2023 # 405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions

CMS Measure ID: #405

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a patient undergoes an imaging study with an incidental abdominal lesion finding during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who provide the professional component of diagnostic imaging studies 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 final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow-up imaging recommended based on radiological findings:
• Cystic renal lesion that is simple appearing* (Bosniak I or II)
• Adrenal lesion less than or equal to 1.0 cm
• Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 0.5
Decile 1: 0.51 – 3.82
Minimum: 3.83 – 14.49
Decile 3: 14.5 – 49.99
Decile 4: 50 – 87.22
Decile 5: 87.23 – 99.48
Decile 6: 99.49 – 99.99
Decile 10: 100 – 100

Denominator

All final reports for imaging studies for patients aged 18 years and older with one or more of the following incidentally noted:

Cystic renal lesion that is simple appearing (Bosniak I or II)

Adrenal lesion less than or equal to 1.0 cm

Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols

DENOMINATOR NOTE: The intent of this measure is to ensure patients with incidental findings that are highly likely to be benign do not receive follow up imaging routinely.

* “Simple-appearing criteria”:

Incidental renal mass on non-contrast enhanced abdominal CT that does not contain fat, is homogenous in appearance, -10-20 HU or ≥70 HU. (ACR, 2017)

Incidental renal mass on contrast-enhanced abdominal CT that does not contain fat, is homogenous in appearance, -10-20 HU. (ACR, 2017)

When reporting this measure, masses and lesions that do not meet all the criteria for “no further work-up” as provided in Management of the Incidental Renal Mass on CT: A White Paper of the ACR Incidental Findings Committee or the Management of the Incidental Adrenal Mass on CT: A White Paper of the ACR Incidental Findings Committee should not be considered in the context or intent of this measure. However, generally accepted radiology practices should be followed with respect to communication and management of any characteristically benign findings. A measure performance goal of 100% should not substitute for clinical judgment in individual cases.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient procedure during the performance period (CPT): 71250, 71260, 71270, 71271, 71275, 71555, 72131, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 74150, 74160, 74170, 74176, 74177, 74178, 74181, 74182, 74183

WITHOUT

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

AND

Incidental finding: Cystic renal lesion that is simple appearing (Bosniak I or II), or Adrenal lesion less than or equal to 1.0 cm or Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols: G9547

Numerator

Final reports for imaging studies that include a description of incidental cystic renal lesion or adrenal lesion stating follow-up imaging is not recommended

Numerator Instructions:

A short note can be made in the final report, such as:

“No follow-up imaging is recommended as incidental lesions are likely benign” or
“No follow-up imaging is recommended per consensus recommendations based on imaging criteria. Further lab evaluation could be pursued based on clinical findings.”

Numerator Options:

Performance Met: Final reports for imaging studies stating no follow-up imaging is recommended (G9548)

Denominator Exception: Documentation of medical reason(s) that follow-up imaging is indicated (e.g., patient has lymphadenopathy, signs of metastasis or an active diagnosis or history of cancer, and other medical reason(s) (G9549)

Performance Not Met: Final reports for imaging studies with follow-up imaging recommended, or final reports that do not include a specific recommendation of no follow-up (G9550)