| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | No | Effective Clinical Care |
Measure Description
The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method
Instruction
This measure is to be reported each time a patient aged 18 and older undergoes a breast cancer operation. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Denominator
The number of patients aged 18 years and older on date of encounter undergoing breast cancer operations
Denominator Criteria (Eligible Cases):
Patients aged 18 and older on date of encounter
AND
Diagnosis for Female/Male Breast Cancer (ICD-10-CM): 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, C79.81, D05.11, D05.12
AND
Patient encounter during the performance period (CPT): 19301, 19302, 19303, 19307
AND NOT
DENOMINATOR EXCLUSION:
Minimally Invasive Biopsy Method attempted but not diagnostic of Breast Cancer (e.g., High Risk Lesion of Breast such as atypical ductal hyperplasia, lobular neoplasia, atypical lobular hyperplasia, lobular carcinoma in situ, atypical columnar hyperplasia, flat epithelial atypia, radial scar, complex sclerosing lesion, papillary lesion, or any lesion with spindle cells): G8946
Numerator
The number of patients aged 18 and older undergoing breast cancer operations who had breast cancer diagnosed preoperatively by a minimally invasive biopsy
Definition:
Minimally invasive biopsy methods – Includes fine needle aspiration, percutaneous core needle biopsy, percutaneous automated vacuum assisted rotating biopsy device, skin biopsy, skin shave or punch biopsy
Numerator Options:
Performance Met: Clinician diagnosed breast cancer preoperatively by a minimally invasive biopsy method (G8875)
OR
Denominator Exception: Documentation of reason(s) for not performing minimally invasive biopsy to diagnose breast cancer preoperatively (e.g., lesion too close to skin, implant, chest wall, etc., lesion could not be adequately visualized for needle biopsy, patient condition prevents needle biopsy [weight, breast thickness, etc.], duct excision without imaging abnormality, prophylactic mastectomy, reduction mammoplasty, excisional biopsy performed by another physician) (G8876)
OR
Performance Not Met: Clinician did not attempt to achieve the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method, reason not given (G8877)