Title/Number
Type
Denominator
Numerator
Biopsy Follow-Up
PQRS 265/NQF 0645
Process
All patients undergoing a biopsy.
Patients whose biopsy results have been reviewed and
communicated to the primary care/referring physician and the
patient by the physician performing the biopsy. The physician
performing the biopsy must also acknowledge and/or document
the communication in a biopsy tracking log and document in the
patient’s medical record.
Melanoma: Continuity of
Care Recall System
PQRS 137/NQF 0650
Structure
All patients, regardless of age, with a current
diagnosis of melanoma or a history of melanoma.
Patients whose information is entered, at least once within the
12 month period, into a recall system that includes:
Biopsy
Measure
Set
Melanoma
A target date for the next complete physical skin exam, AND a
process to follow-up with patients who either did not make an
appointment within the specified timeframe or who missed a
scheduled appointment.
Melanoma: Coordination of
Care
PQRS 138
Process
Reporting Criteria 1:
All visits for patients, regardless of age, diagnosed
with a new occurrence of melanoma during
excision of malignant lesion.
Reporting Criteria 1 and 2 Numerator:
Patient visits with a treatment plan documented in the chart that
was communicated to the physician(s) providing continuing
care within one month of diagnosis.
Reporting Criteria 2:
All visits for patients, regardless of age, diagnosed
with a new occurrence of melanoma evaluated in an
outpatient setting.
Reporting Criteria 1 and 2 Denominator:
All visits for patients, regardless of age, diagnosed
with a new occurrence of melanoma.
American Academy of Dermatology
June 19, 2015
Measure
Set
Title/Number
Melanoma: Overutilization
of Imaging Studies in
Melanoma
PQRS 224/NQF 0562
Type
Process
Denominator
Reporting Criteria 1:
Patients with a current diagnosis of Stage 0 through
IIC melanoma without signs or symptoms
suggesting systemic spread.
Numerator
Reporting Criteria 1 and 2 Numerator:
Patients for whom no diagnostic imaging studies were ordered.
Reporting Criteria 1 Denominator:
All patients, regardless of age, with a current
diagnosis of Stage 0 through IIC melanoma,
without signs or symptoms suggesting systematic
spread, seen for an office visit during the one-year
measurement period.
Reporting Criteria 2:
Patients with a history of any stage melanoma
without signs or symptoms suggesting systemic
spread.
Non-Melanoma Skin Cancer
Reporting Criteria 2 Denominator:
All patients, regardless of age, with a history of
melanoma of any stage, without signs or symptoms
suggesting systemic spread, seen for an office visit
during the one-year measurement period.
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.
American Academy of Dermatology
June 19, 2015
Measure
Set
Title/Number
Type
Denominator
Numerator
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 SCCKA 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 SCC-KA
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.
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 fielddirected 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.
American Academy of Dermatology
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.”
June 19, 2015
Measure
Set
Title/Number
Type
Denominator
Numerator
Use of Biopsy Site Photos
or Directional Diagrams
Prior to Surgery
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
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 –
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 –
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
Measure
Set
Title/Number
Assessment of Psoriasis
Disease Activity
Type
Process
Denominator
All patients with a diagnosis of plaque psoriasis.
Numerator
Patients with disease activity assessed by a standardized
descriptive or numeric scale or composite index.*
Psoriasis
*Assessment and classification of disease activity: Scales and
instruments are examples and cut-off points can differ by scale.
Standardized descriptive or numeric scales and/or composite
indexes could include but are not limited to: Psoriasis Area and
Severity Index (PASI), Body Surface Area (BSA), Physician’s
Global Assessment (PGA), Dermatology Life Quality Index
(DLQI).
Numerator Instructions: To satisfy this measure, psoriasis
activity should be measured using any of the above or other
scales or instruments at least once during the reporting period
for each patient with a diagnosis of plaque psoriasis who
presents for an office visit.
Assessment for Psoriatic
Arthritis
MUC 136/ MAPX3274
Process
All patients with a diagnosis of psoriasis.
Patients who are “screened”* for psoriatic arthritis.
*“Screening” for psoriatic arthritis must, at a minimum, include
inquiry about the presence or absence of joint symptoms
including any of the following: morning stiffness, pain, redness,
and/or swelling of joints. If a dermatologist wishes to perform
additional optional screening measures, these may include
physical examination (e.g. visualization of joints, surrounding
structures (entheses) and fingers/toes for dactylitis) and/or use
of a validated psoriatic arthritis screening instrument (Psoriatic
Arthritis Screening and Evaluation), ToPAS (Toronto Psoriatic
Arthritis Screening) or PEST (Psoriasis Epidemiology
Screening Tool).
Numerator Instructions: To satisfy this measure, presence or
absence of joint symptoms should be documented at least once
during the reporting period.
American Academy of Dermatology
June 19, 2015
Measure
Set
Title/Number
Type
Tuberculosis Prevention for
Psoriasis, Psoriatic
Arthritis and Rheumatoid
Arthritis Patients on a
Biological Immune
Response Modifier
PQRS 337
Process
Clinical Response to Oral
Systemic or Biologic
Medications
MUC 134/MAP X3726
Outcome
Denominator
All patients with a diagnosis of psoriasis, psoriatic
arthritis, or rheumatoid arthritis who are on a
biologic immune response modifier.
Denominator Note: A patient would be considered
denominator eligible for Measure #337 for
reporting purposes, if the patient meets the
denominator criteria with diagnosis of psoriasis or
psoriatic arthritis or rheumatoid arthritis AND is on
a biologic immune response modifier prescribed by
the provider being evaluated for the measure.
All patients with a diagnosis of psoriasis and treated
with an oral systemic or biologic medication for
psoriasis for at least 6 months.
Numerator
Patients who have a documented negative annual TB screening
or have documentation of the management of a positive TB
screening test with no evidence of active tuberculosis,
confirmed through use of radiographic imaging (i.e. chest x-ray,
CT).
Patients who have a documented physician global assessment
(PGA; 6-point scale), body surface area (BSA), psoriasis area
and severity index (PASI) and/or dermatology life quality index
(DLQI) that meet any one of the below specified benchmarks.
Numerator Instructions: To satisfy this measure, a patient must
achieve any ONE of the following:
a. PGA (6-point scale) ˂ 2 (clear to mild skin disease)
b. BSA < 3% (mild disease)
c. PASI < 3 (no or minimal disease)
d. DLQI < 5 (no effect or small effect on patient’s
quality of life).
American Academy of Dermatology
June 19, 2015