CMS Measure ID: #335
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 procedure is performed for patients undergoing delivery by cesarean birth or induction of labor at less than 39 weeks of gestation during the performance period. 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, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.
Denominator
All patients, regardless of age, who gave birth during a 12-month period delivering a live singleton at < 39 weeks of gestation completed
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Single live birth during the performance period (ICD-10-CM): Z37.0
AND
Patient procedure during performance period (CPT): 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
AND
Delivery at < 39 weeks gestation
Numerator
Patients who had elective deliveries (without medical indication) by cesarean birth or induction of labor
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.
Numerator Options:
Performance Met:
Elective delivery (without medical indication) by cesarean birth or induction of labor performed (<39 weeks of gestation) (G9356)
OR
Denominator Exception:
Medical indication for delivery by cesarean birth or induction of labor (< 39 weeks of gestation) [Documentation of reason(s) for elective delivery (e.g., hemorrhage and placental complications, hypertension, preeclampsia and eclampsia, rupture of membranes (premature or prolonged), maternal conditions complicating pregnancy/delivery, fetal conditions complicating pregnancy/delivery, late pregnancy, prior uterine surgery, or participation in clinical trial)] (G9361)
OR
Performance Not Met:
Elective delivery (without medical indication) by cesarean birth or induction of labor not performed (<39 weeks of gestation) (G9355)