Measure #72 (NQF 0385): Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS F INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12- month reporting period INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for all patients with colon cancer seen during the reporting period. It is anticipated that clinicians who treat patients with colon cancer will submit this measure. Measure Reporting via Claims: ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. CPT Category II codes and quality-data codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed ICD-10-CM diagnosis codes, CPT codes, and the appropriate quality-data code AND/ CPT Category II code the CPT Category II code with the modifier. The modifiers allowed for this measure are: 8P- reason not otherwise specified. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. The listed numerator options are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINAT: All patients aged 18 through 80 years with AJCC Stage III colon cancer Denominator Criteria (Eligible Cases): Patients aged 18 through 80 years on date of encounter AND Diagnosis for colon cancer (ICD-10-CM): C18.0, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9 AND Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 NUMERAT: Patients who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or who have previously received adjuvant chemotherapy within the 12 month reporting period Definitions: 11/17/2015 Page 1 of 11
Adjuvant Chemotherapy According to current NCCN guidelines, the following therapies are recommended: 5-FU/LV/oxaliplatin (FOLFOX) or capecitabine/oxaliplatin (CapeOx) (both category 1 and preferred); bolus 5-FU/LV/oxaliplatin (FLOX) (category 1); or single-agent capecitabine or 5-FU/LV in patients felt to be inappropriate for oxaliplatin therapy (NCCN). See clinical recommendation statement for cases where leucovorin is not available. Prescribed May include prescription ordered for the patient for adjuvant chemotherapy at one or more visits in the 12-month period patient already receiving adjuvant chemotherapy as documented in the current medication list. NUMERAT NOTE: The correct combination of numerator code(s) must be reported on the claim form in order to properly report this measure. The correct combination of codes may require the submission of multiple numerator codes. Numerator Quality-Data Coding Options for Reporting Satisfactorily: Adjuvant Chemotherapy Referred, Prescribed or Previously Received (One quality-data code & one CPT II code [G8927 & 3388F] are required on the claim form to submit this numerator option) Performance Met: G8927: AND CPT II 3388F: Adjuvant chemotherapy referred, prescribed or previously received for AJCC Stage III, colon cancer AJCC Colon Cancer, Stage III documented Adjuvant Chemotherapy not Referred, Prescribed or Previously Received for Documented Reasons (One quality-data code & one CPT II code [G8928 & 3388F] are required on the claim form to submit this numerator option) Other Performance Exclusion: G8928: AND CPT II 3388F: Adjuvant chemotherapy not prescribed or previously received, for documented reasons (e.g., medical comorbidities, diagnosis date more than 5 years prior to the current visit date, patient s diagnosis date is within 120 days of the end of the 12 month reporting period, patient s cancer has metastasized, medical contraindication/allergy, poor performance status, other medical reasons, patient refusal, other patient reasons, patient is currently enrolled in a clinical trial that precludes prescription of chemotherapy, other system reasons) AJCC Colon Cancer, Stage III documented If patient is not eligible for this measure because patient is not stage III colon cancer, report: Patient not Stage III Colon Cancer (One CPT II code [33xxF] is required on the claim form to submit this numerator option) Other Performance Exclusion: CPT II 3382F: AJCC Colon Cancer, Stage 0 documented Other Performance Exclusion: CPT II 3384F: AJCC Colon Cancer, Stage I documented Other Performance Exclusion: CPT II 3386F: AJCC Colon Cancer, Stage II documented Other Performance Exclusion: CPT II 3390F: AJCC Colon Cancer, Stage IV documented 11/17/2015 Page 2 of 11
If patient is not eligible for this measure because cancer stage is not documented, report: Cancer Stage not Documented (One CPT II code [3382F-8P] is required on the claim form to submit this category) Append a reporting modifier (8P) to CPT Category II code 3382F to report circumstances when the patient is not eligible for the measure. Other Performance Exclusion: 3382F with 8P: No documentation of cancer stage Adjuvant Chemotherapy not Referred, Prescribed or Previously Received, Reason not Given (One quality-data code & one CPT II code [G8929 & 3388F] are required on the claim form to submit this numerator option) Report G8929 in circumstances when the action described in the numerator is not performed and the reason is not given. Performance Not Met: G8929: AND CPT II 3388F: Adjuvant chemotherapy not prescribed or previously received, reason not given AJCC Colon Cancer, Stage III documented RATIONALE: The receipt of adjuvant