Measure Type: High Priority

Percentage of patients, aged 18 years and older, with cirrhosis of the liver, regardless of etiology, who undergo CT/CTA of the abdomen or abdomen/pelvis, MRI of the abdomen, or abdominal US in which the final report:
Mentions that patients with cirrhosis of the liver have a higher risk of developing hepatocellular carcinoma (HCC),
AND
Includes a recommendation to consider the patient for semi-annual hepatocellular carcinoma (HCC) screening/surveillance.

The percentage of final reports for screening mammograms which include the patient’s estimated numeric risk assessment based on a valid and published model**, and appropriate recommendations for supplemental screening based on the patient’s estimated risk and documentation of the source of recommendation.
** Must be one of the models listed in the numerator instructions of this measure specification.

The percentage of Final Bone Marrow Aspirate Reports of patients with Leukemia, Myelodysplastic syndrome, or Chronic Anemia with documentation of concurrent studies performed, their respective results, and interpretation of those results.

Percentage of emphysema patients, aged 50-80 at the time of service, who undergo a CT/CTA of the chest in which the Final Report:
1) Mentions that the presence of pulmonary emphysema on CT is an independent risk factor for lung cancer, AND
2) Includes a recommendation to consider the patient for low dose CT (LDCT) lung cancer screening in the future (current chest CT serves as a baseline).

The percentage of Final Reports on Urine cytology specimens, for patients of any age, that utilize The Paris System (TPS) for reporting urinary cytology.

Percentage of patients, aged 50-years-old or older, who have had a screening ultrasound for an abdominal aortic aneurysm (AAA), with positive or negative findings, that have recognized clinical follow-up recommendations documented in the final report and direct communication of findings greater than or equal to 5.5 cm in size made to the ordering provider.

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.

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.

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.

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).