| Measure Type | High Priority Measure? | NQS Domain |
|---|---|---|
| Process | No | Effective Clinical Care |
| Data Submission Method(s) | ||
| Registry | ||
Measure Description
Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines
Instructions
This measure is to be submitted 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 submitted by 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 is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.
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:
- History asking about incontinence and its character.
- Urinalysis documented.
- 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)