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)