#099: Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

Quality ID

099

NQF

0391

High Priority Measure

No

Specifications

Registry

Measure Type

Process

Specialty

Pathology

Measure description

Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade

 

Instructions

This measure is to be submitted each time a breast cancer resection surgical pathology examination is performed during the performance period for breast cancer patients. It is anticipated that eligible clinicians who examine breast tissue specimens following resection in a laboratory or institution will submit this measure.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator

All breast cancer resection pathology reports (excluding biopsies)

Denominator Criteria (Eligible Cases):

Diagnosis for breast cancer (ICD-10-CM): C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C50.321, C50.322, C50.329, C50.411, C50.412, C50.419,C50.421, C50.422, C50.429, C50.511, C50.512, C50.519, C50.521, C50.522, C50.529, C50.611, C50.612,C50.619, C50.621, C50.622, C50.629, C50.811, C50.812, C50.819, C50.821, C50.822, C50.829, C50.911,C50.912, C50.919, C50.921, C50.922, C50.929

AND

Patient procedure during the performance period (CPT): 88307, 88309

AND NOT

DENOMINATOR EXCLUSION:

Specimen site other than anatomic location of primary tumor: 3250F

 

Numerator

Reports that include the pT category, the pN category and the histologic grade

Numerator Options:

Performance Met: pT category (primary tumor), pN category (regional lymph nodes), and histologic grade documented in pathology report (3260F)

OR

Denominator Exception: Documentation of medical reason(s) for not including the pT category, the pN category, or the histologic grade in the pathology report (eg, re-excision without residual tumor, non-carcinomas) (3260F with 1P)

OR

Performance Not Met: pT category, pN category, and histologic grade were not documented in pathology report, reason not otherwise specified (3260F with 8P)

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