Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.
This measure is to be submitted once per performance period for patients with colorectal cancer seen 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.
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.
Adult patients with metastatic colorectal cancer who have a RAS (KRAS or NRAS) gene mutation
RAS mutation testing – RAS testing for this measure refers to assays that detect mutations in codons 12 and 13 of exon 2, codons 59 and 61 or exon 3 and codons 117 and 146 in exon 4 in KRAS or NRAS. Do not include results from mutations at other codons or assays for other alterations (e.g., BRAF, PI3K, PTEN genes). The College of American Pathologists (CAP) Perspectives on Emerging Technology (POET) Report on “RAS mutation testing” provides additional guidance on testing.
If multiple RAS mutation tests have been performed, refer to the most recent test results.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
Diagnosis of colon or rectal cancer (ICD-10 CM): C18.0, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20
At least two patient encounters during the performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215
Telehealth Modifier: GQ, GT, 95, POS 02
Patient has metastatic disease at diagnosis: G9842
RAS (KRAS or NRAS) gene mutation: G9843
Anti-EGFR monoclonal antibody therapy not received
Anti-EGFR monoclonal antibody – cetuximab or panitumumab
Performance Met: Patient did not receive anti-EGFR monoclonal antibody therapy (G9844)
Performance Not Met: Patient received anti-EGFR monoclonal antibody therapy (G9845)
The American Society of Clinical Oncology (ASCO) envisions that use of this measure will improve concordance with recommendations for RAS testing for patients with metastatic colorectal cancer. We recognize the importance of ensuring that the appropriate patient population receives guideline concordant treatment as studies demonstrate that the administration of EGFR-targeted therapies, specifically cetuximab or panitumumab, offer no clinical benefit to patients diagnosed with RAS-mutated tumors. Clinical trial data strongly suggest that patients with KRAS or NRAS mutations are better served with other targeted therapies, especially considering the harms and costs of anti-EGFR treatment. Therefore, the measure focus is on halting use of anti-EGFR MoAb therapies in patients who will not derive any benefit.
Clinical Recommendation Statements
This measure is based on ASCO and NCCN Guidelines:
“Colorectal carcinoma patients being considered for anti-EGFR therapy must receive RAS mutational testing. Mutational analysis should include KRAS and NRAS codons 12, 13 of exon 2; 59, 61 of exon 3; and 117 and 146 of exon 4 (“expanded” or “extended” RAS)”
Sepulveda AR, Hamilton SR, Allegra CJ, et al: Molecular Biomarkers for the Evaluation of Colorectal Cancer: Guideline From the American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology, and the American Society of Clinical Oncology. Journal of Clinical Oncology 35:1453-1486, 2017
“All patients with metastatic colorectal cancer should have tumor tissue genotyped for RAS (KRAS and NRAS) and BRAF mutations individually or as part of a next-generation sequencing (NGS) panel. Patients with any known KRAS mutation (exon 2, 3, 4) or NRAS mutation (exon 2, 3, 4) should not be treated with either cetuximab or panitumumab.”
“A sizeable body of literature has shown that tumors with a mutation in codon 12 or 13 of exon 2 of the KRAS gene are essentially insensitive to cetuximab or panitumumab therapy. More recent evidence shows mutations in KRAS outside of exon 2 and mutations in NRAS are also predictive for a lack of benefit to cetuximab and panitumumab.
The panel therefore strongly recommends RAS (KRAS/NRAS) genotyping of tumor tissue (either primary tumor or metastasis) in all patients with metastatic colorectal cancer. Patients with known KRAS or NRAS mutations should not be treated with either cetuximab or panitumumab, either alone or in combination with other anticancer agents, because they have virtually no chance of benefit and the exposure to toxicity and expense cannot be justified. It is implied throughout the guidelines that NCCN recommendations involving cetuximab or panitumumab relate only to patients with disease characterized by RAS wild-type genes. ASCO released a Provisional Clinical Opinion Update on extended RAS testing in patients with metastatic colorectal cancer that is consistent with the NCCN Panel’s recommendations. A guideline on molecular biomarkers for colorectal cancer developed by the ASCP, CAP, AMP and ASCO also recommends RAS testing consistent with the NCCN recommendations” (MS-34)
NCCN Clinical Practice Guidelines in Oncology™. Colon Cancer, V.1.2021 https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf