2022 Pathology Quality Measures

The Pathologists Quality Registry offers 15 quality measures. Six are Merit-based Incentive Payment System (MIPS) clinical quality measures (CQMs). The remaining 9 are specific pathology measures, all developed by the CAP and approved by the CMS as qualified clinical data registry (QCDR) measures—exclusively available in the Pathologists Quality Registry. To better understand how to review and interpret measure specifications, the CMS has developed Quality Payment Program Measure Specification and Measure Flow Guide for MIPS Clinical Quality Measures.

Important 2022 Updates

Quality measure QPP 395 (Lung Cancer Reporting: (Biopsy/Cytology Specimens)) has been modified to align numerator guidance with current recommendations

  • Pathology reports for non-small cell lung cancer specimens must document specific histological type of cancer (as in 2021) and histologic type must follow IASLC guidance by avoiding the phrases “large cell carcinoma”, “AIS (adenocarcinoma in situ)”, “MIA (minimally invasive adenocarcinoma)”, and “BAC (bronchioloalveolar carcinoma)”

Quality measure QPP 397 (Melanoma Reporting) has been modified to align with current recommendations for pathology reporting

  • Pathology reports for cutaneous primary melanoma must document pT category, thickness, ulceration, and mitotic rate (as in 2021) and also peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors

Quality measure CAP 32: Prostate Cancer Gleason Pattern, Score, and Grade Group, has been re-numbered as CAP 38 with the addition of a data element to the numerator

  • Pathology reports for specimens in grade groups 2 and 3 now require percent of pattern 4 as well as pattern(s) and score.

Additional specificity has been provided for Denominator Exceptions for several measures: CAP 30, 34, 36 and 38 (formerly 32)

  • Previously Denominator Exception was indicated as medical reason for not performing the quality action
  • To provide additional guidance, Denominator Exceptions now describe appropriate medical reasons such as insufficient tissue or no residual carcinoma

Pathology Specific QPP Measures

These measures can be reported to the CMS using the Pathologists Quality Registry, through billing/claims, and other registries.

QPP 249: Barrett Esophagus Pathology Reporting Registry and Claims Specifications
QPP 250: Radical Prostatectomy Pathology Reporting Registry and Claims Specifications
QPP 395: Lung Cancer Reporting (biopsy/cytology specimens) Registry and Claims Specifications
QPP 396: Lung Cancer Reporting (resection specimens) Registry and Claims Specifications
QPP 397: Melanoma Reporting Registry and Claims Specifications

These measures can be reported to the CMS using the Pathologists Quality Registry and other registries.

QPP 440: Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician Registry Specifications (American Academy of Dermatology measure)

Scores for the QPP measures depend on the benchmarks CMS sets for each measure. All pathology QPP measures are worth a maximum of 7 points.

Estimate your score by viewing the QPP Measure Benchmarks (coming soon).

Pathologists Quality Registry QCDR Measures

These measures can be reported to the CMS only with the Pathologists Quality Registry.

CAP22: Turnaround Time (TAT) – Biopsies
CAP28: Helicobacter pylori Status and Turnaround Time*
CAP30: Urinary Bladder Biopsy Diagnostic Requirements For Appropriate Patient Management
CAP33: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma
CAP34: Biomarker Status to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer
CAP35: Cancer Protocol and Turnaround Time for Gastrointestinal Carcinomas: Gastric, Esophageal, Colorectal and Hepatocellular Carcinomas
CAP36: p16 Immunohistochemistry Reporting for Human Papillomavirus in Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)
CAP37: Cancer Protocol for Gynecologic and Genitourinary Carcinomas: Carcinoma of the Endometrium, Prostate, and of Renal Tubular Origin
ǂ CAP38: Prostate Cancer Reporting Best Practices*

* = Performance period benchmark for 2020

ǂ = new measure for 2022

In 2021, four QCDR measures received performance year benchmarks and are therefore worth up to 10 points. CMS will create a performance year benchmark for any measure that has at least 20 practices submitting it in 2021. View the Performance Year 2021 QCDR Measure Benchmarks

The CMS recommends that eligible professionals check with the QPP HelpDesk for more information on measures and the QPP.
Professionals may contact the QPP Help Desk.
7:00 AM–7:00 PM CT Monday - Friday
Email: QPP@cms.hhs.gov
Phone: 866-288-8292

Suggest New Quality Measures

The CAP wants to know what matters to pathologists for quality measures. Submit your ideas for measure concepts today! Access the measure concept intake form or contact mips@cap.org for more information about nominating a concept.

Claims-based Reporting Information

The CAP developed an instruction sheet on claims-based reporting to assist with submitting data on quality measures for MIPS through claims. The corresponding document provides the CPT II and quality data codes (QDC) and descriptors for the 2021 QPP measures.

For the 2021 Reporting Period

Pathologists in a group of 16 or more clinicians cannot submit quality measures using claims regardless of whether participating as an individual or a group.

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