Pathology MIPS Specialty Measure Set (2021)

CMS specialty measure sets may be reported as an alternative to reporting 6 separate quality measures. If a measure set has less than 6 measures, eligible groups and clinicians must report all measures in the set. However, if a set has more than 6 measures, participants may choose the 6 measures that best fit their practice. Remember, at least one outcome measure must be reported, regardless of whether or not an outcome measure is included in a measure set.

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
249Barrett’s EsophagusnoProcessPercentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasiaView
250Radical Prostatectomy Pathology ReportingnoProcessPercentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin statusView
395Lung Cancer Reporting (Biopsy/Cytology Specimens)yesProcessPathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology reportView
396Lung Cancer Reporting (Resection Specimens)yesProcessPathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic typeView
397Melanoma ReportingyesProcessPathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rateView
440Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to ClinicianyesProcessPercentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (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 pathologistView

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CMS-2021