Measure Description
Percentage of patients who had an excisional surgery for melanoma or melanoma in situ with initial American Joint Committee on Cancer (AJCC) staging of 0, I, or II, in the past 5 years in which the operating clinician examines and/or diagnoses the patient for recurrence of melanoma.
Instructions
This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for patients with a diagnosis of melanoma or melanoma insitu with initial AJCC staging of 0, I, or II, in the past 5 years. 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. The intent of this measure is to ensure that patients who had an excisional surgery for melanoma or melanoma in situ in the past 5 years with an initial AJCC staging of 0, I, OR II have a follow up exam for melanoma recurrence. The exam for recurrence can be completed by any provider as long as it is documented in the medical record by the excising clinician that the exam was performed.
This measure will be calculated with 2 performance rates:
1) Documentation by the clinician who performed the surgery that an exam for recurrence of melanoma was performed on the patient within the performance period
2) All patients that were diagnosed with a recurrent melanoma in the current performance period
For accountability reporting in the CMS MIPS program, the rate for submission criteria 1 is used for performance.
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 (SUBMISSION CRITERIA 1 & 2):
All patients that the clinician has performed a type of excisional surgery for melanoma or melanoma in situ in the past 5 years with an initial AJCC staging of 0, I, or II
DENOMINATOR NOTE: The past five year timeframe for an encounter begins at the start of the performance period. *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
Denominator Criteria (Eligible Cases):
Patients aged 18 years and older on the date of the encounter
AND
Diagnosis for Melanoma or Melanoma in situ (ICD-10-CM): C43.0, C43.10, C43.111, C43.112, C43.121, C43.122, 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, D03.0, D03.10, D03.111, D03.112, D03.20, D03.121, D03.122, D03.30, D03.39, D03.4, D03.51, D03.52, D03.59, D03.60, D03.61, D03.62, D03.70, D03.71, D03.72, D03.8, D03.9
AND
Patients with an excisional surgery for melanoma or melanoma in situ in the past 5 years with an initial AJCC Staging of 0, I, or II at the start of the performance period: M1386
AND
Patient encounters during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10
AND NOT
DENOMINATOR EXCLUSION:
Patients who died during the performance period: M1387
NUMERATOR (SUBMISSION CRITERIA 1):
Documentation by the clinician who performed the surgery that an exam for recurrence of melanoma was performed on the patient within the performance period
Numerator Instructions:
Lost to Follow-up – For purposes of this measure, in addition to those patients that the clinician is unable to locate for follow-up after documentation of attempt, lost to follow-up includes documentation of patients who relocated outside of the geographic area, transferred to a new clinician, or who had changes in insurance and are unable to follow-up.
Numerator Options:
Performance Met: Patients with documentation of an exam performed for recurrence of melanoma (M1388)
OR
Denominator Exception: Documentation of patient reasons for no examination i.e., refusal of examination OR lost to follow-up (documentation must include information that the clinician was unable to reach the patient by phone, mail or secure electronic mail – at least one method must be documented) (M1392)
OR
Performance Not Met: Patients who do not have a documented exam performed for recurrence of melanoma or no documentation within the performance period (M1390)
NUMERATOR (SUBMISSION CRITERIA 2):
All patients that were diagnosed with a recurrent melanoma in the current performance period
Definitions:
Recurrent – For purposes of this measure, recurrence is local recurrence of where the anatomical location(s) of the excised lesion or Mohs surgery occurred for ALL qualifying excisions identified in the denominator. Other locations should not be counted for this measure.
Reported score – AJCC staging 0, I, or II
Numerator Instructions:
INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
Lost to Follow-up – For purposes of this measure, in addition to those patients that the clinician is unable to locate for follow-up after documentation of attempt, lost to follow-up includes documentation of patients who relocated outside of the geographic area, transferred to a new clinician, or who had changes in insurance and are unable to follow-up.
Numerator Options:
Performance Met: All patients who were diagnosed with recurrent melanoma during the current performance period (M1391)
OR
Denominator Exception: Documentation of patient reasons for no examination, i.e., refusal of examination OR lost to follow-up (documentation must include information that the clinician was unable to reach the patient by phone, mail or secure electronic mail – at least one method must be documented) (M1392)
Performance Not Met: Patients who were not diagnosed with recurrent melanoma during the current performance period (M1393)
Rationale
Melanoma recurrence is an outcome that needs precise evaluation. This measure will allow for the development of a system in which melanomas can accurately be tracked so that we can truly understand the effectiveness of care. The literature describes a lack of a standard for follow-up, tracking, and evaluating melanoma in early-stage disease. This measure will evaluate the frequency of recurrence along with the type of recurrence (local, in transit, LN, systemic) that occurs after an excisional procedure.
It is also recognized that there may be a lack of communication between the excising clinician and the clinician who is following the patient longitudinally. This measure is also an initiative to drive a care-collaborative network that encourages communication about the recurrence status of melanoma patients.
Clinical Recommendation Statements
1. For common follow-up recommendations for all patients: Follow up schedule is influenced by risk of recurrence, prior primary melanoma, and family history of melanoma, and includes other factors such as atypical moles/dysplastic nevi (NCCN Melanoma: Cutaneous, 2022)
2. For patients who present with stage I-II melanoma and who are rendered free of disease after initial treatment, recurrences are distributed as follows: approximately 15% to 20% are local or in transit (NCCN Melanoma: Cutaneous, 2022)
3. Data from several studies suggest that the time it takes for the risk of recurrence to reach its low plateau depends on the stage of disease at first presentation. In a retrospective study of patients who initially presented with stage I melanoma (N = 1568), 80% of the 293 recurrences developed within the first 3 years, but some recurrences (<8%) were detected 5 to 10 years after the initial treatment. A prospective study found that for patients with stage I or II at initial presentation, the risk of recurrence reached a low level by 4.4 years after initial diagnosis (NCCN Melanoma: Cutaneous, 2022)