#434: Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair

Quality ID

434

High Priority Measure

Yes

Specifications

Registry

Measure Type

Outcome

Specialty

Obstetrics/Gynecology Urology

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

 

Instructions

This measure is to be submitted each time an anterior and apical prolapse repair surgery is performed during the performance period ending November 30th. 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

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. Submitting 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 postsurgery (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 nonmedical 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)

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