for general surgeons (MIPS-Qualified

Registry). • ACS Surgical Phases of Care Measures includes options for a wide range of surgical specialties

(MIPS-QCDR).

• ACS Trauma Quality Measures‡ includes options for trauma surgeons (MIPS-QCDR). ‡Only available to surgeons at participating ACS Trauma Quality Improvement Program (TQIP) sites. *Please note that for any other 2018 MIPS Quality reporting options, refer to CMS and the 2018 qualified postings for Qualified Registries and Qualified Clinical Data Registries (QCDR)., for which both documents can be found here: https://qpp.cms.gov/about/resource-library.

For the list of measures, including measure details, within each MIPS Quality reporting option, see Appendix 2 (page 29).

2.2.1) Quality Measures – MIPS Performance Category Requirements

The reporting requirements for the MIPS Quality category are to report six quality measures, including one outcome (which includes Patient-Reported Outcomes (PRO) measures) or high-priority measure, for at least 60 percent of all-payer patients. This requirement applies to each eligible CPT code for each measure reported.

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2.3.) MIPS 2018 Improvement Activities Options Eligible clinicians** (ECs) (e.g. surgeons) may attest to and submit Improvement Activities (IA) data through the SSR for 2018 MIPS with 86 surgically relevant IAs to choose from. For the full list of MIPS 2018 IAs available through the SSR, see here: https://www.facs.org/~/media/files/quality%20programs/ssr/mips/2018_ia_ssr.ashx.

2.3.1.) Improvement Activities – MIPS Performance Category Requirements

Each IA must be attested to for a minimum of 90 consecutive days to earn full credit for the activity. To earn the maximum score for the IA category of MIPS, you must attest to 40 points‡‡ worth of IAs, and each IA is assigned one of two weightings:

• High (20 – 40 points) • Medium (10 – 20 points)

How many IAs you must attest to and the number of points an IA is worth is then dependent on the size of group that you are a part of:

• Individual ECs in groups with more than 15 clinicians must select from one of the following combinations (high-weighted activities = 20 points; medium-weighted activities = 10 points):

o 2 high-weighted activities, or o 1 high-weighted activity and 2 medium-weighted activities, or o 4 medium-weighted activities

• Individual ECs in groups with 15 or fewer clinicians, or ECs that are in a small practice or

rural setting, must select from one of the following combinations (high-weighted activities = 40 points; medium-weighted activities = 20 points):

o 1 high-weighted activity o 2 medium-weighted activities

**For the 2017 and 2018 MIPS performance periods, the following clinician types can participate in MIPS: Physicians; physician assistants (PAs); nurse practitioners (NPs); clinical nurse specialists; certified registered nurse anesthetics; and any clinician group that includes one of the professionals listed above. ‡‡For the 2018 MIPS performance year, earning a maximum score in the IA category (i.e. 40 points) will translate to 15 points toward your MIPS 2018 final score. A MIPS 2018 final score of 15 points will earn you a neutral payment adjustment in 2020.

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III.) Using the SSR to Report MIPS 2018 Data

3.1.) Signing up for MIPS 2018 in the SSR 1. Log into the SSR at https://www.acsdataplatform.com/login.

2. Select “Regulatory” in the main menu.

3. Click on “MIPS 2018 Participation.”

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4. Click on “Add New” next to ‘Add New MIPS 2018 Participation’.

5. Read the “Consent to Disclose Data to the QPP – MIPS from the SSR” agreement and select the check-box labeled “I consent to the terms and conditions of MIPS 2018 participation through the ACS SSR.”

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6. Enter your individual National Provider Identifier (NPI) number.

7. Enter your Taxpayer ID Number (TIN) associated with the billing of your Medicare Part B patients. (Note: if you are reporting on more than TIN, you may enter as many TINs as necessary by clicking on the “Add Instance” button.)

8. Always save your selections by clicking the “Save” button.

9. Click “MIPS 2018 Quality Reporting Options” in the Tabs menu to advance to the next tab where you can select your MIPS Quality measures reporting option.

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3.1.1.) Selecting your MIPS Quality Measures Option and Measures

1. On the tab labeled MIPS Quality Reporting Options, select one of the MIPS 2018 Quality measures reporting options being supported by the SSR and that which is most appropriate to your practice:

• General Surgery Specialty Measures Set

• ACS Surgical Phases of Care Measures Set

For more information about MIPS 2018 Quality Measures Reporting Options and the measures within each option, visit: https://www.facs.org/quality-programs/ssr/mips/2018-participation.

