Merit-Based Incentive Payment System (MIPS)

Impact Summary: This measure supports the Merit‑based Incentive Payment System by assessing short‑term surgical outcomes for adults undergoing primary rhegmatogenous retinal detachment surgery, specifically the absence of a return to the operating room within 90 days of the initial procedure. 

Performance on this measure is consistently high, with most clinicians achieving rates above 90% and a substantial proportion achieving 100%. 

Based on the most recent benchmark data, if clinicians in Deciles 1 through 7 improved to the average performance observed in Decile 8 (100%), the percentage of patients with no return to the operating room within 90 days of surgery could increase by about 5 percentage points, from 94.7% to nearly 100%, potentially improving patient outcomes.

For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:

• 2026 MIPS Quality Benchmarks.csv (referred to as year 2024 in this assessment)
• 2025 MIPS Quality Benchmarks.csv (referred to as year 2023 in this assessment)
• 2024 MIPS Quality Benchmarks.csv (referred to as year 2022 in this assessment)
• 2023 MIPS Quality Benchmarks.csv (referred to as year 2021 in this assessment)

Battelle analyzed benchmark values for “Measure_ID”=384.

About Figure 1: Figure 1 is a boxplot that shows how rates have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of rates. The dots represent the minimum and maximum rates, and the line connecting them shows the range of the rates. The box itself covers the middle 60% of the rates, from the 20th to the 80th percentile. A “+” sign shows the average rate. This type of graph makes overall trends in rates over time as well as the consistency and spread of the results easier to visualize.

Impact Summary: This measure supports the Merit‑based Incentive Payment System (MIPS) by promoting appropriate follow‑up assessment for patients who receive retrievable inferior vena cava (IVC) filters, a process intended to support safe device management and timely removal when clinically appropriate. 

Due to low reporting on this measure, no benchmark data are currently available in the publicly reported MIPS Quality Benchmarks files reviewed for this assessment. As a result, performance trends and the potential impact of improvement on patient outcomes cannot be evaluated at this time. The absence of benchmark data limits the ability to assess the importance or impact of this measure within MIPS. The measure is included in the Interventional Radiology MIPS Value Pathway (MVP), which may help increase adoption and reporting in the future.

For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:

• 2026 MIPS Quality Benchmarks.csv 
• 2025 MIPS Quality Benchmarks.csv 
• 2024 MIPS Quality Benchmarks.csv 
• 2023 MIPS Quality Benchmarks.csv

There are no benchmark values for “Measure_ID”=421 in these files, and therefore no data are available to assess this measure. During these years, CMS did not receive sufficient data submissions to establish a performance period benchmark.

Impact Summary: This measure evaluates documentation quality for esophageal biopsy reports in the Merit‑based Incentive Payment System (MIPS) by assessing whether reports that identify Barrett’s mucosa also include a statement regarding dysplasia. As a process measure, it supports MIPS goals by encouraging complete and standardized pathology reporting, which contributes to accurate diagnosis and informed clinical management. This measure is subject to the 7-point Cap Removal Benchmark and represents one of the few measures applicable for pathologists within the MIPS set. 

Performance has been uniformly high since implementation, with benchmark data indicating that in 2021 and 2022 all reporting clinicians achieved rates greater than 95%. In 2023 and 2024, mean performance remained high, while the distribution of performance rates has widened, with a subset of clinicians reporting rates below 90%. 

For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:

• 2026 MIPS Quality Benchmarks.csv (referred to as year 2024 in this assessment)
• 2025 MIPS Quality Benchmarks.csv (referred to as year 2023 in this assessment)
• 2024 MIPS Quality Benchmarks.csv (referred to as year 2022 in this assessment)
• 2023 MIPS Quality Benchmarks.csv (referred to as year 2021 in this assessment)

Battelle analyzed benchmark values for “Measure_ID”=249 and “Collection Type”= MIPS CQM.

About Figure 1: Figure 1 is a boxplot that shows how rates have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of rates. The dots represent the minimum and maximum rates, and the line connecting them shows the range of the rates. The box itself covers the middle 60% of the rates, from the 20th to the 80th percentile. A “+” sign shows the average rate. This type of graph makes overall trends in rates over time as well as the consistency and spread of the results easier to visualize.

Impact Summary: This measure supports the Merit‑based Incentive Payment System (MIPS) by assessing the occurrence of postoperative renal failure or dialysis among patients undergoing isolated coronary artery bypass graft surgery, an outcome associated with serious postoperative complications and patient safety. 

Due to low reporting on this measure, no benchmark data are currently available in the publicly reported MIPS Quality Benchmarks files reviewed for this assessment. As a result, Battelle cannot evaluate performance trends and the potential impact of improvement on patient outcomes at this time. The absence of benchmark data limits the ability to assess the importance or impact of this measure within MIPS. This measure is in the Surgical MIPS Value Pathway (MVP), which should encourage greater adoption and reporting in the future.

