AAO39: Neck Mass Evaluation

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High Priority Status: No / N/A

CBE Number: N/A

 Measure Description:

Percentage of patients aged 18 years and older diagnosed with a neck mass and suspected/increased risk of malignancy who had a fine needle aspiration (FNA), or refer the patient to someone who can perform FNA and receive a neck computed tomography (or magnetic resonance imaging) with contrast.

Instructions:

This measure is to be submitted a minimum of once per performance period for patients with a new neck mass. This measure may be submitted by clinicians based on the services provided and the measure-specific denominator coding. This measure has two strata separated by numerical indicators (i.e., denominator exception 2 is evaluated in the instance numerator 2 is not performed).

Denominator:

1. Patients aged 18 years and older diagnosed with a neck mass and *suspected/increased risk of malignancy
2. Patients aged 18 years and older diagnosed with a neck mass and *suspected/increased risk of malignancy

Denominator Note:

• Patients with a new neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology, and the mass has been present for ≥ 2 weeks without significant fluctuation or the mass is of uncertain duration.
  • A new neck mass is defined as a neck mass diagnosis for the first time in life
• Patients with a neck mass who are at increased risk for malignancy based on ≥ 1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size > 5 cm, or ulceration of overlying skin.
• Patients with a neck mass who are at low risk for malignancy based on ≥ 1 of these physical examination characteristics: mobile, fluctuant, size ≤ 1.5cm, or swollen lymph nodes.

 Denominator Exclusions:

1. None
2. None

Denominator Criteria:

Patients aged 18 years and older

AND

Diagnosis: Neck Mass

AND

Suspected/Increased Risk of Malignancy Criteria (Reference: Denominator Note)

AND

Patient Visit: Encounter Visit

For a list of codes that qualify as denominator eligible visits, reference Addendum attached.

 Numerator:

1. Patients that have a FNA, or refer the patient to someone who can perform an FNA.
2. Patients that received a neck computed tomography scan or magnetic resonance imaging with contrast
3. Total patient performance average on the above two components

Note: This measure assesses the completion of an FNA prior to an open biopsy, if further testing is required.

 Denominator Exceptions:

1. Documentation of a system reason for not completing an FNA (i.e., cytopathologist unavailable to read FNA)
2. FNA results negative for malignancy.
3. Medical reason(s) to not do an FNA (contraindication, risk, competing diagnosis, etc.)

Measure Classifications:

• Submission Pathway: Traditional MIPS
• Measure Type: Process
• High Priority Type: Patient Safety
• Meaningful Measures Area: Appropriate Use of Healthcare
• Care Setting(s): Ambulatory Care: Clinician Office/Clinic
• Includes Telehealth: No
• Number of Performance Rates: 1
  • Inverse measure: No
  • Continuous measure: No
  • Proportional measure: Yes
  • Ratio measure: No
  • Risk Adjusted measure: No

Clinical Recommendation Statement:

Fine-needle aspiration (FNA), rather than open biopsy, is the preferred method for cancer diagnosis in a neck mass. Open biopsy is suboptimal because it risks tumor seeding and local and regional tumor recurrence.

Clinicians should identify patients with a neck mass who are at increased risk for malignancy when the patient lacks a history of infectious etiology and the mass has been present for =2 weeks without significant fluctuation or the mass is of uncertain duration.

Clinicians should identify patients with a neck mass who are at increased risk or malignancy based on =1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size >1.5 cm, and/or ulceration of overlying skin. Both CT and MRI are effective tools in the assessment of neck masses, although CT has several benefits that support its utilization as a primary imaging modality.91 CT is more read-ily  available,  costs  considerably  less,  and  is  generally  more  easily  tolerated  by  patients  because  of  shorter  scanning  time  (<5 minutes) and larger scanner bore. While CT utilizes ion-izing  radiation,  the  average  dose  of  3  mSv  (equivalent  to  approximately  150  chest  x-rays)  is  considered  acceptable  in  the  adult  population.92  MRI  offers  improved  tissue  contrast  and can help detect subclinical tumors not evident with nasal endoscopy.93  MRI  is  preferred  when  a  primary  tumor  of  the  nasopharynx is suspected or when there is cranial nerve abnor-mality on physical examination because of its improved sensi-tivity to abnormalities of the skull base and in the detection of perineural  spread.

Although the natural history of HPV-OPC is not well understood, this case series suggests that it can be slow growing and mimic benign processes, leading to diagnostic delays. Adults presenting with neck masses should undergo complete diagnostic evaluation.

Base of Tongue/Tonsil/Posterior Pharyngeal Wall/Soft Palate Workup:

• Tumor human papillomavirus (HPV) testing by p16 immunohistochemistry (IHC) required
• H&P including a complete head and neck exam; mirror and fiberoptic examination as clinically indicated
• Biopsy of primary site or fine-needle aspiration (FNA) of the neck

• CT with contrast and/or MRI with contrast of primary and neck
• As clinically indicated: EUA with endoscopy Preanesthesia studiesFDG-PET/CTeChest CTe (with or without contrast)Dental evaluating including PanorexNutrition, speech and swallowing evaluation/therapy, and audiogramSmoking cessation counselingFertility/reproductive counseling
• Multidisciplinary consultation as clinically indicated

Davis, R.J., Rettig, E., Aygun, N., Rooper, L., D’Souza, G., Eisele, D.W. and Fakhry, C. (2020), From presumed benign neck masses to delayed recognition of human papillomavirus–positive oropharyngeal cancer. The Laryngoscope, 130: 392-397. https://doi.org/10.1002/lary.27946Pynnonen, M.A., Gillespie, M.B., Roman, B., Rosenfeld, R.M., Tunkel, D.E., Bontempo, L., Brook, I., Chick, D.A., Colandrea, M., Finestone, S.A., Fowler, J.C., Griffith, C.C., Henson, Z., Levine, C., Mehta, V., Salama, A., Scharpf, J., Shatzkes, D.R., Stern, W.B., Youngerman, J.S. and Corrigan, M.D. (2017), Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngology–Head and Neck Surgery, 157: S1-S30. https://doi.org/10.1177/0194599817722550

National Comprehensive Cancer Network. Bone Cancer (Version 2.2023). https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. Accessed August 22, 2023.

Rationale:

Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass.

Pynnonen, M.A., Gillespie, M.B., Roman, B., Rosenfeld, R.M., Tunkel, D.E., Bontempo, L., Brook, I., Chick, D.A., Colandrea, M., Finestone, S.A., Fowler, J.C., Griffith, C.C., Henson, Z., Levine, C., Mehta, V., Salama, A., Scharpf, J., Shatzkes, D.R., Stern, W.B., Youngerman, J.S. and Corrigan, M.D. (2017), Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngology–Head and Neck Surgery, 157: S1-S30. https://doi.org/10.1177/0194599817722550

Supporting Clinical Practice Guideline (CPG):

For more details, referece the Clinical Practice Guideline: Evaluation of the Neck Mass in Adults (2017)

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The measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The measure and specifications are provided “as is” without warranty of any kind. Neither the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF), nor its members shall be responsible for any use of the measure. The AAO-HNSF and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.

Addendum