chemotherapy in AJCC Stage III colon cancer patients following primary surgical treatment is associated with a significant survival benefit. CLINICAL RECOMMENDATION STATEMENTS: For patients with stage III disease, the panel recommends 6 months of adjuvant chemotherapy after primary surgical treatment. The treatment options are: FOLFOX or CapeOx (both category 1 and preferred); FLOX (category 1); or single-agent capecitabine or 5-FU/LV in patients for whom oxaliplatin therapy is believed to be inappropriate. (NCCN, 2015) A shortage of LV recently existed in the United States. No specific data are available to guide management under these circumstances, and all proposed strategies are empiric. The panel recommends several possible options to help alleviate the problems associated with this shortage. One is the use of levoleucovorin, which is commonly used in Europe. A dose of 200 mg/m2 of leucovorin is equivalent to 400 mg/m2 of standard LV. Another option is for practices or institutions to use lower doses of LV for all doses in all patients, because the panel feels that lower doses are likely to be as efficacious as higher doses, based on several studies. Finally, if none of the above options is available, treatment without LV would be reasonable. For patients who tolerate this without grade II or higher toxicity, a modest increase in 5-FU dose (in the range of 10%) may be considered. (NCCN, 2015) COPYRIGHT: Physician Performance Measures (Measures) and related data specifications, developed by the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI ), are intended to facilitate quality improvement activities by physicians. These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical guidelines and do not establish a standard of medical care. PCPI has not tested its Measures for all potential applications. PCPI encourages the testing and evaluation of its Measures. Measures are subject to review and may be revised or rescinded at any time by PCPI. The Measures may not be altered without the prior written approval of PCPI. Measures developed by PCPI, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for 11/17/2015 Page 3 of 11
commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association, on behalf of PCPI. Neither PCPI nor its members shall be responsible for any use of these Measures. THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND 2007 American Medical Association, American Society of Clinical Oncology, and National Comprehensive Cancer Network. All Rights Reserved. CPT contained in the Measures specifications is copyright 2004-2015 American Medical Association. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. THE SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND. CPT contained in the Measures specifications is copyright 2004-2015 American Medical Association. LOINC copyright 2004-2015 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT ) copyright 2004-2015 International Health Terminology Standards Development Organization. All Rights Reserved. Use of SNOMED CT is only authorized within the United States. 11/17/2015 Page 4 of 11
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2016 Claims Individual Measure Flow PQRS #72 NQF #0385: Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure. 1. Start with Denominator 2. Check Patient Age: a. If the Patient Age at Date of Service equal to 18 Years thru 80 Years equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing. b. If the Patient Age at Date of Service equal to 18 Years thru 80 Years equals Yes during the measurement period, proceed to check Patient Diagnosis. 3. Check Patient Diagnosis: a. If Diagnosis for Colon Cancer as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Diagnosis for Colon Cancer as Listed in the Denominator equals Yes, proceed to Check Encounter Performed. 4. Check Encounter Performed: a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Encounter as Listed in the Denominator equals Yes, include in the Eligible population. 5. Denominator Population: a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 patients in the sample calculation. 6. Start Numerator 7. Check Adjuvant Chemotherapy Referred, Prescribed or Previously Received for Stage III Colon Cancer and AJCC Colon Cancer Stage III Documented: a. If Adjuvant Chemotherapy Referred, Prescribed or Previously Received for Stage III Colon Cancer and AJCC Colon Cancer Stage III Documented equals Yes, include in Reporting Met and Performance Met. b. Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 patients in Sample c. If Adjuvant Chemotherapy Referred, Prescribed or Previously Received for Stage III Colon Cancer and AJCC Colon Cancer Stage III Documented equals No, proceed to Check Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons and AJCC Colon Cancer Stage III Documented. 11/17/2015 Page 7 of 11
