MVP: Surgical Care

To fulfill quality requirements:

1. You must select 4 quality measures from the list below
   (exception for clinicians in a small practice – see # 3 below)
   
2. At least 1 measure must be an outcome measure
   • If no outcome measures are available, you may report a high priority measure.
   • This MVP includes an outcome measure calculated by CMS through administrative claims. If you
     select it as 1 of your 4 required quality measures, this must be included in your MVP registration.
     
     TIP: Before selecting an outcomes-based administrative claims measure, make sure your patient population will allow you to meet the case minimum; if not, you’ll receive 0 achievement points for the measure. If you’re unsure if you’ll meet the case minimum, you may want to report an additional outcome measure.
3. If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don’t need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.
   
4. You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2025 – December 31, 2025).

TIP: For small practices (participating at the individual, group or subgroup level) reporting Medicare Part B claims measures: To meet data completeness requirements, you’ll need to start reporting the Medicare Part B claims measures in your selected MVP in January 2025, prior to the MVP registration period.

TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don’t meet case minimum or data completeness criteria will earn zero points.

Quality Measures (MVP ID: G0055)

To fulfill improvement activity requirements:

1. You must report 1 improvement activity from the list below.

Beginning in 2025, improvement activities don’t have assigned weights.

Improvement Activities (MVP ID: G0055)

Important information to consider:

1. You don’t have to submit any data for this performance category. We’ll use Medicare claims data to
   calculate your cost measure performance.
   
   (You don’t select cost measures during MVP registration. CMS will calculate your performance
   on all the cost measures included in the MVP based on available Medicare claims data.)
   
2. You’ll only be scored on the cost measures in this MVP for which you meet or exceed the established
   case minimum.

Cost Measures (MVP ID: G0055)

To fulfill Promoting Interoperability requirements:

1. Submit the required Promoting Interoperability measures (the same as under traditional MIPS) listed below. Bonus points are available for reporting measures that aren’t required.
   
   • If you’re reporting as a subgroup, you’ll submit your affiliated group’s data for the Promoting Interoperability performance category.
2. Review if you qualify for automatic reweighting of the Promoting Interoperability performance category based on your clinician type, special status, or an approved Promoting Interoperability Performance Category Hardship Exception Application.

Special Status for Automatic Reweighting:

• Ambulatory Surgical Center (ASC)-based
• Hospital-based
• Non-patient facing
• Small practice

Promoting Interoperability Performance Category Hardship Exception Qualifications:

• Decertified EHR technology
• Insufficient internet connectivity
• Experience extreme and uncontrollable circumstances (e.g., disaster, practice closure, severe financial distress, vendor issues)
• Lack control over availability of CEHRT (Certified Electronic Health Record Technology)

Note: Promoting Interoperability requirements are the same in MVPs as they are in traditional MIPS. Learn more about Promoting Interoperability requirements.

You must select 1 population health measure at the time of MVP registration.

• You don’t have to submit any data for this measure, CMS will calculate the population health measures for you using administrative claims data.
  
• This measure will be excluded from scoring if the measure doesn’t have a benchmark or meet the case minimum.
  
• Population health isn’t a new performance category. The population health measure you select during MVP registration will be scored as part of the quality performance category provided you meet the case minimum.
  
• Subgroups will be evaluated at the affiliated group level.

Improvement Activities (All MVPs)