2023 # 433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair

CMS Measure ID: #433

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a pelvic organ prolapse repair surgery is performed during the performance period ending November 30th. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Submission Type:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery

Denominator

All patients undergoing anterior, posterior or apical pelvic organ prolapse (POP) surgery

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Patient procedure during the performance period (CPT): 45560, 57106, 57110, 57120, 57200, 57210, 57240, 57250, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57289, 57423, 57425, 57545, 57555, 57556, 58263, 58270, 58280, 58292, 58294, 58400, 58410

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

Numerator

The number of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within 30 days after surgery

Numerator Instructions:

INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

NUMERATOR NOTE: In order to meet the measure, bowel injury is sustained as a result of the prolapse surgery.

Numerator Options:

Performance Met:

Patient sustained bowel injury at the time of surgery or discovered subsequently up to 30 days post-surgery (G9628)

OR

Denominator Exception:

Documented medical reasons for not reporting bowel injury (e.g. gynecologic or other pelvic malignancy documented, planned (e.g. not due to an unexpected bowel injury) resection and/or re-anastomosis of bowel, or patient death from non-medical causes not related to surgery, patient died during procedure without evidence of bowel injury) (G9629)

OR

Performance Not Met:

Patient did not sustain a bowel injury at the time of surgery nor discovered subsequently up to 30 days post-surgery (G9630)