Quality Performance Category

The Quality performance category will be worth 30 percent of the Merit-based Incentive Payment System (MIPS) final score in 2022.

• 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 70 percent of all their patients to which each measure applies, regardless of payor, over the course of the 2022 calendar year. If a clinician reports via claims, they only need to report data for 70 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. Please note: There are many situations where the points available for reporting a measure are capped below 10 points, making it increasingly difficult to achieve 60 points for this category.

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 2022 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 Web Interface measures (available to groups of 25 or more)
• 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 3 and 10 points for quality measures submitted during the 2022 performance period when they report at least 20 cases, meet the 70 percent data completeness threshold, and when the measure has a benchmark.

Quality measures are scored as follows:

• 3 to 10 points—A surgeon will receive 3 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)
• 3 points—A clinician will receive 3 points if they meet the data completeness criteria, but either (1) the measure doesn't have a benchmark and/or (2) they do not meet the case minimum.
• Measures that do not meet the data completeness criteria, regardless of case minimum or benchmark, will earn 0 points. **Clinicians in small practices will still receive 3 points on a measure, even if it does not meet the data completeness criteria.

Additional Factors That Can Affect Quality Measure Scoring

• 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. In the example from the PY 2021 Quality benchmark file below, if a clinician's performance is anything less than 100 percent, he/she can only earn up to 5 points on the measure:

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.

• Surgeons can receive up to 10 bonus 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. In 2022, CMS adopted a revised complex patient bonus calculation methodology to better target clinicians who serve a higher share of dual-eligible and/or medically complex patients.
• Small practices will receive a 6-point bonus added to their Quality category score when they submit data on at least 1 quality measure.

Please note: CMS will no longer offer bonus points for reporting additional outcomes measures and high-priority measures or for end-to-end electronic reporting.