| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | Yes | Communication and Care Coordination |
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 of biopsy date
Instruction
This measure is to be reported each time a biopsy is performed duringthe performance period. It is anticipated that eligible clinicians providing the pathology services for procedures will submit this measure.
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, C44.510, 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
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 business 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 business 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 business days from the time when the tissue specimen was received by the pathologist (G9786)