American Society of Plastic Surgeons
For Consumers

2021 MIPS - Year 5

Every year, weights are assigned to each of the four components of MIPS and are added together to give you a MIPS final score. In 2021, CMS will use the final score to determine whether to give a positive, neutral, or negative payment adjustment in 2023.

2021 Final Scores and 2023 Payment Adjustments

How to Earn a Positive Payment Adjustment and an Exceptional Performance Bonus

  • Decide whether to apply for the hardship exemption to have PI reweighted to Quality, making Quality worth 65% of your overall score
  • Earn 15 points by fully participating in the IA component
  • Earn up to an additional 50 points through Quality measure reporting
    • Submit 6+ measures with data for a full year (70% of your patients for whom the measure applies, minimum 20 patients per measure, and 1 measure must be an outcome or high priority measure)
  • PI Reporting – Earn 25 points by using 2015 CEHRT to report the PI component

Learn about changes to each of the four program components effective in 2019:

  • Quality
    (40% of MIPS Score)
    • Report 70% of cases for whom the measure applies
    • 20 case minimum for each measure (does not have to be the same 20 patients for each measure, but there can be overlap)
    • Measures are worth 1-10 points depending on performance compared to the benchmark and practice size
  • Promoting Interoperability (PI)
    (25% of MIPS Score)
    • Must attest to the security risk assessment
    • Must report measures or take the exclusion, noting your reason
    • Hospital-based clinicians (those with 75% or more of their billing from their hospital), PAs, and NPs are exempt from PI and will have this category automatically re-weighted to Quality (making Quality 65% of the score)
    • Small practices can apply for a hardship exemption to reweight PI to Quality- visit
  • Improvement Activities (IA)
    (15% of MIPS Score)
    • Simple attestation to various quality improvement activities
    • Must have documentation somewhere in practice for QCDR audit or in case of CMS random audit
  • Cost
    (20% of MIPS Score)
    • No reporting, this is done via claims
    • Read more about how cost measures are structured here

Ready to Report?

ASPS has developed a Qualified Clinical Data Registry (QCDR) to assist with all your MIPS reporting needs.

  • 22 MIPS measures and 13 QCDR (non-MIPS) plastic surgery specific quality measures
    • Plastic surgery measures for reconstruction after skin cancer resection, breast reconstruction, and rhinoplasty
  • Can report all 3 components (Cost component determined by claims)
  • Accepts manual data entry, or integrate your EMR

New to MIPS reporting? Contact Caryn Davidson, Quality Projects Manager at or (847) 228-3349 to set up a FREE consultation for your MIPS reporting needs. Please contact Caryn as soon as possible - do not wait!