CMS Measure ID: #360
Collection Type: CQM
Reporting Frequency: Every visit
Outcome: No
High Priority: Yes
NQS Domain: Patient Safety
Measure Age: > 2 years
Instructions
This measure is to be submitted each time a procedure for a CT imaging report is performed during the performance period. There is no diagnosis associated with this measure. 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 computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 5
Decile 1: 5.01 – 56.09
Minimum: 56.1 – 98.47
Decile 3: 98.48 – 99.84
Decile 4: 99.85 – 99.99
Decile 10: 100 – 100
Denominator
All final reports for patients, regardless of age, undergoing a CT or cardiac nuclear medicine (myocardial perfusion) procedure
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
All patients regardless of age
AND
Patient procedure during the performance period (CPT): 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71271, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74263*, 75571, 75572, 75573, 75574, 75635, 76380, 76497, 77011, 77012, 77014, 77013, 77078, 78072, 78429, 78430, 78431, 78433, 78451, 78452, 78453, 78454, 78491, 78492, 0042T
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
Numerator
CT and cardiac nuclear medicine (myocardial perfusion studies) imaging reports that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study
Numerator Instructions:
Physicians will need to document in the final report all known previous CT and cardiac nuclear medicine (myocardial perfusion) studies the patient has received in the 12-month period prior to the current study as a count that includes studies from the Radiology Information System, patient-provided radiological history or other source.
Numerator Options:
Performance Met:
Count of previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies documented in the 12-month period prior to the current study (G9321)
OR
Performance Not Met:
Count of previous CT and cardiac nuclear medicine (myocardial perfusion) studies not documented in the 12-month period prior to the current study, reason not given (G9322)