2023 # 422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

CMS Measure ID: #422

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Patient Safety

Measure Age: > 2 years

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:

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

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

WITHOUT

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

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)