For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:

• 2026 MIPS Quality Benchmarks.csv 
• 2025 MIPS Quality Benchmarks.csv 
• 2024 MIPS Quality Benchmarks.csv 

• 2023 MIPS Quality Benchmarks.csv 

   

There are no benchmark values for “Measure_ID”=167 in these files, and therefore no data are available to assess this measure. For these years, there has been an insufficient volume of data submitted to establish a performance period benchmark.

Impact Summary: This measure supports the Merit‑based Incentive Payment System (MIPS) by assessing the occurrence of surgical re‑exploration during hospitalization among patients undergoing isolated coronary artery bypass graft surgery, an outcome associated with serious postoperative complications and patient safety. 

Due to low reporting on this measure, no benchmark data are currently available in the publicly reported MIPS Quality Benchmarks files Battelle reviewed for this assessment. As a result, Battelle cannot evaluate performance trends and the potential impact of improvement on patient outcomes at this time. The absence of benchmark data limits the ability to assess the importance or impact of this measure within MIPS. This measure is in the Surgical Care MIPS Value Pathway (MVP), which should increase adoption and reporting in the future.

For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:

• 2026 MIPS Quality Benchmarks.csv 
• 2025 MIPS Quality Benchmarks.csv 
• 2024 MIPS Quality Benchmarks.csv 

• 2023 MIPS Quality Benchmarks.csv 

   

There are no benchmark values for “Measure_ID”=168 in these files, and therefore no data are available to assess. For these years, there has been an insufficient volume of data submitted to establish a performance period benchmark.

Impact Summary: This measure supports the Merit-based Incentive Payment System (MIPS) goals of improving the quality and safety of care for patients and promoting higher-value care by ensuring clinicians document a current and complete medication list at each visit, which supports accurate clinical decision-making and helps reduce preventable medication errors and adverse drug events. 

For the eCQM for this measure, clinician performance remained unchanged from 2021 to 2024, showing consistent documentation of a complete patient medication list. Outliers in clinician performance at the low end of the performance range shown in Figure 1 indicate that some clinicians continue to perform at lower levels and suggest there are still opportunities for improvement. The eCQM identified a medication documentation rate of 99% as achievable; improving performance among lower-scoring clinicians could help ensure 12% more patients have documentation of current medications in their medical record, potentially leading to better health outcomes.

For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:

• 2026 MIPS Quality Benchmarks.csv (referred to as year 2024 in this assessment)
• 2025 MIPS Quality Benchmarks.csv (referred to as year 2023 in this assessment)
• 2024 MIPS Quality Benchmarks.csv (referred to as year 2022 in this assessment)
• 2023 MIPS Quality Benchmarks.csv (referred to as year 2021 in this assessment)

Battelle analyzed benchmark values for “Measure_ID”=130 and “CMS eCQM ID”=CMS68v15 to generate eCQM benchmark data.

About Figure 1: Figure 1 is a boxplot that shows how rates have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of rates. The dots represent the minimum and maximum rates, and the line connecting them shows the range of the rates. The box itself covers the middle 60% of the rates, from the 20th to the 80th percentile. A “+” sign shows the average rate. This type of graph makes overall trends in rates over time as well as the consistency and spread of the results easier to visualize.

Impact Summary: This measure supports the Merit-based Incentive Payment System (MIPS) goals of improving the quality and safety of care for patients and promoting higher-value care by ensuring clinicians document a current and complete medication list at each visit, which supports accurate clinical decision-making and helps reduce preventable medication errors and adverse drug events. 

Clinician performance has consistently increased from 2021 to 2024, but highlighted improvement is needed among lower-performing clinicians. The analysis showed that a medication documentation rate of 100% is achievable. Based on the PY 2024 data, only 7.7% of the assessed visits lacked documentation of medications. While performance for this measure in MIPS continues to be high, there continues to be instances of poor performance as seen by Decile 1: 3.65 - 78.37.

For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:

• 2026 MIPS Quality Benchmarks.csv (which is referred to as year 2024 in this assessment)
• 2025 MIPS Quality Benchmarks.csv (which is referred to as year 2023 in this assessment)
• 2024 MIPS Quality Benchmarks.csv (which is referred to as year 2022 in this assessment)
• 2023 MIPS Quality Benchmarks.csv (which is referred to as year 2021 in this assessment)

Battelle analyzed benchmark values for “Measure_ID”=130 and “CMS eCQM ID”=N/A to generate CQM benchmark data.

About Figure 1: Figure 1 is a boxplot that shows how rates have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of rates. The dots represent the minimum and maximum rates, and the line connecting them shows the range of the rates. The box itself covers the middle 60% of the rates, from the 20th to the 80th percentile. A “+” sign shows the average rate. This type of graph makes overall trends in rates over time as well as the consistency and spread of the results easier to visualize.