2026 #432 MIPS Measure Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair

2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE: ‌Outcome – High Priority

• INVERSE MEASURE: LOWER SCORE – BETTER

Description:

Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bladder or bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.

‌Instructions:

Reporting Frequency:
This measure is to be submitted each time an anterior, posterior, or apical prolapse repair surgery 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 undergoing surgical repair of 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 two strata defined by two submission criteria.
This measure produces two performance rates which are used for a simple average.

There are 2 Submission Criteria for this measure:
1) All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery who sustain a bladder injury.
AND
2) All patients undergoing anterior, posterior, or apical pelvic organ prolapse (POP) surgery who sustain a bowel injury.

This measure contains two submission criteria which together ensure that the proper evaluation and treatment is provided for patients who undergo pelvic organ prolapse repair. Submission Criteria 1 evaluates whether patients sustained a bladder injury intraoperatively or within 30 days after surgery. Submission Criteria 2 evaluates whether patients sustained a bowel injury intraoperatively or within 30 days after surgery. Patients who undergo a procedure that meets the denominator of both submission criteria should be included in both and assessed for each clinical outcome.

This measure will be calculated with 2 performance rates:
1) Percentage of patients undergoing prolapse repair who sustain a bladder injury that necessitates repair either intraoperatively or within 30 days after surgery.
2) Percentage of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within 30 days after surgery.

‌Submission of the two performance rates is required for this measure. A simple average, which is the sum of the performance rates divided by the number of the performance rates will be used to calculate performance.

Implementation Considerations:
For purposes of MIPS implementation, this procedure measure is to be submitted each time a denominator eligible procedure is performed during the denominator identification period.
This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

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.

SUBMISSION CRITERIA 1: ALL PATIENTS UNDERGOING ANTERIOR OR APICAL PELVIC ORGAN PROLAPSE (POP) SURGERY WHO SUSTAIN A BLADDER INJURY

Denominator (Criteria 1):

All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery.

Definitions:
Denominator identification period – the twelve month period in which eligible patients have a procedure, which December 1st of the previous performance period through November 30th of the current performance period.

Denominator Criteria (Eligible Cases)

All patients, regardless of age

AND

Patient procedure during the denominator identification period (CPT): 57106, 57110, 57120, 57240, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57423, 57425, 57556, 58263, 58270, 58280, 58292, 58294, 58400

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10

‌Numerator (Criteria 1):

Percentage of patients undergoing prolapse repair who sustain a bladder injury that necessitates repair either intraoperatively or within 30 days after surgery.

Numerator Instructions:

INVERSE MEASURE –see Implementation Considerations

NUMERATOR NOTE:
In order to meet the measure, bladder injury is sustained as a result of the prolapse surgery.

Numerator Options:

Performance Not Met: Patient did not sustain bladder injury at the time of surgery nor discovered subsequently up to 30 days post-surgery (G9627)

OR

Denominator Exception: Documented medical reasons for not reporting bladder injury (e.g. gynecologic or other pelvic malignancy documented, concurrent surgery involving bladder pathology, injury that occurs during a urinary incontinence procedure, patient death from non-medical causes not related to surgery, patient died during procedure without evidence of bladder injury) (G9626)

OR

Performance Met: Patient sustained bladder injury at the time of surgery or discovered subsequently up to 30 days post-surgery (G9625)

AND

SUBMISSION CRITERIA 2: ALL PATIENTS UNDERGOING ANTERIOR, POSTERIOR, OR APICAL PELVIC ORGAN PROLAPSE (POP) SURGERY WHO SUSTAIN A BOWEL INJURY.

‌Denominator (Criteria 2):

All patients undergoing anterior, posterior, or apical pelvic organ prolapse (POP) surgery.

Definitions:
Denominator identification period – the twelve month period in which eligible patients have a procedure, which December 1st of the previous performance period through November 30th of the current performance period.

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Patient procedure during the denominator identification period (CPT): 45560, 57106, 57110, 57120, 57200, 57210, 57240, 57250, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57289, 57423, 57425, 57545, 57555, 57556, 58263, 58270, 58280, 58292, 58294, 58400, 58410

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10

‌Numerator (Criteria 2):

Percentage of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within 30 days after surgery.

Numerator Instructions:

INVERSE MEASURE – see Implementation Considerations

NUMERATOR NOTE:
In order to meet the measure, bowel injury is sustained as a result of the prolapse surgery.

Numerator Options:

Performance Not Met: Patient did not sustain a bowel injury at the time of surgery nor discovered subsequently up to 30 days post-surgery (G9630)

OR

Denominator Exception: Documented medical reasons for not reporting bowel injury (e.g. gynecologic or other pelvic malignancy documented, planned (e.g. not due to an unexpected bowel injury) resection and/or re-anastomosis of bowel, or patient death from non-medical causes not related to surgery, patient died during procedure without evidence of bowel injury) (G9629)

OR

Performance Met: Patient sustained bowel injury at the time of surgery or discovered subsequently up to 30 days post-surgery (G9628)

RATIONALE:

There are numerous approaches to surgical correction of pelvic organ prolapse- vaginal, open, laparoscopic and robotic. The incidence of visceral injury ranges from 0.1-4% (SGS Systemic Review Obstet Gynecol 2008: 112: 1131- 1142), depending on the approach, with high potential for morbidity. Unrecognized injury to the intestine increases the risk of mortality from 2 to 23% (Chapron et al. J Am Coll Surg. 1991;185:461-465, Baggish, MS J Gynecol Surg. 2003;19:63-73). It is critically important for surgeons who are performing these procedures to recognize and repair any visceral injuries intraoperatively, in order to minimize postoperative morbidity, includingthe need for subsequent surgical intervention to address these complications. Surgeons benefit from interventions to improve the quality of their surgical care if they have a higher than expected rate of visceral injury during pelvic organ prolapse repair.

Bladder injury is a common and potentially debilitating complication of pelvic surgery but more common in surgery for pelvic organ prolapse. Surgeons may benefit from interventions to improve the quality of their surgical care if they have a higher than expected rate of bladder injury during pelvic organ prolapse repair.