2017 MIPS Measure #450: Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy

Measure Description

Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab

Instruction

This measure is to be reported a minimum of once per performance period for patients with breast cancer seen during the performance period. 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

Adult women with AJCC stage I (T1c)– III, HER2 positive breast cancer who receive adjuvant chemotherapy

Definitions:
Use the following definitions to determine HER2 status-
Positive:
IHC 3+ based on circumferential membrane staining that is complete, intense
• ISH positive based on:
• Single-probe average HER2 copy number =6.0 signals/cell
• Dual-probe HER2/CEP17 ratio =2.0 with an average HER2 copy number =4.0 signals/cell
• Dual-probe HER2/CEP17 ratio =2.0 with an average HER2 copy number <4.0 signals/cell
• Dual-probe HER2/CEP17 ratio <2.0 with an average HER2 copy number =6.0 signals/cell
Equivocal:
• IHC 2+ based on circumferential membrane staining that is incomplete and/or weak/moderate and within > 10% of the invasive tumor cells or complete and circumferential membrane staining that is intense and within = 10% of the invasive tumor cells
ISH equivocal based on:
• Single-probe ISH average HER2 copy number = 4.0 and < 6.0 signals/cell
• Dual-probe HER2/CEP17 ratio < 2.0 with an average HER2 copy number = 4.0 and < 6.0 signals/cell
Negative:
IHC 1+ as defined by incomplete membrane staining that is faint/barely perceptible and within > 10% of the invasive tumor cells or IHC 0 as defined by no staining observed or membrane staining that is incomplete and is faint/barely perceptible and within = 10% of the invasive tumor cells
ISH negative based on:
• Single-probe average HER2 copy number < 4.0 signals/cell
• Dual-probe HER2/CEP17 ratio < 2.0 with an average HER2 copy number < 4.0 signals/cell
Indeterminate:
Indeterminate if technical issues prevent one or both tests (IHC and ISH) from being reported as positive,
negative, or equivocal.
Conditions may include:
• Inadequate specimen handling,
• Artifacts (crush or edge artifacts) that make interpretation difficult
• Analytic testing failure.

Denominator Criteria (Eligible Cases):
Female Patients aged ≥ 18 years on date of encounter
AND
Diagnosis of breast cancer (ICD-10-CM): C50.011, C50.012, C50.019, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919
AND
Patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215
AND
Two or more encounters at the reporting site
AND
Breast Adjuvant Chemotherapy administered: G9829
AND
HER-2/neu positive: G9830
AND
AJCC stage at breast cancer diagnosis = II or III: G9831
OR
AJCC stage at breast cancer diagnosis = I (IA or IB) and T-Stage at breast cancer diagnosis does
NOT equal = T1, T1a, T1b: G9832
AND NOT
DENOMINATOR EXCLUSIONS:
Patient transfer to practice after initiation of chemotherapy: G9833
OR
Patient has metastatic disease at diagnosis: G9834

Numerator

Trastuzumab administered within 12 months of diagnosis

Numerator Options:
Performance Met: Trastuzumab administered within 12 months of diagnosis (G9835)
OR
Denominator Exception: Reason for not administering Trastuzumab documented (e.g. patient declined, patient died, patient transferred, contraindication or other clinical exclusion, neoadjuvant chemotherapy or radiation NOT complete) (G9836)
OR
Performance Not Met: Trastuzumab not administered within 12 months of diagnosis (G9837)