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.

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.

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.

For 2023, QPP 491, a new measure in the pathology measure set, received a performance year benchmark. View the Performance Year 2023 Benchmark for QPP 491. This measure is worth between 7 and 10 points for 2023 scoring.

Scores for the QPP measures depend on the benchmarks CMS sets for each measure. Estimate your score by viewing the QPP Measure Benchmarks.

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

* = Performance period benchmark for 2022

ǂ = new measure for 2023

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 are now available.

For 2023, three QCDR measures received performance year benchmarks and are worth up to 10 points. View the Performance Year 2023 QCDR Measure Benchmarks.

For 2023, two QCDR measures have historical benchmarks. Estimate your score by viewing the QCDR Measure Benchmarks.

The CMS recommends that eligible professionals check with the QPP Help Desk 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 measures@cap.org for more information about nominating a concept.

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.

• 2023 MIPS Claims-Based Data Reporting Instruction Sheet
• 2023 QPP Reporting Codes
• 2023 MIPS Claims-Based Quality Measure Benchmarks
• 2022 MIPS Claims-Based Quality Measure Benchmarks