2023 # 102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

CMS Measure ID: #102

Collection Type: CQM

Reporting Frequency: Once per episode of treatment

Outcome: No

High Priority: Yes

NQS Domain: Efficiency and Cost Reduction

Measure Age: > 2 years

Instructions

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, or 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:

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 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

Denominator

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

Definitions:

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 patient, regardless of age

AND

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

AND

Patient encounter during the performance period (CPT): 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55875, 55880, 77427, 77435, 77772, 77778, 77799

WITHOUT

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

AND

Low (or very low) risk of recurrence, prostate cancer: G9706

Numerator

Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer

Definition:
Bone scan – “bone scan” refers to the conventional technetium-99m-MDP bone scan as well as 18F-NaF PET (or PET/CT) scan.

Numerator Instructions:
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.

Numerator Options:

Performance Met:

Bone scan not performed prior to initiation of treatment nor at any time since diagnosis of prostate cancer (3270F)

OR

Denominator Exception:

Documentation of medical reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reasons) (3269F with 1P)

OR

Denominator Exception:

Documentation of system reason(s) for performing a bone scan (including bone scan ordered by someone other than the reporting physician) (3269F with 3P)

OR

Performance Not Met:

Bone scan performed prior to initiation of treatment or at any time since diagnosis of prostate cancer (3269F)