Non-Melanoma Skin Cancer
Measure
Set
Title
Type
Denominator
Numerator
Use of Preventive Screening
Protocol for Transplant Patients
Process
All organ transplant recipients seen by provider
in an outpatient setting within the reporting
period.
Number of patients receiving sun protection education and
a full skin exam once within the reporting period (1 year)
by the provider or documentation of either a referral to or
completion of these preventative activities by a
dermatologist.
Use of Mohs Surgery for Superficial
Basal Cell Carcinomas on the
Trunk
Process
All pathologically-proven primary superficial
basal cell carcinoma (BCC) lesions on the trunk
(chest, back, abdomen) on immune-competent
patients treated by the provider within the
reporting period.
Number of pathologically-proven primary superficial
BCC’s treated by the provider utilizing Mohs surgery.
Use of Mohs Surgery For Squamous
Cell Carcinoma In Situ And
Keratoacanthoma Type - Squamous
Cell Carcinoma On The Trunk that
are 1 cm or smaller
Process
All pathologically-proven primary SCCis or
SCC-KA lesions on the trunk (chest, back,
abdomen) that are 1 cm or smaller in
immunocompetent patients treated by the
provider within the reporting period.
Number of pathologically-proven primary SCCis or SCCKA lesions on the trunk (chest, back, abdomen) that are 1
cm or smaller in immunocompetent patients treated by the
provider utilizing Mohs surgery.
Listing of SCC AJCC Reporting
Criteria
Process
All skin specimens diagnosed histologically as
primary invasive cutaneous squamous cell
carcinoma within the reporting period.
Number of skin specimens with a diagnosis of SCC for
which the pathology report listed the differentiation (well
and/or, moderately, (not poorly) vs poorly and/or,
undifferentiated) of the tumor, perineural invasion
involving nerves > 0.1mm, and depth of invasion.
Numerator statement: Satisfactory tumor differentiation
(a “well differentiated tumor”) will be achieved by
including a statement that lists the Squamous Cell
Carcinoma Keratoacanthoma type.
American Academy of Dermatology
June 19, 2015
Listing of BCC Subtyping on the
Biopsy Report
Process
All skin specimens diagnosed histologically as
cutaneous basal cell carcinoma within the
reporting period.
Number of skin specimens with a diagnosis of BCC for
which the pathology report listed the histopathological
BCC subtype.
Documentation of Patient Input for
Treatment Type
Process
All patients treated for at least one superficial
basal cell carcinoma or squamous cell carcinoma
in situ by scalpel-based excisional surgery
(including standard excision and Mohs surgery)
within the reporting period.
Number of patients for whom there is documentation of
patient (or legal caregiver) input regarding treatment
options at least once per reporting period.
Documentation of discussion
w/patients about potential use of
field-directed therapies prior to
destruction of Actinic Keratoses
(17004 code)
Process
All patients with destruction of 15 or more AKs
in a single visit (code 17004).
Number of patients with destruction of 15 or more AKs
who have documentation of a discussion of risks and
benefits of using field-directed therapy with their
physician.
Numerator Instructions: This measure will be reported at
least once per 12 month reporting period. To satisfy this
measure, patients undergoing destruction of 15 or more
AKs need a statement such as the following documented
in their chart at least once during the reporting period:
“The patient was informed of the risks and benefits of
using field-directed therapy and their questions were
answered.”
American Academy of Dermatology
June 19, 2015
Use of Biopsy Site Photos or
Directional Diagrams Prior to
Surgery (NMSC)
Process
All cutaneous biopsies by the clinician consistent
with cutaneous basal or squamous cell carcinoma
(including in situ disease) that the clinician
treated with an excision, electrodesiccation,
curettage, cryosurgery, or Mohs surgery, or
referred to another clinician to perform one of
these procedures.
Number of cutaneous biopsies by the clinician consistent
with basal cell carcinoma or squamous cell carcinoma (to
include in situ disease) that the clinician treated with an
excision, electrodesiccation, curettage, cryosurgery or
Mohs surgery, or referred to another clinician to perform
one of these procedures for which a biopsy site photo or
detailed directional diagram was made available to the
operating provider prior to surgical treatment for use in his
or her pre-op evaluation.
Biopsy Clinical History Anatomic
Location Accuracy (NMSC)
Intermediate
Outcome
All cutaneous biopsies by the clinician consistent
with cutaneous basal or squamous cell carcinoma
(including in situ disease).
Number of cutaneous biopsies by the clinician for which
the clinical site listed on the clinical history portion of the
pathology report is NOT consistent with the clinical
information in the clinician’s biopsy tracking system or
with the actual biopsy site on the patient.
Biopsy Reporting Time (NMSC)–
Clinician
Process
critical to
outcomes
All cutaneous biopsies by the clinician consistent
with cutaneous basal or squamous cell carcinoma
(including in situ disease).
Number of cutaneous biopsies by the clinician consistent
with basal cell carcinoma or squamous cell carcinoma (to
include in situ disease) for which the patient was notified
of their final biopsy pathology findings within 15 business
days from the time when the biopsy was performed.
Distinct dates of service resulting in an eligible patient
procedure should be reported separately.
Biopsy Reporting Time (NMSC) –
Pathologist
Process
critical to
outcomes
All pathology reports generated by the
Pathologist/Dermatopathologist consistent with
cutaneous basal cell carcinoma or squamous cell
carcinoma (to include in situ disease).
Number of final pathology reports diagnosing cutaneous
basal cell carcinoma or squamous cell carcinoma (to
include in situ disease) sent from the Pathologist/
Dermatopathologist to the biopsying clinician for review
within 5 business days from the time when the tissue
specimen was received by the pathologist.
American Academy of Dermatology
June 19, 2015