Who is eligible for MIPS 354?

Patients aged 18 years and older undergoing gastric bypass or colectomy surgery.

Is MIPS 354 the same as MIPS 354?

Yes. CMS uses zero-padded three-digit Quality IDs (354) in official specifications, while clinicians often search for MIPS 354 or Quality ID 354 without the leading zero. Both refer to the same 2026 MIPS quality measure reported through the Quality Payment Program (QPP).

What codes do I submit for MIPS 354: Anastomotic Leak Intervention?

Submission codes: G9306 (Intervention for presence of leak of endoluminal contents through an anastomosis required); G9305 (Intervention for presence of leak of endoluminal contents through an anastomosis not required)

How do I report MIPS Measure 354 in 2026?

MIPS Measure 354 (Quality ID 354) is reported through the Quality Payment Program (QPP) as a MIPS Clinical Quality Measure (CQM) via qualified registry, or Medicare Part B claims where applicable.

Is MIPS 354 a topped-out measure?

No, MIPS 354 is not topped out, meaning there is still meaningful performance variation across clinicians.

Measure ID: MIPS 354|Surgery|2026 Performance Year

2026 MIPS Measure #354: Anastomotic Leak Intervention

Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.

Outcome – High PrioritySurgeryPatient Safety

Measure ID:MIPS 354 (Quality ID 354)

Collection:MIPS CQM

Topped Out:No

View CMS Spec ↗

Measure Specification

Eligible Population

All patients aged 18 years and older

ANDPatient procedure during the performance period

Exclusions

None

Numerator

Intervention (via return to operating room, interventional radiology, or interventional gastroenterology) for presence of leak of endoluminal contents (such as air, fluid, GI contents, or contrast material) through an anastomosis. The presence of an infection/abscess thought to be related to an anastomosis, even if the leak cannot be definitively identified as visualized during an operation, or by contrast extravasation would also be considered an anastomotic leak.

Reporting Codes

Performance Met:

G9306Intervention for presence of leak of endoluminal contents through an anastomosis required

Performance Not Met:

G9305Intervention for presence of leak of endoluminal contents through an anastomosis not required

VBCA Insights

Why This Measure Matters

Anastomotic leak—where a surgical connection between bowel segments breaks down—is rare but devastating: patients develop infection, abscess, sepsis, or need emergency reoperation. This measure flags cases requiring intervention. While not every leak is preventable, measuring it highlights technique, patient factors, or institutional patterns you can improve. Low leak rates reflect good surgical judgment, precise technique, and appropriate patient selection. This is an outcome that matters.

VBCA is a CMS-approved Qualified Clinical Data Registry (QCDR) that submits MIPS Measure 354 to the Quality Payment Program (QPP). Practices can report this measure as a MIPS Clinical Quality Measure (CQM) or through qualified registry submission.

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Specialty Measure Sets

General Surgery

Related Measures

Surgery

MIPS 355: Unplanned Reoperation within the 30-Day Postoperative Period MIPS 356: Unplanned Hospital Readmission within 30 Days of Principal Procedure MIPS 357: Surgical Site Infection (SSI)MIPS 404: Anesthesiology Smoking Abstinence

Patient Safety

MIPS 130: Documentation of Current Medications in the Medical Record MIPS 145: Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy MIPS 155: Falls: Plan of Care MIPS 164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation MIPS 168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration MIPS 181: Elder Maltreatment Screen and Follow-Up Plan MIPS 259: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured MIPS 275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before MIPS 286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia MIPS 351: Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk MIPS 355: Unplanned Reoperation within the 30-Day Postoperative Period MIPS 357: Surgical Site Infection (SSI)MIPS 374: Closing the Referral Loop: Receipt of Specialist Report MIPS 384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating MIPS 385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement MIPS 392: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation MIPS 393: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation,MIPS 413: Door to Puncture Time for Endovascular Stroke Treatment MIPS 422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse MIPS 432: Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic MIPS 513: Patient Reported Falls and Plan of Care

Official Resources

📄 CMS Measure Specification (PDF)🔗 QPP Quality Payment Program

Clinical Rationale

This is an adverse surgical outcome, which is often a preventable cause of harm, thus it is important to measure and report. It is feasible to collect the data and produce reliable and valid results about the quality of care. It is useful and understandable to stakeholders. As highlighted earlier, this measure was developed in a collaborative effort by the American College of Surgeons (ACS) and the American Board of Surgery (ABS).

This measure addresses the National Quality Strategy’s priorities, and was identified by an expert panel of physician providers to be a critical outcome for this procedure. This measure addresses a high-impact condition as it is one of the most common procedures performed in the U.S. The measure aligns well with the intended use. The care settings include acute care facilities/hospitals.

Data are being collected in a clinical registry that has been in existence for over 10 years, with over 5500 current, active users. Thus, we are requesting consideration of this measure in the MIPS CQM reporting option. The level of analysis is the clinician/individual. All populations are included, except children. The measure allows measurement across the person- centered episode of care out to 30 days after the procedure whether an inpatient, outpatient, or readmitted.

The measure addresses disparities in care. The risk adjustment is performed with a parsimonious dataset and aims to allow efficient data collection resources and data reporting. Measures have been harmonized when possible.

Clinical Recommendations

A modified-Delphi methodology using an expert panel of surgeons, who are directors of the ABS, identified this to be a critical outcome for this surgical procedure (Surgeon Specific Registry Report on Project for ABS MOC Part IV. Unpublished study by the American College of Surgeons in conjunction with the American Board of Surgery, 2011).

Implementation Notes

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period. There is no diagnosis associated with this measure. Include only patients that have procedures through November 30th of the performance period.

This will allow the evaluation of at least 30 days after the gastric bypass or colectomy surgery within the performance period. This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control.

Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

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