Measure Description
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.
Instructions
This measure is to be submitted once per performance period for patients who are seen for an office visit and have a biopsy performed during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: While this measure is only required to be submitted once per eligible patient per performance period, it is recommended that the MIPS eligible clinician performing the biopsy communicates the results to the primary care/referring physician and patient each time a biopsy is done.
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 new patients undergoing a biopsy
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs. Only the first biopsy results for new patients should be reported for this measure. Do not include specimens sent for debridement.
Denominator Criteria (Eligible Cases):
All patients regardless of age on date of encounter
AND
Patient procedure during the performance period (CPT): 11102, 11104, 11106, 11755, 19081, 19083, 19085, 19100, 19101, 19125, 20200, 20205, 20206, 20220, 20225, 20240, 20245, 20250, 20251, 21550, 21920, 21925, 23065, 23066, 23100, 23101, 24065, 24066, 24100, 24101, 25065, 25066, 25100, 25101, 26100, 26105, 26110, 27040, 27041, 27050, 27052, 27323, 27324, 27330, 27331, 27613, 27614, 27620, 28050, 28052, 28054, 29800, 29805, 29830, 29840, 29860, 29870, 29900, 30100, 31050, 31051, 31237, 31510, 31535, 31536, 31576, 31625, 31628, 31629, 31717, 32096, 32097, 32098,32400, 32604, 32606, 32607, 32608, 32609, 37200, 37609, 38221, 38500, 38505, 38510, 38520, 38525, 38530, 38570, 38572, 40490, 40808, 41100, 41105, 41108, 42100, 42400, 42405, 42800, 42804, 42806, 43193, 43197, 43198, 43202, 43239, 43261, 43605, 44010, 44020, 44025, 44100, 44322, 44361, 44377, 44382, 44386, 44389, 45100, 45305, 45331, 45380, 45392, 46606, 47000, 47100, 47553, 48100, 48102, 49000, 49010, 49180, 49321, 50200, 50205, 50555, 50557, 50574, 50576, 50955, 50957, 50974, 50976, 52007, 52204, 52224, 52250, 52354, 53200, 54100, 54105, 54500, 54505, 54800, 54865, 55700, 55705, 55706, 55812, 55842, 55862, 56605, 56821, 57100, 57105, 57421, 57454, 57455, 57460, 57500, 57520, 58100, 58558, 58900, 59015, 60100, 60540, 60545, 60650, 61140, 61575, 61576, 61750, 61751, 62269, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 64795, 65410, 67346, 67400, 67450, 67810, 68100, 68510, 68525, 69100, 69105, 75970, 93505
WITHOUT
Telehealth Modifier: GQ, GT, 95, POS 02
AND
Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99241*, 99242*, 99243*, 99244*, 99245*
WITH OR WITHOUT
Telehealth Modifier: GQ, GT, 95, POS 02
Numerator
Patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and the patient by the provider and/or office and medical team. There must also be acknowledgement and/or documentation of the communication in a biopsy tracking log and document in the patient’s medical record
Definition:
Communication – Acceptable “communication” methods which are to be documented in the biopsy tracking log and patient medical record include:
- Directly speaking with the patient or a person designated by the patient to discuss biopsyresults
- Documented telephone message or voice mail regarding the availability of biopsy results
- Mailer/fax sent to the patient indicating the availability of biopsy results or discussing the diagnosis itself
- Any HIPAA secure electronic communication with the patient discussing the biopsy results
The components of a tracking log incorporate the following-
- Initials of physician performing the biopsy
- Patient name
- Date of biopsy
- Type of biopsy
- Biopsy result
- Date of biopsy result
Numerator Instructions:
To satisfy this measure, the biopsying physician and/or office and medical team must:
- Review the biopsy results with the patient
- Communicate those results to the primary care/referring physician
- Track communication in a log
- Document tracking process in the patient’s medical record
NUMERATOR NOTE: For Denominator Exception(s), patients are ineligible for this measure if at the time of encounter there are patient reason(s) for not communicating the results to the Primary Care or referring physician (e.g. patient self-referred or has no Primary Care Physician, etc.) as further specified below.
Numerator Options:
Performance Met: Biopsy results reviewed, communicated, tracked, and documented (G8883)
OR
Denominator Exception: Clinician documented reason that patient’s biopsy results were not reviewed, [e.g., patient asks that biopsy results not be communicated to the primary care/referring physician, patient does not have a primary care/referring physician or is a self-referred patient] (G8884)
OR
Performance Not Met: Biopsy results not reviewed, communicated, tracked, or documented (G8885)
Rationale
The purpose of this measure is to ensure that biopsy results with potentially serious consequences for patient care are not lost or ignored. Large health plan/delivery systems have identified a prominent quality of care issue as involving missing or overlooked biopsy pathology reports. All biopsy results should be accounted for and the results communicated to the patient or patient’s guardian/caregiver and to the patient’s primary care physician and/or other physician/professional responsible for follow-up care. Failure of the medical team to take appropriate action based on the result of a biopsy may lead to significant delays in obtaining appropriate treatment with subsequent poor outcomes, complications and even death. This measure will facilitate physician quality assurance that all biopsies are read, recorded and the results communicated.
Clinical Recommendation Statements
The measure does not directly address that follow-up care has been concluded, but rather addresses the critical first step in the treatment chain. Appropriate follow-up care must be specifically tailored to each clinical diagnosis. Biopsy results are not only essential to making a final diagnosis, but they are also essential to disease staging and treatment planning. The patient needs to be informed of the biopsy results so they can not only be completely aware of their condition, but also so they can make informed decisions about their care and treatment.