2021 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.

Beginning January 1, 2021, the following measures have been combined into a single quality measure:

• CAP 13, CAP 16, and CAP 19 are now CAP 34: Biomarker Status to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer
• CAP 18 and CAP 31 (with gastroesophageal and small bowel carcinoma added) are now CAP 33: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma
• Several of the Cancer Protocol measures have been combined into two measures:
  • CAP 35: Cancer Protocol and Turnaround Time for Gastrointestinal Carcinomas: Gastric, Esophageal, Colorectal and Hepatocellular Carcinomas
  • CAP 37: Cancer Protocol for Gynecologic and Genitourinary Carcinomas: Carcinoma of the Endometrium, Prostate, and of Renal Tubular Origin

For quality measure CAP 32: Prostate Cancer Gleason Pattern, Score, and Grade Group, the denominator now includes biopsy specimens as well as resection specimens

Quality measure CAP 20 has been simplified and is now CAP 36: p16 Immunohistochemistry Reporting for Human Papillomavirus in Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)

• First stratum removed; numerator is now documentation of p16 testing for high-risk HPV in oropharyngeal tumors using the 70% nuclear and cytoplasmic staining cutoff
• Denominator remains the same

Quality measures CAP 9, 10, 11, 12, 15, 17, 21, 24, 25, and 29 have been retired for 2021

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

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

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

* = high-priority measure

ǂ = new measure for 2021
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.

• 2021 MIPS Claims-Based Data Reporting Instruction Sheet
• 2021 QPP Reporting Codes
• 2020 MIPS Claims-Based Quality Measure Benchmarks
• 2021 MIPS Claims-Based Quality Measure Benchmarks