2017 CMS Web Interface

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1 CMS Web Interface PREV-5 (NQF 2372): Breast Cancer Screening Measure Steward: NCQA Web Interface V1.0 Page 1 f 18 11/15/2016

2 Cntents INTRODUCTION... 3 WEB INTERFACE SAMPLING INFORMATION... 4 BENEFICIARY SAMPLING... 4 NARRATIVE MEASURE SPECIFICATION... 5 DESCRIPTION:... 5 IMPROVEMENT NOTATION:... 5 INITIAL POPULATION:... 5 DENOMINATOR:... 5 DENOMINATOR EXCLUSIONS:... 5 DENOMINATOR EXCEPTIONS:... 5 NUMERATOR: NUMERATOR EXCLUSIONS:... 5 DEFINITION:... 5 GUIDANCE:... 5 SUBMISSION GUIDANCE... 6 PATIENT CONFIRMATION... 6 SUBMISSION GUIDANCE... 7 DENOMINATOR CONFIRMATION... 7 SUBMISSION GUIDANCE... 8 NUMERATOR REPORTING... 8 DOCUMENTATION REQUIREMENTS... 9 APPENDIX I: PERFORMANCE CALCULATION FLOW APPENDIX II: DOWNLOADABLE RESOURCE MAPPING TABLE APPENDIX III: MEASURE RATIONALE AND CLINICAL RECOMMENDATION STATEMENTS RATIONALE: CLINICAL RECOMMENDATION STATEMENTS: APPENDIX V: USE NOTICES, COPYRIGHTS, AND DISCLAIMERS COPYRIGHT Web Interface V1.0 Page 2 f 18 11/15/2016

3 INTRODUCTION There are a ttal f 15 individual measures (including ne cmpsite cnsisting f tw measures) included in the CMS Web Interface targeting high-cst chrnic cnditins, preventive care, and patient safety. The measures dcuments are represented individually and cntain measure specific infrmatin. The crrespnding cding dcuments are psted separately in an Excel frmat. The Measure Dcuments are being prvided t allw grup practices and Accuntable Care Organizatins (ACOs) an pprtunity t better understand each f the 15 individual measures included in the CMS Web Interface data submissin methd. Each Measure Dcument cntains infrmatin necessary t submit data thrugh the CMS Web Interface. Narrative specificatins, supprting submissin dcumentatin, and calculatin flws are prvided within each dcument. Please review all f the measure dcumentatin in its entirety t ensure cmplete understanding f these measures. Web Interface V1.0 Page 3 f 18 11/15/2016

4 WEB INTERFACE SAMPLING INFORMATION BENEFICIARY SAMPLING Fr mre infrmatin n the sampling prcess and methdlgy please refer t the Web Interface Sampling Dcument, available at CMS.gv. Web Interface V1.0 Page 4 f 18 11/15/2016

5 NARRATIVE MEASURE SPECIFICATION DESCRIPTION: Percentage f wmen years f age wh had a mammgram t screen fr breast cancer IMPROVEMENT NOTATION: Higher scre equals better quality INITIAL POPULATION: Wmen years f age with a visit during the measurement perid DENOMINATOR: Equals Initial Ppulatin DENOMINATOR NOTE: The intent f the measure is that starting at age 50 wmen shuld have ne r mre mammgrams every 24 mnths with a 3 mnth grace perid. DENOMINATOR EXCLUSIONS: Wmen wh had a bilateral mastectmy r wh have a histry f a bilateral mastectmy r fr whm there is evidence f a right and a left unilateral mastectmy DENOMINATOR EXCEPTIONS: Nne NUMERATOR: Wmen with ne r mre mammgrams during the measurement perid r the 15 mnths prir t the measurement perid NUMERATOR EXCLUSIONS: Nt Applicable DEFINITION: Nne GUIDANCE: Nne Web Interface V1.0 Page 5 f 18 11/15/2016

6 PATIENT CONFIRMATION SUBMISSION GUIDANCE Establishing patient eligibility fr reprting requires the fllwing: Guidance Determine if the patient s medical recrd can be fund OR OR If yu can lcate the medical recrd select Yes If yu cannt lcate the medical recrd select N - Medical Recrd Nt Fund Determine if the patient is qualified fr the sample Patient Cnfirmatin If the patient is deceased, in hspice, mved ut f the cuntry r was enrlled in HMO select Nt Qualified fr Sample, select the applicable reasn frm the prvided drp-dwn menu, and enter the date the patient became ineligible If N Medical Recrd Nt Fund r Nt Qualified fr Sample is selected, the patient is cmpleted but nt cnfirmed. The patient will be skipped and anther patient must be reprted in their place, if available. The Web Interface will autmatically skip any patient fr whm N Medical Recrd Nt Fund r Nt Qualified fr Sample is selected in all ther measures int which they have sampled. If Nt Qualified fr Sample is selected and the date is unknwn, yu may enter the last date f the measurement perid (i.e., 12/31/). The Measurement Perid is defined as January 1 December 31,. NOTE: - In Hspice: Select this ptin if the patient is nt qualified fr sample due t being in hspice care at any time during the measurement perid (this includes nn-hspice patients receiving palliative gals r cmfrt care) - Mved ut f Cuntry: Select this ptin if the patient is nt qualified fr sample because they mved ut f the cuntry any time during the measurement perid - Deceased: Select this ptin if the patient died during the measurement perid - HMO Enrllment: Select this ptin if the patient was enrlled in an HMO at any time during the measurement perid (i.e., Medicare Advantage, nn-medicare HMOs, etc.) Web Interface V1.0 Page 6 f 18 11/15/2016

