2023 # 448 Appropriate Workup Prior to Endometrial Ablation

CMS Measure ID: #448

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Communication and Care Coordination

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a procedure for endometrial ablation is performed during the performance 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:

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-based submissions; however, these codes may be submitted for those registries that utilize claims data.

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

Denominator

All patients aged 18 years and older who undergo an endometrial ablation procedure during the performance period

Definition: 

Index Date: Date of first endometrial ablation during the performance period

Denominator Criteria (Eligible Cases):

All patients, aged 18 years and older on date of encounter

AND

Endometrial ablation during the performance period (ICD-10-PCS): 0U5B0ZZ, 0U5B3ZZ, 0U5B4ZZ, 0U5B7ZZ, 0U5B8ZZ, 0UDB7ZZ, 0UDB8ZZ

AND/OR

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

WITHOUT

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

AND NOT

DENOMINATOR EXCLUSION:

Patients who had an endometrial ablation procedure during the 12 months prior to the index date (exclusive of the index date): G9822

Numerator

Patients who received endometrial sampling or hysteroscopy with biopsy and results were documented during the 12 months 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 during the 12 months prior to the index date (exclusive of the index date) of the endometrial ablation (G9823)

OR

Performance Not Met:

Endometrial sampling or hysteroscopy with biopsy and results not documented during the 12 months prior to the index date (exclusive of the index date) of the endometrial ablation (G9824)