| Measure Type | High Priority Measure? | NQS Domain |
|---|---|---|
| Process | Yes | Patient Safety |
| Data Submission Method(s) | ||
| Claims, Registry | ||
Measure Description
Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse
Instructions
This measure is to be submitted each time a prolapse organ 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 surgery for pelvic organ prolapse involving vaginal closure/ obliterative procedure
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient procedure during the performance period (CPT): 57106, 57110, 57120
AND NOT
DENOMINATOR EXCLUSION:
Patients who have had a hysterectomy: G9774
Numerator
Number of patients screened for uterine malignancy or those that had an ultrasound and/or endometrial sampling of any kind
Numerator Options:
Performance Met:
Documentation of screening for uterine malignancy, or those that had an ultrasound and/or endometrial sampling of any kind (G9618)
OR
Performance Not Met:
Patient not screened for uterine malignancy, or those that have not had an ultrasound and/or endometrial sampling of any kind, reason not given (G9620)