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Measure 397


Melanoma Reporting

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

Type: Process

CMS Derm Specialty Set: No

High priority: Yes

Topped out: Yes

Reporting methods: Registry/QCDR, or Claims

Maximum points:

Measure purpose: This measure encourages proper pathology testing for primary cutaneous melanoma. 

Calculator

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.

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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.

Important note

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.


Click on the image to download PDF.

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 3Decile 3Decile 4Decile 5
Decile 6Decile 7
 Performance rate  1 patient  91.96 - 99.99
      --
      --       --  100.00
 Points  3 points  3-3.9        7

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