Description: The number of pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration, and mitotic rate.
Measure ID: 397
CMS Derm Specialty Set: No
High priority: Yes
Topped out: Yes
Reporting methods: Registry/QCDR, or Claims
Maximum points: 7
Measure purpose: This measure encourages proper pathology testing for primary cutaneous melanoma.
The numerator: The number of pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration, and mitotic rate.
The denominator: All melanoma pathology reports for primary malignant cutaneous melanoma.
Measure calculation example
Dr. Ika generated 47 pathology reports for patients with primary malignant cutaneous melanoma during the reporting period. This is the denominator.
Of these 47 pathology reports, 44 included the pT category and a statement on thickness, ulceration, and mitotic rate. This is the numerator.
Quality of patient care = 44/47. Dr. Ika has a score of 93.6% for this measure. This translates to 3.0 to 3.9 points when reporting by registry.
Because this measure is topped out, it is difficult for physicians to earn more than 3 points. Physicians who report by registry must achieve a performance score of more than 91.6% to earn more than 3 points. Physicians who achieve a 99.99% score still receive only 3.9 points. They must score a perfect 100% to earn the full 7 points available. Also, CMS has removed the benchmarks for claims reporting for this measure. As a result, physicians who report this measure by claims can earn a maximum of only 3 points, regardless of their performance score.
Quality measure score benchmark
CMS will award points based on a comparison of your performance rate to CMS benchmarks listed below. Reach the performance rate listed to achieve the corresponding points per measure. Points achieved for the Quality category will account for 45% of the overall MIPS score.
|Below 3||Decile 3||Decile 4||Decile 5||Decile 6||Decile 7|
|Performance rate||1 patient|| 91.96 - 99.99