Medicare Approves
MBSAQIP for Data Collection and Submission

What This Means For You and Us

Published in June 2014 Issue             

Matthew Hutter, MD, MPH

In April of 2014, the Centers for Medicare and Medicaid Services (CMS) approved the MBSAQIP Data Registry as a Qualified Clinical Data Registry (QCDR), one of only over 30 organizations to receive such a designation. As a QCDR, MBSAQIP participants will now have the option of reporting their data on quality measures through the MBSAQIP to satisfy the agency’s Physician Quality Reporting System (PQRS) requirements.

Matthew Hutter, MD, MPH, is co-chair of the Data Registry and Reporting Subcommittee of the Committee on Metabolic and Bariatric Surgery (CMBS), which oversees all aspects of the MBSAQIP Data Collection Program. Here Dr. Hutter explains PQRS, what it means to be a QCDR, how it may be helpful to MBSAQIP participants and ultimately patients, as well as the entire bariatric community.

How did the approval of MBSAQIP as a QCDR come about?

In January, we applied to CMS for inclusion in the 2014 program and provided details on how MBSAQIP meets all CMS requirements for collecting and reporting PQRS data. We developed quality metrics based on the MBSAQIP data. CMS reviewed our submission and after some discussions back and forth, approved the MBSAQIP as a QCDR in April.

What is PQRS?

PQRS is a government mandated reporting program that uses incentive payments and penalties to promote the reporting of quality measures by eligible professionals. Data is reported for covered Physician Fee Schedule (PFS) services furnished to Medicare part B fee-for-Service beneficiaries. Eligible professionals are identified on claims by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN).

Why did MBSAQIP apply to become a QCDR?

There are several ways for physicians to report PQRS measures. However, this year CMS made a new reporting mechanism available, the Qualified Clinical Data Registry (QCDR). We saw this as an opportunity to provide a service to our participants and the bariatric community. We wanted to make it easier for them to satisfy government requirements for reporting data, to allow them to use meaningful metrics that are related directly to the care of the patient who has metabolic and bariatric surgery, and to better enable them to earn 2014 PQRS incentive payments and/or avoid future penalties.

What is the advantage of the MBSAQIP becoming a QCDR?

By becoming a QCDR, the MBSAQIP is able to develop its own quality measures; in effect, enabling metabolic and bariatric surgeons to choose what is reported to CMS. We believe the measures we identify and provide will be more relevant, clinically appropriate and actionable, when compared to traditional PQRS measures.

Are MBSAQIP participants required to report their data to CMS through MBSAQIP?

No. The decision to report data to CMS through MBSAQIP is entirely up to the participant. An MBSAQIP participant may choose to satisfy Medicare reporting requirements in any way they choose. Additional PQRS reporting options for individual EPs include claims-based reporting, registry-based reporting, and EHR-based reporting.

The goal for the MBSAQIP was to simply provide what we believe to be an easy, convenient, and meaningful option for MBSAQIP participants who are already reporting data to us. Participants who elect to submit PQRS data through MBSAQIP will be provided with reports of their individual results of the QCDR measures.

What does an MBSAQIP participant have to do to submit their PQRS data through MBSAQIP?

Participants must authorize the MBSAQIP in writing to submit the data on their behalf. The MBSAQIP will not submit data to PQRS without such authorization.

Is there a special form that MBSAQIP participants must submit for this authorization? Where can it be found?

The Agreement/Consent Form will be available soon and more information regarding the MBSAQIP QCDR will be posted to the MBSAQIP website and shared via email.

How does the PQRS incentive and penalty system work?

PQRS is transitioning from a pay-for-reporting to a pay-for-performance program. The incentive payment for the 2014 reporting year is 0.5 percent of the total allowed charges to a physician or group of physicians for Medicare Part B professional services covered under the physician fee schedule and furnished during the reporting period. Additionally, eligible professionals who fall short of meeting the PQRS requirements in 2014 will be penalized 2.00 percent in 2016. Penalties are applied based on performance two years prior to the calendar year -- 2016 penalties will be based on the 2014 performance year. Participation in PQRS will also impact the physician value-based payment modifier (VM), a separate incentive program. The VM provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule based on the quality of care furnished compared to cost during a performance period. Physicians who are successful PQRS reporters will be eligible for VM bonuses, and those who are not successful PQRS reporters will be subject to penalties under the VM.

How can PQRS incentives be earned?

To earn the PQRS incentive by using the MBSAQIP QCDR in 2014, an eligible professional must successfully report at least nine individual measures including at least one outcome measure, covering at least three National Quality Strategy (NQS) domains. The measures must be reported for at least 50 percent of the provider’s applicable patients seen during the reporting period. Participation in MBSAQIP satisfies all of these requirements.

How can penalties be avoided?

To avoid a payment penalty in 2016, an eligible professional must successfully report in 2014 at least three individual measures covering at least one National Quality Strategy (NQS) domain. MBSAQIP is currently qualified to submit nine measures under the following
NQS domains:

  • Effective Clinical Care
  • Efficiency and Cost Reduction
  • Patient Safety
  • Communication and Care Coordination

What are the nine measures covered under these NQS domains?

The nine measures currently are:

  • Risk Standardized 30-Day Postoperative Complication Rate (Effective Clinical Care)
  • Risk Standardized 30-Day Readmission Rate (Efficiency and Cost Reduction)
  • Risk Standardized 30-Day Reoperation Rate (Efficiency and Cost Reduction)
  • Risk Standardized 30-Day Anastomotic/Staple Line Leak Rate (Effective Clinical Care)
  • Risk Standardized 30-Day Perioperative Bleeding Rate (Effective Clinical Care)
  • Risk Standardized 30-Day Postoperative Surgical Site Infection Rate (Effective Clinical Care)
  • Risk Standardized 30-Day Postoperative Nausea, Vomiting or Fluid/Electrolyte/Nutritional Depletion Rate (Effective Clinical Care)
  • Risk Standardized Extended Length of Stay (> 7 days) (Patient Safety)
  • 30-Day Postoperative Follow-Up Rate (Communication and Care Coordination)

What are the advantages of surgeons submitting their data through the MBSAQIP QCDR?

There are several advantages. As previously discussed, participation in PQRS through the MBSAQIP is simple and convenient. Minimal additional effort is required of MBSAQIP participants. The MBSAQIP is already collecting all of the data measures necessary to satisfy PQRS standards. Other reporting options may be more demanding and complicated. In addition, this is an excellent opportunity for metabolic and bariatric surgeons to engage in quality improvement initiatives and fulfill Part IV of the American Board of Surgery Maintenance of Certification (MOC) program. Finally, and perhaps even more importantly, through the MBSAQIP, we can provide high quality data that can be used to drive quality improvement and optimal outcomes for patients. As a QCDR, the MBSAQIP is able to identify and provide more relevant, clinically appropriate and actionable data, when compared to traditional PQRS data points.

Where can members get more information?

This is just an initial announcement. More detailed information is forthcoming from the ASMBS, ACS, and the MBSAQIP.

For specific questions, please contact

More information can be found via the following links: