| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Claims, Registry | Process | Yes | Patient Safety | Obstetrics/Gynecology |
Measure Description
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse
Instruction
This measure is to be reported each time a procedure is performed during the performance period for patients who undergo a hysterectomy for pelvic organ prolapse. 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 hysterectomy for pelvic organ prolapse
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Diagnosis for Pelvic Organ Prolapse (ICD-10-CM): N81.10, N81.11, N81.12, N81.2,N81.3, N81.4, N81.5, N81.6, N81.82, N81.83, N81.84, N81.89, N81.9
AND
Patient procedure during the performance period (CPT): 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573
Numerator
Patients in whom an intraoperative cystoscopy was performed to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse
Numerator Options:
Performance Met: Intraoperative cystoscopy performed to evaluate for lower tract injury (G9606)
OR
Denominator Exception: Documented medical reasons for not performing intraoperative cystoscopy (e.g., urethral pathology precluding cystoscopy, any patient who has a congenital or acquired absence of the urethra) (G9607)
OR
Performance Not Met: Intraoperative cystoscopy not performed to evaluate for lower tract injury (G9608)