2. Select and review your “Selected Measures” in the box below.

3. Click the “Save” button, and you will now be able to report on these measures within all applicable, eligible cases in your case log.

4. Click “Improvement Activities” in the Tabs menu to advance to the next tab where you can select your IAs to attest to.

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3.1.2.) Selecting your MIPS Improvement Activities in the SSR

1. On the MIPS Improvement Activities (IA) options tab, and before selecting your IAs, please check off any of the IA criteria that applies to you on the IA tab by answering the question “Do any of the following apply to the eligible clinician (Select all that apply).”

2. Enter the “Start” and “End” dates to indicate the consecutive 90-day attestation period.

3. Select one or more IAs from the Activity List, and review your selections.

4. Click the “Save” button.

5. Click “2018 Summary” in the Tabs menu to advance to the final tab where you can review all your MIPS 2018 selections (i.e. Quality measures and Improvement Activities).

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3.1.3.) Reviewing and Saving your MIPS 2018 Selections in the SSR

1. On the “2018 Summary” tab, review your selections for your Quality measures and your Improvement Activities (IAs).

2. If you are satisfied with your selections, click “Save and Exit” to complete signing up for MIPS 2018 in the SSR.

• Please note that you can always return later to alter your selections.

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3.2.) Entering Cases for MIPS Quality Measures 1. Open a new or existing 2018 case from the cases main page.

2. If new, enter a 2018 procedure date.

3. Select the check-box “MIPS Consideration.”

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4. Enter the minimum required data variables for the case:

• 2018 General Surgery Specialty Measures Set – required case data variables: o ‘MIPS Consideration’ checkbox o ‘Medical Record Number’ (MRN) o ‘Date of Birth’ (DoB) o ‘Procedure Date’ o ‘Primary Procedure’ [must be an eligible CPT code]

• 2018 ACS Surgical Phases of Care Measures – required case data variables:

o ‘MIPS Consideration’ checkbox o ‘Long Form’ checkbox o ‘Medical Record Number’ (MRN) o ‘Date of Birth’ (DOB) o ‘Sex’ o ‘Functional Status’ o ‘Preop SIRS/Sepsis/Septic Shock’ o ‘Hospital Admission Date’ [must be same date as ‘Procedure Date’] o ‘Procedure Date’ o ‘Primary Procedure’ [must be an eligible CPT code] o ‘Surgical Approach (MIPS)’ o ‘Surgeon Role’ [must be ‘Primary’ or ‘Co-Surgeon’] o ‘Emergency Case’ [must be ‘No’] o ‘Elective Surgery’ [must be ‘Yes’] o ‘ASA Classification’ o ‘Wound Classification’ o ‘Dyspnea’* o ‘Ascites’*

*Located in the “Preop Risk Factors” tab in the Tabs menu.

5. Once all data points are entered under the “Short Form” tab (and “Long Form” tab for ACS Surgical Phases of Care Measures), click on the “Measures” tab in the Tabs menu on the right to access the measures data fields to complete.

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6. Select the appropriate attestation (i.e. numerator option) “Performance Met”, “Performance Not Met”, or “Performance Exclusion”, etc. on all applicable measures.

7. Select the “Complete” checkbox at the top of the case form.

8. Click the “Save”, “Save & New”, “Save & Duplicate”, or “Save & Exit” button to finish the case.

9. Continue either entering new cases and/or editing previously entered cases following the same steps.

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3.2.1.) Important Information about Measure Attestation

Please read carefully! 1. Inverse Measures (i.e. Selecting ‘Performance Not Met’ for Outcome Measures) – NOTE: All outcome

type measures are designated as “inverse measures” by CMS. A lower calculated performance rate for this type of measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control. The following measures are designated as inverse measures:

• General Surgery Specialty Measures Set o #354 – Anastomotic Leak Intervention o #355 – Unplanned Reoperation within the 30-Day Postoperative Period o #356 – Unplanned Hospital Readmission within 30 Days of Principal Procedure o #357 – Surgical Site Infection (SSI)

• ACS Surgical Phases of Care Measures o #SPC 8 – Unplanned Reoperation within the 30-Day Postoperative Period o #SPC 9 – Unplanned Hospital Readmission within 30 Days of Principal Procedure o #SPC 10 – Surgical Site Infection

2. Unable to Select (i.e. grayed-out) Measures – NOTE: As you are entering MIPS cases, you may notice

that you are unable to select certain measures within a case. The following are the most likely scenarios for why a measure is grayed-out:

• Your Procedure Date is after November 30, 2018 – Outcome type measures (i.e. QPP #’s 354, 355,

356, 357; SPC #’s 8, 9, 10) are only eligible to be reported during January 1 – November 30, 2018. CMS has structured the measure reporting period for outcome measures so that the 30 day outcomes/assessments fall within the 2018 calendar year. This means that you are not supposed to report encounters for these measure for the month of December 2018 (i.e. cases with a December 2018 procedure date).

