Merit-Based Incentive Payment System Reporting

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. 

The following are the performance thresholds and category weights for the 2021 performance period 

  • The performance threshold is 60 points
  • The additional performance threshold for exceptional performance is 85 points
  • The Quality performance category is weighted at 40% 
  • The Cost performance category is weighted at 20% 
  • The Promoting Interoperability performance category is weighted at 25% 
  • The Improvement Activities performance category is weighted at 15%

The MIPS program is designed to be budget neutral. The amount provided for positive payment adjustments is determined by the amount provided for negative payment adjustments. The maximum payment adjustment for the 2023 payment year (2021 performance period) is +/- 9%.

For MIPS reporting in 2021, the STS National Database has been designated a Qualified Clinical Data Registry (QCDR), which is a CMS-approved entity that collects clinical data on behalf of eligible professionals 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.

STS will report to CMS all of the following Quality measures on behalf of consenting surgeons in the Adult Cardiac Surgery Database: