pqrs #72 nqf #0385: colon cancer: chemotherapy … if patient is not eligible for this measure...

Version 10.0 CPT only copyright 2015 American Medical Association. All rights reserved. 11/17/2015 of 11

Measure #72 (NQF 0385): Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients – National Quality Strategy Domain: Effective Clinical Care

2016 PQRS OPTIONS FOR 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/OR CPT Category II code OR 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.

DENOMINATOR: 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

NUMERATOR: Patients who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or who have previously received adjuvant chemotherapy within the 12 month reporting period

Definitions:


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 OR patient already receiving adjuvant chemotherapy as documented in the current medication list.

NUMERATOR 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: Adjuvant chemotherapy referred, prescribed or

previously received for AJCC Stage III, colon cancer AND CPT II 3388F: AJCC Colon Cancer, Stage III documented

OR 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: Adjuvant chemotherapy not prescribed or previously

received, for documented reasons (e.g., medical co-morbidities, 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)

AND CPT II 3388F: AJCC Colon Cancer, Stage III documented

OR

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 OR Other Performance Exclusion: CPT II 3384F: AJCC Colon Cancer, Stage I documented OR Other Performance Exclusion: CPT II 3386F: AJCC Colon Cancer, Stage II documented OR Other Performance Exclusion: CPT II 3390F: AJCC Colon Cancer, Stage IV documented


OR

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

OR 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: Adjuvant chemotherapy not prescribed or previously

received, reason not given AND CPT II 3388F: 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)

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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 Calculation.

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.


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 Calculation.

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 Calculation.

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 Calculation.

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 Calculation.

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.


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 Calculation.


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 Calculation.

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 Calculation.

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.

pqrs #72 nqf #0385: colon cancer: chemotherapy … if patient is not eligible for this measure...

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