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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
422 2063 Process Yes Patient Safety Registry

Measure Description

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse

Instructions

This measure is to be submitted each time a procedure is performed during the performance period for patients who undergo 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 Submission

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.

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 Quality-Data Coding Options

Performance Met:

Patient discharge to home no later than post-operative day #7 (G9601)

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)

Performance Not Met:

Intraoperative cystoscopy not performed to evaluate for lower tract injury (G9608)

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, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573

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