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)