2023 Pathology Quality Measures

The Pathologists Quality Registry offers 13 quality measures. Seven are Merit-based Incentive Payment System (MIPS) clinical quality measures (CQMs). The remaining 6 are pathology measures 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 2023 Updates

Quality measure CAP 33: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma, has been changed from a QCDR measure to a QPP measure, meaning it is available for all pathologists to use.

  • There is no change to the specification from the 2022 version (CAP 33) to the 2023 version (QPP 491).

Quality measure CAP 22: Turnaround Time (TAT)—Biopsies has a change to the Denominator Exclusion criteria at the request of CMS.

  • This measure now EXCLUDES certain specimen types that are captured in other measures: gastric biopsies for gastritis and urinary bladder biopsies for urothelial carcinoma.

Quality measure CAP 39: High-Risk Human Papillomavirus Status to Inform Patient Prognosis in Oropharyngeal Squamous Cell Carcinoma is an updated version of previous measure CAP 36.

  • This measure now includes fine needle aspiration specimens as well as biopsies and resections. The available tests for HR-HPV have also been updated to reflect the new specimen types.

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)
ǂ QPP 491: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma Registry Specifications

Scores for the QPP measures depend on the benchmarks CMS sets for each measure. 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*
CAP34: Biomarker Status to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer
CAP38: Prostate Cancer Reporting Best Practices*
ǂ CAP 39: High-Risk Human Papillomavirus Status to Inform Patient Prognosis in Oropharyngeal Squamous Cell Carcinoma

* = Performance period benchmark for 2022

ǂ = new measure for 2023

In 2021, four QCDR measures received performance year benchmarks and were therefore worth between 3 and 10 points. View the Performance Year 2021 QCDR Measure Benchmarks.

In 2022, four QCDR measures were eligible for performance year benchmarks and were therefore worth between 3 and 10 points (CAP 33 is no longer a QCDR measure in 2023). Performance Year 2022 QCDR Measure Benchmarks will be available in summer of 2023.

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 measures@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 2023 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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