• The Primary Procedure (i.e. CPT code) you entered is not an Eligible Procedure for the Measure(s)

– Each measure has its own set of eligibility criteria, including CPT codes, which can be found in each measure’s specifications document. Additionally, some measures such as #47 – Care Plan or #130 – Documentation of Current Medications in the Medical Record require Evaluation & Management (E&M) codes for eligible encounters. This means you will need to create separate cases for these types of encounters to report on these measures, for which you will enter the date of the encounter in the “Procedure Date” field and enter the E&M code in the “Primary Procedure” field. Regardless of the reason, always refer back to the measures specifications documents for these specific eligibility criteria (see Appendix 2).

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3.3.) Reviewing your MIPS 2018 Data in the SSR There are three MIPS Measures Reports available to help analyze your MIPS cases data. These reports can help you check your measure performance rates, identify any cases with missing data points, and ensure your cases are complete and ready for submission, among other uses. The three reports are: • Measures Summary Report

• Measure Details Report

• Missing Data View Report

3.3.1) Accessing the MIPS Measures Reports

1. Click on “Regulatory” in the SSR main menu.

2. Click on “MIPS 2018 Measures Reports.”

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3. Ensure that the Reporting Year is set to “2018.”

4. Click on “Apply Parameters” to run the MIPS reports.

3.3.2) Using the MIPS Measures Reports Quality Measures Summary This section is a Quality Measures cases summary, which is always displayed regardless of which measures report is selected. This section displays several counts of your cases in regards to the status of MIPS completeness. The following is a breakdown of those counts: • Total # of Cases for Reporting Period: This number reflects how many existing total cases fall into

the specific MIPS reporting period and is based on ‘Procedure Date’. • Total Eligible Cases (MIPS Quality): This number reflects how many existing total cases are eligible

for MIPS 2018 reporting and is based on ‘Procedure Date’ and ‘Primary Procedure’. • Total Eligible Cases (MIPS Quality) selected for submission for CMS Data Submission: This number

reflects how many existing total MIPS eligible cases have been selected for inclusion in the submission and is based on the ‘MIPS Consideration’ checkbox in the case entry form.

• Completed Eligible Cases ready for CMS Data Submission: This number reflects how many existing total MIPS eligible cases are marked as “Complete” (checkbox at the top of the case entry form) with all required data variables and measures entered.

• IA Score: The number points for your Improvement Activities (IA) score. To access any of the three MIPS Measures reports, use the tabs at the top of the report.

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Measures Summary Report The “Measures Summary” report is the default that will display when initially running the report. All the measures selected by the surgeon will display as tiles with high-level information specific to each measure. This report is useful for checking your measure performance rates and the number of cases reported for each measure. Each measure tile is labeled by the measure number and title, and includes the measure ‘Performance Rate’ (displayed as a percentage) and the ‘Case Volume’, which indicates how many cases have been reported for the measure. White tiles with black text indicate a normal measure (i.e. 100% performance rate signifies the best clinical care or control), and black tiles with white text indicate an inverse measure (i.e. 0% performance rate signifies the best clinical care or control). Additionally, the number of cases for the Case Volume count is followed by a descriptor, Low Case Volume < 20, which is there to serve as a reminder of a MIPS 2018 Quality Measures requirement: quality measures are each worth 10 points in the MIPS Quality performance category, and if a provider has less than 20 cases reported for a quality measure then that quality measure is capped at 3 points for the provider.

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Measure Details Report The “Measure Details” report will allow you to drill down into more details for a specific measure. When selecting on of the listed measures in this report, the system will show counts for aspects of both the measure denominator and numerator. You also have the ability to drill down to the case level for each of those counts. This report is useful for breaking down how you have performed on a measure and identifying which cases have been specifically reported for the measure.