8. Check Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons and AJCC Colon Cancer Stage III Documented: a. If Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons and AJCC Colon Cancer Stage III Documented equals Yes, include in Reporting Met and Performance Exclusion. b. Reporting Met and Performance Exclusion is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter b1 equals 1 patient in the Sample c. If Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons and AJCC Colon Cancer Stage III Documented equals No, proceed to Check Patient is Not Eligible for this Measure Because Patient is Not Stage III Colon Cancer. 9. Check Patient is Not Eligible for this Measure Because Patient is Not Stage III Colon Cancer: a. If Patient is Not Eligible for this Measure Because Patient is Not Stage III Colon Cancer equals Yes, include in Reporting Met and Performance Exclusion. b. Reporting Met and Performance Exclusion is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter b2 equals 0 patients in the Sample c. If Patient is Not Eligible for this Measure Because Patient is Not Stage III Colon Cancer equals No, proceed to Check No Documentation of Cancer Stage. 10. Check No Documentation of Cancer Stage: a. If Check No Documentation of Cancer Stage equals Yes, include in Reporting Met and Performance Exclusion. b. Reporting Met and Performance Exclusion is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter b3 equals 0 patients in the Sample c. If Check No Documentation of Cancer Stage equals No, proceed to Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given and AJCC Colon Cancer Stage III Documented. 11. Check Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given and AJCC Colon Cancer Stage III Documented: a. If Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given and AJCC Colon Cancer Stage III Documented equals Yes, include in the Reporting Met and Performance Not Met. b. Reporting Met and Performance Not Met letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter c equals 2 patients in the Sample c. If Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given and AJCC Colon Cancer Stage III Documented equals No, proceed to Reporting Not Met. 12. Check Reporting Not Met: a. If Reporting Not Met, the Quality Data Code or equivalent was not reported. 1 patient has been subtracted from the reporting numerator in the sample calculation. 11/17/2015 Page 8 of 11
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2015 Registry Individual Measure Flow PQRS #72 NQF #0385: Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure. 1. Start with Denominator 2. Check Patient Age: a. If the Patient Age at Date of Service equal to 18 Years thru 80 Years equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing. b. If the Patient Age at Date of Service equal to 18 Years thru 80 Years equals Yes during the measurement period, proceed to check Patient Diagnosis. 3. Check Patient Diagnosis: a. If Diagnosis for Colon Cancer as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Diagnosis for Colon Cancer as Listed in the Denominator equals Yes, proceed to Check AJCC Colon Cancer Stage III, Documented. 4. Check AJCC Colon Cancer Stage III, Documented: a. If AJCC Colon Cancer Stage III, Documented equals No, do not include in Eligible Patient Population. Stop Processing. b. If AJCC Colon Cancer Stage III, Documented equals Yes, proceed to check Encounter Performed. 5. Check Encounter Performed: a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Encounter as Listed in the Denominator equals Yes, include in the Eligible population. 6. Denominator Population: a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 patients in the sample calculation. 7. Start Numerator 8. Check Adjuvant Chemotherapy Referred, Prescribed or Previously Received for Stage III Colon Cancer: a. If Adjuvant Chemotherapy Referred, Prescribed or Previously Received for Stage III Colon Cancer equals Yes, include in Reporting Met and Performance Met. b. Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 patients in Sample 11/17/2015 Page 10 of 11
c. If Adjuvant Chemotherapy Referred, Prescribed or Previously Received for Stage III Colon Cancer equals No, proceed to Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons. 9. Check Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons: a. If Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons equals Yes, include in Reporting Met and Performance Exclusion. b. Reporting Met and Performance Exclusion is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter b equals 1 patient in the Sample c. If Adjuvant Chemotherapy Not Prescribed or Previously Received for Documented Reasons equals No, proceed to Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given. 10. Check Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given: a. If Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given equals Yes, include in the Reporting Met and Performance Not Met. b. Reporting Met and Performance Not Met letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter c equals 2 patients in the Sample c. If Adjuvant Chemotherapy Not Prescribed or Previously Received, Reason Not Given equals No, proceed to Reporting Not Met. 11. Check Reporting Not Met: a. If Reporting Not Met, the Quality Data Code or equivalent was not reported. 1 patient has been subtracted from the reporting numerator in sample calculation. 11/17/2015 Page 11 of 11