The Centers for Medicare and Medicaid Services (CMS) has finalized new MIPS Value Pathways (MVPs) that are relevant to specialties we serve. One of these is the Surgical Care MVP, which is available for reporting in the 2025 performance year.
Although MVP reporting is currently voluntary, CMS has expressed the intention of sunsetting traditional MIPS and transitioning to MVPs entirely in the future. In the 2025 MIPS proposed rule, CMS requested feedback on the possibility of making MVPs mandatory as early as 2029.
Anatomy IT will continue to advocate for MVPs to be optional and for improvements to the Surgical Care MVP to make it possible for all surgical specialties and subspecialties to be successful.
In this blog, we’ll break down what MVPs are, how to report them, and what measures and activities are included in the Surgical Care MVP.
What is a MIPS Value Pathway (MVP)?
CMS introduced MVPs as an alternative reporting option to traditional MIPS in 2023. According to CMS, MVPs aim to simplify MIPS, reduce reporting burden, and help patients make more informed decisions when choosing their clinicians.
Each MVP has its own specific set of quality measures, improvement activities (IAs), and cost measures, and you are limited to those measures and activities when reporting the MVP. The Promoting Interoperability (PI) category is included as part of a “foundational layer,” meaning that PI requirements are the same for every MVP. Also included in the foundational layer is a population health measure, which contributes to your overall Quality score.
How Are MVPs Different from Traditional MIPS?
The table below highlights the differences by category between reporting traditional MIPS versus reporting an MVP.
If you choose to report both traditional MIPS and an MVP, CMS will assign you the higher of the two scores.
How Do I Report an MVP?
To report an MVP for the 2025 performance year, you must register between April 1, 2025, and December 1, 2025, at 8 pm ET. Registration is available through your QPP account.
At the time of registration, you must include the following information:
- The MVP you are choosing to report,
- Any administrative claims measures you would like to be included as 1 of your 4 required Quality measures,
- Whether you are planning to count the CAHPS for MIPS Survey measure towards 1 of the 4 required Quality measures, and
- Your participation level (group, subgroup, individual, APM).*
**If you report at the group level and are part of a multispecialty group, you will be required to report at the subgroup level starting in 2026.*
If you are an Anatomy IT client, we will discuss whether to report an MVP during your kickoff call.
What Measures Are Included in the Surgical Care MVP?
Click on the category names below to see the measures and activities included in the Surgical Care MVP.
Surgical Care Measures (Specific to This MVP)
Surgical Care MVP Quality Measures
- 47: Advance Care Plan (high priority)
- 164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation (outcome)
- 167: Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure (outcome)
- 168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration (outcome)
- 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- 264: Sentinel Lymph Node Biopsy for Invasive Breast Cancer
- 354: Anastomotic Leak Intervention (outcome)
- 355: Unplanned Reoperation within the 30-Day Postoperative Period (outcome)
- 357: Surgical Site Infection (SSI) (outcome)
- 358: Patient-Centered Surgical Risk Assessment and Communication (high priority)
- 445: Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) (outcome)
- 459: Back Pain After Lumbar Surgery (outcome)
- 461: Leg Pain After Lumbar Surgery (outcome)
- 471: Functional Status After Lumbar Surgery (outcome)
- 487: Screening for Social Drivers of Health (high priority)
- AHE_3: Promote use of Patient-Reported Outcome Tools
- AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
- BE_12: Use evidence-based decision aids to support shared decision-making
- CC_15: PSH Care Coordination
- CC_17: Patient Navigator Program
- CC_18: Relationship-Centered Communication
- PM_11: Regular review practices in place on targeted patient population needs
- PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B
- PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
- PSPA_8: Use of Patient Safety Tools
- PCMH: Electronic submission of Patient Centered Medical Home accreditation
- MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
- Medicare Spending Per Beneficiary (MSPB) – Clinician
35-episode case minimum
- Colon and Rectal Resection
20-episode case minimum
- Femoral or Inguinal Hernia Repair
10-episode case minimum
- Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
10-episode case minimum
- Lumpectomy, Partial Mastectomy, Simple Mastectomy
10-episode case minimum
- Non-Emergent Coronary Artery Bypass Graft (CABG)
10-episode case minimum
Foundational Layer (Applies to All MVPs)
- 479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Systems (MIPS) Groups
- 484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
All of the following attestations and measures are required (no exclusions):
- Use of CEHRT
- Actions to Limit or Restrict Interoperability of CEHRT
- ASTP/ONC Direct Review
- High Priority SAFER Guides Assessment
- Security Risk Analysis
- Provide Patients Electronic Access to Their Health Information
All of the following measures are required (unless claiming an exclusion):
- e-Prescribing
- Query of Prescription Drug Monitoring Program (PDMP)
- Immunization Registry Reporting
- Electronic Case Reporting
One of the following options is required:
- Option 1: Support Electronic Referral Loops by Sending Health Information + Support Electronic Referral Loops by Receiving and Reconciling Health Information
Exclusions are available for both measures in this option.
You can optionally report on one (only one) of the following measures for 5 bonus points in the PI category:
- Syndromic Surveillance Reporting
- Clinical Data Registry Reporting
- Public Health Registry Reporting
Is Reporting the Surgical Care MVP in 2025 Worth It?
Yes. CMS is considering making MVP reporting mandatory starting in 2029. That means there are only a few MIPS performance years left to find flaws, gather data, and recommend improvements before MVPs become the only way in which you can participate in MIPS and avoid a penalty. By reporting the 2025 Surgical Care MVP, you will:
- Gain invaluable experience to prepare you for mandatory MVP reporting,
- Not negatively impact your MIPS payment adjustment as long as you also report traditional MIPS (even if you score poorly in the MVP), and
- Be able to provide real-world feedback to CMS to help them improve the MVP available to you before MVP reporting becomes mandatory. You can communicate with us to describe your experience with the MVP or you can tell CMS directly by commenting on the 2026 Medicare Physician Fee Schedule Proposed Rule this summer or by following the steps outlined here by CMS.
Next Steps
- Share this information with your colleagues.
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- If you are an Anatomy IT client, contact your MIPS Expert if you have any questions.
- If you are not an Anatomy IT client, contact us to learn more about our MIPS Success Plan and to reap the rewards of our combined decades of experience.
If you have any questions on this, let us know!
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Written By: **Sarrah Hakim, MHSA
About the Author: Sarrah is a Manager of Health Policy at Anatomy IT.