MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
MEASURE TYPE: Process – High Priority
Description:
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.
Instructions:
Reporting Frequency:
This measure is to be submitted each time a procedure is performed for denominator eligible cases as defined in the denominator criteria.
Intent and Clinician Applicability:
This measure is intended to reflect the quality of services provided for patients who are undergoing a hysterectomy for pelvic organ prolapse. 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 Strata and Performance Rates:
This measure contains one strata defined by a single submission criteria.
This measure produces a single performance rate.
Implementation Considerations:
For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period.
Telehealth:
NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting. This measure is procedure based and therefore doesn’t allow for the denominator criteria to be conducted via telehealth. It would be appropriate to remove these patients from the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.
Measure Submission :
The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator:
All patients undergoing hysterectomy for pelvic organ prolapse
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Diagnosis for Pelvic Organ Prolapse (ICD-10-CM): N81.10, N81.11, N81.12, N81.2, N81.3, N81.4, N81.89, N81.9
AND
Patient procedure during the performance period (CPT): 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573
Numerator:
Patients in whom an intraoperative cystoscopy was performed to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse
Numerator Options:
Performance Met: Intraoperative cystoscopy performed to evaluate for lower tract injury (G9606)
OR
Denominator Exception: Documented medical reasons for not performing intraoperative cystoscopy (e.g., urethral pathology precluding cystoscopy, any patient who has a congenital or acquired absence of the urethra) or in the case of patient death (G9607)
OR
Performance Not Met: Intraoperative cystoscopy not performed to evaluate for lower tract injury (G9608)
RATIONALE:
Lower urinary tract (bladder and/or ureter(s)) injury is a common complication of prolapse repair surgery, occurring in up to 5% of patients. Delay in detection of lower urinary tract injury has an estimated cost of $54, 000 per injury (Visco et al), with significant morbidity for patients who experience them. Universal cystoscopy may detect up to 97% of all injuries at the time of surgery (Ibeanu et al, 2009), resulting in the prevention of significant morbidity and providing significant cost savings (over $108 million per year).
There is a gap in the performance of cystoscopy at the time of hysterectomy for pelvic organ prolapse. In a recent study we found that only 84.5% (539/638) of surgeons performed cystoscopy at the time of hysterectomy for pelvic organ prolapse. As many as 97% of high volume surgeons performed a cystoscopy at the time of hysterectomy for pelvic organ prolapse while low volume surgeons performed this procedure only 75 % of the time (p<.001).
Stay updated with the latest news regarding MACRA and MIPS
The Healthmonix Advisor is a free news source that connects you to the latest in the value-based care industry!