2023 # 249 Barrett’s Esophagus

CMS Measure ID: #249

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: No

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a patient’s esophageal surgical pathology report demonstrates Barrett’s Esophagus; however, only one quality data code (QDC) per date of service for a patient is required. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

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 esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 96.24
Decile 1: 96.25 – 99.99
Decile 10: 100 – 100

Denominator

All surgical pathology esophageal biopsy reports for Barrett’s Esophagus

Denominator Criteria (Eligible Cases):

Diagnosis for Barrett’s esophagus (ICD-10-CM): K22.70, K22.710, K22.711, K22.719

AND

Patient procedure during the performance period (CPT): 88305

WITHOUT

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

AND NOT

DENOMINATOR EXCLUSION:

Specimen site other than anatomic location of esophagus: G8797

Numerator

Esophageal biopsy report documents the presence of Barrett’s mucosa and includes a statement about dysplasia

Numerator Options:

Performance Met:

Esophageal biopsy reports with the histological finding of Barrett’s mucosa that contains a statement about dysplasia (present, absent, or indefinite and if present, contains appropriate grading) (3126F)

OR

Denominator Exception:

Documentation of medical reason(s) for not submitting the histological finding of Barrett’s mucosa (e.g., malignant neoplasm or absence of intestinal metaplasia) (3126F with 1P)

OR

Performance Not Met: Pathology report with the histological finding of Barrett’s mucosa that does not contain a statement about dysplasia (present, absent, or indefinite, and if present, contains appropriate grading), reason not otherwise specified (3126F with 8P)