Quality Reporting Options for Surgeons 2021 MIPS Performance Year

Changes for 2021

Beginning with the 2021 MIPS Performance Year, the ACS Surgeon Specific Registry (SSR) will no longer support CMS MIPS reporting. However, the Centers for Medicare and Medicaid Services (CMS) offers multiple options for submitting your quality measure data for MIPS 2021 performance year. Certain reporting mechanisms are available depending on your MIPS eligibility and the quality measures you choose to report.

Surgeons can be eligible for MIPS as an:

Individual;
Part of a Group;
MIPS APM; and/or
Part of a Virtual Group

The following collection types are available for MIPS quality measures, depending on eligibility:

Electronic Clinical Quality Measures (eCQMs)
MIPS Clinical Quality Measures (CQMs)
Qualified Clinical Data Registries (QCDRs)
Qualified Registries (QRs)
Electronic Health Records (EHRs)
Medicare Part B Claims Measures (those who report through claims only have to report on Medicare patients)
CMS Web Interface Measures

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey (must be reported in conjunction with another data submission mechanism).

	Medicare Part B Claims	Sign In and Upload via the QPP Portal at qpp.cms.gov	CMS Web Interface	Direct Submission (API)	Qualified Clinical Data Registries (QCDR)	Qualified Registries (QR)
A MIPS eligible Clinician in a practice with 15 or fewer clinicians	X	X			X	X
A MIPS eligible Clinician in a practice with 16 or more clinicians		X			X	X
A representative of a Group, Virtual Group, or APM Entity with 15 or fewer clinicians	X	X			X	X
A representative of a Group, Virtual Group, or APM Entity with 16-24 clinicians		X			X	X
A representative of a Group, Virtual Group, or APM Entity with 25 or more clinicians		X	X	X	X	X

For surgeons who are interested in reporting to MIPS via a QCDR or QR, CMS offers a list of QCDRs and QRs that are available for each performance year.

2022 QCDR and QR listing

Surgeons can also review additional quality reporting guidance from CMS below and on the QPP website.

Quality Reporting Options for Surgeons 2021 MIPS Performance Year

See which options work best for you

Changes for 2021