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.

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

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

• Overview of the 2022 Changes to the QPP Measures
• 2022 QPP Measures Summary with Examples

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

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).

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

* = 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

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.

• 2022 MIPS Claims-Based Data Reporting Instruction Sheet
• 2022 QPP Reporting Codes
• 2022 MIPS Claims-Based Quality Measure Benchmarks
• 2021 MIPS Claims-Based Quality Measure Benchmarks