MVP ID: M1425
Most applicable medical specialty(s):
General Surgery, Neurosurgery, Cardiothoracic Surgery, Anesthesiologists, Nonphysician Practitioners, Certified Registered Nurse Anesthetists, Nurse Practitioner, Physician Assistants
The Surgical Care MVP focuses on the clinical theme of surgery.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 047: Advance Care Plan
- Quality ID: 164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation
- Quality ID: 167: Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
- Quality ID: 168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
- Quality ID: 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Quality ID: 264: Sentinel Lymph Node Biopsy for Invasive Breast Cancer
- Quality ID: 354: Anastomotic Leak Intervention
- Quality ID: 355: Unplanned Reoperation within the 30 Day Postoperative Period
- Quality ID: 357: Surgical Site Infection (SSI)
- Quality ID: 358: Patient-Centered Surgical Risk Assessment and Communication
- Quality ID: 445: Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)
- Quality ID: 459: Back Pain After Lumbar Surgery
- Quality ID: 461: Leg Pain After Lumbar Surgery
- Quality ID: 471: Functional Status After Lumbar Surgery
- Quality ID: 487: Screening for Social Drivers of Health
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_AHE_3: Promote Use of Patient-Reported Outcome Tools - High
- IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols - Medium
- IA_BE_12: Use evidence-based decision aids to support shared decision-making.
- IA_CC_15: PSH Care Coordination
- IA_CC_17: Patient Navigator Program
- IA_CC_18: Relationship-Centered Communication
- IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways - High
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_11: Regular review practices in place on targeted patient population needs
- IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
- IA_PSPA_8: Use of Patient Safety Tools
Cost
Calculated by CMS using administrative claims data:
- Measure ID: COST_CRR_1 - Colon and Rectal Resection
- Measure ID: COST_FIHR_1 - Femoral or Inguinal Hernia Repair
- Measure ID: COST_LSFDD_1 - Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
- Measure ID: COST_LPMSM_1 - Lumpectomy, Partial Mastectomy, Simple Mastectomy
- Measure ID: MSPB_1 - Medicare Spending Per Beneficiary (MSPB) Clinician
- Measure ID: COST_NECABG_1 - Non-Emergent Coronary Artery Bypass Graft (CABG)
Population Health Measures
Select one population health measure to be scored by CMS using administrative claims data:
- #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)
Promoting Interoperability
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Prevention of Information Blocking
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP) (Optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops By Sending Health Information AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- Security Risk Analysis
- Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
- ONC Direct Review
MVP Registration
- MVP Participants must register between April 1 – December 1, 2025 to report an MVP in 2025.
- To register, MVP Participants must select:
- The MVP they intend to report.
- 1 population health measure included in the MVP.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- MVP Participants won’t be able to:
- Submit/make changes to the MVP they select after the close of the registration period (December 1, 2025).
- Report on an MVP they didn’t register for during the 2025 performance year.
- Report on more than one MVP.