Quality Performance Category

The Quality performance category will be worth 30 percent of the Merit-based Incentive Payment System (MIPS) final score in 2025.

• Surgeons participating in traditional MIPS 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 a quality measure  for at least 75 percent of all eligible patients, regardless of payor, over the course of the 2025 calendar year. If a clinician reports a Part B claims measure, they only need to report data on at least  75 percent of applicable Medicare patients.
• Surgeons can earn up to 10 points on most quality measures. To receive the full 30 percent weight assigned to the Quality category for their MIPS final score, surgeons must earn 60 quality measure points. 

There are numerous quality measures available for MIPS reporting. Some of these measures have been organized into specialty measure sets, which serve to guide clinicians in the selection of measures that are most relevant to their practice 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 2025 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 listed below:

• Medicare Part B Claims measures (Claims reporting is only available to surgeons in small practices – i.e., 15 or fewer clinicians billing under a practice’s TIN.)
• 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 2025 performance period when they meet the case minimum (at least 20 cases), meet the 75 percent data completeness threshold, and when the measure has a benchmark.

CMS uses national benchmarks to score clinicians on each quality measure. Each benchmark is broken into deciles, with each decile identifying the range of points generally available for the measure. For example, if your performance on a measure falls within the 5^th decile, you can earn between 5 and 5.9 points on the measure depending on your performance.

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 be subject to a 7-point floor in its first year and a 5-point floor in its second year.
• 0 points—Measures that do not meet the case minimum (at least 20 patients), do not meet the data completeness threshold, or do not have a historic or performance year benchmark (other than measures in their first two years of the program) will receive 0 points, except for small practices, which will receive 3 points on such measures.
• 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 now considered "topped-out;"  In other words, these measures have such consistently high performance that CMS believes that opportunities for improvement or meaningful distinctions in quality are limited. These measures have previously been capped at 7 points, making it extremely difficult to earn the maximum 60 measure points in Quality. The CY 2025 MPFS, however, finalized a policy removing this cap for certain measures in specialty sets with limited measure choice. This policy does not apply to all topped-out measures, and surgeons’ scores may still be impacted. Surgeons can view the MIPS Quality Benchmark files to determine which measures are toppe-out and subject to scoring caps in each year.

Similarly, performance rates for some measure benchmarks are not distributed across all deciles if a large proportion of clinicians achieved the maximum performance rate. In these scenarios, anything less than a perfect score (100 percent) may fall into a lower decile than expected (e.g., a 99 percent performance rate may translate into a score of 5.9 instead of 9.9).

If a surgeon chooses to report more than the required 6 measures, CMS will score the physician's top six performing measures.

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 to their final score 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.
• New in 2025: Virtual Groups and APM Entities will receive one measure achievement point in the Quality category for each submitted eCQM that meets the case minimum and data completeness requirements. CMS refers to this as the Complex Organization Adjustment.