2018 MIPS Measure #397: Melanoma Reporting

Measure Type High Priority Measure? NQS Domain
Process Yes Communication and Care Coordination
Data Submission Method(s)
Claims, Registry

Measure Description

Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate

Instructions

This measure is to be submitted each time a patient’s pathology report addresses specimens with a diagnosis of malignant cutaneous melanoma; however, only one quality-data code (QDC) per date of service for a patient is required. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Denominator

All melanoma pathology reports for primary malignant cutaneous melanoma

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for malignant cutaneous melanoma (ICD-10-CM): C43.0, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9

AND

Patient encounter during performance period (CPT): 88305

AND NOT

DENOMINATOR EXCLUSION:

Specimen site other than anatomic cutaneous location: G9430

Numerator

Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate

Numerator Options:

Performance Met:

Pathology report includes the pT Category and a statement on thickness and ulceration and for pT1, mitotic rate (G9428)

OR

Denominator Exception:

Documentation of medical reason(s) for not including pT Category and a statement on thickness and ulceration and for pT1, mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons) (G9429)

OR

Performance Not Met:

Pathology report does not include the pT Category and a statement on thickness and ulceration and for pT1, mitotic rate (G9431)

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