Percentage of final reports for computed tomography/computed tomography angiography (CT/CTA) of the abdomen or abdomen/pelvis or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) of the abdomen for patients 18 years of age and older with a pancreatic cyst incidentally noted that include documentation of cyst classification/morphology and follow-up imaging recommendation(s) in accordance with published guidelines and source of recommendation.
Submission Method: Registry
Reporting Breast Arterial Calcification (BAC) on Screening Mammography
Percentage of Final Screening Mammography Reports for female patients aged 40 years or older that include documentation of the presence or absence of Breast Arterial Calcification (BAC) and its clinical relevance.
Use of Appropriate Classification System for Lymphoma Specimen
Percentage of Final Lymphoma Specimen Pathology Reports, regardless of patient age, that classify the lymphoma using a validated and published model for lymphoma classification**.
** Must be one of the models listed in the Numerator Instructions below.
Appropriate Use of Bethesda System for Reporting Thyroid Cytopathology on Fine Needle Aspirations (FNA) of Thyroid Nodule(s)
Percentage of final pathology reports for thyroid nodule fine needle aspiration (FNA) specimens that include documentation of the diagnostic category, range of estimated risk of malignancy (ROM), and clinical management options in accordance with the Bethesda System for Reporting Cytopathology, 3rd edition (2023), and for thyroid nodule specimens of indeterminate cytology (Bethesda 3 or 4), documentation that direct communication was sent to patient and/or treating physician (if known) to inform them that molecular panel testing may be appropriate.
Intracerebral Hemorrhage (ICH) on Non-Contrast CT Head
All patients 18 years of age and older undergoing non-contrast CT (NCCT) Head with an initial diagnosis of intracerebral hemorrhage (ICH), also referred to as intra-axial or
intraparenchymal hemorrhage (IPH), who have documentation of the location of ICH, ICH volume, and presence or absence of intraventricular hemorrhage (IVH) in the Final Report.
Immunohistochemistry (IHC) and/or Molecular BRAF Testing Status in Metastatic Melanoma
Percentage of final immunohistochemical staining reports for patients with an initial diagnosis of metastatic melanoma that contain a recommendation for or the results of BRAF testing (either by immunohistochemistry (IHC) and/or molecular testing).
Antiemetic Therapy for Low- and Minimal-Emetic-Risk Antineoplastic Agents – Avoidance of Overuse (Lower Score – Better)
Percentage of cancer patients aged 18 years and older treated with low- or minimal-emetic-risk antineoplastic agents who are administered inappropriate pre-treatment antiemetic therapy
Appropriate Antiemetic Therapy for High- and Moderate-Emetic-Risk Antineoplastic Agents
Percentage of cancer patients aged 18 years and older treated with high- or moderate-emetic-risk antineoplastic agents who are administered appropriate pre-treatment antiemetic therapy
Oncology: Screening and Achieving Resolution or Improvement of Distress for Cancer Care
Percentage of patients 18 years and older with an active cancer diagnosis who are screened for distress AND if screen is positive, achieve resolution or improvement within 6 months for at least 1 of their concerns.
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
1) Patients 18 years and older with an active cancer diagnosis who are screened for distress using a comprehensive, standardized tool which assesses physical, emotional, social, practical, and spiritual concerns.
AND
2) Patients 18 years and older with an active cancer diagnosis who screen positive for distress using a comprehensive, standardized screening tool and achieve resolution or improvement within 6 months for at least 1 of their concerns.
The measure contains two submission criteria which aim to identify patients who were screened for distress (Submission Criteria 1) and of those patients who screened positive for distress, did corresponding interventions following a positive distress screening lead to meaningful improvement or resolution within 6 months (Submission Criteria 2). By separating this measure into various submission criteria, the MIPS eligible clinician or practice will be able to better ascertain where gaps in performance exist and identify opportunities for improvement. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance.
Use of Peripheral Nerve Block within the Emergency Department in Patients Admitted with Low Energy Hip Fracture
Percentage of patients aged 65 years and older that receive a peripheral nerve block for analgesia following diagnosis of isolated hip fracture within the Emergency Department