Melanoma
Biopsy
Measure
Set
Measure Title
Type of
Measure
Denominator
Numerator
Biopsy Follow-Up #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.
Use of Biopsy Site Photos
or Directional Diagrams
Prior to Surgery
Process
Biopsy Clinical History
Anatomic Location
Accuracy
Intermedi
ate
Outcome
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.
All cutaneous biopsies by the clinician consistent
with cutaneous basal or squamous cell carcinoma
(including in situ disease).
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).
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 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.
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.
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.
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.
Melanoma: Continuity of
Care Recall System #137
(NQF 0650)
Structure
All patients, regardless of age, with a current
diagnosis of melanoma or a history of melanoma.
American Academy of Dermatology
Patients whose information is entered, at least once within the 12 month
period, into a recall system that includes:
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.
June 19, 2015
Melanoma: Coordination
of Care #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.
Melanoma:
Overutilization of Imaging
Studies in Melanoma #224
(NQF 0562)
Process
Reporting Criteria 1 and 2 Denominator:
All visits for patients, regardless of age, diagnosed
with a new occurrence of melanoma.
Reporting Criteria 1:
Patients with a current diagnosis of Stage 0
through IIC melanoma without signs or symptoms
suggesting systemic spread.
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.
Non-Melanoma
Skin Cancer
Reporting Criteria 2:
Patients with a history of any stage melanoma
without signs or symptoms suggesting systemic
spread.
Use of Preventive
Screening Protocol for
Transplant Patients
Process
Use of Mohs Surgery for
Superficial Basal Cell
Carcinomas on the Trunk
Process
American Academy of Dermatology
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.
All organ transplant recipients seen by provider in
an outpatient setting within the reporting period.
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 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.
Number of pathologically-proven primary superficial BCC’s treated by
the provider utilizing Mohs surgery.
June 19, 2015
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.
Listing of BCC Subtyping
on the Biopsy Report
Process
All skin specimens diagnosed histologically as
cutaneous basal cell carcinoma within the
reporting period.
Documentation of Patient
Input for Treatment Type
Process
Documentation of
discussion w/patients
about potential use of
field-directed therapies
prior to destruction of
Actinic Keratoses (17004
code)
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.
All patients with destruction of 15 or more AKs in
a single visit (code 17004).
American Academy of Dermatology
Numerator statement: Satisfactory tumor differentiation (a “well
differentiated tumor”) will be achieved by including a statement that
lists the Squamous Cell Carcinoma Keratoacanthoma type.
Number of skin specimens with a diagnosis of BCC for which the
pathology report listed the histopathological BCC subtype.
Number of patients for whom there is documentation of patient (or legal
caregiver) input regarding treatment options at least once per reporting
period.
Number of patients with destruction of 15 or more AKs who have
documentation of a discussion of risks and benefits of using fielddirected 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.”
June 19, 2015
Assessment of Psoriasis
Disease Activity
Process
All patients with a diagnosis of plaque psoriasis.
Patients with disease activity assessed by a standardized descriptive or
numeric scale or composite index.*
*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.
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).
Psoriasis
Assessment for Psoriatic
Arthritis (MUC 136/
MAPX3274)
Numerator Instructions: To satisfy this measure, presence or absence
of joint symptoms should be documented at least once during the
reporting period.
Tuberculosis Prevention
for Psoriasis, Psoriatic
Arthritis and Rheumatoid
Arthritis Patients on a
Biological Immune
Response Modifier #337
Process
All patients with a diagnosis of psoriasis, psoriatic
arthritis, or rheumatoid arthritis who are on a
biologic immune response modifier.
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).
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.
American Academy of Dermatology
June 19, 2015
Clinical Response to Oral
Systemic or Biologic
Medications (MUC 134/
MAP X3726)
Outcome
All patients with a diagnosis of psoriasis and
treated with an oral systemic or biologic
medication for psoriasis for at least 6 months.
Patients who have a documented physician global assessment (PGA; 6point 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