Measure 397
Melanoma Reporting
DESCRIPTION:
The number of pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration, mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.
| MEASURE ID: | 397 |
|---|---|
| Type: | Process |
CMS Derm Specialty Set: | No |
| High priority: | Yes |
| Topped out: | Yes |
| Telehealth Eligible: | No |
| Reporting methods: | Registry/QCDR, or Claims |
| Maximum points: | 10 |
MEASURE PURPOSE:
This measure encourages more precise staging for primary cutaneous melanoma as they are important prognostic determinants.
Measure 397 FAQs
Q. Is this measure reportable via claims?
A. Yes.
Q. Are patient encounters conducted via telehealth allowable?
A. No, telehealth encounters are not allowable.
Q. Can I report on this measure if I get a copy of the biopsy pathology report but do not createthe biopsy report?
A. No, only the pathologist/dermatopathologist can report on this measure.
Q. Do I have to report this measure every time a specimen is diagnosed as melanoma?
A. Yes, this measure must be reported at every eligible encounter.
Q. Can I report melanoma in situ in this measure?
A. No, melanoma in situ does not qualify for this measure.
Q. Are there any exceptions in the measure?
A. Yes, medical exceptions are included in this measure, such as negative skin biopsies in a patient with a history of melanoma.
Q. My practice only saw two new melanoma patients. Are these sufficient to use for measure 397 or do I need more patients?
A. When reporting measures, you will need a minimum of 20 cases for each measure. If you only saw 2 new melanoma patients, you may not want to report measure 397 because this measure is only applicable to patient visits with a new occurrence of melanoma.
Q. We have been receiving our patients' pathology reports from a pathologist who works at a local hospital. Are we allowed to report 397 even if the pathologist is not employed by our practice?
A. When group reporting, you can use the data reported by the pathologist, even if they are not directly employed by your practice because the assessment is at the TIN level (as opposed to the individual provider level).
Calculator
The numerator: The number of pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.
The denominator: All pathology reports for primary malignant cutaneous melanoma covering biopsies and excisions to include wide excisions and re-excisions.
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, peripheral and deep margin status, and presence or absence of microsatellitosis for invasive tumors. This is the numerator.
Quality of patient care = 44/47. Dr. Ika has a score of 93.6% for this measure. This translates to 5.0 to 5.9 points when reporting by registry. Dr. Ika needs 100% to receive 10 points.
Important note
Because this measure is topped out, physicians are unable to earn points if scoring below 84%. Physicians achieve 3 points if a small practice. They must score a perfect 100% to earn the full 10 points available.
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 30% of the overall MIPS score.
Benchmarks for registry submissions
The table below shows CMS benchmarks for registry submissions.
Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
|---|---|---|---|---|---|---|---|---|---|---|
Performance rate |
84.00 - 85.99 |
86.00 - 87.99 |
88.00 - 89.99 |
90.00 - 91.99 |
92.00 - 93.99 |
94.00 - 95.99 |
96.00 - 97.99 |
98.00 - 98.99 |
99.00 - 99.99 |
100 |
Points |
1.0 - 1.9 |
2.0 - 2.9 |
3.0 - 3.9 |
4.0 - 4.9 |
5.0 - 5.9 |
6.0 - 6.9 |
7.0 - 7.9 |
8.0 - 8.9 |
9.0 - 9.9 |
10 |
Benchmarks for claims submissions
The table below shows CMS benchmarks for claims submissions.
Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
|---|---|---|---|---|---|---|---|---|---|---|
Performance rate |
84.00 - 85.99 |
86.00 - 87.99 |
88.00 - 89.99 |
90.00 - 91.99 |
92.00 - 93.99 |
94.00 - 95.99 |
96.00 - 97.99 |
98.00 - 98.99 |
99.00 - 99.99 |
100 |
Points |
1.0 - 1.9 |
2.0 - 2.9 |
3.0 - 3.9 |
4.0 - 4.9 |
5.0 - 5.9 |
6.0 - 6.9 |
7.0 - 7.9 |
8.0 - 8.9 |
9.0 - 9.9 |
10 |
