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*RETIRED* Clinical Quality Measures Report - Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer

 

***As of 2017, this Quality Measure has been retired by CMS. It is no longer able to be reported for Meaningful Use nor MIPS Quality measures. MacPractice maintains this documentation only for reference.***

Overview
Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER, or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period

  • Denominator
    • The patient must be a female 18 years old or older
    • They must be diagnosed with Breast Cancer in the last 5 years prior to their first visit within the filtered date range, indicated with the listed ICD-9, ICD-10, or snomed codes in the report footer an an Onset Date on the diagnosis
    • They must be seen at least twice during the filtered date range, indicated with the listed CPT codes in the report footer
    • They must have a Breast Cancer ER or PR Positive diagnosis, indicated with the listed snomed codes in the report footer. This must be dated before their Breast Cancer diagnosis, indicated with the Onset Date of the diagnosis code
    • They must have a Breast Distant Metastasis M0 snomed code entered in the EMR or EHR form with a Start Date after the Breast cancer diagnosis
    • They need a Clinical Staging procedure snomed code entered in the EMR or EHR form with a Start Date after the Diagnoses and before the Procedure Date of their first office visit
    • The Clinical Staging Procedure snomed code needs a Breast Cancer Regional Lymph Node Status N3 snomed codes entered in as the CQM Value on the Clinical Staging Procedure snomed code itself
    • They need an additional indication of one of the following, entered in as CQM Values on additional Clinical Staging Procedure snomed codes-
      • Breast Cancer Regional Lymph Node Status N3
      • Breast Cancer Primary Tumor Size T0, T1, T1a, T1b, T1c, or T1mi and Breast Cancer Regional Lymph Node Status N1, pN1a, pN1b, pN1c, pN1mi, or N2
      • Breast Cancer Primary Tumor Size T2, T3, or T4 Breast Cancer Regional Lymph Node Status N0, N1, or N2
      • Breast Cancer Primary Tumor Size T1c and Breast Cancer Regional Lymph Node Status N0
  • Numerator
    • A Tamoxifen or Arimatase Inhibitor medication needs to be prescribed before or during their visit
  • Exclusions
    • Any patient that has been seen for Radiation Therapy II or Chemotherapy or has had a Bilateral Oophorectomy is excluded from the requirements of this report and thus removed from the denominator
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