CMS Measure ID: #147
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 bone scintigraphy is performed during the performance period. There is no diagnosis associated with this measure. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the professional component of the bone scintigraphy study 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-based submissions; however, these codes may be submitted for those registries that utilize claims data.
Description
Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 33.93
Decile 1: 33.94 – 96.1
Minimum: 96.11 – 99.87
Decile 3: 99.88 – 99.99
Decile 10: 100 – 100
Denominator
All final reports for patients, regardless of age, undergoing bone planar and whole body scintigraphy
Denominator Criteria (Eligible Cases):
Patient encounter during the performance period (CPT): 78300, 78305, 78306, 78315
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
Numerator
Final reports that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.)
Definition:
Relevant Imaging Studies – “Relevant imaging studies” are defined as studies that correspond to the same anatomical region in question.
Numerator Options:
Performance Met:
Final report for bone scintigraphy study includes correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT) corresponding to the same anatomical region in question (3570F)
OR
Denominator Exception:
Documentation of system reason(s) for not documenting correlation with existing relevant imaging studies in final report (e.g., no existing relevant imaging study available, patient did not have a previous relevant imaging study) (3570F with 3P)
Note: Correlative studies are considered to be unavailable if relevant studies (reports and/or actual examination material) from other imaging modalities exist but could not be obtained after reasonable efforts to retrieve the studies are made by the interpreting physician prior to the finalization of the bone scintigraphy report.
OR
Performance Not Met:
Bone scintigraphy report not correlated in the final report with existing relevant imaging studies, reason not otherwise specified (3570F with 8P)