CMS Measure ID: #250
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 radical prostatectomy surgical pathology examination is performed during the performance period for prostate patients. It is anticipated that eligible clinicians who examine prostate tissue specimens following resection in a laboratory or institution 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 radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 97.77
Decile 1: 97.78 – 99.99
Decile 10: 100 – 100
Denominator
All radical prostatectomy surgical pathology examinations performed during the measurement period for primary prostate cancer
Denominator Criteria (Eligible Cases):
Diagnosis for malignant neoplasm of prostate (ICD-10-CM): C61
AND
Patient procedure during the performance period (CPT): 88309
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
AND NOT
DENOMINATOR EXCLUSION:
Specimen site other than anatomic location of prostate: G8798
Numerator
Radical Prostatectomy reports that include the pT category, the pN category, Gleason score and a statement about margin status
Numerator Options:
Performance Met:
Pathology report includes pT category, pN category, Gleason score and statement about margin status (3267F)
OR
Denominator Exception:
Documentation of medical reason(s) for not including pT category, pN category, Gleason score and statement about margin status in the pathology report (e.g., specimen originated from other malignant neoplasms, transurethral resections of the prostate (TURP), or secondary site prostatic carcinomas) (3267F with 1P)
OR
Performance Not Met: pT category, pN category, Gleason score and statement about margin status were not documented in pathology report, reason not otherwise specified (3267F with 8P)