7 DENOMINATOR CONFIRMATION SUBMISSION GUIDANCE Determine if the patient is qualified fr the measure OR OR If the patient is qualified fr the measure select Yes If there is a denminatr exclusin fr patient disqualificatin frm the measure select Denminatr Exclusin If there is an "ther" CMS apprved reasn fr patient disqualificatin frm the measure select N - Other CMS Apprved Reasn Denminatr Exclusin cdes can be fund in the Web Interface PREV Cding Dcument. The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument. Guidance Denminatr If Denminatr Exclusin r N Other CMS Apprved Reasn is selected, the patient will be skipped and anther patient must be reprted in their place, if available. The patient will nly be remved frm the measure fr which ne f these ptins was selected, nt all Web Interface measures. CMS Apprved Reasn may nly be selected when apprved by CMS. T request a CMS Apprved Reasn, yu wuld need t prvide the patient rank, measure, and reasn fr request in a Quality Payment Prgram Service Desk inquiry. A CMS decisin will be prvided in the reslutin f the inquiry. Patients fr whm a CMS Apprved Reasn is selected will be skipped and anther patient must be reprted in their place, if available. Web Interface V1.0 Page 7 f 18 11/15/2016

8 NUMERATOR REPORTING SUBMISSION GUIDANCE Determine if a mammgram t screen fr breast cancer was perfrmed during the measurement perid r the 15 mnths prir t the measurement perid OR If a mammgram t screen fr breast cancer was nt perfrmed during the measurement perid r the 15 mnths prir t the measurement perid select N If a mammgram t screen fr breast cancer was perfrmed during the measurement perid r the 15 mnths prir t the measurement perid select Yes Numeratr cdes can be fund in the Web Interface PREV Cding Dcument. The Dwnladable Resurce Mapping Table can be lcated in Appendix II f this dcument. Guidance NOTE: - Dcumentatin in the medical recrd must include bth f the fllwing: A nte indicating the date the breast cancer screening was perfrmed AND the result r findings - Dcumentatin f nrmal r abnrmal is acceptable - Patient Reprted Requirement: Date and type f test AND result/finding - Screening includes: Breast x-ray, diagnstic mammgraphy, mammgram, screening mammgraphy - MRI and Ultrasund are nt cnsidered breast cancer screening fr this measure - Dcumentatin f screening fr breast cancer may be cmpleted during a telehealth encunter Web Interface V1.0 Page 8 f 18 11/15/2016

9 DOCUMENTATION REQUIREMENTS When submitting data thrugh the CMS Web Interface, the expectatin is that medical recrd dcumentatin is available that supprts the actin reprted in the Web Interface i.e., medical recrd dcumentatin is necessary t supprt the infrmatin that has been submitted. Web Interface V1.0 Page 9 f 18 11/15/2016

10 Appendix I: Perfrmance Calculatin Flw Web Interface V1.0 Page 10 f 18 11/15/2016

11 Web Interface V1.0 Page 11 f 18 11/15/2016

12 Web Interface V1.0 Page 12 f 18 11/15/2016

13 Patient Cnfirmatin Flw Fr, cnfirmatin f the Medical Recrd Fund, r indicating the patient is Nt Qualified fr Sample with a reasn f In Hspice, Mved ut f Cuntry, Deceased, r HMO Enrllment, will nly need t be dne nce per patient. Refer t the Measure Reprting Dcument fr further instructins. 1. Start Patient Cnfirmatin Flw. 2. Check t determine if Medical Recrd can be fund. a. If n, Medical Recrd nt fund, mark apprpriately fr cmpletin and stp abstractin. This remves the patient frm the beneficiary sample fr all measures. The patient will be skipped and replaced. Stp prcessing. b. If yes, Medical Recrd fund, cntinue prcessing. 3. Check t determine if Patient Qualified fr the sample. a. If n, the patient des nt qualify fr the sample, select the reasn why and enter the date (if date is unknwn, enter 12/31/) the patient became ineligible fr sample. Fr example; In Hspice, Mved ut f Cuntry, Deceased, HMO Enrllment. Mark apprpriately fr cmpletin and stp abstractin. This remves the patient frm the beneficiary sample fr all measures. The patient will be skipped and replaced. Stp prcessing. b. If yes, the patient des qualify fr the sample; cntinue t the Measure Cnfirmatin Flw fr PREV-5. Web Interface V1.0 Page 13 f 18 11/15/2016

