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)