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 performance thresholds and category weights for the 2020 performance period (which equates to the 2022 payment year):

• The performance threshold is 45 points
• The additional performance threshold for exceptional performance is 85 points
• The Quality performance category is weighted at 45% 
• The Cost performance category is weighted at 15% 
• 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. Payment adjustments are based on performance two years prior, and the maximum payment adjustment for the 2022 payment year (2020 performance period) is +/- 9%.

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.

Surgeons who participate in the STS Adult Cardiac Surgery Database can satisfy the Quality category by signing a 2020 MIPS Data Sharing Consent and Release Form. Surgeons who consent to have STS submit data to CMS on their behalf in the quality category will avoid an automatic 9% negative payment adjustment in 2022. Even surgeons whose hospitals already are reporting for them may benefit from the Society’s submission, as CMS will count the highest-scoring measures. Consent forms may be completed by surgeons or a designee with access to the IQVIA platform. The consent form submission deadline is December 1, 2020.

The STS MIPS enrollment guide provides instructions on how to complete the consent form. A MIPS dashboard is under development and will be available in the platform later this year. 

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

Surgeons will have the opportunity to attest to satisfying the Promoting Interoperability and Improvement Activities categories via a CMS attestation portal.

COVID-19 Update
The Centers for Medicare & Medicaid Services has implemented policy exceptions and extensions for upcoming measure reporting and data submission deadlines for MIPS for clinicians and groups affected by extreme and uncontrollable circumstances, including COVID-19. MIPS-eligible sites may submit an application for re-weighting of any or all MIPS performance categories. Applicants must first register for a HCQIS Access and Roles Profile (HARP) account through December 31, 2020. Learn more about applying.