| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | Yes | Efficiency and Cost Reduction | General Oncology |
Measure Description
Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies
Instruction
This measure is to be reported a minimum of once per performance period for patients with breast cancer seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Denominator
Adult women with breast cancer that are HER2 negative or HER2 undocumented
Definitions:
Use the following definitions to determine HER-2/neu status- Positive: IHC 3+ based on circumferential membrane staining that is complete, intense ISH positive based on:
•Single-probe average HER2 copy number =6.0 signals/cell
•Dual-probe HER2/CEP17 ratio =2.0 with an average HER2 copy number =4.0 signals/cell
•Dual-probe HER2/CEP17 ratio =2.0 with an average HER2 copy number <4.0 signals/cell
•Dual-probe HER2/CEP17 ratio < 2.0 with an average HER2 copy number =6.0 signals/cell
Equivocal:
•IHC 2+ based on circumferential membrane staining that is incomplete and/or weak/moderate andwithin > 10% of the invasive tumor cells or complete and circumferential membrane staining that isintense and within = 10% of the invasive tumor cells
ISH equivocal based on:
•Single-probe ISH average HER2 copy number = 4.0 and < 6.0 signals/cell
•Dual-probe HER2/CEP17 ratio < 2.0 with an average HER2 copy number = 4.0 and < 6.0 signals/cell
Negative:
IHC 1+ as defined by incomplete membrane staining that is faint/barely perceptible and within > 10% of theinvasive tumor cells or IHC 0 as defined by no staining observed or membrane staining that is incompleteand is faint/barely perceptible and within = 10% of the invasive tumor cells
ISH negative based on:
•Single-probe average HER2 copy number < 4.0 signals/cell
•Dual-probe HER2/CEP17 ratio < 2.0 with an average HER2 copy number < 4.0 signals/cel
Indeterminate:
Indeterminate if technical issues prevent one or both tests (IHC and ISH) from being reported as positive, negative, or equivocal.
Conditions may include:
• Inadequate specimen handling,
• Artifacts (crush or edge artifacts) that make interpretation difficult
• Analytic testing failure
Transferred to Practice:
Patients who have transferred to the reporting practice after the initiation of HER2 targeted therapy at another practice. This prevents practices from being held accountable for another practices’ treatment decisions. The clinician submitting the measure should have initiated the treatment for the denominator eligible patient.
Denominator Criteria (Eligible Cases):
Female Patients aged ≥ 18 years on date of encounter
AND
Diagnosis of Breast Cancer (ICD-10-CM): C50.011, C50.012, C50.019, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919
AND
Patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215
AND
Two or more encounters at the reporting site
AND
HER-2/neu Negative or Undocumented/Unknown: G9825
AND NOT
DENOMINATOR EXCLUSION:
Patient transferred to practice after initiation of chemotherapy: G9826
Numerator
HER2-targeted therapies not administered during the initial course of treatment
Numerator Options:
Performance Met: HER2-targeted therapies not administered during the initial course of treatment (G9827)
OR
Performance Not Met: HER2-targeted therapies administered during the initial course of treatment (G9828)