| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | Yes | Patient Safety | Obstetrics/Gynecology |
Measure Description
Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy before undergoing an endometrial ablation
Instruction
This measure is to be reported each time a procedure for endometrial ablation is performed during the measurement period. This measure is to 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 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
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 Options:
Performance Met: Endometrial sampling or hysteroscopy with biopsy and results documented (G9823)
OR
Performance Not Met: Endometrial sampling or hysteroscopy with biopsy and results not documented (G9824)