1. To drill down into your data, click on the Case Volume count next to a specific measure.

2. Click on any of the bars in the graph to drill down to the case level.

3. To open a specific case in a new browser tab, click on the case link under the “Access Case” column.

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Missing Data View Report The “Missing Data View” report will allow you to filter cases for missing data and then drill down to case-level variable details to find specific missing data points in incomplete MIPS cases; furthermore, you may also use this report to see which cases are eligible, completed, and those not selected for MIPS submission. The Missing Data View report has four filters to help you analyze your MIPS cases: • All Eligible Cases: all eligible MIPS cases in your account based on ‘Procedure Date’ and ‘Primary

Procedure’ • Missing Data for Measure: eligible MIPS cases with missing data points • Submission Ready: completed and finalized MIPS cases • Not selected for MIPS: all cases NOT selected for MIPS (i.e. ‘MIPS Consideration’ checkbox is not

selected in the case form)

1. To find MIPS cases with missing data, select the “Missing Data for Measure” filter.

2. From the list of filtered cases, select a case to see both the measures that are eligible for the case and which required data points are missing (highlighted yellow “Not Reported” label).

3. To open a specific case in a new browser tab, click on the case link under the “Access Case” column.

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3.4.) Approving Your MIPS Data Submission Approving your MIPS Data Submission is the final action you must take in order for the ACS to submit MIPS data to CMS on your behalf. Even if you have reported on all Quality Measures within your 2018 cases, and attested to an adequate amount of Improvement Activities, you must approve your data submission within the MIPS Preview Submission Report, otherwise your data will not be submitted. The deadline to approve your MIPS 2018 data submission in the SSR is January 31, 2019.

1. Go to “Regulatory” in the SSR main menu.

2. Click on the “MIPS 2018 Preview Submission Report” link.

3. Review your information in the Eligible Clinician (surgeon) Information section, and add a phone

number and preferred email for best contact. Additionally review your NPI and TIN numbers for accuracy. (Note: if you need to edit your NPI or TIN, you must go back to the MIPS 2018 Participation consent form under “Regulatory” where you initially enrolled.)

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4. Save your progress continually as you finalize your MIPS 2018 Preview Submission Report by clicking

on the “Save Submission” button. After saving your submission for the first time, you will see the Progress Bar update.

5. If you are reporting the MIPS 2018 Quality Measures category, select the cases you would like to include in your submission. If you want to select all cases at once, select the checkbox at the top of the ‘Case List’ table (circled in orange). You can also select/deselect cases on an individual basis. Only completed and finalized cases that are ready for MIPS 2018 submission will appear in this list.

6. If you are reporting on multiple TINs for the MIPS Quality category, then select which TIN applies to which case. (If you are only reporting on one TIN, then skip this step.)

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7. At the bottom of the ‘Case List’ section, review the number of cases you have selected for accuracy.

8. After you have finished selecting your cases for the Quality category, review your measure performance rates and case volumes for each measure in the “MIPS Quality Component Details” section, which is a summary table below the ‘Case List’ section. Also review the number of outcome and/or high-priority measures you have reported on to ensure that you have at least one of either type of measure (i.e. outcome or high-priority). Additionally, if you are reporting on more than one TIN, then each TIN will have its own separate details table.

9. If you are reporting on the MIPS Improvement Activities category, review the activities you have selected for accuracy including the attestation period.

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10. After you are satisfied with the review of your data, scroll up the top of the page and click the “Save Submission” button.

11. Then, click the “Approve Submission” button.

12. In the pop-up window labeled “Approve MIPS 2018 Data Submission”, select the “I approve the submission of my MIPS data” checkbox.

13. Then click the blue “Save and Close” button.

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14. Your MIPS 2018 data submission is now approved! No further action is required on your part. The progress bar on the top of the page should display like so:

• Please note: your data will not be submitted until early March 2019. Once the ACS SSR has submitted your data, you will be notified whether your MIPS 2018 data was accepted for review by CMS.

3.4.1.) Un-Approving (i.e. Cancelling) Your MIPS 2018 Data Submission for Editing or Cancelling Participation

1. If you need to make any changes to your MIPS 2018 data submission prior to the Jan. 31, 2019 deadline, click the “Un-Approve Submission” button at the top of the Preview Submission Report.

• Note: if you want to cancel your MIPS 2018 data submission entirely, then just click the “Un-Approve Submission” button.

2. Make your edits.

3. Re-approve your submission following the same steps as you did before.

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Appendix 1 – Reporting MIPS 2018 through the SSR – Participation Checklist

Check your MIPS 2018 participation eligibility by entering your NPI into the “Check Your

Participation” status tool on the QPP website. [Section 1.4.]

