MIPS Quality Component

For the 2020 performance year, eligible clinicians will receive a Quality performance category score that accounts for 45% 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.

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 Quality Measures

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, or are related to opioids. Eligible clinicians are not required to report "cross-cutting" measures or across National Quality Strategy domains.

MIPS-eligible clinicians may select their measures from a list of all MIPS measures or from a set of specialty-specific measures. Measure specifications for performance year 2020 are available on the CMS Quality Payment Program website. Remember that measure specifications may have changed from previous years. Practices 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 2020:

  • MIPS #44: CABG: Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
  • MIPS #76: Prevention of CVC-Related Bloodstream Infections*
  • MIPS #404: Anesthesiology Smoking Abstinence*
  • MIPS #424: Perioperative Temperature Management*
  • MIPS #430: Prevention of PONV - Combination Therapy*
  • MIPS #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)*
  • MIPS#477: Multimodal Pain Management*

* designates a proposed "high priority measure"

Benchmarking and scoring

Measure-specific benchmarks, based upon a measure's performance rate, are established by 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 20 MIPS eligible clinicians who reported the measure for at least 20 cases. Benchmarks are updated based on performance in the previous year and, if sufficient data is available, the current reporting year.

Download 2019 MIPS Quality Benchmarks.

Bonus Points

CMS will award bonus points for reporting additional high-priority and outcome measures above initial reporting requirements. Bonus points are capped at 10 percentage points in the MIPS Quality Component. Eligible clinicians and groups can receive bonus points in the Quality component based on their rate of improvement across the performance category compared to the previous year. Beginning in 2019, eligible clinicians and groups with the small practice designation (15 or fewer eligible clinicians) will receive 6 bonus points in the quality category.