2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY

Transcription

1 Measure #71 (NQF 0387): Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS F INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for all female patients with breast cancer seen during the reporting period. Review estrogen receptor (ER) or progesterone receptor (PR) AND breast cancer stage status AND tumor size to determine which quality-data codes should be submitted. It is anticipated that clinicians who treat female breast cancer patients will submit this measure. Measure Reporting via Claims: ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. CPT Category II codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed ICD-10-CM diagnosis codes, CPT codes, and the appropriate CPT Category II codes the CPT Category II code(s) with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: ICD-10-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. The listed numerator options are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINAT: All female patients aged 18 years and older with a diagnosis of breast cancer with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer Denominator Criteria (Eligible Cases): Patients aged 18 years on date of encounter AND Diagnosis for breast cancer (ICD-10-CM): C50.011, C50.012, C50.019, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C AND Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, NUMERAT: Patients who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period Definition: 11/17/2015 Page 1 of 16

2 Prescribed Prescribed may include prescription given to the patient for tamoxifen or aromatase inhibitor (AI) at one or more visits in the 12-month period patient already taking tamoxifen or aromatase inhibitor (AI) as documented in the current medication list. NUMERAT NOTE: The correct combination of numerator code(s) must be reported on the claim form in order to properly report this measure. The correct combination of codes may require the submission of multiple numerator codes. Numerator Quality-Data Coding Options for Reporting Satisfactorily: Tamoxifen or Aromatase Inhibitor Prescribed (Three CPT II codes [4179F & 337xF & 3315F] are required on the claim form to submit this numerator option) Performance Met: CPT II 4179F: AND CPT II 3374F: CPT II 3376F: CPT II 3378F: AND CPT II 3315F: Tamoxifen or aromatase inhibitor (AI) prescribed AJCC Breast Cancer Stage I: TIC (tumor size > 1 cm to 2 cm), documented AJCC Breast Cancer Stage II documented AJCC Breast Cancer Stage III documented Estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer Tamoxifen or Aromatase Inhibitor not Prescribed for Medical, Patient, or System Reasons (Three CPT II codes [4179F-xP & 337xF & 3315F] are required on the claim form to submit this numerator option) Append a modifier (1P, 2P or 3P) to CPT Category II code 4179F to report documented circumstances that appropriately exclude patients from the denominator. Medical Performance Exclusion, Patient Performance Exclusion, or System Performance Exclusion: 4179F with 1P: 4179F with 2P: 4179F with 3P: AND CPT II 3374F: Documentation of medical reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient s disease has progressed to metastatic; patient is receiving a gonadotropin-releasing hormone analogue, patient has received oophorectomy, patient is receiving radiation or chemotherapy, patient s diagnosis date was > 5 years from reporting date, patient s diagnosis date is within 120 days of the end of the 12-month reporting period, other medical reasons) Documentation of patient reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient refusal, other patient reasons) Documentation of system reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient is currently enrolled in a clinical trial, other system reasons) AJCC Breast Cancer Stage I: T1C (tumor size > 1 cm to 2 cm), documented 11/17/2015 Page 2 of 16

3 CPT II 3376F: CPT II 3378F: AND CPT II 3315F: AJCC Breast Cancer Stage II documented AJCC Breast Cancer Stage III documented Estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer If patient is not eligible for this measure because patient is not stage IC through IIIC breast cancer, report: Patient not Stage IC through IIIC Breast Cancer (One CPT II code [33xxF] is required on the claim form to submit this numerator option) Note: If reporting a code from the category below (3370F or 3372F or 3380F), it is not necessary to report the patient s ER/PR status. Other Performance Exclusion: CPT II 3370F: Other Performance Exclusion: CPT II 3372F: Other Performance Exclusion: CPT II 3380F: AJCC Breast Cancer Stage 0, documented AJCC Breast Cancer Stage I: T1 mic, T1a or T1b (tumor size 1 cm), documented AJCC Breast Cancer Stage IV documented If patient is not eligible for this measure because patient is estrogen receptor (ER) and progesterone receptor (PR) negative, report: Patient is Estrogen Receptor (ER) and Progesterone Receptor (PR) Negative (One CPT II code [3316F] is required on the claim form to submit this numerator option) Note: If reporting code 3316F, it is not necessary to report the patient s AJCC Cancer Stage. Other Performance Exclusion: CPT II 3316F: Estrogen receptor (ER) and progesterone receptor (PR) negative breast cancer If patient is not eligible for this measure because the cancer stage is not documented the ER/PR is not documented, report: Cancer Stage not Documented ER/PR not Documented (One CPT II code [33xxF-8P] is required on the claim form to submit this numerator option) Append a reporting modifier (8P) to CPT Category II codes 3370F or 3316F to report circumstances when the patient is not eligible for the measure. Other Performance Exclusion: 3370F with 8P: Other Performance Exclusion: 3316F with 8P: No documentation of cancer stage No documentation of estrogen receptor (ER) and progesterone receptor (PR) status Tamoxifen or Aromatase Inhibitor not Prescribed, Reason not Otherwise Specified (Three CPT II codes [4179F-8P & 337xF & 3315F] are required on the claim form to submit this numerator option) Append a reporting modifier (8P) to CPT Category II code 4179F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 11/17/2015 Page 3 of 16

