Updated January 2019.
- IRIS Registry manual data entry: groups and individuals
- Claims-based reporting: individuals and small groups only
Measure Type: Process - High Priority
NQS Domain: Communication and Care Coordination
Meaningful Measure Area: Transfer of Health Information and Interoperability
Description: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate
Instructions: This measure is to be submitted each time a patient’s pathology report addresses specimens with a diagnosis of malignant cutaneous melanoma; however, only one quality-data code (QDC) per date of service for a patient is required.
To Which Patients Does the Measure Apply?
Denominator: All melanoma pathology reports for primary malignant cutaneous melanoma for patients 18 years and older.
There are three criteria for inclusion of a patient into the denominator.
- Patient characteristics: Description located in “Denominator” (see above).
- Diagnosis codes (ICD-10-CM): Codes located in “Diagnosis Codes.”
- Procedure codes (CPT and HCPCS): Codes located in “CPT Codes” and "HCPCS Code."
The quality measure also has exclusions for the denominator.
Diagnosis for malignant cutaneous melanoma: C43.0, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9
Patient encounter during performance period: 88305
How to Report the Measure
IRIS Registry Manual & Claims Reporting
Numerator: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate
- Performance met: Pathology report includes the pT Category and a statement on thickness, ulceration and mitotic rate (G9428)
- Denominator Exception: Documentation of medical reason(s) for not including pT Category and a statement on thickness, ulceration and mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons) (G9429)
- Performance not met: Pathology report does not include the pT Category and a statement on thickness, ulceration and mitotic rate (G9431)
- Denominator Exclusion: Specimen site other than anatomic cutaneous location (G9430)
How CMS Scores Your Performance
- If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
- Small practices (≤ 15 clinicians) will receive 3 points,
- Larger practices (> 15 clinicians) will receive 1 point.
- If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
- If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a performance period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
- There is a 7 point cap for this measure for claims and IRIS Registry manaul data entry.
||Registry (No EHR)
||96.14 – 99.99