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Intravesical Bacillus-Calmette-Guerin for nonmuscle invasive bladder cancer

Pre-Rulemaking eCQMs

General eCQM Information

CMS Measure ID CMS646v1
NQF Number None
Measure Description

Percentage of patients initially diagnosed with nonmuscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging.

Initial Population All patients initially diagnosed with T1, Tis or high grade Ta nonmuscle invasive bladder cancer and a qualified encounter in the measurement period.
Denominator Statement

Equals Initial population

Denominator Exclusions

Immunosupppressed patients, includes HIV and immunocompromised state.

Immunosuppressive drug therapy.

Active Tuberculosis.

Mixed histology urothelial cell carcinoma including micropapillary, plasmacytoid, sarcomatoid, adenocarcinoma and squamous disease.

Patients who undergo cystectomy, chemotherapy or radiation within 6 months of Bladder Cancer Staging.

Numerator Statement

Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series.

BCG is initiated within 6 months of the bladder cancer staging and overlaps the measurement period.

Numerator Exclusions


Denominator Exceptions

Unavailability of BCG

Measure Steward Oregon Urology
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

A higher score is the preferred result and indicates better quality


Ta bladder cancer must be high grade Ta only and is supported by the 2016 AUA guidelines and 2018 NCCN guidelines.

The BCG dose can be full or partial and can be from any lot or manufacturer.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Meaningful Measure Appropriate Use of Healthcare
Last Updated: Dec 18, 2020