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QCDR measure ACMS 1

Adherence to Mohs Micrographic Surgery Appropriate Use Criteria

Description: The percentage of Mohs micrographic surgery cases that meet the criteria according to published Mohs surgery appropriate use criteria (AUC) guidelines.

Measure ID: ACMS1

Type: Efficiency and Cost/Resource Use

CMS Derm Specialty Set: N/A

High priority: N/A

Topped out: No

Reporting methods: Registry/QCDR

Maximum points: 3

Measure purpose: This measure encourages adherence to appropriate use criteria for Mohs micrographic surgeries.


The numerator: The number of Mohs micrographic surgery cases (as defined by the denominator) regardless of patient age or gender for which the lesion treated and clinical scenario meet with an AUC score of 4-9


The denominator: All cases of Mohs micrographic surgery (MMS) performed regardless of patient age or gender (as defined by initial Mohs surgery stage codes 17311 or 17313).

Measure calculation example

Dr. Welch saw 19 patients who underwent Mohs micrographic surgery (MMS) during the period. This is the denominator.

Of these 19 patients, 17 had an AUC score of 4-9 for the lesion treated and clinical scenario. This is the numerator.

Quality of patient care = 17/19. Dr. Welch has a score of 89.5% for this measure. This translates to 3 points.

Important note

Since this is a new measure for 2019 reporting, CMS has not set benchmarks for this measure. As a result, only 3 points can be achieved in reporting this measure.

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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.