MVP: Vascular Surgery
Most applicable medical specialty(s): Vascular Surgery, Nonphysician Practitioners, Nurse Practitioners, Physician Assistants
The Vascular Surgery MVP assesses meaningful outcomes in surgical, interventional, and general vascular surgery, and patient’s experience of care.
Quality
To fulfill quality requirements:
- You must report 4 quality measures from the list below
- (except for clinicians in a small practice – see # 3 below)
- At least 1 measure must be an outcome measure.
- If no outcome measures are available, you may report a high priority measure.
- 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 Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.
- You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2026 – December 31, 2026).
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 2026, 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.
| ID | Title | Specs |
| 001 | Diabetes: Glycemic Status Assessment Greater Than 9% | Details |
| 047 | Advance Care Plan | Details |
| 130 | Documentation of Current Medications in the Medical Record | Details |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Details |
| 259 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) | Details |
| 321 | CAHPS for MIPs Clinician/Group Survey | Details |
| 344 | Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | Details |
| 355 | Unplanned Reoperation within the 30-Day Postoperative Period | Details |
| 356 | Unplanned Hospital Readmission within 30 Days of Principal Procedure | Details |
| 357 | Surgical Site Infection (SSI) | Details |
| 358 | Patient-Centered Surgical Risk Assessment and Communication | Details |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Details |
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | Details |
| RCOIR12 | Tunneled Hemodialysis Catheter Clinical Success Rate | Not supported by MIPSpro* |
| RCOIR13 | Percutaneous Arteriovenous Fistula for Dialysis – Clinical Success Rate | Not supported by MIPSpro* |
| RPAQIR14 | Arteriovenous Graft Thrombectomy Clinical Success Rate | Not supported by MIPSpro* |
| RPAQIR15 | Arteriovenous Fistulae Thrombectomy Clinical Success Rate | Not supported by MIPSpro* |
Improvement Activities
To fulfill improvement activity requirements:
1. You must report 1 improvement activity from the list below.
Improvement activities no longer have assigned weights.
Download 2026 Improvement Activities Inventory (ZIP)
| ID | Title |
| IA_BE_1 | Use of certified EHR to capture patient reported outcomes |
| IA_BE_12 | Use evidence-based decision aids to support shared decision-making. |
| IA_BE_26 | Promote Use of Patient-Reported Outcome Tools |
| IA_BE_4 | Engagement of Patients through Implementation of New Patient Portal |
| IA_CC_15 | PSH Care Coordination |
| IA_EPA_2 | Use of telehealth services that expand practice access |
| IA_EPA_3 | Collection and use of patient experience and satisfaction data on access |
| IA_EPA_8 | Provide Education Opportunities for New Clinicians |
| IA_MVP | Practice-Wide Quality Improvement in MIPS Value Pathways |
| IA_PCMH | Electronic submission of Patient Centered Medical Home accreditation |
| IA_PM_11 | Regular review practices in place on targeted patient population needs |
| IA_PM_15 | Implementation of episodic care management practice improvements |
| IA_PM_16 | Implementation of medication management practice improvements |
| IA_PM_2 | Anticoagulant Management Improvements |
| IA_PM_21 | Advance Care Planning |
| IA_PM_5 | Engagement of community for health status improvement |
| IA_PSPA_1 | Participation in an AHRQ-listed patient safety organization. |
Cost
Important information to consider:
- 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.
- You’ll only be scored on the cost measures in this MVP for which you meet or exceed the established case minimum.
Foundational Layer – Promoting Interoperability
To fulfill Promoting Interoperability requirements:
- 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.
- 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.s.
| ID | Title |
|---|---|
| PI_EP_1 | e-Prescribing |
| PI_EP_2 | Query of the Prescription Drug Monitoring Program (PDMP) |
| PI_EP_2_EX_1 | Query of the Prescription Drug Monitoring Program (PDMP) |
| PI_EP_2_EX_2 | Query of the Prescription Drug Monitoring Program (PDMP) Exclusion |
| PI_HIE_1 | Support Electronic Referral Loops By Sending Health Information |
| PI_HIE_4 | Support Electronic Referral Loops By Receiving and Reconciling Health Information |
| PI_HIE_5 | Health Information Exchange (HIE) Bi-Directional Exchange |
| PI_HIE_6 | Enabling Exchange Under TEFCA |
| PI_INFBLO_1 | Actions to Limit or Restrict the Compatibility of CEHRT |
| PI_LVITC_2 | Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion |
| PI_LVOTC_1 | Support Electronic Referral Loops By Sending Health Information Exclusion |
| PI_LVPP_1 | e-Prescribing Exclusion |
| PI_ONCACB_1 | ONC-ACB Surveillance Attestation |
| PI_ONCDIR_1 | ONC Direct Review Attestation |
| PI_PEA_1 | Provide Patients Electronic Access to Their Health Information |
| PI_PHCDRR_1 | Immunization Registry Reporting |
| PI_PHCDRR_1_EX_1 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_EX_2 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_EX_3 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_PRE | Immunization Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_1_PROD | Immunization Registry Reporting Active Engagement Level 2 |
| PI_PHCDRR_2 | Syndromic Surveillance Reporting |
| PI_PHCDRR_2_PRE | Syndromic Surveillance Reporting Active Engagement Level 1 |
| PI_PHCDRR_2_PROD | Syndromic Surveillance Reporting Active Engagement Level 2 |
| PI_PHCDRR_3 | Electronic Case Reporting |
| PI_PHCDRR_3_EX_1 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_EX_2 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_EX_3 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_PRE | Electronic Case Reporting Active Engagement Level 1 |
| PI_PHCDRR_3_PROD | Electronic Case Reporting Active Engagement Level 2 |
| PI_PHCDRR_4 | Public Health Registry Reporting |
| PI_PHCDRR_4_PRE | Public Health Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_4_PROD | Public Health Registry Reporting Active Engagement Level 2 |
| PI_PHCDRR_5 | Clinical Data Registry Reporting |
| PI_PHCDRR_5_PRE | Clinical Data Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_5_PROD | Clinical Data Registry Reporting Active Engagement Level 2 |
| PI_PHCDRR_6 | Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM) |
| PI_PPHI_1 | Security Risk Analysis |
| PI_PPHI_2 | High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide |
Foundational Layer – Population Health
- You won’t be required to select a population health measure during registration. You don’t have to submit any data for this measure, we will calculate all available population health measures for you, using administrative claims data.
- This measure will be excluded if you can’t be scored on either (the measure doesn’t have a benchmark or you don’t meet the case minimum).
- Population health isn’t a new performance category. The population health measures within the MVP 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.