|Measure Type||High Priority Measure?||Collection Type(s)|
|Process||yes||eCQM, MIPS CQM|
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer
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This measure is to be submitted once per performance period for patients with a diagnosis of prostate cancer at low (or very low) risk of recurrence who receive interstitial prostate brachytherapy, external beam radiotherapy to the prostate, radical prostatectomy during the performance period. The quality data code or equivalent needs to be submitted only once during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the listed procedures as specified in the denominator coding will submit this measure.
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.
All patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy
Risk Strata: Very Low, Low, Intermediate, High, or Very High
Very Low/Low Risk – PSA < 10 ng/mL; AND Gleason score 6 or less/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.
High/Very High Risk – PSA > 20 ng/mL; OR Gleason score 8 to 10/Gleason grade group 4-5; OR clinically localized stage T3 to T4 (adapted from the National Comprehensive Cancer Network, 2018).
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 NOTE: Most recent risk assessment of recurrence completed before the first prostate cancer treatment during the performance period will be used for denominator eligibility.
Denominator Criteria (Eligible Cases):
Any male patient, regardless of age
Diagnosis for prostate cancer (ICD-10-CM): C61
Patient encounter during the performance period (CPT): 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55875, 55880, 77427, 77435, 77772, 77778, 77799
Telehealth Modifier: GQ, GT, 95, POS 02
Low (or very low) risk of recurrence, prostate cancer: G9706
Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer
Bone scan – “bone scan” refers to the conventional technetium-99m-MDP bone scan as well as 18F-NaF PET (or PET/CT) scan.
A higher score indicates appropriate treatment of patients with prostate cancer at low (or very low) risk of recurrence.
NUMERATOR NOTE: Denominator Exception(s) are determined any time after diagnosis of Prostate Cancer.
Bone scan not performed prior to initiation of treatment nor at any time since diagnosis of prostate cancer (3270F)
Documentation of medical reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reasons) (3269F with 1P)
Documentation of system reason(s) for performing a bone scan (including bone scan ordered by someone other than the reporting physician) (3269F with 3P)
Performance Not Met:
Bone scan performed prior to initiation of treatment or at any time since diagnosis of prostate cancer (3269F)