14 Measure Cnfirmatin Flw fr PREV-5 Fr, measure specific reasns a patient is Nt Cnfirmed r excluded fr Denminatr Exclusin r Other CMS Apprved Reasn will need t be dne fr each measure where the patient appears. Refer t the Measure Reprting Dcument fr further instructins. 1. Start Measure Cnfirmatin Flw fr PREV-5. Cmplete fr cnsecutively ranked patients aged 50 t 74 years at the beginning f the measurement perid. Further infrmatin regarding patient selectin fr specific disease and patient care measures can be fund in the Web Interface Sampling Methdlgy Dcument. Fr patients wh have the incrrect gender r date f birth listed, a change f the gender r patient date f birth by the abstractr may result in the patient n lnger qualifying fr the PREV-5 measure. If this is the case, the system will autmatically remve the patient frm the measure requirements. 2. Check t determine if the patient qualifies fr the measure (Denminatr Exclusin). a. If n, the patient des nt qualify fr the measure select: Denminatr Exclusin fr patient disqualificatin. Mark apprpriately fr cmpletin and stp abstractin. Patient is remved frm the perfrmance calculatins fr this measure. The patient will be skipped and replaced. Stp prcessing. b. If yes, the patient des qualify fr the measure, cntinue prcessing. 3. Check t determine if the patient qualifies fr the measure (Other CMS Apprved Reasn). a. If n, the patient des nt qualify fr the measure select: N Other CMS Apprved Reasn fr patient disqualificatin. Mark apprpriately fr cmpletin and stp abstractin. Patient is remved frm the perfrmance calculatins fr this measure. The patient will be skipped and replaced. Other CMS Apprved Reasn may nly be selected if yu have received an apprval frm CMS in the reslutin f a requested Quality Payment Prgram Service Desk Inquiry at QPP Service Desk. Stp prcessing. b. If yes, the patient des qualify fr the measure, cntinue t the PREV-5 measure flw. Web Interface V1.0 Page 14 f 18 11/15/2016

15 Measure Flw fr PREV-5 The measure diagrams were develped by CMS as a supplemental resurce t be used in cnjunctin with the measure specificatins. They shuld nt be used as a substitutin fr the measure specificatins. Fr Dwnladable Resurce Mapping Table, g t Appendix II and use the Variable Names lcated in the appendix alng with the applicable tabs within the PREV Cding Dcument. 1. Start prcessing PREV-5 Flw fr the patients that qualified fr sample in the Patient Cnfirmatin Flw and the Measure Cnfirmatin Flw fr PREV-5. Nte: Include remainder f patients listed in Web Interface that were cnsecutively cnfirmed and cmpleted fr this measure in the denminatr. Fr the sample calculatin in the flw these patients wuld fall int the d categry (denminatr, i.e. 230 patients). 2. Check t determine if the patient had a mammgram t screen fr breast cancer perfrmed during the measurement perid r the 15 mnths prir t the measurement perid. a. If n, the patient did nt have a mammgram perfrmed during the measurement perid r the 15 mnths prir t the measurement perid; perfrmance is nt met and shuld nt be included in the numeratr. Stp prcessing. b. If yes, the patient did have a mammgram perfrmed during the measurement perid r the 15 mnths prir t the measurement perid, perfrmance is met and the patient will be included in the numeratr. Fr the sample calculatin in the flw these patients wuld fall int the a categry (numeratr, i.e. 188 patients). Stp prcessing. Sample Calculatin Perfrmance Rate Equals Perfrmance Met is categry a in the measure flw (188 patients) Denminatr is categry d in the measure flw (230 patients) 188 (Perfrmance Met) divided by 230 (Denminatr) equals a perfrmance rate f percent Calculatin May Change Pending Perfrmance Met Web Interface V1.0 Page 15 f 18 11/15/2016

16 Appendix II: Dwnladable Resurce Mapping Table Each data element within this measure s denminatr r numeratr is defined as a pre-determined set f clinical cdes. These cdes can be fund in the Web Interface PREV Cding Dcument. *PREV-5: Preventive Care and Screening: Breast Cancer Screening Measure Cmpnent/Excel Tab Data Element Variable Name Cding System(s) Denminatr Exclusin/ Denminatr Exclusin Cdes Exclusin BILATERAL_CODE I10 SNM UNILATERAL_CODE C4 I9 I10 SNM WITH evidence f a right and a left mastectmy Numeratr/ Numeratr Cdes Breast Cancer Screening MAMMO_CODE HCPCS LN *Fr EHR mapping, the cding within PREV-5 is cnsidered t be all inclusive Web Interface V1.0 Page 16 f 18 11/15/2016

