| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS646v2 |
| NQF Number | Not Applicable |
| MIPS Quality ID | 481 |
| Description |
Percentage of patients initially diagnosed with non-muscle 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 non-muscle invasive bladder cancer and a qualified encounter in the measurement period. |
| Numerator |
Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series. BCG is initiated within 6 months of the bladder cancer staging and during the measurement period. |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Equals Initial population |
| Denominator Exclusions |
Immunosuppressed 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. |
| Denominator Exceptions |
Unavailability of BCG |
| Steward | Oregon Urology |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
A higher score is the preferred result and indicates better quality |
| Guidance |
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. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
| Telehealth Eligible | No |
| Next Version | |
| Previous Version |
Compare eCQM Versions
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Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period |
|---|---|---|---|
| Title | Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancer | Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancer | Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancer |
| CMS eCQM ID | CMS646v2 | CMS646v3 | CMS646v4 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable |
| Description |
Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging. |
Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging |
Percentage of patients initially diagnosed with non-muscle 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 non-muscle invasive bladder cancer and a qualified encounter in the measurement period. |
All patients initially diagnosed with T1, Tis or high grade Ta non-muscle invasive bladder cancer and a qualified encounter in the measurement period |
All patients initially diagnosed with T1, Tis or high grade Ta non-muscle invasive bladder cancer with bladder cancer staging within 6 months before to 6 months after the start of the measurement period and a qualified encounter in the measurement period |
| Denominator |
Equals Initial population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions | Immunosuppressed 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. | Immunosuppressed 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. | Immunosuppressed patients, includes HIV and immunocompromised state, with a diagnosis prior to Bladder Cancer Staging Immunosuppressive drug therapy starting on or before Bladder Cancer Staging Active Tuberculosis diagnosis during the Bladder Cancer Staging Mixed histology urothelial cell carcinoma including micropapillary, plasmacytoid, sarcomatoid, adenocarcinoma and squamous disease prior to Bladder Cancer Staging Patients who undergo cystectomy, chemotherapy or radiation within 6 months of Bladder Cancer Staging |
| Numerator |
Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series. BCG is initiated within 6 months of the bladder cancer staging and during the measurement period. |
Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series BCG is initiated within 6 months of the bladder cancer staging and during the measurement period |
Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series: BCG is initiated within 6 months of the bladder cancer staging |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
Unavailability of BCG |
Unavailability of BCG |
Unavailability of BCG within 6 months after Bladder Cancer Staging |
| Measure Steward | Oregon Urology | Oregon Urology | Oregon Urology |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure |
| Improvement Notation |
A higher score is the preferred result and indicates better quality |
A higher score is the preferred result and indicates better quality |
A higher score is the preferred result and indicates better quality |
| Guidance |
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. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
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. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
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. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| MIPS Quality ID | 481 | 481 | 481 |
| Telehealth Eligible | No | No | No |
| Next Version | CMS646v3 | No Version Available | No Version Available |
| Previous Version |
Data Element Repository
Header
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Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
-
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
-
Updated the Rationale to reflect current citations and statistics.
Measure Section: Rationale
Source of Change: Measure Lead
-
Updated references.
Measure Section: Reference
Source of Change: Annual Update
-
Corrected spelling of 'immunosupppressed' to 'immunosuppressed' for accuracy.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
-
Replaced 'overlaps' with 'during' the measurement period for clarity.
Measure Section: Numerator
Source of Change: Annual Update
-
Replaced 'None' with 'Not Applicable' to conform with Blueprint recommended language.
Measure Section: Numerator Exclusions
Source of Change: Annual Update
-
Updated punctuation for 'nonmuscle' to 'non-muscle' for consistency.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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Changed timing in the Bladder Cancer Diagnosis definition from 'starts same day or before' to 'starts before' end of measurement period to reflect measure intent.
Measure Section: Initial Population
Source of Change: Measure Lead
-
Changed timing in the Most Recent Bladder Cancer Staging Procedure definition to 'overlaps day of' bladder cancer prevalence period to correctly meet measure intent.
Measure Section: Initial Population
Source of Change: Measure Lead
-
Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards Update
-
Changed timing in the Acute Tuberculosis Diagnosis definition to allow for a resolved diagnosis to no longer be excluded from the measure.
Measure Section: Multiple Sections
Source of Change: Expert Work Group Review
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Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Changed spelling in 'Has Most Recent Bladder Cancer Tumor Staging isTa HG, Tis, T1' to'Has Most Recent Bladder Cancer Tumor Staging is Ta HG, Tis, T1' for accuracy.
Measure Section: Definition
Source of Change: Measure Lead
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Changed 'BCG Not Available' definition to 'BCG Not Available Within 6 Months After Bladder Cancer Staging' for clarity.
Measure Section: Definition
Source of Change: Measure Lead
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value set Immunosuppressive Drugs for Urology Care (2.16.840.1.113762.1.4.1151.32): Deleted 3 RxNorm codes (1654082, 199343, 199967) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Renamed value set Immunocompromised Conditions (2.16.840.1.113883.3.666.5.1940) based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Immunocompromised Conditions (2.16.840.1.113883.3.666.5.1940): Deleted 1 SNOMED CT code (404132005) based on terminology update. Added 3 ICD-10-CM codes (D84.81, D84.821, D84.822) based on new or changed coding guidelines.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Chemotherapy for Advanced Cancer (2.16.840.1.113883.3.7643.3.1048): Deleted 15 RxNorm codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 10 SNOMED codes (838377003, 840498003, 10755671000119100, 15928141000119107, 771119002, 771126002, 771127006, 72631000119101, 79019005, 840442003) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update