Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer
This measure is to be submitted once per performance period for patients with a diagnosis of prostate cancer at low (or very low) risk of recurrence who receive interstitial prostate brachytherapy, external beam radiotherapy to the prostate, radical prostatectomy during the performance period. The quality data code or equivalent needs to be submitted only once during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the listed procedures as specified in the denominator coding 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.
All patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy
Risk Strata: Very Low, Low, Intermediate, High, or Very High
Very Low/Low Risk – PSA < 10 ng/mL; AND Gleason score 6 or less/Gleason grade group 1; AND clinical stage T1 to T2a
Intermediate Risk – PSA 10 to 20 ng/mL; OR Gleason score 7/Gleason grade group 2-3; OR clinical stage T2b to T2c
High/Very High Risk – PSA > 20 ng/mL; OR Gleason score 8 to 10/Gleason grade group 4-5; OR clinically localized stage T3 to T4 (adapted from the National Comprehensive Cancer Network, 2018)
External beam radiotherapy – external beam radiotherapy refers to 3D conformal radiation therapy (3DCRT), intensity modulated radiation therapy (IMRT), stereotactic body radiotherapy (SBRT), and proton beam therapy.
DENOMINATOR NOTE: Most recent risk assessment of recurrence completed before the first prostate cancer treatment during the performance period will be used for denominator eligibility.
Denominator Criteria (Eligible Cases):
Any patient, regardless of age
Diagnosis for prostate cancer (ICD-10-CM): C61
Patient encounter during the performance period (CPT): 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55875, 55880, 77427, 77435, 77772, 77778, 77799
Telehealth Modifier: GQ, GT, 95, POS 02
Low (or very low) risk of recurrence, prostate cancer: G9706
Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer
Bone scan – “bone scan” refers to the conventional technetium-99m-MDP bone scan as well as 18FNaF PET (or PET/CT) scan.
A higher score indicates appropriate treatment of patients with prostate cancer at low (or very low) risk of recurrence.
NUMERATOR NOTE: Denominator Exception(s) are determined any time after diagnosis of Prostate Cancer.
Performance Met: Bone scan not performed prior to initiation of treatment nor at any time since diagnosis of prostate cancer (3270F)
Denominator Exception: Documentation of medical reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reasons) (3269F with 1P)
Denominator Exception: Documentation of system reason(s) for performing a bone scan (including bone scan ordered by someone other than the reporting physician) (3269F with 3P)
Performance Not Met: Bone scan performed prior to initiation of treatment or at any time since diagnosis of prostate cancer (3269F)
Multiple studies have indicated that a bone scan is not clinically necessary for staging prostate cancer with a low (or very low) risk of recurrence and receiving primary therapy. For patients who are categorized as low-risk, bone scans are unlikely to identify their disease. Furthermore, bone scans are not necessary for low-risk patients who have no history or if the clinical examination suggests no bony involvement. Less than 1% of low-risk patients are at risk of metastatic disease.
While clinical practice guidelines do not recommend bone scans in low-risk prostate cancer patients, overuse is still common. An analysis of prostate cancer patients in the Surveillance, Epidemiology and End Results (SEER)- Medicare database diagnosed from 2004-2007 found that 43% of patients for whom a bone scan was not recommended received it (Falchook, Hendrix, & Chen, 2015). The analysis also found that the use of bone scans in low-risk patients leads to an annual cost of $4 million dollars to Medicare. The overuse of bone scan imaging for lowrisk prostate cancer patients is a concept included on the American Urological Association’s (AUA) list in the Choosing Wisely Initiative as a means to promote adherence to evidence-based imaging practices and to reduce health care dollars wasted (AUA, 2017). This measure is intended to promote adherence to evidence-based imaging practices, lessen the financial burden of unnecessary imaging, and ultimately to improve the quality of care for prostate cancer patients in the United States.
Clinical Recommendation Statements
For symptomatic patients and/or those with a life expectancy of greater than 5 years, bone imaging is appropriate for patients with unfavorable intermediate-risk prostate cancer and T2 disease with PSA over 10 ng/mL, high- or very-high risk disease; or symptomatic disease (National Comprehensive Cancer Network, 2020) (Evidence Level: Category 2A).
Clinicians should not perform routine bone scans in the staging of asymptomatic very low- or low-risk localized prostate cancer patients (AUA, American Society for Radiation Oncology, & Society of Urologic Oncology, 2017) (Strong Recommendation; Evidence Level: Grade C).
Very low-risk or low-risk patients are unlikely to have disease identified by bone scan. Accordingly, bone scans are generally unnecessary in patients with newly diagnosed prostate cancer who have a PSA <10.0 ng/mL and a Gleason score less than 7 unless the patient’s history or clinical examination suggests bony involvement. Progression to the bone is much more common in advanced local disease or in high-grade disease that is characterized by fast and aggressive growth into surrounding areas such as bones or lymph nodes (AUA, 2019).