Determine which Quality Measures reporting option and/or Improvement Activities options are most appropriate for you. [Section 2.2. – Section 2.3.]

Sign up for MIPS 2018 participation in the SSR and select your MIPS 2018 options. [Section 3.1.]

Enter new cases, or edit previously entered 2018 eligible cases for MIPS 2018 Quality Measures. [Section 3.2.]

Review your MIPS 2018 data for accuracy and completeness, as well as any missing data. [Section 3.3.]

Approve your MIPS 2018 data submission (REQUIRED). [Section 3.4.]

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Appendix 2 – MIPS 2018 Quality Measures Details

• General Surgery Specialty Measures Set [page 29]

• ACS Surgical Phases of Care Measures [page 32]

• ACS Trauma Quality Measures [page 36]

General Surgery Specialty Measures Set

Quality ID# Measure Title and Description Measure

Type

High-Priority Measure

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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 see within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for who 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

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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

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

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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

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ACS Surgical Phases of Care Measures

Approach to Surgical Measurement: Phases of Surgical Care

• Preoperative/Perioperative o Preoperative Composite o Patient Frailty Evaluation o Preventive Care and Screening: Tobacco Screening and Cessation Intervention o Preoperative Key Medications Review for Anticoagulation Medication o Patient-Centered Surgical Risk Assessment and Communication

• Intraoperative o Intraoperative Composite

• Postoperative o Optimal Postoperative Communication Plan and Patient Care Coordination

Composite • Post-Discharge

o Post-Acute Recover Composite o Unplanned Reoperation within the 30 Day Postoperative Period o Unplanned Hospital Readmission within 30 Days of Principal Procedure o Surgical Site Infection (SSI) o Surgical Phases of Care Patient-Reported Outcome Composite

CMS Measure ID#

Measure Title and Description Measure Type

MIPS or QCDR Measure

ACS15

Preoperative Composite

Percentage of patients who are taken to the operating room for an elective surgical under regional, monitored anesthesia care (MAC), and/or general anesthesia who have been documented for having all three preoperative components addressed during the preoperative phase of care:

1. The purpose for the recommended procedure AND goals of care discussion has been documented in the medical record.

2. An identification of significant co-morbid condition(s), if any, documented in the medical record within 30 days of operation date.

3. An updated history and physical (H&P), documentation that recent laboratory values were reviewed, and documentation of the site and side of surgery in the medical record within the 24 hours prior to surgery.

Composite QCDR

ACS18

Patient Frailty Evaluation

Percentage of patients age 65 and older who have been evaluated for frailty prior to an elective operation.

Process QCDR

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ACS16

Preventive Care and Screening: Tobacco Screening and Cessation Intervention

Percentage of patients age 18 or older who are active tobacco users who receive tobacco screening AND are offered cessation counseling at least 2 months prior to an elective surgical procedure in order to delay the procedure until smoking cessation is possibly achieved.

Process QCDR

ACS17

Preoperative Key Medications Review for Anticoagulation Medication

Percentage of patients who take anticoagulation medication who are taken to the operating room for an elective intervention under regional anesthesia, monitored anesthesia care (MAC), and/or general anesthesia who have a perioperative management plan for anticoagulation medications documented in the medical record.

Process QCDR

QPP 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 MIPS

ACS19

Intraoperative Composite

Percentage of patients age 18 years or older who are taken to the operating room for an elective or emergent surgical procedure under regional, MAC, and/or general anesthesia who have been documented for having all two intraoperative components addressed during the intraoperative phase of care:

1. An intraoperative safety checklist is performed prior to incision that includes the verification of patient’s name, the procedure to be performed, laterality, confirmation of site marking, allergies, confirmation of the administration of preoperative antibiotic prophylaxis and VTE prophylaxis if appropriate, anticipated equipment, placement of Bovie pad, correct patient positioning, and display of essential imaging.

2. An intraoperative surgical debriefing takes place at the end of the case by the surgeon confirming wound classification, correct counts, procedure performed, specimen review, equipment review, postoperative destination and postoperative care plan including plan for perioperative antibiotics, VTE prophylaxis and Foley catheter.

Composite QCDR

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ACS20

Optimal Postoperative Communication Plan and Patient Care Coordination Composite

Percentage of patients, age 18 years or older, who are brought from their home or normal living environment and who are taken to the operating room for an elective surgical intervention under regional anesthesia, MAC, and/or general anesthesia who have been documented for having all four of the following patient care communication and care coordination planning components addressed at the beginning of the postoperative phase of care:

1. A postoperative care plan is established, addressing mobilization, pain management, diet, resumption of preoperative medications, management of drains/catheters/invasive lines, and wound care.

