2023 # 364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

CMS Measure ID: #364

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 a procedure for a CT imaging with an incidental pulmonary nodule 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 final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Minimum: 0 – 61.38
Decile 3: 61.39 – 78.94
Decile 4: 78.95 – 95.64
Decile 10: 100 – 100
Decile 5: 95.65 – 99.99

Denominator

All final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older

Definition:
Heavy Tobacco Smokers – Patients who are ‘heavy tobacco smokers’ includes patients with a 30 pack-year tobacco smoking history and currently smoke tobacco or have quit within the past 15 years. This definition is consistent with the USPSTF recommendation for lung cancer screening.

DENOMINATOR NOTE: CT imaging studies include all studies in which all or part of the thorax can be seen.

Granulomas, hamartomas or lesions with internal fat, or other characteristically benign findings are not considered incidental findings in the context or intent of this measure. Therefore, they are not included in the measure denominator. However, generally accepted radiology practices should be followed with respect to communication and management of these characteristically benign findings.

Denominator Criteria (Eligible Cases):

All patients age 35 years and older

AND

Patient procedure during the performance period (CPT): 70490, 70491, 70492, 75571, 75572, 75573, 75574, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178

WITHOUT

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

AND

A finding of an incidental pulmonary nodule: G9754

AND NOT

DENOMINATOR EXCLUSIONS:
Patients with an active diagnosis or history of cancer (except basal cell and squamous cell skin carcinoma), patients who are heavy tobacco smokers, lung cancer screening patients: M1018

Numerator

Final reports that contain an impression or conclusion that includes a recommended interval and modality for followup (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians)

Definition:
Follow-up Recommendations – No follow-up recommended in the final CT report OR follow-up is recommended within a designated time frame in the final CT report. Recommendations noted in the final CT report should be in accordance with recommended guidelines.

Numerator Options:

Performance Met:

Follow-up recommendations documented according to recommended guidelines for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors (G9345)

OR

Denominator Exception:

Documentation of medical reason(s) for not including a recommended interval and modality for follow-up or for no follow-up, and source of recommendations (e.g., patients with unexplained fever, immunocompromised patients who are at risk for infection) (G9755)

OR

Performance Not Met:

Follow-up recommendations not documented according to recommended guidelines for incidentally detected pulmonary nodules, reason not given (G9347)


Tags

CQM-2023