Dermatology Quality Measures
Melanoma
Biopsy
Topic
Title/Number
Type
Denominator
Biopsy Follow-Up
PQRS 265
NQF 0645
Process
All patients undergoing a biopsy.
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.
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.
Numerator
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.
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.
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
Page 1
December 2015
Dermatology Quality Measures
Topic
Title/Number
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.
Melanoma
Melanoma:
Overutilization of
Imaging Studies in
Melanoma
PQRS 224
NQF 0562
Type
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.
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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.
December 2015
Dermatology Quality Measures
Non-Melanoma Skin Cancer
Topic
Title/Number
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
Listing of SCC AJCC
Reporting Criteria
Type
Denominator
Numerator
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.
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
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.
American Academy of Dermatology
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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.
December 2015
Dermatology Quality Measures
Non-melanoma Skin Cancer
Topic
Title/Number
Type
Denominator
Numerator
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.
Documentation of
discussion w/patients
about potential use of
field-directed therapies
prior to destruction of
Actinic Keratoses
(17004 code)
Process
Surgical Safety - PostOperative
Communication
Process
All patients undergoing a scalpel-based surgical
procedure for non-melanoma skin cancer located
on the trunk or upper extremities (codes 17313
through 17315, 11600 through 11646, 17260
through 17266) within the reporting period.
Surgical Safety - PostOperative
Bleeding/Hematoma
Outcome
All patients undergoing a scalpel-based surgical
procedure for non-melanoma skin cancer located
on the trunk or upper extremities (codes 17313
through 17315, 11600 through 11646, 17260
through 17266) within the reporting period.
American Academy of Dermatology
Page 4
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.”
1. Process Measure: Post-Operative
Communication Numerator:
The number of patients that were contacted by the
clinician’s practice within 15 days of the surgical
encounter and documentation of the communication is
made in the patient’s chart. Appropriate forms of
communication include HIPAA secure messaging, a
telephone call, or a clinic visit in which the wound was
evaluated. The secure messaging and telephone call
only requires documentation that the clinician’s
practice has attempted communication with the patient.
An example of appropriate documentation in the
patient’s chart is as follows: “The patient was sent a
HIPAA secure message and/or was called on (date) to
check on their status following their procedure.”
Number of patients seen for bleeding or hematoma
formation within 15 days of surgical encounter that
required an intervention by the clinician beyond
standard wound care (e.g. direct pressure to stop
bleeding).
Exclusion: patients with genetic or non-pharmacologic
induced acquired bleeding disorders are excluded.
December 2015
Dermatology Quality Measures
Topic
Title/Number
Surgical Safety - PostOperative Infection
Type
Outcome
Denominator
All patients undergoing a scalpel-based surgical
procedure for non-melanoma skin cancer located
on the trunk or upper extremities (codes 17313
through 17315, 11600 through 11646, 17260
through 17266) within the reporting period.
Numerator
Number of patients seen for a surgical site infection
within 15 days of surgical encounter - measure adopted
from the American College of Surgery Superficial
Incisional Surgical Site Infection (SSI) measure #357:
Superficial Incisional SSI: Superficial Incisional SSI is
an infection that occurs within 15 days after the
operation and infection involves only skin or
subcutaneous tissue of the incision and diagnosis of
superficial incisional SSI by the surgeon or attending
physician and at least one of the following:
Use of Biopsy Site
Photos or Directional
Diagrams Prior to
Surgery
Process
American Academy of Dermatology
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.
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Purulent drainage, with or without laboratory
confirmation, from the superficial incision
Organisms isolated from an aseptically obtained culture
of fluid or tissue from the superficial incision
At least one of the following signs or symptoms of
infection: pain or tenderness, localized swelling,
redness, or heat AND superficial incision is
deliberately opened by the surgeon, unless incision is
culture-negative
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.
December 2015
Dermatology Quality Measures
Title/Number
Type
Denominator
Numerator
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).
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).
Assessment of Psoriasis
Disease Activity
Process
All patients with a diagnosis of plaque psoriasis.
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.
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).
Psoriasis
Non-Melanoma Skin Cancer
Topic
American Academy of Dermatology
Page 6
Numerator Instructions: To satisfy this measure,
psoriasis activity should be measured using any of the
December 2015
Dermatology Quality Measures
Topic
Title/Number
Type
Denominator
Numerator
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
Process
All patients with a diagnosis of psoriasis.
Patients who are “screened”* for psoriatic arthritis.
Psoriasis
*“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).
Tuberculosis
Prevention for
Psoriasis, Psoriatic
Arthritis and
Rheumatoid Arthritis
Patients on a Biological
Immune Response
Modifier
PQRS 337
Process
American Academy of Dermatology
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.
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Numerator Instructions: To satisfy this measure,
presence or absence of joint symptoms should be
documented at least once during the reporting period.
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).
December 2015
Dermatology Quality Measures
Topic
Title/Number
Clinical Response to
Oral Systemic or
Biologic Medications
PQRS 410
Type
Outcome
Denominator
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 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
Page 8
December 2015