2023 # 440 Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician

CMS Measure ID: #440

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Communication and Care Coordination

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a biopsy is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians providing the pathology services for procedures will submit this measure.

NOTE: To be eligible for this measure, the denominator must be met during the measurement period of 01/01/2023 to 12/24/2023. This is to provide sufficient time for the pathology results to be received by the biopsying clinician and for the performance of the numerator to be met within the performance period.

Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. 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 by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Description

Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 71.04
Decile 1: 71.05 – 96.73
Minimum: 96.74 – 98.98
Decile 3: 98.99 – 99.73
Decile 4: 99.74 – 99.99
Decile 10: 100 – 100

Denominator

All pathology reports generated by the Pathologist/Dermatopathologist consistent with cutaneous basal cell carcinoma, squamous cell carcinoma, or melanoma (to include in situ disease)

Denominator Criteria (Eligible Cases):

Diagnosis for cutaneous basal carcinoma or squamous cell carcinoma (ICD-10-CM): C44.01, C44.02, C44.111, C44.1121, C44.1122, C44.1191, C44.1192, C44.121, C44.1221, C44.1222, C44.1291, C44.1292, C44.211, C44.212, C44.219, C44.221, C44.222, C44.229, C44.310, C44.311, C44.319, C44.320, C44.321, C44.329, C44.41, C44.42, C44.510, C44.511, C44.519, C44.520, C44.521, C44.529, C44.611, C44.612, C44.619, C44.621, C44.622, C44.629, C44.711, C44.712, C44.719, C44.721, C44.722, C44.729, C44.81, C44.82, C44.91, C44.92, D00.01, D04.0, D04.10, D04.111, D04.112, D04.121, D04.122, D04.20, D04.21, D04.22, D04.30, D04.39, D04.4, D04.5, D04.60, D04.61, D04.62, D04.70, D04.71, D04.72, D04.8, D04.9

OR

Diagnosis for melanoma (ICD-10-CM): C43.0, C43.10, C43.111, C43.112, C43.121, C43.122, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9, D03.0, D03.10, D03.111, D03.112, D03.121, D03.122, D03.20, D03.21, D03.22, D03.30, D03.39, D03.4, D03.51, D03.52, D03.59, D03.60, D03.61, D03.62, D03.70, D03.71, D03.72, D03.8, D03.9

Other malignant diagnosis (ICD-10-CM): C06.0, C06.1, C06.2, C06.80, C06.89, C06.9, C44.90, C44.99, C46.0, C46.1, C49.0, C49.10, C49.11, C49.12, C49.20, C49.21, C49.22, C49.3, C49.4, C49.5, C49.6, C49.8, C49.9

AND

Patient procedure during the performance period (CPT): 88304, 88305

WITHOUT

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

AND NOT

DENOMINATOR EXCLUSION:

Pathologists/Dermatopathologists providing a second opinion on a biopsy: G9784

Pathologists/Dermatopathologists is the same clinician who performed the biopsy: G9939

Numerator

Number of final pathology reports diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma or melanoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsying clinician for review within 7 days from the time when the tissue specimen was received by the pathologist

Numerator Instructions:
Requirements for calculating the numerator include the following documentation in the pathologist/ dermopathologist’s tracking system:

Date tissue specimen received
Date pathology report was sent to the biopsying clinician

Numerator Options:

Performance Met:

Pathology report diagnosing cutaneous basal cell carcinoma, squamous cell carcinoma, or melanoma (to include in situ disease) sent from the Pathologist/ Dermatopathologist to the biopsying clinician for review within 7 days from the time when the tissue specimen was received by the pathologist (G9785)

Denominator Exception:

Pathology report for tissue specimens produced from wide local excisions or re-excisions (M1166)

Performance Not Met:

Pathology report diagnosing cutaneous basal cell carcinoma, squamous cell carcinoma, or melanoma (to include in situ disease) was not sent from the Pathologist/ Dermatopathologist to the biopsying clinician for review within 7 days from the time when the tissue specimen was received by the pathologist (G9786)