4 Performance Not Met: 4179F with 8P: AND CPT II 3374F: CPT II 3376F: CPT II 3378F: AND CPT II 3315F: Tamoxifen or aromatase inhibitor not prescribed, reason not otherwise specified AJCC Breast Cancer Stage I: TIC (tumor size > 1 cm to 2 cm), documented AJCC Breast Cancer Stage II documented AJCC Breast Cancer Stage III documented Estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer RATIONALE: Despite evidence suggesting the role of adjuvant endocrine therapy in lowering the risk of tumor recurrence, many female patients who should be receiving this therapy are not. This measure assesses whether patients with a certain stage of breast cancer (IC through IIIC) and ER/PR+ are currently receiving the therapy. There are allowable medical, patient, and system reasons to document instances in which a woman with stage IC through IIIC, ER/PR+ may not be a candidate for the therapy. Note: The reporting/managing physician does not need to have actually written the prescription; however, the reporting/managing physician must verify that the patient already has been prescribed the hormonal therapy by another physician. CLINICAL RECOMMENDATION STATEMENTS: 1. Women diagnosed with hormone receptor-positive breast cancer who are pre- or perimenopausal should be offered adjuvant endocrine therapy with: a. Tamoxifen for an initial duration of 5 years. b. After 5 years, women should receive additional therapy based on menopausal status. i. If women are pre- or perimenopausal, or if menopausal status is unknown or cannot be determined, they should be offered continued tamoxifen for a total duration of 10 years. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) ii. If women have become definitively postmenopausal, they should be offered continued tamoxifen for a total duration of 10 years or switching to up to 5 years of an aromatase inhibitor (AI), for a total duration of up to 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality for tamoxifen: High, Evidence Quality for AI: High, Strength of Recommendation: Strong) 2. Women diagnosed with hormone receptor-positive breast cancer who are postmenopausal should be offered adjuvant endocrine therapy with one of the following options: a. Tamoxifen for a duration of 10 years. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) Or b. An AI for a duration of 5 years. There are insufficient data currently to recommend an AI for a duration of greater than 5 years. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) Or 11/17/2015 Page 4 of 16

5 c. Tamoxifen for an initial duration of 5 years, then switching to an AI for up to 5 years, for a total duration of up to 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) Or d. Tamoxifen for a duration of 2 to 3 years and switching to an AI for up to 5 years, for a total duration of up to 7 to 8 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) 3. Women who are postmenopausal and are intolerant of either tamoxifen or an AI should be offered the alternative type of adjuvant endocrine therapy. a. If women have received an AI but discontinued treatment at less than 5 years, they may be offered tamoxifen for a total of 5 years. (Type: Informal consensus, Evidence Quality: Low, Strength of Recommendation: Weak) b. If women have received tamoxifen for 2 to 3 years, they should be offered switching to an AI for up to 5 years, for a total duration of up to 7 to 8 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) 4. Women who have received 5 years of tamoxifen as adjuvant endocrine therapy should be offered additional adjuvant endocrine treatment. a. If women are postmenopausal, they should be offered continued tamoxifen for a total duration of 10 years or switching to up to 5 years AI, for a total duration of up to 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) b. If women are pre- or perimenopausal, or menopausal status cannot be ascertained, they should be offered 5 additional years of tamoxifen, for a total duration of 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) (ASCO, 2014) Patients with invasive breast cancers that are ER- or PR-positive should be considered for adjuvant endocrine therapy regardless of patient age, lymph node status, or whether adjuvant chemotherapy is to be administered. (NCCN, 2014) The most firmly established adjuvant endocrine therapy is tamoxifen for both premenopausal and postmenopausal women. In women with ER-positive breast cancer, adjuvant tamoxifen decreases the annual odds of recurrence by 39% and the annual odds of death by 31% irrespective of the use of chemotherapy, patient age, menopausal status, or ALN status. In patients receiving both tamoxifen and chemotherapy, chemotherapy should be given first, followed by sequential tamoxifen. Prospective, randomized trials have demonstrated that 5 years of tamoxifen is more effective than 1 to 2 years of tamoxifen. (NCCN, 2014) Patients with lymph node involvement or with tumors greater than 1cm in diameter are appropriate candidates for adjuvant systemic therapy (category 1). For women with lymph node-negative, hormone receptor-negative tumors greater than 1 cm in diameter, chemotherapy is recommended (category 1). For those with lymph node-negative, hormone receptor-positive breast cancer tumors greater than 1 cm, endocrine therapy with chemotherapy is recommended (category 1). (NCCN, 2014) COPYRIGHT: Physician Performance Measures (Measures) and related data specifications, developed by the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI ), are intended to facilitate quality improvement activities by physicians. 11/17/2015 Page 5 of 16