2. A postoperative review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate.

3. A postoperative care coordination with the patient’s primary/referring provider regarding the surgery within 30 days following surgery.

4. A postoperative patient care communication plan with the patient and/or patient’s family regarding the surgery and plan for care after discharge.

Composite QCDR

ACS21

Post-Acute Recovery Composite

Percentage of patients age 18 years or older who are taken to the operating room for an elective intervention under regional, MAC, and/or general anesthesia who have been documented for having all two post-acute components addressed at the beginning of the post-discharge phase of care:

1. A post-discharge review of the patient goals of care that were expressed preoperatively and updating those goals of care as appropriate occurring after discharge up until 30 days following discharge date.

2. A post-discharge follow-up encounter within 30 days updating patient improvements in mobility, pain control, diet, resumption of home medications, wound care, and management of cutaneous/invasive devices (drains, IV lines, etc.).

Composite QCDR

ACS22 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 QCDR

ACS23

Unplanned Hospital Readmission within 30 Days of Principal Procedure

Percentage of patient 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.

Outcome QCDR

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ACS25 Surgical Site Infection (SSI)

Percentage of patients aged 18 years and older who had a surgical site infection (SSI).

Outcome QCDR

ACS24

Surgical Phases of Care Patient-Reported Outcome Composite

Composite measure consisting of 12 items intended to measure the constructs of Surgeon Communication Before Surgery, Surgical Goals of Care, Satisfaction with Information, and Postoperative Care Coordination from the patient’s perspective. Of these 12 items, nine originate from the CAHPS Surgical Care Survey (S-CAHPS). Specifically, these 9 items are questions 3, 9, 11, 17, 26, 27, 31, 33, and 34 from the original S-CAHPS survey. Three additional items are included to appropriately measure Goals of Care; these questions ask whether the surgeon discussed what the patient hoped to gain from surgery, whether the surgeon discussed how surgery would affect their daily activities, and what life might look like for the patient in the long-term.

Patient-Reported Outcome (PRO)

QCDR

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

Page | 36

ACS Trauma Quality Measures

CMS Measure ID#

Measure Title and Description Measure Type

MIPS or QCDR Measure

ACSTrauma1

Trauma Initial Assessment Composite

Percentage of blunt multisystem trauma patients having the following components documented upon presentation to the emergency department (ED) within 30 minutes of arrival:

1. Glasgow Coma Scale (GSC) score 2. Temperature

Process QCDR

ACSTrauma5

Optimal Timing of Surgical or Procedural Intervention for Hemorrhage in Trauma

Percentage of patients presenting with traumatic hemorrhagic shock who undergo an operative or procedural intervention for hemorrhage control within 4 hours.

Process QCDR

ACSTrauma6

Optimal Ratio of Blood Product Transfusion

Percentage of patients presenting with traumatic hemorrhagic shock who receive plasma and packed red blood cells (pRBC’s) in a ratio higher or equal to 1 unit of plasma for every 2 units of pRBCs over the first four hours after arrival to the emergency department.

Process QCDR

ACSTrauma7

Timely Initiation of VTE Prophylaxis in Trauma Patients

Percentage of seriously injured patients with pharmacologic venous thromboembolism (VTE) prophylaxis initiated within 48 hours of admission.

Process QCDR

ACSTrauma4 Splenic Removal Rate

Percentage of patients with a spleen injury (spleen AIS ≥ 2 and < 5) that undergo a splenectomy.

Outcome QCDR

ACSTrauma2

Mortality Rate Following Blunt Traumatic Injury to the Chest and/or Abdomen

In-hospital mortality rate for patients with severe blunt injury to the abdomen and/or chest (Abbreviated Injury Score [AIS] ≥ 3).

Outcome QCDR

ACSTrauma3

Mortality Rate Following Penetrating Traumatic Injury to the Chest and/or Abdomen

In-hospital mortality rate for patients with severe penetrating injury to the abdomen and/or chest (Abbreviated Injury Score [AIS] ≥ 3).

Outcome QCDR

ACS Trauma Quality Measures – Appendices

Appendix 1 – Inclusion Criteria | Appendix 2 – TQIP/NTDB Eligible ICD-10 Injury Diagnoses