CMS is proposing some changes that surgeons will
In contrast to the previous PQRS requirement that
physicians report nine quality measures, the MIPS quality component requires providers to report only six
measures. One of these six measures must be an “
outcome” measure and another must be a “cross-cutting”
measure. Although the reporting threshold for the percentage of patients for which reports will be required is
proposed to increase substantially, the ACS and other
physician organizations will be advocating that the
required percentage published in the final rule be close
to the 50 percent level found in current programs.
A surgeon who has been participating in the PQRS
program is well positioned to successfully meet the
quality component requirements. A good first step
for a surgeon who has not been participating in PQRS
is to start using the ACS Surgeon Specific Registry
(SSR).† The SSR allows surgeons to more easily participate in the PQRS and the new quality component
Resource use component
The resource use component replaces the value-based
modifier (VBM). Surgeons will not have to fulfill any
reporting requirements for the resource use component. Medicare will complete the calculations based
on the claims submitted by surgeons. Beginning in
2018, CMS also plans to take into account such factors as patient condition and attribution of costs as
appropriate to the relationship of the physician to
The ACI component modifies and replaces the Electronic Health Record (EHR) Incentive Program.
The proposed overall score for this component is
derived from two separate scores:
•Base score ( 50 percent)
•Performance score (up to an additional 50 percent)
The threshold for achieving the base score continues
to be defined as “all or nothing.” Only after meeting the
requirements for the base score is a physician eligible to
receive the additional performance score credit, which
will be based on the level of performance on a subset of
the same measures required to achieve the base score.
ACI scores in 2017 are expected to be based on criteria similar to those in the 2016 requirements for the
EHR Incentive Program.
The fourth component of MIPS is the CPIA component.
This is a new component with no analogous previous
program requirement. As such, this facet of MIPS is
In the first year of MIPS assessment (2017), achieving full credit for the CPIA component should pose a
nominal additional administrative burden, as reporting will be by simple attestation. Physicians will choose
from a list of activities (the proposed rule comprises
94 possible activities) assigned two different weighted
values. To receive full credit for the CPIA component,
most providers will need to attest that they have participated in a minimum of three and a maximum of
six of the 94 activities, depending on the weight of the
activities selected, for 90 days.
• 982-page regulation
• Published April 27, 2016
• ACS feedback provided
to CMS June 27, 2016
• 2 tracks:
†American College of Surgeons. Quality Programs; Surgeon Specific Registry. Available at: facs.org/quality-programs/ssr. Accessed August 16, 2016.
• Quality (formerly PQRS)
• Resource use (formerly VBM)
• ACI (formerly EHR
FIGURE 1. MACRA AT A GLANCE
OCT 2016 BULLETIN American College of Surgeons