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

General eCQM Information

CMS Measure ID CMS646v2
NQF Number Not Applicable
Measure 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.
Denominator Statement

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.

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 during the measurement period.

Numerator Exclusions

Not Applicable

Denominator Exceptions

Unavailability of BCG

Measure Steward Oregon Urology
Domain Effective Clinical Care
Measure Scoring Proportion
Measure Type Process
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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Meaningful Measure Appropriate Use of Healthcare
Telehealth Eligible No

Release Notes

Header

  • 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

  • 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

  • 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

  • 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

  • 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.

  • 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

  • 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

  • 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

  • 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

  • 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

Last Updated: Jul 08, 2021