CMS Measure ID: #406
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 patients undergoes a computed tomography or magnetic resonance imaging with an incidental thyroid nodule 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 for computed tomography or magnetic resonance imaging 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 computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Decile 0: 50.01 – 100
Decile 1: 13.05 – 50
Minimum: 6.07 – 13.04
Decile 3: 2.44 – 6.06
Decile 4: 0.01 – 2.43
Decile 10: 0 – 0
Denominator
All final reports for CT, CTA, MRI or MRA studies of the chest or neck for patients aged 18 and older with an incidentally-detected thyroid nodule < 1.0 cm noted
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. Denominator eligible patients would be those for whom an incidental thyroid nodule of < 1.0 is noted in the final report.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the performance period (CPT): 70486, 70487, 70488, 70490, 70491, 70492, 70498, 70540, 70542,70543, 70547, 70548, 70549, 71250, 71260, 71270, 71271, 71555, 72125, 72126, 72127, 71550, 71551, 71552, 72141, 72142, 72156
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
AND
Incidental Thyroid Nodule < 1.0 cm noted in report: G9552
Numerator
Final reports for CT, CTA, MRI or MRA of the chest or neck with follow-up imaging recommended for reports with an incidentally-detected thyroid nodule < 1.0 cm noted
Numerator Instructions:
INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
Numerator Options:
Performance Met:
Final reports for CT, CTA, MRI or MRA of the chest or neck with follow-up imaging recommended (G9554)
OR
Denominator Exception:
Documentation of medical reason(s) for recommending follow-up imaging (e.g., patient has multiple endocrine neoplasia, patient has cervical lymphadenopathy, other medical reason(s)) (G9555)
OR
Performance Not Met:
Final reports for CT, CTA, MRI or MRA of the chest or neck with follow-up imaging not recommended (G9556)