• Measure 397: Melanoma Reporting


    Updated January 2019.

    Reporting Options: 

    • 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.

    1. Patient characteristics: Description located in “Denominator” (see above).
    2. Diagnosis codes (ICD-10-CM): Codes located in “Diagnosis Codes.”
    3. Procedure codes (CPT and HCPCS): Codes located in “CPT Codes” and "HCPCS Code."

    The quality measure also has exclusions for the denominator.

    Diagnosis Codes

    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

    CPT Codes

    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.
    Decile/Points Registry (No EHR) Claims
    3 96.14 – 99.99 --
    4 -- --
    5 -- --
    6 -- --
    7 -- --
    8 -- --
    9 -- --
    10 100 100