Quality Performance Category

The Quality performance category will be worth 30 percent of the Merit-based Incentive Payment System (MIPS) final score in 2024.

• Surgeons are expected to report on a minimum of six quality measures, including one outcome measure (a high-priority measure may be substituted if an outcome measure is not available) for the duration of the 12-month performance period.
• To receive a performance score on a quality measure, clinicians or groups must report quality data for 75 percent of all their patients to which each measure applies, regardless of payor, over the course of the 2024 calendar year. If a clinician reports via claims, they only need to report data for 75 percent of Medicare beneficiaries to which each measure applies.
• Surgeons can earn up to 10 points on most quality measures. To receive the full 30 percent weight assigned to the Quality category for your MIPS final score, you will need to earn 60 quality measure points. 

There are numerous clinical quality measures (CQMs) available for MIPS reporting. Some of these measures have been organized into optional specialty measure sets. For example, general surgeons can utilize the General Surgery specialty measure set to determine the MIPS measures that might fit best with the care they provide. All quality measures available for 2024 MIPS reporting can be found in the CMS QPP Resource Library.

Depending on the measures selected, surgeons can choose from the multiple Quality data collection types submission mechanisms listed below:

• Medicare Part B Claims measures (Claims reporting is only available to surgeons in small practices. Those who report claims only have to report on 70 percent of all Medicare patients to which the measure applies)
• Electronic Clinical Quality Measures (eCQMs)
• MIPS Clinical Quality Measures (CQMs)
• Qualified Clinical Data Registry (QCDR) measures
• CMS-approved survey vendor for Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS (must be reported in conjunction and with another data submission mechanism

Surgeons may receive between 1 and 10 points for quality measures submitted during the 2043 performance period when they report at least 20 cases, meet the 75 percent data completeness threshold, and when the measure has a benchmark.

Quality measures are scored as follows:

• 1 to 10 points—A surgeon will receive 1 to 10 points based on performance compared to a historical or performance year benchmark as long as the measure meets the data completeness criteria, has a benchmark, and has a sufficient number of cases (>20 cases for most measures). If surgeons report a measure that is in its first two years of inclusion of the MIPS program, the measure will still be worth between 3 and 10 points for its first two years.
• 0 points—A clinician will now receive 0 points if they report a measure that doesn’t have a benchmark, unless the measure is new to the program, or the surgeon is part of a small practice.
• Measures that do not meet the case minimum (at least 20 patients) will no longer be eligible for 3 points. If surgeons report a measure that does not meet the case minimum they will receive 0 points, unless the measure is new to the program or the surgeon is part of a small practice.

Many measures that are most relevant to surgeons are now considered "topped-out." This makes it extremely hard to earn the maximum 60 points in Quality, because many of these measures are subject to scoring caps where the highest achievable score for the measure is 7 out of 10 points.

If a surgeon chooses to report more than the required 6 measures, CMS will only provide performance scores for a physician's top six performing measures.

MIPS measures can also be subject to scoring caps if they do not have a benchmark for all 10 deciles. This happens when about 10–60 percent or more of clinicians performed at the maximum achievable performance rate. In these situations, performance scores lower than 100 percent are capped at the specified level.

If you meet the definition of a facility-based clinician or group, CMS may use your Hospital Value-Based Purchasing (VBP) Program score in lieu of a MIPS score if the VBP score translates to a higher score than the clinician's combined Quality and Cost score under MIPS. Learn more about facility-based scoring. This policy can only help clinicians earn a higher score and does not require any special action or election on the part of the facility-based clinician.

• Small practices will receive a 6-point bonus added to their Quality category score when they submit data on at least 1 quality measure.
• Surgeons can receive up to 10 additional percentage points in Quality for demonstrating improvement in the category, overall, from year to year.
• Surgeons can earn up to 10 bonus points for those who qualify for the complex patient bonus.  Beginning in 2024, facility-based MIPS eligible clinicians are eligible to receive the complex patient bonus even if they do not submit data for at least one MIPS performance category.