QCDR measure AAD 6
Skin Cancer: Biopsy Reporting Time — Clinician to Patient
DESCRIPTION:
The percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal, squamous cell carcinoma, or melanoma (including in situ disease), or primary cutaneous malignancies who are notified of their final biopsy pathology findings within less than or equal to 10 days from the time the biopsy was performed.
| MEASURE ID: | AAD6 |
|---|---|
| Type: | Process |
CMS Derm Specialty Set: | N/A |
| High priority: | Yes |
| Topped out: | Yes |
| Telehealth Eligible: | No |
| Reporting methods: | Registry/QCDR |
| Maximum points: | 7 |
MEASURE PURPOSE:
This measure encourages effective communication and 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.
AAD6 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. Do I have to report on this measure every time a biopsy is performed?
A. Yes, you must report it every time.
Q. When should the patient be notified of their final biopsy pathology findings?
A. The patient should be notified of their final biopsy pathology findings within less than or equal to 10 days from the time the biopsy was performed.
Q. What are acceptable methods of communication?
A. The following are acceptable methods of communication and should be documented:
Directly speaking with the patient or a person designated by the patient to discuss this lab result
Documented telephone message or voice mail regarding the availability of lab result
Mailer/fax sent to the patient indicating the availability of lab result or discussing the diagnosis itself
Any HIPAA secure electronic communication with the patient discussing the diagnosis
For reporting purposes, the communication needs to be documented. This is for data validation purposes and in case of an audit. Documentation necessary would include the date of communication, type of communication, and we advise including a brief summary of the communication. For example, if the patient is called and it goes to voicemail, document the date the patient was contacted and that a voicemail was left. This information is not extracted via code.
Q. Is in situ disease reportable in this measure?
A. Yes.
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 10 days from the time the biopsy was performed
The denominator: The number of adult patients with a diagnosis of basal cell carcinoma, squamous cell carcinoma, melanoma (including in situ disease) or primary cutaneous malignancies.
Measure calculation example
Dr. Abadi has 129 biopsies come from the pathologist diagnosed as BCC, SCC, or melanoma (including in situ disease) or primary cutaneous malignancies during the reporting period. This is the denominator.
Dr. Abadi informed patients of their biopsy results within 10 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 2.0 to 2.9 points.
Important note
Physicians who achieve a 99.99% score receive 6.9 points. They must score a perfect 100% to earn the maximum of 7 points available. Clinicians score 3 points even if they report on only one patient. This is applicable only to small practices with 15 providers or fewer.
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 | |
|---|---|---|---|---|---|---|---|
Performance rate |
1.51 - 82.83 |
82.84 - 96.31 |
96.32 - 98.34 |
98.35 - 99.32 |
99.33 - 99.76 |
99.77 - 99.99 |
100 |
Points |
1 - 1.9 |
2 - 2.9 |
3 - 3.9 |
4 - 4.9 |
5 - 5.9 |
6 - 6.9 |
7.0 |