17 Appendix III: Measure Ratinale and Clinical Recmmendatin Statements RATIONALE: Breast cancer is ne f the mst cmmn types f cancers, accunting fr a quarter f all new cancer diagnses fr wmen in the U.S. (BreastCancer.Org, 2011). It ranks as the secnd leading cause f cancer-related mrtality in wmen, accunting fr nearly 40,000 estimated deaths in 2013 (American Cancer Sciety, 2011). Accrding t the Natinal Cancer Institute s Surveillance Epidemilgy and End Results prgram, the chance f a wman being diagnsed with breast cancer in a given year increases with age. By age 30, it is ne in 2,212. By age 40, the chances increase t ne in 235, by age 50, it becmes ne in 54, and, by age 60, it is ne in 25. Frm 2004 t 2008, the median age at the time f breast cancer diagnsis was 61 years amng adult wmen (Tangka et al, 2010). In the U.S., csts assciated with a diagnsis f breast cancer range frm $451 t $2,520, factring in cntinued testing, multiple ffice visits and varying prcedures. The ttal csts related t breast cancer add up t nearly $7 billin per year in the U.S., including $2 billin spent n late-stage treatment (Lavigne et al, 2008, Bykff et al, 2009). CLINICAL RECOMMENDATION STATEMENTS: The U.S. Preventive Services Task Frce (USPSTF) recmmends biennial screening mammgraphy fr wmen aged years (B recmmendatin). The decisin t start regular, biennial screening mammgraphy befre the age f 50 years shuld be an individual ne and take patient cntext int accunt, including the patient's values regarding specific benefits and harms (C recmmendatin). (USPSTF, 2009) The Task Frce cncludes the evidence is insufficient t assess the additinal benefits and harms f screening mammgraphy in wmen 75 years and lder (I statement). U.S. Preventive Services Task Frce (2009) Grade: B recmmendatin. The USPSTF recmmends biennial screening mammgraphy fr wmen aged 50 t 74 years. Grade: C recmmendatin. The decisin t start regular, biennial screening mammgraphy befre the age f 50 years shuld be an individual ne and take patient cntext int accunt, including the patient's values regarding specific benefits and harms. Grade: I Statement. The USPSTF cncludes that the current evidence is insufficient t assess the additinal benefits and harms f screening mammgraphy in wmen 75 years r lder. Grade: D recmmendatin. The USPSTF recmmends against teaching breast self-examinatin (BSE). Grade: I Statement. The USPSTF cncludes that the current evidence is insufficient t assess the additinal benefits and harms f clinical breast examinatin (CBE) beynd screening mammgraphy in wmen 40 years r lder. Grade: I Statement. The USPSTF cncludes that the current evidence is insufficient t assess the additinal benefits and harms f either digital mammgraphy r magnetic resnance imaging (MRI) instead f film mammgraphy as screening mdalities fr breast cancer. Web Interface V1.0 Page 17 f 18 11/15/2016

18 Appendix V: Use Ntices, Cpyrights, and Disclaimers COPYRIGHT These perfrmance measures were develped and are wned by the Natinal Cmmittee fr Quality Assurance ("NCQA"). These perfrmance measures are nt clinical guidelines and d nt establish a standard f medical care. NCQA makes n representatins, warranties, r endrsement abut the quality f any rganizatin r physician that uses r reprts perfrmance measures and NCQA has n liability t anyne wh relies n such measures. NCQA hlds a cpyright in this measure and can rescind r alter this measure at any time. Users f the measure shall nt have the right t alter, enhance, r therwise mdify the measure and shall nt disassemble, recmpile, r reverse engineer the surce cde r bject cde relating t the measure. Anyne desiring t use r reprduce the measure withut mdificatin fr a nncmmercial purpse may d s withut btaining any apprval frm NCQA. All cmmercial uses must be apprved by NCQA and are subject t a license at the discretin f NCQA. Use by health care prviders in cnnectin with their wn practices is nt cmmercial use. A "cmmercial use" refers t any sale, license, r distributin f a measure fr cmmercial gain, r incrpratin f a measure int any prduct r service that is sld, licensed, r distributed fr cmmercial gain, even if there is n actual charge fr inclusin f the measure Natinal Cmmittee fr Quality Assurance, all rights reserved. Perfrmance measures develped by NCQA fr CMS may lk different frm the measures slely created and wned by NCQA. CPT cntained in the Measures specificatins is cpyright American Medical Assciatin. Web Interface V1.0 Page 18 f 18 11/15/2016