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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
448 Process Yes Communication and Care Coordination Registry

Measure Description

Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation

Instructions

This measure is to be submitted each time a procedure for endometrial ablation is performed during the measurement 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

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:

Women who received endometrial sampling or hysteroscopy with biopsy and results documented during the year prior to the index date (exclusive of the index date) of the endometrial ablation

Numerator Quality-Data Coding Options

Performance Met:

Endometrial sampling or hysteroscopy with biopsy and results documented (G9823)

Performance Not Met:

Endometrial sampling or hysteroscopy with biopsy and results not documented (G9824)

Denominator:

All women aged 18 years and older who undergo an endometrial ablation procedure during the measurement year

Denominator Criteria (Eligible Cases):
All female patients

AND
Codes for endometrial ablation (ICD-10-PCS): 0U5B0ZZ, 0U5B3ZZ, 0U5B4ZZ, 0U5B7ZZ, 0U5B8ZZ, 0UDB7ZZ, 0UDB8ZZ

AND/OR
Patient procedure during the performance period (CPT): 58353, 58356, 58563

AND NOT
DENOMINATOR EXCLUSION:
Women who had an endometrial ablation procedure during the year prior to the index date
(exclusive of the index date): G9822

 

Definition:
Index Date (exclusive of the index date) – This date is in reference to the date of procedure for endometrial sampling or hysteroscopy with biopsy.

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