| Measure Type | High Priority Measure? | NQS Domain |
|---|---|---|
| Process | Yes | Communication and Care Coordination |
| Data Submission Method(s) | ||
| Registry | ||
Measure Description
Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist
Instructions
This measure is to be submitted each time a biopsy is performed during the performance period. It is anticipated that eligible clinicians providing the pathology services for procedures will submit this measure.
NOTE: To be eligible for this measure, the denominator and numerator criteria must be met during the performance period of 01/01/2018 to 12/24/2018. This is to provide sufficient time for the pathology results to be received by the biopsying clinician.
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 pathology reports generated by the Pathologist/Dermatopathologist consistent with cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease)
Denominator Criteria (Eligible Cases):
Diagnosis for cutaneous basal carcinoma or squamous cell carcinoma (ICD-10-CM): C44.01, C44.02, C44.111, C44.112, C44.119, C44.121, C44.122, C44.129, C44.211, C44.212, C44.219, C44.221, C44.222, C44.229, C44.310, C44.311, C44.319, C44.320, C44.321, C44.329, C44.41, C44.42, CC44.510, C44.511, C44.519, C44.520, C44.521, C44.529, C44.611, C44.612, C44.619, C44.621, C44.622, C44.629, C44.711, C44.712, C44.719, C44.721, C44.722, C44.729, C44.81, C44.82, C44.91, C44.92, D04.0, D04.10, D04.11, D04.12, D04.20, D04.21, D04.22, D04.30, D04.39, D04.4, D04.5, D04.60, D04.61, D04.62, D04.70, D04.71, D04.72, D04.8, D04.9
AND
Patient procedure during the performance period (CPT): 88304, 88305
AND NOT
DENOMINATOR EXCLUSION:
Pathologists/Dermatopathologists providing a second opinion on a biopsy: G9784
OR
Pathologists/Dermatopathologists is the same clinician who performed the biopsy: G9939
Numerator
Number of final pathology reports diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsying clinician for review within 7 days from the time when the tissue specimen was received by the pathologist
Numerator Instructions: Requirements for calculating the numerator include the following documentation in the pathologist/ dermopathologist’s tracking system:
-
Date tissue specimen received
- Date pathology report was sent to the biopsying clinician
Numerator Options:
Performance Met:
Pathology report diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsying clinician for review within 7 days from the time when the tissue specimen was received by the pathologist (G9785)
OR
Performance Not Met:
Pathology report diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) was not sent from the Pathologist/ Dermatopathologist to the biopsying clinician for review within 7 days from the time when the tissue specimen was received by the pathologist (G9786)