MIPS Quality Performance Category (2021)

For the 2021 performance year, eligible clinicians will receive a Quality performance category score that accounts for 40% 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)
  • Electronic Health Record (EHR) 
  • Qualified Registry – supported by NACOR®
  • Qualified Clinical Data Registry (QCDR) – supported by 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 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.

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 2021:

  • QID #44: CABG: Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
  • QID #76: Prevention of CVC-Related Bloodstream Infections*
  • 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. 

Learn more about the MIPS Quality performance category:

  • MIPS Quality Performance Category Scoring (2021)
  • MIPS Quality Performance Category FAQs (2021)