CMS Measure ID: #397
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 patient’s pathology report addresses specimens with a diagnosis of malignant cutaneous melanoma; however, only one quality data code (QDC) per date of service for a patient is required. In instances where multiple specimens from different/unique lesions are submitted and resulted in a single report, each eligible specimen must be Met in order for the case to be considered Met (Denominator Exclusions and Denominator Exceptions are not considered eligible specimens). If any eligible specimen is Not Met, the quality data code for Not Met should be submitted for this report. 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
Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 41.32
Decile 1: 41.33 – 99.99
Decile 10: 100 – 100
Denominator
All pathology reports for primary malignant cutaneous melanoma covering biopsies and excisions to include wide excisions and re-excisions.
Denominator Instruction:
The intent of the measure is to only include pathology reports for primary malignant cutaneous melanoma that may be staged with the following components: pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors. Melanoma in situ cases do not meet the criteria for this denominator. In the instance a pathology report meets the denominator criteria, but represents a diagnosis of Melanoma in situ G9430 should be utilized.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for malignant cutaneous melanoma (ICD-10-CM): C43.0, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9
AND
Patient procedure during 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 cutaneous location: G9430
Numerator
Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors
Numerator Options:
Performance Met:
Pathology report includes the pT Category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors (G9428)
OR
Denominator Exception:
Documentation of medical reason(s) for not including pT Category,thickness,ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors (e.g., negative skin biopsies, insufficient tissue, or other documented medical reasons) (G9429)
OR
Performance Not Met:
Pathology report does not include the pT Category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors (G9431)