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Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancer

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Measure Information 2023 Performance Period
CMS eCQM ID CMS646v3
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 5.6. Please refer to the QDM page for more information on the QDM.
Telehealth Eligible No
Next Version No Version Available
Previous Version
CMS646v2

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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 StagingImmunosuppressive drug therapy starting on or before Bladder Cancer StagingActive Tuberculosis diagnosis during the Bladder Cancer StagingMixed histology urothelial cell carcinoma including micropapillary, plasmacytoid, sarcomatoid, adenocarcinoma and squamous disease prior to Bladder Cancer StagingPatients 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
CMS646v3
CMS646v2
CMS646v3
Notes
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Specifications
Attachment Size
CMS646v3.html 78.16 KB
CMS646v3.zip 80.27 KB
CMS646v3-TRN.xlsx 20.99 KB

Data Element Repository

Value Sets
Value Sets to be used with CMS646v3
CMS646v3-TRN.xlsx

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated citations to align with APAv6 Style Guide standards.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Updated grammar, punctuation, and formatting to improve readability.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Restructured denominator exclusion definitions into a group to streamline by combining definitions with the same timing.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Removed one set of open brackets from each exclusion definition to comply with the CQL Style Guide.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Revised timing from 'end Measurement Period' to 'end of Measurement Period' in the 'Bladder Cancer Diagnoses' definition to improve readability.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced 'Bladder Cancer Diagnoses' definition in the initial population with 'First Bladder Cancer Staging Procedure during Measurement Period' to align with measure intent to capture patients whose first bladder cancer staging occurred during the measurement period.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Replaced direct reference code SNOMED CT code (258232002) with direct reference code SNOMED CT code (254292007).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated logic using the new QDM 5.6 'Encounter, Performed' class attribute to exclude telehealth (or virtual) encounters using the logical representation (class !~ virtual), for measures containing telehealth-eligible codes, where telehealth is not appropriate. For more information, please refer to the 2023 Telehealth Guidance document.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

Value set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Immunocompromised Conditions (2.16.840.1.113883.3.666.5.1940): Deleted 1 SNOMED CT code (404145009) based on new or changed coding guidelines. Deleted 1 ICD-10-CM code (D84.8) based on new or changed coding guidelines.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced direct reference code SNOMED CT code (258232002) with direct reference code SNOMED CT code (254292007) based on terminology updates and review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Added 6 ICD-10-CM codes (O98.711, O98.712, O98.713, O98.719, O98.72, O98.73) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code ActCode code (VR) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 02, 2023