2026 # 102 MIPS Measure Prostate Cancer Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE: Process

Description:

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer.

Instructions:

Reporting Frequency:
This measure is to be submitted once per performance period for denominator eligible cases as defined in the denominator criteria.

Intent and Clinician Applicability:
This measure is intended to reflect the quality of services provided for patients with a diagnosis of prostate cancer at low or very low risk of recurrence. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions as defined by the numerator based on the services provided and the measure-specific denominator coding.

Measure Strata and Performance Rates:
This measure contains one strata defined by a single submission criteria.
This measure produces a single performance rate.

Implementation Considerations:
For the purposes of MIPS implementation, this patient-periodic measure is submitted a minimum of once per patient per timeframe specified by the measure for the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once for the specified timeframe. If more than one QDC is submitted during the episode time period, performance shall be calculated by using the most advantageous QDC.

Telehealth:
NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting. Patient encounters for this measure conducted via telehealth should be removed from the denominator eligible patient population. Therefore, if the patient meets all denominator criteria but the encounter is conducted via telehealth, it would be appropriate to remove them from the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

Measure Submission:
The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

DENOMINATOR:

All patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy.

Definitions:
Risk Strata: Very Low, Low, Intermediate, High, or Very High
Very Low/Low Risk – PSA < 10 ng/mL; AND Gleason score 6 or less/Gleason grade group 1; AND clinical stage T1 to T2a.
Intermediate Risk – PSA 10 to 20 ng/mL; OR Gleason score 7/Gleason grade group 2-3; OR clinical stage T2b to T2c.
High/Very High Risk – PSA > 20 ng/mL; OR Gleason score 8 to 10/Gleason grade group 4-5; OR clinically localized stage T3 to T4 (adapted from the National Comprehensive Cancer Network, 2018).
External beam radiotherapy – “external beam radiotherapy” refers to 3D conformal radiation therapy, intensity modulated radiation therapy, stereotactic body radiotherapy, and proton beam therapy

DENOMINATOR NOTE:
Most recent risk assessment of recurrence completed before the first prostate cancer treatment during the performance period will be used for denominator eligibility. In 2022, the American Urological Association published guidance recommending that clinicians not perform bone scan in asymptomatic patients with low or favorable intermediate risk prostate cancer. However, this quality measure remains focused on patients with low (or very low) risk of recurrence

Denominator Criteria (eligible Cases):

Any patient, regardless of age

And

Diagnosis for prostate cancer (ICD-10-CM): C61

And

Patient encounter during the performance period (CPT): 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55868, 55869, 55875, 55877, 55880, 55881, 55882, 77427, 77435, 77772, 77778, 77799

Without

Encounters conducted via telehealth: M1426

And

Low (or very low) risk of recurrence, prostate cancer: G9706

NUMERATOR:

Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer.

Definition:
Bone scan – “bone scan” refers to the conventional technetium-99m-methyl diphosphonate bone scan as well as 18F-sodium fluoride or prostate-specific membrane antigen (PSMA) PET/CT scan.

Numerator Instructions:
A higher score indicates appropriate treatment of patients with prostate cancer at low (or very low) risk of recurrence.

NUMERATOR NOTE:
Denominator Exception(s) are determined any time after diagnosis of Prostate Cancer.

Numerator Options:

Performance Met: Bone scan not performed prior to initiation of treatment nor at any time since diagnosis of prostate cancer (3270F)

Or

Denominator Exception: Documentation of medical reason(s) for performing a bone scan (including documented pain related to prostate cancer, salvage therapy, other medical reasons) (M1427)

Or

Denominator Exception: Documentation of system reason(s) for performing a bone scan (including bone scan ordered by someone other than the reporting physician) (3269F with 3P)

Or

Performance Not Met:Bone scan performed prior to initiation of treatment or at any time since diagnosis of prostate cancer (3269F)

Rationale:

Multiple studies have indicated that a bone scan is not clinically necessary for staging prostate cancer with a low (or very low) risk of recurrence and receiving primary therapy. For patients who are categorized as low risk, bone scans are unlikely to identify their disease. Furthermore, bone scans are not necessary for low-risk patients who have no history of bony involvement or if the clinical examination suggests no bony involvement. Less than 1% of low risk patients are at risk of metastatic disease.

While clinical practice guidelines do not recommend bone scans in low risk prostate cancer patients, overuse is still common. An analysis of prostate cancer patients in the Surveillance, Epidemiology and End Results Medicare database diagnosed from 2004-2007 found that 43% of patients for whom a bone scan was not recommended received it (Falchook, Hendrix, & Chen, 2015). The analysis also found that the use of bone scans in low risk patients leads to an annual cost of $4 million dollars to Medicare. The overuse of bone scan imaging for low risk prostate cancer patients is a concept included on the American Urological Association’s (AUA) list in the Choosing Wisely Initiative as a means to promote adherence to evidence-based imaging practices and to reduce health care dollars wasted (NCCN, 2022). This measure is intended to promote adherence to evidence-based imaging practices, lessen the financial burden of unnecessary imaging, and ultimately to improve the quality of care for prostate cancer patients in the United States.