MVP ID: M1503
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
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 001 - Diabetes: Glycemic Status Assessment Greater Than 9%
- Quality ID: 047 - Advance Care Plan
- Quality ID: 130 - Documentation of Current Medications in the Medical Record
- Quality ID: 226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Quality ID: 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)
- Quality ID: 321 - CAHPS for MIPS Clinician/Group Survey
- Quality ID: 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)
- Quality ID: 355 - Unplanned Reoperation within the 30 Day Postoperative Period
- Quality ID: 356 - Unplanned Hospital Readmission within 30 Days of Principal Procedure
- Quality ID: 357 - Surgical Site Infection (SSI)
- Quality ID: 358 - Patient-Centered Surgical Risk Assessment and Communication
- Quality ID: 374 - Closing the Referral Loop: Receipt of Specialist Report
- Quality ID: 438 - Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
- Quality ID: RCOIR12 - Tunneled Hemodialysis Catheter Clinical Success Rate (QCDR)
- Quality ID: RCOIR13 - Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate (QCDR)
- Quality ID: RPAQIR14 - Arteriovenous Graft Thrombectomy Clinical Success Rate (QCDR)
- Quality ID: RPAQIR15 - Arteriovenous Fistulae Thrombectomy Clinical Success Rate (QCDR)
Improvement Activities
Report one improvement activity from the list below:
- Activity ID: IA_BE_1 - Use of certified EHR to capture patient reported outcomes
- Activity ID: IA_BE_12 - Use evidence-based decision aids to support shared decision-making
- Activity ID: IA_BE_26 - Promote Use of Patient-Reported Outcome Tools
- Activity ID: IA_BE_4 - Engagement of Patients through Implementation of New Patient Portal
- Activity ID: IA_CC_15 - PSH Care Coordination
- Activity ID: IA_EPA_2 - Use of telehealth services that expand practice access
- Activity ID: IA_EPA_3 - Collection and use of patient experience and satisfaction data on access
- Activity ID: IA_EPA_8 - Provide Education Opportunities for New Clinicians
- Activity ID: IA_MVP - Practice-Wide Quality Improvement in MIPS Value Pathways
- Activity ID: IA_PCMH - Electronic submission of Patient Centered Medical Home accreditation
- Activity ID: IA_PM_11 - Regular Review Practices in Place on Targeted Patient Population Needs
- Activity ID: IA_PM_15 - Implementation of episodic care management practice improvements
- Activity ID: IA_PM_16 - Implementation of medication management practice improvements
- Activity ID: IA_PM_2 - Anticoagulant management improvements
- Activity ID: IA_PM_21 - Advance Care Planning
- Activity ID: IA_PM_5 - Engagement of community for health status improvement
- Activity ID: IA_PSPA_1 - Participation in an AHRQ-listed patient safety organization
Cost
Calculated by CMS using administrative claims data:
- Measure ID: COST_CCLI_1 - Revascularization for Lower Extremity Chronic Critical Limb Ischemia
- Measure ID: COST_HAC_1 - Hemodialysis Access Creation
- Measure ID: MSPB_1 - Medicare Spending Per Beneficiary (MSPB) Clinician Measure
Population Health Measures
CMS will calculate both population health measures using administrative claims data (if case minimum requirements are met) and assign the higher of these measures to the Quality score. If neither of the population health measures can be calculated, they will be excluded from scoring.
- #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:
- Actions to Limit or Restrict Compatibility or Interoperability of CEHRT Attestation
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP)
- 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 Attestation
- Public Health Reporting Using TEFCA
MVP Registration
- MVP Participants must register between April 1 – December 1, 2026 to report an MVP in 2026.
- To register, MVP Participants must select:
- The MVP they intend to report.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- Whether they plan to administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey, if it’s a quality measure option in the selected MVP.
- The participation option they plan to use: individual, group, subgroup, or APM Entity.
- Starting in 2026, to register for MVP reporting as a group, the practice will need to attest to their specialty composition (whether they are a single specialty group or multispecialty small practice) during the MVP registration process. CMS won’t make this determination for the practice. All other groups will need to participate as subgroups or as individuals (if eligible) to report an MVP.
- 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, 2026).
- Report on an MVP they didn’t register for during the 2026 performance year.
- Report on more than one MVP.