Merit-Based Incentive Payment System

The Merit-Based Incentive Payment System (MIPS) is a program under the Centers for Medicare & Medicaid Services (CMS) and is designed to promote reporting of quality information by eligible professionals. MIPS consolidates elements of existing Medicare physician quality programs—including the Physician Quality Reporting System, the Value Modifier, and the Electronic Health Record Incentive Program—into one streamlined program.

Eligible professionals who do not satisfactorily report at least one Quality measure spanning any time during the January 1–December 31, 2017 reporting period will be subject to a 4% negative payment adjustment (penalty) in the 2019 Medicare Part B Fee Schedule. Surgeons participating in the STS Adult Cardiac Surgery Database (ACSD) can avoid this penalty by consenting to have STS report data on 14 Quality measures to CMS on their behalf. In addition, surgeons could potentially qualify for a small to moderate upward payment adjustment depending on performance and the number of measures and activities reported under MIPS.

The STS National Database has been designated a Qualified Clinical Data Registry (QCDR) for MIPS reporting in 2017. A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission. The data submitted to CMS via a QCDR cover quality measures across multiple payers and are not limited to Medicare beneficiaries or measures within MIPS. CMS will publish physician results on a select set of measures from the 2017 MIPS submission on the Physician Compare website.

This service is free for STS members. Non-members will be assessed a $500 annual fee for the Society to transmit data on their behalf. To avoid this fee, surgeons have the opportunity to become STS members.

Complete the 2017 MIPS Data Sharing Consent Form (coming soon!) by October 31, 2017, to participate. A new consent form must be submitted every year.

STS will not report for surgeons who are enrolled in or part of an Accountable Care Organization or plan to report in a group.

To learn more about MIPS, watch this CMS video.

Also, STS has compiled a MACRA Toolkit for Cardiothoracic Surgeons that explains the changes for 2017 and beyond in greater detail.

STS will report to CMS all of the following Quality measures on behalf of individual consenting surgeons:

 Measure#  Description (click on title for measure specifications) Measure Type
 21  Antibiotic selection Process
 43 CABG IMA Use Process
 44 CABG Preop Beta Blocker Process
 164  CABG Prolonged Postop Ventilation
 Outcome
 165  CABG Deep Sternal Wound Infection Outcome
 166  CABG Postop CVA Outcome
 167  CABG Postop Renal Failure Outcome
 168  CABG Reoperation Outcome
 226  Tobacco Screening & Intervention Process
 445  CABG Operative Mortality Outcome
 STS PLOS Following CABG Outcome
 STS PLOS Following CABG + Valve Outcome
 STS PLOS Following Valve Outcome
 STS Patient-Centered Risk Assessment/Communication Process


If you have questions, contact Derek Steck, STS National Database Coordinator, at dsteck [at] sts [dot] org.

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