Quality Metrics

CF/BM/SR/DTC/RSW/KS/CCT: CMS established reimbursement criteria for LCS exams. Included in those requirements is that specific data must be submitted to an approved clinical practice registry.9

Currently there is only one approved CMS registry which has additional data elements required/requested and requires use of Lung-RADS™.16,17

Required Elements

Exam details:
Facility ID number, patient name, exam date

Smoking status in pack years
Smoking cessation counseling
Documentation of shared decision making
Height, weight, comorbidities, cancer history
Radiologist name, ordering provider and NPI
Indication for the exam
Exam modality, manufacturer, radiation exposure
CT exam results by Lung-RADS™ category
Other abnormalities- CT exam result S modifier
Prior history of lung cancer and years since diagnosis

Follow-up within 1 year
Documentation of an exam anytime within prior 12 months and date
Follow-up diagnostic for tissue:

  • Tissue Diagnosis
  • Tissue diagnosis method
  • Location from which sample was obtained
  • Histology
  • Stage- Clinical or pathologic
  • Overall stage
  • T, N, M status
  • Period of follow-up for incidence (in months)

Additional Risk Factors:
Education level, radiation exposure, occupational exposures, history of cancers associated with a higher risk of lung cancer, lung cancer in first-degree relative, other family history of lung cancer, COPD, pulmonary fibrosis, secondhand smoke exposure.
Name of person performing data collection for the exam, submission date.

BM/SR: Program coordinator and patient navigator collect quality metrics. Specific metrics are reported to the steering committee every week, including number of qualified patients, number of scans performed, number of baseline scans performed, number of Lung-RADS™ 4 exams, number of patients discharged, net enrollment, and cancers diagnosed. Other metrics, such as percent breakdown of Lung-RADS™ results, PPV, and breakdown of diagnoses/staging are reported on an ad-hoc basis.

RSW/KS: LCS physician director and screening coordinator collect metrics; LCS physician director presents summary metrics to LCS multidisciplinary steering committee at quarterly meeting. Metrics: number screened/month (baseline and annual), percentage screened that did not meet eligibility criteria, breakdown of screened by Lung-RADS™ category, cancers diagnosed and their stages, and ad hoc reporting on invasive procedures and complications.

CF: Program coordinator/patient navigator collects information and enters into database. Metrics are reviewed with LCS physician director monthly and with the steering committee quarterly.

CCT/KK: Quality metrics are collected in many areas of our program. Radiology metrics are collected within radiology and include screening studies and eligibility criteria with an evaluation by radiology of those indications, quality reporting of Lung-RADS™, biopsy number, results and complications, and CMS metrics that fall under radiology; the navigator who sits in pulmonary collects all clinical evaluation data, process measures related to referral patterns and access, clinical results, therapies, and outcome; thoracic surgery collects data on thoracic surgery volume, technique, diagnosis, and complications; and oncology collects data on cancer diagnosis, stage, and clinical therapies including radiation therapy and chemotherapy, as well as outcome. Quality and outcome data is presented monthly at our oncology steering committee meeting.

KK/CCT: Many programs utilize radiology databases for tracking orders and results. Transferring data into other management systems for surveillance is also a method to ensure tracking orders and completion of orders. Manual review of the database is often required to ensure this occurs. EHR systems can be programmed to create critical results for lung nodules that are sent to the ordering provider and the multidisciplinary team managing lung nodules at the institution. In our program we have a critical result reporting function, a notification to the nodule program, and a movement of these patients into a registry for management by the team. If a patient does not show for a follow-up or an order is not completed, the navigator can follow-up to ensure its completion or the reason why it was not followed if not clinically indicated. The team manages the removal of patients from the registry when follow-up is no longer indicated or a diagnosis is made.

SR/BM/CCT: We have two order codes that are specific to LCS. One order is for the initial and annual screening exams and has the G0297 CPT code attached to it. The second is for follow-up low-dose CTs that stem from screening exams and has the 71250 CPT code attached. These exam codes fall onto a work queue in our EHR to be reviewed, pre-authorized, and scheduled; they also migrate into our LCS patient database.

MG: Screening exams are tracked in the Radiology Information System by using unique exam codes.

AM: The steering committee evaluates the number of referrals by primary care provider, qualified rate, best practice advisory (BPA) activity, how patients access program, patient satisfaction surveys, time between referral and exam date, no-show rate, program discharge rate, demographic and racial inequities, smoking cessation rates, and program outreach efforts. This data is collected through dedicated LCS database, which is derived from radiology information system and electronic health record and is reported annually to the steering committee. Program navigators are responsible for collating and ensuring data entry is performed accurately. Data is reported to the steering committee, reading radiologists, and to a CMS approved registry. Navigators oversee electronic submission of data to a CMS approved registry. Cancer detection rate, qualified rate, patient enrollment, discharges, and program outreach activities are sent out weekly to steering committee and reviewed in person at steering committee meetings every other month.

CCT/KK: There are two major areas of data that are tracked by our program. Those metrics necessary for reporting to the CMS registry is one major area. The other group of metrics is those related to quality of our program and providing excellent patient care. The program tracks the number of patients referred to the program, the number of screening CTs, eligibility criteria, access times for each diagnostic and therapeutic step, number and percentage of each therapeutic area, and number of patients cared for outside of our system. We also have a prospective and retrospective surveillance program, which tracks follow-up and provides outreach to patients and providers for overdue follow-up. Data is collected by radiology, oncology, thoracic surgery, our screening program, and nodule program. We review program related metrics internally through our steering committee and through the oncology steering committee. Externally, data is reported to the ACR registry, as well as specific registries associated with oncology and radiation oncology, and thoracic surgery.

AR: Because of previous experience with ELCAP,15 we collect for Mount Sinai registry/ Delaware registry and all ACR data points for Medicare and additional public health data fields for the state program.