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

2026 MIPS Measure #358: 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
Measure ID:MIPS 358 (Quality ID 358)
Collection:MIPS CQM
Topped Out:Yes
View CMS Spec ↗

Measure Specification

Eligible Population
Patients aged ≥ 18 years on date of encounter
ANDPatient procedure during the performance period
Exclusions
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.
Reporting Codes

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
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.

VBCA is a CMS-approved Qualified Clinical Data Registry (QCDR) that submits MIPS Measure 358 to the Quality Payment Program (QPP). Practices can report this measure as a MIPS Clinical Quality Measure (CQM) or through qualified registry submission.

🧮MIPS Score Simulator

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

%Benchmarks vary by collection type
💡 Tip: Enter your performance rate to compare MIPS points across all collection types. The same rate can score differently depending on how you submit.

2026 MIPS 358 Benchmarks

Historical CMS benchmark deciles for MIPS quality measure 358 by collection type. Your performance rate falls into a decile, which determines your measure points (3–10).

MIPS CQMAvg. performance rate: 88.96%Topped Out — 7-point cap
DecilePerformance Rate RangePoints
Decile 10.85 - 45.70%1 – 1.9
Decile 245.71 - 95.03%2 – 2.9
Decile 395.04 - 99.99%3 – 3.9
Decile 10100.00%10

Clinical Context

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.

Frequently Asked Questions

Who is eligible for MIPS 358?

The total number of adult patients (age 18 and over) having had non-emergency surgery. Denominator Instructions: CPT Category I procedure codes billed by surgeons performing surgery on the same patient, submitted with modifier 62 (indicating two surgeons, i.e., dual procedures) will be included in the denominator population, therefore both surgeons will be fully accountable for the clinical action described in the measure.

Is MIPS 358 the same as MIPS 358?

Yes. CMS uses zero-padded three-digit Quality IDs (358) in official specifications, while clinicians often search for MIPS 358 or Quality ID 358 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 358: Patient-Centered Surgical Risk Assessment and Communication?

Submission codes: G9316 (Documentation 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); G9317 (Documentation 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)

How do I report MIPS Measure 358 in 2026?

MIPS Measure 358 (Quality ID 358) 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 358 a topped-out measure?

Yes, MIPS 358 is currently topped out, which means most clinicians perform well on this measure and it may be subject to a 7-point scoring cap.

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