Measure ID: MIPS 358|Shared Decision-Making|2026 Performance Year

Patient-Centered Surgical Risk Assessment and Communication

Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.

Process – High PriorityShared Decision-MakingPatient Communication

Last updated: January 15, 2026

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Measure Specification

Denominator (Eligible Population)

Patients aged ≥ 18 years on date of encounter
ANDPatient procedure during the performance period

Denominator Exclusions1

G9752Emergency surgery

Numerator

Documentation of empirical, personalized risk assessment based on the patient’s risk factors with a validated risk calculator using multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient and/or family.

Submission Codes (QDCs)

✓ Performance Met
G9316Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family
✗ Performance Not Met
G9317Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family not completed

Denominator Exceptions

None — this measure has no denominator exceptions.

🧮MIPS Score Simulator

Estimate only — actual CMS scoring may vary based on reporting method, data completeness, and annual rule updates.

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VBCA Insights

💡Why This Measure Matters

Before non-emergency surgery, are your surgeons using a validated risk calculator to discuss personalized complication risks with patients? This measure captures whether shared decision-making is actually happening—not just a consent form signed, but real conversation about the patient's individual risks. Good performance means documented use of a clinical tool (like the ACS NSQIP calculator) and evidence that the surgeon discussed those specific risks with the patient. This builds patient trust and aligns expectations with reality.

📖Clinical Rationale

Preoperative risk assessment and communication between surgeons and patients is critical for effective informed consent and shared decision making in surgical care. Shared decision-making is considered an integral component of patient-centered care, especially for preference-sensitive issues. Evidence suggests that there is room for improving communication and the informed consent/shared decision-making processes between physicians and patients.

Use of a risk calculator helps improve the quality of the informed consent/shared decision-making process by providing a personalized, customized, empirically- based estimate of a patient’s risk of post-operative complications. Moreover, evidence suggests that sharing numeric estimates of patient-specific risk may enhance patient trust in providers.

📝Clinical Recommendations

Preoperative risk assessment and communication between surgeons and patients is critical for effective informed consent and shared decision making in surgical care. Shared decision-making is considered an integral component of patient-centered care, especially for preference-sensitive issues. Evidence suggests that there is room for improving communication and the informed consent/shared decision-making processes between physicians and patients.

Use of a risk calculator helps improve the quality of the informed consent/shared decision-making process by providing a personalized, customized, empirically- based estimate of a patient’s risk of post-operative complications. Moreover, evidence suggests that sharing numeric estimates of patient-specific risk may enhance patient trust in providers.

📋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 for the performance period. There is no diagnosis associated with this measure.

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