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Measure 440


Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time — Pathologist to Clinician

Description: The percentage of biopsies with a diagnosis of cutaneous BCC and SCC (including in situ disease) in which the pathologist communicates results to the clinician within seven days from receipt of the tissue specimen.

Measure ID: 440

Type: Process

CMS Derm Specialty Set: Yes

Priority: Yes

Topped out: Yes

Reporting methods: Registry/QCDR

Maximum points: 10

Measure purpose: This measure encourages effective treatment for the patient through timely communication of biopsy results between the pathologist and referring physician.

Calculation

The numerator: The 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 7 days from the time when the tissue specimen was received by the pathologist.

÷

The denominator: All pathology reports generated by the Pathologist/Dermatopathologist consistent with cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease).

*Exclusions are removed from the denominator:
Pathologists/Dermatopathologists providing a second opinion on a biopsy, or the pathologist/dermatopathologist is the same clinician who performed the biopsy.

Measure calculation example

Dr. Farhad performed biopsies for 29 patients during the reporting period who receive a diagnosis of cutaneous BCC or SCC. This is the denominator. Two patients are excluded from the denominator because Dr. Farhad was providing a second opinion on a biopsy.

For the remaining 27 patients, Dr. Farhad communicated the biopsy results within 7 days 22 times. This is the numerator.

Quality of patient care = 22/27. Dr. Farhad has a score of 81.5% for this measure. This translates to 3 points.

Important note

This measure is topped out, so it is extremely difficult to score more than 3 points. Physicians must score a perfect score to receive 10 points. A score of 99.9% earns a score of only 5.9 points. In effect, there is a large gap in earned points between a nearly perfect score and a perfect score.


Click on the link 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 6 Decile 7Decile 8Decile 9Decile 10
 Performance rate  1 patient  96.91 -
98.95
98.96 -
99.87
99.88 -
99.99 
     --      --      --      --  100.00
 Points 3 points   3 - 3.9  4 - 4.9  5 - 5.9  6 - 6.9  7 - 7.9  8 - 8.9  9 - 9.9  10

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