CMS Measure ID: #432
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 prolapse organ repair surgery is performed during the performance period ending November 30th. There is no diagnosis associated with this measure. 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 measurespecific 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 undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery
Denominator
All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery
Denominator Criteria (Eligible Cases)
All patients, regardless of age
AND
Patient procedure during the performance period (CPT): 57106, 57110, 57120, 57240, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57423, 57425, 57556, 58263, 58270, 58280, 58292, 58294, 58400
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
Numerator
Total number of patient’s receiving a bladder injury at the time of surgery to repair a pelvic organ prolapse with repair during the procedure or subsequently up to 30 days post-surgery
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 or were not in proper control.
NUMERATOR NOTE: In order to meet the measure, bladder injury is sustained as a result of the prolapse surgery.
Numerator Options:
Performance Met:
Patient sustained bladder injury at the time of surgery or discovered subsequently up to 30 days post-surgery (G9625)
OR
Denominator Exception:
Documented medical reasons for not reporting bladder injury (e.g. gynecologic or other pelvic malignancy documented, concurrent surgery involving bladder pathology, injury that occurs during a urinary incontinence procedure, patient death from non-medical causes not related to surgery, patient died during procedure without evidence of bladder injury) (G9626)
OR
Performance Not Met:
Patient did not sustain bladder injury at the time of surgery nor discovered subsequently up to 30 days post-surgery (G9627)