2023 # 104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer

CMS Measure ID: #104

Collection Type: CQM

Reporting Frequency: Once per episode of treatment

Outcome: No

High Priority: No

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted once per episode of radiation therapy for all male patients with prostate cancer who receive external beam radiotherapy to the prostate during the performance period. Each episode of radiation therapy in an eligible patient receiving external beam radiotherapy to the prostate occurring during the performance period will be counted when calculating the data completeness and performance rates. The quality-data code or equivalent needs to be submitted only once during the episode of radiation therapy (e.g., 8 weeks of therapy). It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform external beam radiotherapy to the prostate will submit this measure.

Measure Submission Type:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate

Denominator

All patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate

Definitions:

Risk Strata – Very Low, Low, Intermediate, High, or Very High–

Very Low Risk – PSA < 10 ng/mL; AND Gleason score 6 or less/Gleason grade group 1; AND clinical stage T1c; AND presence of disease in fewer than 3 biopsy cores; AND ≤ 50% prostate cancer involvement in any core; AND PSA density < 0.15 ng/mL/cm3.

Low Risk – PSA < 10 ng/mL; AND Gleason score 6/Gleason grade group 1; AND clinical stage T1 to T2a.

Intermediate Risk – PSA 10 to 20 ng/mL; OR Gleason score 7/Gleason grade group 2-3; OR clinical stage T2b to T2c.

Note: Patients with multiple adverse factors may be shifted into the high risk category.

High Risk – PSA > 20 ng/mL; OR Gleason score 8 to 10/Gleason grade group 4-5; OR clinically localized stage T3a.

Note: Patients with multiple adverse factors may be shifted into the very high risk category.

Very High Risk – Clinical stage T3b to T4; OR primary Gleason pattern 5; OR more than 4 cores with Gleason score 8 to 10/Gleason grade group 4-5. (NCCN, 2017)

External beam radiotherapy – External beam radiotherapy refers to 3D conformal radiation therapy (3D- CRT), intensity modulated radiation therapy (IMRT), stereotactic body radiotherapy (SBRT), and proton beam therapy.

Denominator Criteria (Eligible Cases):

Any male patient, regardless of age 

AND

Diagnosis for prostate cancer (ICD-10-CM): C61

AND

Patient encounter during the performance period (CPT): 77427, 77435

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

AND

High or very high risk of recurrence of prostate cancer: G8465

AND NOT

DENOMINATOR EXCLUSION:

Diagnosis for metastatic cancer (ICD-10-CM): C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.63, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9

Numerator

Patients who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate 

NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Definition:

Prescribed – Includes patients who are currently receiving medication(s) that follow the treatment plan recommended at an encounter during the performance period, even if the prescription for that medication was ordered prior to the encounter.

Numerator Options:

Performance Met:

Androgen deprivation therapy prescribed/administered in combination with external beam radiotherapy to the prostate (G9894)

OR

Denominator Exception:

Documentation of medical reason(s) for not prescribing/administering androgen deprivation therapy in combination with external beam radiotherapy to the prostate (eg, salvage therapy) (G9895)

OR

Denominator Exception:

Documentation of patient reason(s) for not prescribing/administering androgen deprivation therapy in combination with external beam radiotherapy to the prostate (G9896)

OR

Performance Not Met:

Patients who were not prescribed/administered androgen deprivation therapy in combination with external beam radiotherapy to the prostate, reason not given (G9897)