6 These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical guidelines and do not establish a standard of medical care. PCPI has not tested its Measures for all potential applications. PCPI encourages the testing and evaluation of its Measures. Measures are subject to review and may be revised or rescinded at any time by PCPI. The Measures may not be altered without the prior written approval of PCPI. Measures developed by PCPI, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association, on behalf of PCPI. Neither PCPI nor its members shall be responsible for any use of these Measures. THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND 2007 American Medical Association, American Society of Clinical Oncology, and National Comprehensive Cancer Network. All Rights Reserved. CPT contained in the Measures specifications is copyright American Medical Association. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. THE SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND. CPT contained in the Measures specifications is copyright American Medical Association. LOINC copyright Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT ) copyright International Health Terminology Standards Development Organization. All Rights Reserved. Use of SNOMED CT is only authorized within the United States. 11/17/2015 Page 6 of 16

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10 2016 Claims Individual Measure Flow PQRS #71 NQF #0387: Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure. 1. Start with Denominator 2. Check Patient Age: a. If Female Patient Age is greater than or equal to 18 Years of age at Date of Service equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing. b. If Female Patient Age is greater than or equal to 18 Years of age at Date of Service equals Yes during the measurement period, proceed to check Patient Diagnosis. 3. Check Patient Diagnosis: a. If Diagnosis of Breast Cancer as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Diagnosis of Breast Cancer as Listed in the Denominator equals Yes, proceed to check Encounter Performed. 4. Check Encounter Performed: a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Encounter as Listed in the Denominator equals Yes, include in the Eligible population. 5. Denominator Population: a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 patients in the sample calculation. 6. Start Numerator 7. Check Tamoxifen or Aromatase Inhibitor (AI) Prescribed AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive: a. If Tamoxifen or Aromatase Inhibitor (AI) Prescribed AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals Yes, include in Reporting Met and Performance Met. b. Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 patients in Sample Calculation. 11/17/2015 Page 10 of 16

11 c. If Tamoxifen or Aromatase Inhibitor (AI) Prescribed AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals No, proceed to check Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive. 8. Check Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive: a. If Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b1 equals 1 patient in the c. If Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals No, proceed to check Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive. 9. Check Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive: a. If Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b2 equals 0 patients in the c. If Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals No, proceed to check Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive. 10. Check Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive: a. If Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b3 equals 0 patients in the c. If Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals No, proceed to Check Patient Not Stage IC through IIIC Breast Cancer. 11/17/2015 Page 11 of 16

12 11. Check Patient Not Stage IC through IIIC Breast Cancer: a. If Patient Not Stage IC through IIIC Breast Cancer equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b4 equals 0 patients in the c. If Patient Not Stage IC through IIIC Breast Cancer No, proceed to check Patient is Estrogen or Progesterone Receptor Negative. 12. Check Patient is Estrogen or Progesterone Receptor Negative: a. If Patient is Estrogen or Progesterone Receptor Negative Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b5 equals 0 patients in the c. If Patient is Estrogen or Progesterone Receptor Negative No, proceed to Check Cancer Stage Not Documented. 13. Check Cancer Stage Not Documented: a. If Cancer Stage Not Documented Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b6 equals 0 patients in the c. If Cancer Stage Not Documented equals No, proceed to Check Estrogen Receptor or Progesterone Receptor is Not Documented. 14. Check Estrogen Receptor or Progesterone Receptor is Not Documented: a. If Estrogen Receptor or Progesterone Receptor is Not Documented equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b7 equals 0 patients in the c. If Estrogen Receptor or Progesterone Receptor is Not Documented No, proceed to Check Tamoxifen Aromatase Inhibitor (AI) Not Prescribed, Reason Not Specified AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive. 15. Check Tamoxifen Aromatase Inhibitor (AI) Not Prescribed, Reason Not Specified AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive: a. If Tamoxifen Aromatase Inhibitor (AI) Not Prescribed, Reason Not Specified AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals Yes, include in Reporting Met and Performance Not Met. 11/17/2015 Page 12 of 16

