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.

Eligible professionals who do not satisfactorily report at least one Quality measure spanning any time during the January 1–December 31, 2017 reporting period will be subject to a 4% negative payment adjustment (penalty) in the 2019 Medicare Part B Fee Schedule. Surgeons participating in the STS Adult Cardiac Surgery Database (ACSD) can avoid this penalty by consenting to have STS report data on 14 Quality measures to CMS on their behalf. In addition, surgeons could potentially qualify for a small to moderate upward payment adjustment depending on performance and the number of measures and activities reported under MIPS.

The STS National Database has been designated a Qualified Clinical Data Registry (QCDR) for MIPS reporting in 2017. A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians 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. CMS will publish physician results on a select set of measures from the 2017 MIPS submission on the Physician Compare website.

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.

Complete the 2017 MIPS Data Sharing Consent Form by October 31, 2017, 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 MembershipA new consent form must be submitted every year. 

Different reporting systems are in place for surgeons enrolled in or part of an Accountable Care Organization (ACO) or participating in the group reporting option; therefore, if you are part of an ACO or group reporting, you do not need to fill out the STS consent form. Surgeons employed by hospitals or health systems are encouraged to check to see if other reporting arrangements have been made.

To learn more about MIPS, watch this CMS video.

Also, STS has compiled a MACRA Toolkit for Cardiothoracic Surgeons that explains the changes for 2017 and beyond in greater detail.

STS will report to CMS all of the following Quality measures on behalf of individual consenting surgeons:

Measure # 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
STS PLOS Following CABG Outcome
STS PLOS Following CABG + Valve Outcome
STS PLOS Following Valve Outcome
STS Patient-Centered Risk Assessment/Communication Process