2017 MIPS Measure #428: Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Registry Process No Effective Clinical Care

Measure Description

Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines

Instruction

This measure is to be reported each time an anterior and/or apical pelvic organ prolapse repair surgery is performed during the performance period. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Denominator

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

Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient procedure during the performance period (CPT): 57106, 57110, 57120, 57240, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57423, 57425, 57556, 58263, 58270, 58280, 58292, 58294, 58400

Numerator

Number of patients undergoing preoperative assessment

Definition:
Preoperative Assessment – Includes the following:
1)History asking about incontinence and its character.
2)Urinalysis documented.
3)Physical exam testing for stress incontinence whether or not a patient is symptomatic.

Numerator Options:
Performance Met: Preoperative assessment documented (G9615)
OR
Denominator Exception: Documentation of reason(s) for not documenting a preoperative assessment (e.g., patient with a gynecologic or other pelvic malignancy noted at the time of surgery) (G9616)
OR
Performance Not Met:
Preoperative assessment not documented, reason not given (G9617)

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