2018 MIPS Measure #100: Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

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

Measure Description

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

Instructions

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

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 colon and rectum cancer resection pathology reports

Denominator Criteria (Eligible Cases):

Diagnosis for colon or rectum cancer (ICD-10-CM): C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C21.2, C21.8

AND

Patient procedure during the performance period (CPT): 88309

AND NOT

DENOMINATOR EXCLUSION:

Specimen site is other than anatomic location of primary tumor: G8723

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 were documented in pathology report (G8721)

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 (e.g., re-excision without residual tumor; non-carcinomas, anal canal) (G8722)

OR

Performance Not Met:

pT category, pN category and histologic grade were not documented in the pathology report, reason not given (G8724)

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