MIPS Performance Categories and Weights
- Quality (30% of MIPS score for 2026 performance year, per the CY2026 Medicare Physician Fee Schedule Final Rule): Report 6 quality measures including at least 1 outcome or high-priority measure. Surgical practices should select from the 80+ measures tagged to procedural specialties in the QPP Measures Catalog. Data must cover at least a 12-month reporting period to receive full credit.
- Promoting Interoperability (25% of MIPS score): Requires use of 2015 Edition CEHRT (Certified EHR Technology). Four required measures: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Surgeons who bill fewer than 100 Part B claims for office visits may apply for a hardship exception to reweight this category to 0%.
- Improvement Activities (15% of MIPS score): Complete 2 high-weighted or 4 medium-weighted activities from the CMS Improvement Activities Inventory. Surgical practices can claim credit for care coordination activities (post-discharge follow-up protocols), patient safety activities (surgical site infection reduction programs), and population management (tracking surgical outcomes). Activities must be performed for at least a continuous 90-day period.
- Cost (30% of MIPS score): CMS calculates this category automatically from Medicare claims data. Surgeons are attributed episode-based cost measures for procedures they perform. Measures include Total Per Capita Cost, Medicare Spending Per Beneficiary (MSPB), and 22 episode-based cost measures. No data submission is required, but understanding which episodes are attributed to your practice helps identify cost-reduction opportunities.
Surgical-Specific Quality Measures to Consider
- Q358 (Appropriate Use of DXA Scans for Osteoporosis) and Q024 (Communication with the Physician Managing Ongoing Care Post-Fracture) are relevant for orthopedic practices. Q431 (Perioperative Temperature Management) applies to all surgical specialties and tracks maintenance of normothermia (core temperature above 36C) in the perioperative period.
- Q226 (Preventive Care and Screening: Tobacco Use) applies across specialties and has high benchmark rates, making it a reliable points earner. Q130 (Documentation of Current Medications in the Medical Record) is another broadly applicable measure with high performance thresholds achievable by most EHR systems.
- Outcome measures earn bonus points: Q259 (Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery) for ophthalmology, Q350 (Total Knee Replacement: Shared Decision-Making Trial of Conservative Therapy) for orthopedics, and Q370 (Surgical Site Infection Rate for Total Knee and Hip Replacement) for joint replacement programs.
- Avoid measures where your patient population will score poorly due to factors outside your control. The CMS Measure Benchmarks file (published annually on the QPP Resource Library at qpp.cms.gov) shows national decile thresholds for each measure. Select measures where your practice data falls at or above the median.
Reporting Deadlines and Payment Adjustments
- The MIPS performance period runs January 1 through December 31. Data submission opens January 2 of the following year and closes on a date CMS announces annually (historically late March or early April). For the 2025 performance year, the submission deadline was March 31, 2026. Late submissions receive a score of zero.
- Payment adjustments apply two years after the performance period. Performance Year 2026 determines 2028 Medicare Part B payment adjustments. The adjustment ranges from negative 9% to positive 9%, applied to all Part B covered professional services. CMS distributes positive adjustments using a budget-neutral scaling factor, meaning the actual positive adjustment depends on the total pool of penalties collected.
- The performance threshold (minimum score to avoid a negative adjustment) rises annually. For PY2025, the performance threshold was 75 points (out of 100). Practices scoring below the threshold receive proportionally negative adjustments. The exceptional performance threshold (currently eliminated as of PY2024) previously offered additional bonus payments.
- Small practices (15 or fewer clinicians) receive automatic bonus points on quality measures (per the 2018 MIPS small practice bonus provision codified at 42 CFR 414.1380) and may qualify for additional technical assistance through CMS-funded SURS (Small, Underserved, and Rural Support) programs. Eligible practices should verify small practice status in the QPP Participation Status Tool.
Avoiding Common MIPS Pitfalls for Surgeons
- Measure selection errors are the most common cause of low MIPS scores. Practices that report all 6 measures from a single registry or EHR module without reviewing applicability often submit measures with denominator counts below the 20-case minimum, earning zero points. Before the performance year begins, run denominator queries against your prior year claims to confirm each measure will have sufficient volume.
- Incomplete data submission costs more points than poor performance. A measure submitted with data on 60% of eligible patients scores lower than one submitted with data on 100% of patients, even if the actual performance rate is identical. The data completeness threshold is 75% (below this, the measure earns 0 to 3 points regardless of performance). Target 90%+ completeness for every measure.
- Promoting Interoperability exemptions are underutilized by surgical practices. Surgeons who do not have face-to-face patient encounters in an office setting (hospital-based surgeons) are automatically reweighted. Those with fewer than 100 Part B office visit claims can apply for the hardship exception. When PI is reweighted, its 25% is redistributed to the Quality category, making quality measure selection even more consequential.
- Cost category attribution catches many practices off guard. CMS assigns episode costs to the clinician who bills the plurality of E&M services or the procedural TIN during the episode window. Understanding attribution methodology (published in the CMS Episode-Based Cost Measure Field Testing reports) helps practices identify high-cost episodes and implement targeted cost reduction (reducing preventable ED visits, standardizing implant purchasing, improving discharge protocols).