| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Outcome | Yes | Patient Safety | Obstetrics/Gynecology |
Measure Description
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery
Instruction
This measure is to be reported each time a prolapse organ repair surgery is performed during the performance period ending November 30th. 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
The number of patients receiving a ureter injury with repair at the time of initial surgery or subsequently up to 1 month postoperatively surgery
Numerator Instructions:
INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trendscloser to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
NUMERATOR NOTE: In order to meet the measure, ureter injury is sustained as a result of the prolapse surgery.
Numerator Options:
Performance Met: Patient sustained ureter injury at the time of surgery or discovered subsequently up to 1 month post-surgery (G9631)
OR
Denominator Exception: Documented medical reasons for not reporting ureter injury (e.g. gynecologic or other pelvic malignancy documented, concurrent surgery involving bladder pathology, injury that occurs during a urinary incontinence procedure, patient death from non-medical causes not related to surgery, patient died during procedure without evidence of ureter injury) (G9632)
OR
Performance Not Met: Patient did not sustain ureter injury at the time of surgery nor discovered subsequently up to 1 month post-surgery (G9633)