2017 MIPS Measure #099: Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Claims, Registry Process No Effective Clinical Care Pathology

Measure Description

Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade

Instruction

This measure is to be reported each time a breast cancer resection surgical pathology examination is performed during the performance period for breast cancer patients. It is anticipated that eligible clinicians who examine breast tissue specimens following resection in a laboratory or institution will submit this measure.

Denominator

All breast cancer resection pathology reports (excluding biopsies)

Denominator Criteria (Eligible Cases):
Diagnosis for breast cancer (ICD-10-CM): C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C50.321, C50.322, C50.329, C50.411, C50.412, C50.419,C50.421, C50.422, C50.429, C50.511, C50.512, C50.519, C50.521, C50.522, C50.529, C50.611, C50.612,C50.619, C50.621, C50.622, C50.629, C50.811, C50.812, C50.819, C50.821, C50.822, C50.829, C50.911,C50.912, C50.919, C50.921, C50.922, C50.929
AND
Patient procedure during the performance period (CPT): 88307, 88309
AND
NOT DENOMINATOR EXCLUSION:
Specimen site other than anatomic location of primary tumor: 3250F

Numerator

Reports that include the pT category, the pN category and the histologic grade

Numerator Options:
Performance Met: pT category (primary tumor), pN category (regional lymph nodes), and histologic grade documented in pathology report (3260F)
OR
Denominator Exception: Documentation of medical reason(s) for not including the pT category, the pN category, or the histologic grade in the pathology report (eg, re-excisionwithout residual tumor, non-carcinomas) (3260F with 1P)
OR
Performance Not Met: pT category, pN category, and histologic grade were not documented in pathology report, reason not otherwise specified (3260F with 8P)

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