Measure Description
Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.
Instructions
This measure is to be submitted each time a patient’s pathology report addresses specimens with a diagnosis of malignant cutaneous melanoma; however, only one quality data code (QDC) per date of service for a patient is required. In instances where multiple specimens from different/unique lesions are submitted and resulted in a single report, each eligible specimen must be Met in order for the case to be considered Met (Denominator Exclusions and Denominator Exceptions are not considered eligible specimens). If any eligible specimen is Not Met, the quality data code for Not Met should be submitted for this report. 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.
Denominator
All pathology reports for primary malignant cutaneous melanoma covering biopsies and excisions to include wide excisions and re-excisions
Denominator Instruction:
The intent of the measure is to only include pathology reports for primary malignant cutaneous melanoma that may be staged with the following components: pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors. Melanoma in situ cases do not meet the criteria for this denominator. In the instance a pathology report meets the denominator criteria, but represents a diagnosis of Melanoma in situ G9430 should be utilized.
Denominator Criteria (Eligible Cases):
Patients ≥ 18 years of age on date of service
AND
Diagnosis for malignant cutaneous melanoma (ICD-10-CM): C43.0, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9
AND
Patient procedureduring performance period (CPT): 88305
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
AND NOT
DENOMINATOR EXCLUSION:
Specimen site other than anatomic cutaneous location: G9430
Numerator
Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors
Numerator Options:
Performance Met: Pathology report includes the pT Category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors (G9428)
OR
Denominator Exception: Documentation of medical reason(s) for not including pT Category,thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors (e.g., negative skin biopsies, insufficient tissue, or other documented medical reasons) (G9429)
OR
Performance Not Met: Pathology report does not include the pT Category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors (G9431)
Rationale
Research and the publication of new guidelines in 2017 indicate newer tumor characteristics for more precise staging, with implications for treatment outcomes. In 2017, the American Joint Committee on Cancer (AJCC) Melanoma Expert Panel introduced several important changes to the Tumor, Nodes, Metastasis (TNM) classification. The relevant change for this measure in the eighth edition AJCC Cancer Staging Manual include: 1) tumor thickness measurements to be recorded to the nearest 0.1 mm, not 0.01 mm; 2) definitions of T1a and T1b are revised (T1a, <0.8 mm without ulceration; T1b, 0.8-1.0 mm with or without ulceration or <0.8 mm with ulceration), with mitotic rate no longer a T category criterion. (Gershenwald et al.)
The new guidelines state: “As supported by this univariate analysis and previous reports, the mitotic rate is likely an important prognostic determinant when evaluated using its dynamic range across melanomas of all tumor thickness categories. Therefore, the AJCC Melanoma Expert Panel strongly recommends that mitotic rate be assessed and recorded for all primary melanomas, although it is not used for T1 staging in the eighth edition. The mitotic rate will likely be an important parameter for inclusion in the future development of prognostic models applicable to individual patients..” (http://onlinelibrary.wiley.com/doi/10.3322/caac.21409/pdf )
The American Academy of Dermatology recently updated guidelines for management of primary cutaneous melanoma. In addition to re-affirming the importance of pT, thickness, ulceration and mitotic rate (“There is strong evidence that at least 3 histologic features of the primary tumor are dominant predictors of outcome: Breslow thickness, ulceration, and dermal mitotic rate”), these guidelines also emphasized the importance of other elements include peripheral and deep margin status, microsatellitosis and lymphovascular invasion (Swetter et al). For margin status, the guidelines note that “An additional essential element of the pathology report is the status of the peripheral and deep margins (positive or negative) of the specimen. Presence or absence of tumor at the surgical margin indicates whether the entire lesion was available for histologic evaluation and provides guidance for further management.” Microsatellites, or tumors nests in the vicinity of the main invasive tumor, are an important component of the eighth edition of the AJCC staging system and per the AAD guideline “the presence or absence of microscopic satellites must be reported for accurate staging.”
The 2023 measure has been revised to conform with AJCC requirements, recent AAD guidelines and College of American Pathologists (CAP) Cancer Protocol recommendations that went into effect August 2021.(Shon et al).
Gershenwald, J. E., Scolyer, R. A., Hess, K. R., Sondak, V. K., Long, G. V., Ross, M. I., Lazar, A. J., Faries, M. B., Kirkwood, J. M., McArthur, G. A., Haydu, L. E., Eggermont, A. M. M., Flaherty, K. T., Balch, C. M., Thompson, J. F. and for members of the American Joint Committee on Cancer Melanoma Expert Panel and the International Melanoma Database and Discovery Platform (2017), Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA: A Cancer Journal for Clinicians, 67: 472–492 http://onlinelibrary.wiley.com/doi/10.3322/caac.21409/full
Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S and Lamina T. (2018) Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol 80 (1): 208-250. https://www.jaad.org/article/S0190-9622(18)32588-X/fulltext
Wonwoo Shon; David P. Frishberg; Jeffrey E. Gershenwald; Pavandeep Gill; Jeffrey North; Victor G. Prieto; Richard A. Scolyer; Bonnie L. Balzer; Thomas J. Flotte; Timothy H. McCalmont; Bruce Robert Smoller (2021). Protocol for the Examination of Excision Specimens From Patients With Melanoma of the Skin. College of American Pathologists. https://documents.cap.org/protocols/Skin.Melanoma_4.3.0.1.REL_CAPCP.pdf
Wonwoo Shon; David P. Frishberg; Jeffrey E. Gershenwald; Pavandeep Gill; Jeffrey North; Victor G. Prieto; Richard A. Scolyer; Bonnie L. Balzer; Thomas J. Flotte; Timothy H. McCalmont; Bruce Robert Smoller (2021). Protocol for the Examination of Biopsy Specimens From Patients With Melanoma of the Skin. College of American Pathologists. https://documents.cap.org/protocols/Skin.Melanoma.Bx_4.3.0.1.REL_CAPCP.pdf
Clinical Recommendation Statements
There is strong evidence that at least 3 histologic features of the primary tumor are dominant predictors of outcome: Breslow thickness, ulceration, and dermal mitotic rate.
An additional essential element of the pathology report is the status of the peripheral and deep margins (positive or negative) of the specimen.
Depending on the specific T- and N-category criteria, such patients would be staged as either stage IIIC or IIID. Therefore, the presence or absence of microscopic satellites must be reported for accurate staging.