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. 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.

The MIPS program consists of four categories—Quality, Cost, Advancing Care Information, and Improvement Activities.

Because the STS National Database has been designated a Qualified Clinical Data Registry (QCDR) for MIPS reporting in 2018, physicians who participate in two of its component databases—the Adult Cardiac Surgery Database (ACSD) and, new for 2018, the General Thoracic Surgery Database (GTSD)—can satisfy the Quality category requirements by signing a 2018 MIPS Data Sharing Consent Form (see below). The Cost category will not be scored for 2018, and CMS will release an attestation portal later this year for the Advancing Care and Improvement Activities categories. CMS will publish physician results on a select set of measures from the 2018 MIPS submission on the Physician Compare website.

For surgeons who return a completed 2018 MIPS Data Sharing Consent Form, STS can report data to CMS on their performance on specific quality measures (14 for adult cardiac and eight for general thoracic). Eligible professionals who do not satisfactorily report at least six quality measures with 60% data completeness spanning the January 1–December 31, 2018 reporting period will not satisfy the Quality category and may be subject to a 5% negative payment adjustment (penalty) in the 2020 Medicare Part B Fee Schedule. In addition, surgeons potentially could qualify for a small to moderate upward payment adjustment depending on performance and the number of measures and activities reported under MIPS.

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. All surgeons must be approved as members before October 31, 2018, to avoid the fee.

Even surgeons whose hospitals are already reporting for them may benefit from reporting via the Society, as CMS will count the highest-scoring measures.

Complete the 2018 MIPS Data Sharing Consent Form by October 31, 2018, to participate. You must log in with your STS Web Portal username and password. If you need assistance locating your STS Web Portal login information, contact Membership. A new consent form must be submitted every year.

To learn more about MIPS, watch this CMS video. Also, STS has compiled a MACRA Toolkit for Cardiothoracic Surgeons.

STS will report to CMS all of the following Quality measures on behalf of consenting participants in the ACSD:

Adult Cardiac Measures
Measure ID 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
STS1 PLOS Following CABG Outcome
STS3 PLOS Following CABG + Valve Outcome
STS5 PLOS Following Valve Outcome
STS7 Patient-Centered Risk Assessment/Communication Process


STS will report to CMS all of the following Quality measures on behalf of consenting participants in the GTSD:

General Thoracic Measures