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QCDR measure AAD 5


Biopsy: Reporting Time — Clinician to Patient

Description: The percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma (including in situ disease) who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.

Measure ID: AAD5

Type: Process

CMS Derm Specialty Set: N/A

High priority: N/A

Topped out: Yes

Reporting methods: Registry/QCDR

Maximum points: 10

Measure purpose: This measure encourages effective communication through the biopsy report between the dermatologist and the pathologist. The measure seeks to standardize the amount of time it takes for the clinician to notify patients of the final biopsy results, to ensure timely communication and effective treatment for the patient. 

Calculation

The numerator: The number of patients in the denominator who are informed of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed

÷

The denominator: The number of patients 18 years and older with a diagnosis of basal cell carcinoma, squamous cell carcinoma or carcinoma of the skin in situ.

Measure calculation example

Dr. Abadi has 129 biopsies come from the pathologist diagnosed as BCC, SCC, or carcinoma in situ during the reporting period. This is the denominator.

Dr. Abadi informed patients of their biopsy results within 14 days in 112 cases. This is the numerator.

Quality of patient care = 112/129. Dr. Abadi has a score of 86.8% for this measure. This translates to 3.1-3.9 points.

Important note

This measure is topped out, so it is 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.


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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.

Measure NameMeasure IDSubmission MethodMeasure TypeBenchmarkStandard DeviationAverageDecile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10Topped Out?Seven Point Cap?

Biopsy: Reporting Time - Clinician to Patient

AAD5

Registry/QCDR

Process

Y

23

87

73.58 - 90.13

90.14 - 98.61

98.62 - 99.99

--

--

--

--

100

Yes

No

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