Measure Description
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period
Instructions
This measure is to be submitted a minimum of once per performance period for all patients with a diagnosis of chronic hepatitis C cirrhosis seen during the performance period. This measure is intended to reflect the quality of services provided for patients with chronic hepatitis C cirrhosis. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians or other qualified healthcare professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
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 patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for chronic hepatitis C (ICD-10-CM): B18.2, B19.20, B19.21
AND
Diagnosis for cirrhosis (ICD-10-CM): K70.30, K70.31, K74.60, K74.69
AND
Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215
Numerator
Patients who underwent abdominal imaging with either ultrasound, contrast enhanced CT or MRI
Numerator Options:
Performance Met: Patient underwent abdominal imaging with ultrasound, contrast enhanced CT or contrast MRI for HCC (G9455)
OR
Denominator Exception: Documentation of medical or patient reason(s) for not ordering or performing screening for HCC. Medical reason: Comorbid medical conditions with expected survival <5 years, hepatic decompensation and not a candidate for liver transplantation, or other medical reasons. Patient reasons: Patient declined or other patient reasons (e.g., cost of tests, time related to accessing testing equipment) (G9456)
OR
Performance Not Met: Patient did not undergo abdominal imaging and did not have a documented reason for not undergoing abdominal imaging in the submission period (G9457)
Rationale
HCC (hepatocellular carcinoma) is the fourth most common cancer in the world and is the fastest rising cause of cancer-related deaths in the United States. HCV is the leading cause of HCC and the risk of developing HCC is highest in patients with established HCV cirrhosis.
Several potentially curative treatments are available for patients with early-stage HCC. These include surgical resection, liver transplantation, and local ablation. Long-term survival of patients who have liver resection or transplantation for HCC can be high (40% to 70% for resection and 52% to 81% for transplant patients after 5 years) (Kansagara 2014).
A recent systematic review of 18 nonrandomized studies found that more screened patients had early-stage HCC than clinically diagnosed patients. More screened patients received potentially curative treatment. However, these studies were limited by their observational nature (including lead time bias) and thus the effect on overall mortality was unclear. There are no randomized controlled trials that evaluated the impact of HCC screening versus no screening on survival in patients with cirrhosis. A randomized trial of HCC screening is not forthcoming because, even in the absence of high quality data, most informed patients and their clinicians consider randomization unethical and prefer surveillance (Poustchi 2011). In a recent modeling based study (that corrected for lead time bias), US based screening for HCC in compensated HCV cirrhosis patients reduced mortality compared to no screening (Mourad 2014).
Collectively, these data suggest that screening has a potential to produce benefits in the highest-risk patients, such as those with HCV cirrhosis who are good candidates for potentially curative treatment (Atkins AIM 2014).
Clinical Recommendation Statements
Patients at high risk for developing HCC, including patients with hepatitis C cirrhosis, should be entered into surveillance programs (Level II). Surveillance for HCC should be performed using ultrasonography (Level II). Patients should be screened at 6-month intervals (Level II) (AASLD, 2011).
HCC surveillance must be continued indefinitely in patients with cirrhosis (A1). Patients with cirrhosis should undergo regular surveillance for HCC, irrespective of SVR (B1) (EASL, 2014)
While current guidelines only specify using ultrasound, evidence suggests that using multiple screening methods, including incorporating the alpha fetoprotein biomarker into surveillance plans, may be more effective in identifying early stages of HCC.