2026 COLLECTION TYPE:
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
MEASURE TYPE: Process – High Priority
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.
Instructions:
Reporting Frequency:
This measure is to be submitted for each procedure that is denominator eligible as defined in the denominator criteria.
Intent and Clinician Applicability:
The intent of this measure is to assess that primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection surgical pathology reports include an impression or conclusion of or recommendation for testing of MMR by immunohistochemistry, MSI by DNA-based testing status, or both. This measure may be submitted by Meritbased 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 purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the
performance period. The most advantageous quality data code (QDC) submitted will be used for performance.
Telehealth:
NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting. This measure is procedure based and therefore doesn’t allow for the denominator criteria to be conducted via telehealth. It would be appropriate to remove these patients 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 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, C16.2, 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 procedure 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)
RATIONALE
Detection of defective mismatch repair in colorectal carcinomas is important for detection of Lynch syndrome (hereditary nonpolyposis colorectal cancer syndrome [HNPCC]), which accounts for approximately 2 percent to 4 percent of all colorectal carcinomas and has clinical implications for treatment of the affected patient and family members (Sepulveda et al, 2017; Bartley et al 2022). National Comprehensive Cancer Network (NCCN) recommends that all patients with a personal history of colon or rectal cancer should have MMR or MSI testing (NCCN, 2023). In the Molecular Biomarkers for the Evaluation of Colorectal Cancer guideline from the American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology, and American Society of Clinical Oncology it is recommended that mismatch repair status testing in patients with colorectal cancers is necessary for the identification of patients at high risk for Lynch syndrome and/or prognostic stratification (Sepulveda et al, 2017; Bartley et al 2022).
One of two different initial tests can be performed on colorectal specimens to identify individuals who might have Lynch Syndrome: 1) immunohistochemistry (IHC) for MMR protein expression, which is often diminished because of mutation; or 2) analysis for microsatellite instability (MSI), which results from MMR deficiency. NCCN guidelines state IHC and MSI on newly diagnosed colorectal and endometrial cancers regardless of family history to determine Lynch Syndrome, is cost effective and has been confirmed for colorectal cancer and endorsed by the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) working group at the CDC, the US Multi-Society Task Force on Colorectal Cancer, and the American Gastroenterological Association (NCCN, 2022; NCCN, 2019).
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