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2020 MIPS Measure #146: Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms

Quality ID

146

NQF

0508

High Priority Measure

Yes

Specifications

Registry

Measure Type

Process

Specialty

Diagnostic Radiology

Measure Description

Percentage of final reports for screening mammograms that are classified as “probably benign”

 

Instructions

This measure is to be submitted each time a screening mammogram is performed during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide the professional component of diagnostic imaging studies for screening mammograms will submit this measure.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

 

Denominator

All final reports for screening mammograms

Denominator Criteria (Eligible Cases):

Diagnosis for screening mammogram (ICD-10-CM): Z12.31

AND

Patient procedure during the performance period (CPT or HCPCS): 77067

 

Numerator

Final reports classified as “probably benign”

Definition:

“Probably Benign” Classification – Mammography Quality Standards Act (MQSA) assessment category of “probably benign”; Breast Imaging-Reporting and Data System (BI-RADS®) category 3; or Food and Drug Administration (FDA)-approved equivalent assessment category.

Numerator Instructions:

INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
A lower percentage, with a definitional target approaching 0%, indicates appropriate assessment of screening mammograms.

The mammogram assessment category (corresponding CPT Category II 33xxF code for assessment categories”) to be submitted is the final assessment for the screening mammographic study. If a diagnostic mammographic study follows the screening exam, the assessment category for the screening exam should be submitted with the corresponding CPT Category II code, i.e. 3340F for Mammogram assessment category of “incomplete: need additional imaging evaluation,” documented. Of note, the performance tags indicating ‘Performance Met’ and ‘Performance Not Met’ are included to highlight what is being measured and submitted and not to encourage the use and documentation of “probably benign”.

Numerator Options:

Performance Met: Mammogram assessment category of “probably benign,” documented (3343F)

OR

Performance Not Met: Mammogram assessment category of “incomplete: need additional imaging evaluation,” documented (3340F)

OR

Performance Not Met: Mammogram assessment category of “negative,” Documented (3341F)

OR

Performance Not Met: Mammogram assessment category of “benign,” Documented (3342F)

OR

Performance Not Met: Mammogram assessment category of “suspicious,” Documented (3344F)

OR

Performance Not Met: Mammogram assessment category “highly suggestive of malignancy,” documented (3345F)

OR

Performance Not Met: Mammogram assessment category of “known biopsy proven malignancy,” documented (3350F)

 

Rationale

The “probably benign” assessment category is reserved for findings that have a high probability (≥98%) chance of being benign and should not be used as a category for indeterminate findings. Inappropriate designation of findings as “probably benign” can result in unnecessary follow-up of lesions that could have been quickly classified or delayed diagnosis and treatment of cancerous lesions. Published guidance documents emphasize the need to conduct a complete diagnostic imaging evaluation before making a probably benign (Category 3) assessment; making it inadvisable to use the probably benign categorization when interpreting a screening mammogram. Immediate completion of a diagnostic imaging evaluation for abnormal screening mammograms eliminates potential anxiety that women would endure with the short interval follow-up that is recommended for “probably benign” findings.


Clinical Recommendation Statements

A category 3, 4, or 5 assessment is not recommended for a screening mammogram, even though in some instances a highly suspicious abnormality may be identified that will warrant a recommendation for biopsy. Rather, all patients with screening abnormalities should be given a BI-RADS® category 0 assessment and recalled for further diagnostic studies. (ACR, 2013)

All the previously cited studies emphasize the need to conduct a complete diagnostic imaging evaluation before making a probably benign (category 3) assessment; hence it is recommended not to render such an assessment in interpreting a screening mammography examination. The practice of rendering category 3 assessments directly from screening examination also has been shown to result in adverse outcomes: 1) unnecessary follow-up of many lesions that could have been promptly assessed as benign, and 2) delayed diagnosis of a small number of cancers that otherwise may have been smaller in size and less likely to be advanced in stage (ACR, 2013)

The use of assessment category 3, probably benign, has been clarified in the lexicon of the 2013 edition. It is emphasized that this is not an indeterminate category used simply when the radiologist is unsure whether to render a benign (BI-RADS® category 2) or suspicious (BI-RADS® category 4) assessment, but one that is reserved for specific imaging findings known to have a greater than essentially 0% but ≤ 2% likelihood of representing malignancy. (ACR, 2013)

For mammography, there is robust literature describing three findings (noncalcified circumscribed solid mass, focal asymmetry and solitary group of punctate calcifications) that have likelihoods of malignancy in the defined (≤ 2%) probably benign range, for which short interval (6-month) follow-up mammography and then periodic mammographic surveillance represents appropriate management. Use of assessment category 3 for mammographic findings other than these three should be considered only if the radiologist has personal experience to justify a watchful-waiting approach, preferably involving observation of a sufficient number of cases of an additional mammographic finding to suggest a likelihood of malignancy within the defined (≤ 2%) probably- benign range. Two large-scale studies performed in the United States have validated that in the usual-care setting, category 3 assessments indeed are associated with a likelihood of malignancy of <2%. (ACR 2013)

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