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).
Measure Type: Process
Use of Structured Reporting for Urine Cytology Specimens
The percentage of Final Reports on Urine cytology specimens, for patients of any age, that utilize The Paris System (TPS) for reporting urinary cytology.
Screening Abdominal Aortic Aneurysm Reporting with Recommendations
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.
Appropriate Classification and Follow-up Imaging for Incidental Pancreatic Cysts
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.
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).
Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy
Proportion of stage IV nsNSCLC patients tested for actionable biomarkers and received targeted therapy or chemotherapy based on biomarker results