13 b. Reporting Met and Performance Not Met letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter c equals 2 patients in the c. If Tamoxifen Aromatase Inhibitor (AI) Not Prescribed, Reason Not Specified AND AJCC Breast Cancer Stage I, II, III Documented AND Estrogen or Progesterone Receptor Positive equals No, proceed to Reporting Not Met. 16. Check Reporting Not Met: a. If Reporting Not Met, the Quality Data Code or equivalent was not reported. 1 patient has been subtracted from the reporting numerator in sample calculation. 11/17/2015 Page 13 of 16

14 2016 Registry Individual Measure Flow PQRS #71 NQF #0387: Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure. 1. Start with Denominator 2. Check Patient Age: a. If Female Patient Age is greater than or equal to 18 Years of age at Date of Service equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing. b. If Female Patient Age is greater than or equal to 18 Years of age at Date of Service equals Yes during the measurement period, proceed to check Patient Diagnosis. 3. Check Patient Diagnosis: a. If Diagnosis of Breast Cancer as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Diagnosis of Breast Cancer as Listed in the Denominator equals Yes, proceed to check AJCC Breast Cancer Stage1. 4. Check AJCC Breast Cancer Stage I: TIC (tumor size > 1 cm to 2cm, II or III Documented). a. If AJCC Breast Cancer Stage I: TIC (tumor size >1 cm to 2 cm, II or III Documented) equals No, do not include in Eligible Patient Population. Stop Processing. b. If AJCC Breast Cancer Stage I: TIC (tumor size > 1 cm to 2cm, II or III Documented) equals Yes, proceed to check (ER) or (PR) Positive Breast Cancer. 5. Check (ER) or (PR) Positive Breast Cancer: a. If (ER) or (PR) Positive Breast Cancer equals No, do not include in Eligible Patient Population. Stop Processing. b. If (ER) or (PR) Positive Breast Cancer equals Yes, proceed to check Encounter Performed. 6. Check Encounter Performed: a. If Encounter Performed as Listed in Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Encounter Performed as Listed in Denominator equals Yes, include in the Eligible population. 7. Denominator Population: a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 patients in the sample calculation. 8. Start Numerator 11/17/2015 Page 14 of 16

15 9. Check Tamoxifen or Aromatase Inhibitor (AI) Prescribed: a. If Tamoxifen or Aromatase Inhibitor (AI) Prescribed equals Yes, include in Reporting Met and Performance Met. b. Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 patients in Sample Calculation. c. If Tamoxifen or Aromatase Inhibitor (AI) Prescribed equals No, proceed to check Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI). 10. Check Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI): a. If Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b1 equals 1 patient in the c. If Documentation of Medical Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) equals No, proceed to check Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI). 11. Check Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI): a. If Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b2 equals 0 patients in the c. If Documentation of Patient Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) equals No, proceed to check Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI). 12. Check Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI): a. If Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) equals Yes, include in Reporting Met and Performance Exclusion. Rate in the Sample Calculation listed at the end of this document. Letter b3 equals 0 patients in the c. If Documentation of System Reason(s) for Not Prescribing Tamoxifen or Aromatase Inhibitor (AI) equals No, proceed to Tamoxifen or Aromatase Inhibitor (AI) Not Prescribed, Reason Not Otherwise Specified. 13. Check Tamoxifen or Aromatase Inhibitor (AI) Not Prescribed, Reason Not Specified: a. If Tamoxifen or Aromatase Inhibitor (AI) Not Prescribed, Reason Not Specified equals Yes, include in Reporting Met and Performance Not Met. 11/17/2015 Page 15 of 16

16 b. Reporting Met and Performance Not Met letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter c equals 2 patients in the c. If Tamoxifen or Aromatase Inhibitor (AI) Not Prescribed, Reason Not Specified equals No, proceed to Reporting Not Met. 14. Check Reporting Not Met: a. If Reporting Not Met, the Quality Data Code or equivalent was not reported. 1 patient has been subtracted from the reporting numerator in sample calculation. 11/17/2015 Page 16 of 16