| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Claims, Registry | Process | Yes | Patient Safety | Radiation Oncology |
Measure Description
Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues
Instruction
This measure is to be reported a minimum of once per reporting period for patients with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy seen during the reporting period. It is anticipated that eligible clinicians providing radiation therapy for patients with cancer will submit this measure.
Denominator
All patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy
Denominator Criteria (Eligible Cases):
Diagnosis for breast, rectal, pancreatic or lung cancer (ICD-10-CM): C19, C20, C21.2, C21.8,C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C34.00, C34.01, C34.02, C34.10, C34.11,C34.12, C34.2, C34.30, C34.31, C34.32, C34.80, C34.81, C34.82, C34.90, C34.91, C34.92, C50.011,C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129,C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C50.321, C50.322,C50.329, C50.411, C50.412, C50.419, C50.421, C50.422, C50.429, C50.511, C50.512, C50.519, C50.521,C50.522, C50.529, C50.611, C50.612, C50.619, C50.621, C50.622, C50.629, C50.811, C50.812, C50.819,C50.821, C50.822, C50.829, C50.911, C50.912, C50.919, C50.921, C50.922, C50.929
AND
Patient procedure during the reporting period (CPT): 77295
AND NOT
Diagnosis for metastatic cancer (ICD-10-CM): C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8,C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80,C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49,C79.51, C79.52, C79.60, C79.61, C79.62, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9
Numerator
Patients who had documentation in medical record that radiation dose limits to normal tissues were establishedprior to the initiation of a course of 3D conformal radiation for a minimum of two tissues
Numerator Options:
Performance Met: Radiation dose limits to normal tissues established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissue/organ (0520F)
OR
Performance Not Met: Radiation dose limits to normal tissues not established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissue/organ, reason not otherwise specified (0520F with 8P)