2021 MIPS Measure #422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

Measure Description

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse

Instructions

This measure is to be submitted each time a procedure is performed during the performance period for patients who undergo a hysterectomy for pelvic organ prolapse. 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:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. 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 by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

All patients undergoing hysterectomy for pelvic organ prolapse

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Diagnosis for Pelvic Organ Prolapse (ICD-10-CM): N81.10, N81.11, N81.12, N81.2, N81.3, N81.4, N81.89, N81.9

AND

Patient procedure during the performance period (CPT): 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573

Numerator

Patients in whom an intraoperative cystoscopy was performed to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse

Numerator Options:

Performance Met:

Intraoperative cystoscopy performed to evaluate for lower tract injury (G9606)

OR

Denominator Exception:

Documented medical reasons for not performing intraoperative cystoscopy (e.g., urethral pathology precluding cystoscopy, any patient who has a congenital or acquired absence of the urethra) or in the case of patient death (G9607)

OR

Performance Not Met:

Intraoperative cystoscopy not performed to evaluate for lower tract injury (G9608)