For the 2023 performance year, eligible clinicians will receive a Quality performance category score that accounts for 30% of their final MIPS score. Anesthesiologists may elect to submit quality measures through any of the following mechanisms. Reporting specific measures is dependent upon the collection type an eligible clinician or group practice chooses to report.
- Claims (small practices only / limited availability of measures)
- Electronic Health Record (EHR)
- Qualified Registry – supported by AQI NACOR®
- Qualified Clinical Data Registry (QCDR) – supported by AQI NACOR®
- Web Interface (Group only)
- CAHPS for MIPS (Group only)
Except for Web Interface and CAHPS for MIPS, physician anesthesiologists may use these collection types to report quality measures either individually or as a group.
MIPS eligible clinicians must report six (6) measures during the 12-month MIPS reporting year. If fewer than six (6) measures apply to the eligible clinician, and a QCDR mechanism is not being used, the eligible clinician or group must report on all applicable measures. One (1) of the six (6) measures must be an outcome measure. If there is no applicable outcome measure, the eligible clinician must report a high priority measure instead. High priority measures are defined as those that measure appropriate use, patient safety, efficiency, patient experience, care coordination, health equity, or are related to opioids.
For a measure to be scored, the EC or group must submit complete data for at least 70% of the cases to which the quality measure applies.
MIPS-eligible clinicians and groups reporting via a Qualified Registry may select their measures from a list of all MIPS measures, including those in the anesthesiology measure set. MIPS ECs and their groups reporting via a Qualified Clinical Data Registry may report any combination of MIPS and QCDR measures to meet the six-measure threshold.
Measure specifications for MIPS measures are only available on the CMS Quality Payment Program website. QCDR measure specifications are available on the Anesthesia Quality Institute website. Each year, ECs, their groups and vendors should make sure they are accurately reporting quality measures for the current performance year.
CMS finalized the Anesthesiology Specialty-Specific Measure Set for physician anesthesiologists for performance year 2023:
- QID #404: Anesthesiology Smoking Abstinence*
- QID #424: Perioperative Temperature Management*
- QID #430: Prevention of PONV - Combination Therapy*
- QID #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)*
- QID #477: Multimodal Pain Management*
* designates a proposed "high priority measure"
The Anesthesiology Measure Set measures are suggested by CMS to ease the decision-making process of ECs and groups using the Qualified Registry reporting option. If using a QCDR to report measures, these measures may be used in combination with any QCDR measures so long as the minimum number of measures are submitted.
If an anesthesiologist or group chooses to report a MIPS Value Pathway (MIPS), the anesthesiology or group may only choose to report quality measures included in the MVP.
Quality Measure Scoring
Eligible clinicians will receive credit for the quality measures they successfully report. Each measure will be scored on a 0 to 10-point scale based upon an eligible clinician or group practice’s performance. In some cases, for groups of 16 or more eligible clinicians, CMS will apply population-based measures. For 2023, those measures are “Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program,” the “Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System,” and the “Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions” measures.
Measure-specific benchmarks, based upon a measure's performance rate, are established by the Centers for Medicare & Medicaid Services (CMS) to determine an eligible clinician's score on the 10-point scale. CMS will award points to eligible clinicians based on benchmarking performance rates. Each benchmark must have a minimum of twenty (20) MIPS eligible clinicians who reported the measure for at least twenty (20) cases. Each measure must have a data completeness of more than 70% of the cases to which the measure applies. Benchmarks are updated based on performance in the previous year. Same year benchmarking is available if historical benchmarks are not available and if the minimum criteria described above are met. CMS provides an algorithm for scoring on the Quality Payment Program Resource Library.
If reporting via a qualified registry and you have reported on less than six measures but all the measures that apply to your patient population, CMS will proportionally increase the 10-point scale. For instance, if you reported on three measures and no other measures applied to you or your group, those measures will be scored out of 20 points. The method of evaluating whether all measures applicable to the practice were reported is known as the “Eligible Measures Applicability (EMA)” process.
When each measure is scored, those scores, along with CMS assessment of the one population-based measure that is dependent on group practice size, will be summed and then divided by the points possible in the MIPS Quality performance category. That score would then be multiplied by 30 points (or more depending on whether other performance categories have been reweighted) possible to determine the Quality performance category score of the MIPS totals score.