CMS Measure ID: #491
Collection Type: CQM
Reporting Frequency: Every visit
Outcome: No
High Priority: No
NQS Domain: Effective Clinical Care
Measure Age: New
Instructions
This measure is to be submitted each time a primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection surgical pathology examination is performed during the performance period. 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:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. 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 by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data.
Description
Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both
Denominator
All surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection
Denominator Criteria (Eligible Cases):
Patients regardless of age
AND
Diagnosis of primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection (ICD-10-CM): C15.3, C15.4, C15.5, C15.8, C15.9, C16.0, C16.1, C16.3, C16.4, C16.5, C16.6, C16.8, C16.9, C17.0, C17.1, C17.2, C17.3, C17.8, C17.9, C18.0, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C26.0, C54.1, C54.3, C54.8, C54.9, C55
AND
Patient encounter during the performance period (CPT): 88305, 88307, 88309
AND NOT
DENOMINATOR EXCLUSION:
Patients with an existing diagnosis of Lynch Syndrome (ICD-10-CM): Z15.04, Z15.09, Z80.0
OR
Patients with an existing diagnosis of squamous cell carcinoma of the esophagus: M1192
OR
Hospice services provided to patient any time during the measurement period: M1191
Numerator
Surgical pathology reports that contain impression or conclusion of or recommendation for testing of MMR by immunohistochemistry, MSI by DNA-based testing status, or both
Numerator Options:
Performance Met: Surgical pathology reports that contain impression or conclusion of or recommendation for testing of MMR by immunohistochemistry, MSI by DNA-based testing status, or both (M1193)
OR
Denominator Exception: Documentation of medical reason(s) surgical pathology reports did not contain impression or conclusion of or recommendation for testing of MMR by immunohistochemistry, MSI by DNA-based testing status, or both tests were not included (e.g., patient will not be treated with checkpoint inhibitor therapy, no residual carcinoma is present in the sample [tissue exhausted or status post neoadjuvant treatment], insufficient tumor for testing) (M1194)
OR
Performance Not Met: Surgical pathology reports that do not contain impression or conclusion of or recommendation for testing of MMR by immunohistochemistry, MSI by DNA-based testing status, or both, reason not given (M1195)