American Society of Plastic Surgeons
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The quality of the care you provide is assessed through (1) your tracking patient data, (2) your connecting that data to quality measures, and (3) your reporting of those quality measures to the Centers for Medicare and Medicaid Services.

Your first step in successful participation in the MIPS Quality Performance Category is identifying the measures you want to track and report. Below, you can access the MIPS quality measures most relevant to plastic surgeons.

PLEASE NOTE: The descriptions for measures listed below under the "VIEW THE MIPS PLASTIC SURGERY MEASURE SET" box and the "VIEW OTHER RELEVANT MIPS QUALITY MEASURES" box contain a link to the ASPS-QCDR. This ASPS-developed tool will allow you to capture and report on MIPS quality measures.

Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis.

Measure Number
  • NQF: 0268
  • Quality ID: 021
NQS Domain

Patient Safety

High Priority Measure

YES

Measure Type

Process

Data Submission Method
Primary Measure Steward

American Society of Plastic Surgeons

Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.

Measure Number
  • NQF: 0239
  • Quality ID: 023
NQS Domain

Patient Safety

High Priority Measure

YES

Measure Type

Process

Data Submission Method
Primary Measure Steward

American Society of Plastic Surgeons

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

Measure Number
  • eMeasure ID: 68v6
  • NQF: 0419
  • Quality ID: 130
NQS Domain

Patient Safety

High Priority Measure

YES

Measure Type

Process

Data Submission Method
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.

Measure Number
  • eMeasure ID: 138v5
  • NQF: 0228
  • Quality ID: 226
NQS Domain

Community/Population Health

Measure Type

Process

Data Submission Method
Primary Measure Steward

Physician Consortium for Performance Improvement Foundation (PCPI®)

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.

Measure Number
  • eMeasure ID: 22v5
  • Quality ID: 317
NQS Domain

Community/ Population Health

Measure Type

Process

Data Submission Method
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.

Measure Number
  • Quality ID: 355
NQS Domain

Patient Safety

High Priority Measure

YES

Measure Type

Outcome

Data Submission Method
Primary Measure Steward

American College of Surgeons

Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.

Measure Number
  • Quality ID: 356
NQS Domain

Effective Clinical Care

High Priority Measure

YES

Measure Type

Outcome

Data Submission Method
Primary Measure Steward

American College of Surgeons

Percentage of patients aged 18 years and older who had a surgical site infection (SSI).

Measure Number
  • Quality ID: 357
NQS Domain

Effective Clinical Care

High Priority Measure

YES

Measure Type

Outcome

Data Submission Method
Primary Measure Steward

American College of Surgeons

Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.

Measure Number
  • Quality ID: 358
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

High Priority Measure

YES

Measure Type

Process

Data Submission Method
Primary Measure Steward

American College of Surgeons