Product Lines:
Advantage MD.

Measurement Period: January 1 - December 31

Description: 
The percentage of men 70 years and older who were screened unnecessarily for prostate cancer using prostate-specific antigen (PSA)-based screening.

Improvement Notation:
Decreased score indicates improvement.

Data Collection:

• Administrative.
  

Note: Supplemental data may not be used for this measure, except for denominator exclusions.

Initial Population:

• Measure Item Count: Person.
• Age: 70 years of age and older as of the last day of the measurement period.
• Gender/sex criteria: Administrative Gender of Male (AdministrativeGender code male) any time in the person’s history.
• Benefits: Medical.
• Continuous Enrollment: During the treatment period.
• Allowable Gap: No gaps.

Denominator:
The initial population minus denominator exclusions.

Numerator:
A PSA-based screening test performed during the measurement year.

Summary of changes:
Added an administrative gender code to the initial population.

Best Practice and Measure Tips

• This measure focus on unnecessary screening for prostate cancer using prostate-specific antigen (PSA)-based screening.
• The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.
• According to the National Institutes of Health (NIH) Routine screening should be discontinued in men with a life expectancy of 10 years or less based on comorbidities.
• Engage in a comprehensive discussion, providing education to patients on the goal of screening for prostate cancer and the screening recommendations.
• Avoid testing for Low-risk patients (i.e. No prior family history of prostate cancer; No prior history of elevated PSA test).

Measure Exclusions 

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died any time during the measurementperiod.
• Persons with a diagnosis or event for which PSA-based testing is clinically appropriate. Any of the following meet criteria:
  • Prostate cancer diagnosis any time during the member’s history through December 31 of the measurement period.
  • Dysplasia of the prostate any time during the measurement year or the year prior to the measurement period.
  • A PSA test during the year prior to the measurement period, where laboratory data indicate an elevated result (>4.0 nanograms/milliliter [ng/mL]).
  • An abnormal PSA test result or finding during the year prior to the measurement period.
  • Dispensed prescription for a 5-alpha reductase inhibitor during the measurement period.
    • 5 ARI Medications: Finasteride and Dutasteride

Exclusion Codes

Prostate Cancer and History of Prostate Cancer

• ICD-10-CM: C61, D07.5, D40.0, Z15.03, Z85.46
• SNOMED CT US Edition: 92691004, 93974005, 94503003, 95014000, 254900004, 255149000, 278060005, 314969001, 369485004, 369486003, 396198006, 399068003, 399490008, 399590005, 427492003, 428262008, 446711009, 448213004, 448217003, 449318001, 712849003, 715412008, 722103009, 822970008, 823017009, 1208457007, 1237422007, 1240353009, 1240359008, 1251485006, 1259388006, 1259598001, 1259666003, 1259669005, 1259672003, 1259674002, 1259710009, 1264500002, 96901000119105, 353091000119100, 353101000119105, 459381000124106, 681221000124106, 1098981000119101[

Prostate Dysplasia

• ICD-10-CM: N42.30, N42.31, N42.32, N42.39
• SNOMED CT US Edition: 254901000, 445068007, 446710005, 446711009, 74411000119100[

PSA Lab Test Exclusion

• • CPT: 84153
• HCPCS: G0103
• LOINC: 2857-1, 35741-8, 83112-3[

Abnormal PSA Test Result or Finding

• SNOMED CT: 166160000, 396152005

Measure Codes

PSA Lab Test

• CPT: 84152, 84153, 84154
• HCPCS: G0103
• LOINC: 10886-0, 12841-3, 2857-1, 33667-7, 35741-8, 83112-3, 83113-1

PSA Test Result or Finding

• SNOMED CT: 166159005, 166160000, 396152005