2021 MIPS Measure #448: Appropriate Workup Prior to Endometrial Ablation

Measure Description

Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.

Instructions

This measure is to be submitted each time a procedure for endometrial ablation is performed during the measurement period. This measure is to 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 aged 18 years and older who undergo an endometrial ablation procedure during the measurement year

Definition:

Index Date: This date is in reference to the date of procedure for endometrial sampling or hysteroscopy with biopsy.

Denominator Criteria (Eligible Cases):

All patients, aged 18 years and older

AND

Codes for endometrial ablation (ICD-10-PCS): 0U5B0ZZ, 0U5B3ZZ, 0U5B4ZZ, 0U5B7ZZ, 0U5B8ZZ, 0UDB7ZZ, 0UDB8ZZ

AND/OR

Patient procedure during the performance period (CPT): 58353, 58356, 58563

AND NOT

DENOMINATOR EXCLUSION:

Patients who had an endometrial ablation procedure during the year prior to the index date (exclusive of the index date): G9822

Numerator

Patients who received endometrial sampling or hysteroscopy with biopsy and results documented during the year prior to the index date (exclusive of the index date) of the endometrial ablation

Numerator Options:

Performance Met:

Endometrial sampling or hysteroscopy with biopsy and results documented (G9823)

OR

Performance Not Met:

Endometrial sampling or hysteroscopy with biopsy and results not documented (G9824)