| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | No | Effective Clinical Care |
Measure Description
Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow
Instruction
This measure is to be reported a minimum of once per performance period for all myelodysplastic syndrome (MDS) and Acute Leukemia patients seen during the performance period, regardless of when MDS or Acute Leukemia diagnosis was made; the quality action being measured is that baseline cytogenetic testing on bone marrow was performed for each patient with MDS and Acute Leukemia at the time of diagnosis or prior to initiating treatment. It is anticipated that eligible clinicians who provide services for patients with the diagnosis of myelodysplastic syndromes or an acute leukemia (not in remission) will submit this measure.
Denominator
All patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for MDS or acute leukemia – not in remission (ICD-10-CM): C91.00, C91.02, C92.00, C92.02,
C92.40, C92.42, C92.50, C92.52, C92.60, C92.62, C92.A0, C92.A2, C93.00, C93.02, C94.00, C94.02,
C94.20, C94.22, C95.00, C95.02, D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9, D46.A, D46.B,
D46.C, D46.Z
AND
Patient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215
WITHOUT
Telehealth Modifier: GQ, GT
Numerator
Patients who had baseline cytogenetic testing performed on bone marrow
Definition:
Baseline Cytogenetic Testing – Testing that is performed at time of diagnosis or prior to initiating treatment (transfusion, growth factors, or antineoplastic therapy) for that diagnosis
Numerator Options:
Performance Met: Cytogenetic testing performed on bone marrow at time of diagnosis or prior to initiating treatment (3155F)
OR
Denominator Exception: Documentation of medical reason(s) for not performing baseline cytogenetic testing on bone marrow (eg, no liquid bone marrow or fibrotic
marrow) (3155F with 1P)
OR
Denominator Exception: Documentation of patient reason(s) for not performing baseline cytogenetic testing on bone marrow (eg, at time of diagnosis receiving
palliative care or not receiving treatment as defined above) (3155F with 2P)
OR
Denominator Exception: Documentation of system reason(s) for not performing baseline cytogenetic testing on bone marrow (eg, patient previously treated by another
physician at the time cytogenetic testing performed) (3155F with 3P)
OR
Performance Not Met: Cytogenetic testing not performed on bone marrow at time to initiating treatment, reason not
otherwise specified (3155F with 8P)