2023 # 465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

CMS Measure ID: #465

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 for uterine artery embolization is performed during the performance period. 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-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.

Denominator

All patients undergoing uterine artery embolization for leiomyomas and/or adenomyosis

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Diagnosis for leiomyomas or adenomyosis (ICD-10-CM): D25.0, D25.1, D25.2, D25.9, N80.00, N80.01, N80.02, N80.03

AND

Patient procedure during the performance period (CPT): 37243

WITHOUT

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

Numerator

Number of patients undergoing uterine artery embolization for symptomatic leiomyomas and/or adenomyosis in whom embolization endpoints are documented separately for each embolized vessel AND ovarian artery angiography or embolization performed in the presence of variant uterine artery anatomy.

Definitions:

Embolization Endpoints –

  • Complete stasis (static contrast column for at least 5 heartbeats)
  • Near-stasis (not static, but contrast visible for at least 5 heartbeats)
  • Slowed flow (contrast visible for fewer than 5 heartbeats)
  • Normal velocity flow with pruning of distal vasculature
  • Other [specify]
  • Not documented

Variant uterine artery anatomy – Treatment strategy

  • Not applicable – Normal uterine artery anatomy
  • Ovarian artery angiography
  • Ovarian artery embolization
  • Abdominal aortic angiography
  • No additional angiography or embolization performed

Numerator Options:

Performance Met:

Embolization endpoints are documented separately for each embolized vessel AND ovarian artery angiography or embolization performed in the presence of variant uterine artery anatomy (G9962)

OR

Performance Not Met:

Embolization endpoints are not documented separately for each embolized vessel OR ovarian artery angiography or embolization not performed in the presence of variant uterine artery anatomy (G9963)


Tags

CQM-2023