Measure 440
Skin Cancer: Biopsy Reporting Time — Pathologist to Clinician
DESCRIPTION:
The percentage of biopsies with a diagnosis of cutaneous BCC, SCC, or melanoma (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 |
| High priority: | Yes |
| Topped out: | Yes |
| Telehealth Eligible: | No |
| 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 biopsy referring physician.
Measure 440 FAQs
Q. Is this measure reportable via claims?
A. No.
Q. Are patient encounters conducted via telehealth allowable?
A. No, telehealth encounters are not allowable.
Q. If a skin biopsy is performed and billed as D48.5: neoplasm of uncertain behavior, but is found to be a BCC or SCC, can we report this measure, or does it have to be billed specifically on the biopsy billing?
A. Yes, this encounter can be reported for this measure. The date of diagnosis of BCC/SCC would need to be documented.
Q. The pathologist/dermatopathologist communicates the results to the clinician, does the clinician need to be a dermatologist or can the clinician be a mid-level provider?
A. Results should be communicated back to the biopsy referring clinician.
Q. Do I need to report on this measure every time a patient comes into the office?
A. Yes, this measure must be reported for every eligible encounter.
Q. Can I report on this measure if I do not make the pathology report?
A. No, this measure must be reported by the physician who creates the pathology report.
Q. Can I report on this measure if I performed the biopsy and pathology report?
A. No, the clinician who does the pathology report cannot be the same clinician who performed the biopsy.
Q. Can we report 440 via claims?
A. No, measure 440 is not a claims-based measure and should not be reported via claims. The measure is meant to be reported via a registry. When reporting via a registry, notes, keywords, as well as the code can be pulled to distinguish between biopsies and excisions.
Calculation
The numerator: The number of final pathology reports diagnosing cutaneous basal cell carcinoma, squamous cell carcinoma, or melanoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsy referring 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, squamous cell carcinoma, or melanoma (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 pathology for 29 biopsy specimens during the reporting period that received a diagnosis of cutaneous BCC, SCC, or melanoma (to include in situ disease). 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 back to the biopsying physician within seven days 26 times. This is the numerator.
Quality of patient care = 26/27. Dr. Farhad has a score of 96.3% for this measure. This translates to 7.0 to 7.9 points.
Important note
Because of how this measure is structured, physicians score 3 points even if they report on only one patient. This is applicable only to small practices with 15 providers or fewer. Physicians who achieve a 99.99% score receive 9.9 points. 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.
| 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 |
