QCDR measure AAD 12
Melanoma: Appropriate Surgical Margins
DESCRIPTION:
Percentage of primary excisional surgeries for melanoma or melanoma in situ with Breslow depth and appropriate surgical margins per the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology-Melanoma (NCCN Guideline).
| MEASURE ID: | AAD12 |
|---|---|
| Type: | Intermediate Outcome |
CMS Derm Specialty Set: | N/A |
| High priority: | Yes |
| Topped out: | No |
| Telehealth Eligible: | No |
| Reporting methods: | Registry/QCDR |
| Maximum points: | 3 |
MEASURE PURPOSE:
This measure encourages that appropriate surgical margins for melanoma/melanoma in situ are based on initial Breslow depth be taken during primary excisional surgeries to reduce risk of local recurrence and progression to metastatic disease.
AAD12 FAQs
Q. Is this measure reportable via claims?
A. No. This measure can only be reported via DataDerm.
Q. Are patient encounters conducted via telehealth allowable?
A. No. Telehealth encounters are not allowable.
Q. What is the numerator?
A. The numerator is whether the Breslow depth of the initial biopsy and the initial surgical margin used is documented in the medical record and is in compliance with the minimum margin recommended in the current NCCN guideline.
Q. What is the denominator?
A. The denominator is all primary excisional surgeries for melanoma or melanoma in situ.
Q. Are there any exclusions or exceptions for this measure?
A. Yes. The following are exceptions for the measure:
Patient is in a clinical trial that requires a smaller initial surgical margin
Margins modified to accommodate individual anatomic or functional considerations on the face/ears per the NCCN guidelines
The following are exclusions for the measure:
The second surgery or second stage (when performing a staged excisional technique) performed on a melanoma in which a positive margin was found on the initial primary surgery necessitating the second surgery or second stage to be taken.
Q. What is considered a ‘primary excisional surgery’?
A. Primary excisional surgeries include wide local excision, Mohs surgery, Modified Mohs surgery, and staged excisions for therapeutic purposes.
Q. What are the minimum requirements for margins, per the current NCCN guidelines?
A. See below.
MMIS: ≥ 0.5 cm - 1.0 cm margin around the entire tumor
Breslow depth of ≤ 1.0 mm = 1.0 cm
Breslow depth of > 1.0 - 2.0 mm = 1.0 - 2.0 cm
Breslow depth of > 2.0 - 4.0 mm = 2.0 cm
Breslow depth of > 4.0 mm = 2.0 cm
Calculation
The numerator: The Breslow depth of the initial biopsy and the initial surgical margin used documented in the medical record is in compliance with the minimum margin recommended in the current NCCN guideline
The denominator: All primary excisional surgeries for melanoma or melanoma in situ.
Measure calculation example
Dr. Sami saw 72 patients who were diagnosed with melanoma or melanoma in situ and had a primary excisional surgery of a malignant lesion. This is the denominator.
Of the 72 patients, Dr. Sami took appropriate margins and documented them in the medical record 62 times. This is the numerator.
Quality of patient care = 62/72. Dr. Sami has a score of 86.1% for this measure. This translates to 3 points.
Important note
CMS has not set benchmarks for this measure. As a result, only 3 points can be achieved in reporting this measure. This is applicable only to small practices with 15 providers or fewer.
