MIPS Clinical Quality Measures (CQMS)
MEASURE TYPE: Process – High Priority
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.
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
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. 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 by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
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
AND/OR
Patient procedure during the performance period (CPT): 58353, 58356, 58563
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
Denominator Exclusions:
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)
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