American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Surgeons Can Access Facility-Based Score for 2019 MIPS Reporting

Beginning with the 2019 performance year of the Merit-based Incentive Payment System (MIPS), clinicians, groups, or virtual groups who meet the Centers for Medicare & Medicaid Services (CMS) facility-based clinician criteria will be able to use their Hospital Value-Based Purchasing (VBP) program performance score for MIPS reporting. Surgeons can determine whether they meet the facility-based criteria through the QPP Participation Status lookup tool.

This new policy uses the surgeon’s facility-based VBP score for the Quality and Cost performance categories in MIPS in an effort to reduce administrative burdens. Although the policy eliminates the need for facility-based clinicians to report Quality and Cost for MIPS, health care professionals have the option to report MIPS measures themselves, and CMS will use the higher of the two scores to calculate the MIPS final score. Clinicians who are identified as facility-based and who provide services attributed to a facility with a fiscal year (FY) 2020 Hospital VBP score will receive a Facility-based Preview to help estimate their Quality and Cost scores based on their Hospital VBP data. Previews can be accessed by logging into the QPP portal on the QPP website and clicking on the Preview Facility Score on the home page. It is important to remember that preview reports are not 2019 MIPS performance scores; rather, they are generated from past data to help surgeons estimate their possible scores for 2019.

For more information, contact the American College of Surgeons Quality Affairs team by e-mail at or by phone at 202-672-1517.