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).
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 13.26
Decile 1: 13.27 – 45.33
Minimum: 45.34 – 68.34
Decile 3: 68.35 – 92.1
Decile 4: 92.11 – 99.99
Decile 10: 100 – 100
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)