Measure Description
Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast-feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning
Instructions
This measure is to be submitted a minimum of once per performance period for all patients seen for post-partum care within 8 weeks of giving birth during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
All patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient procedure during performance period (CPT): 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622
AND
Post-partum care visit before or at 8 weeks post-delivery
Numerator
Patients receiving the following at a post-partum visit:
• Breast feeding evaluation and education, including patient-reported breast feeding
• Post-partum depression screening
• Post-partum glucose screening for gestational diabetes patients and
• Family and contraceptive planning
Definitions:
Breast Feeding Evaluation and Education – Patients who were evaluated for breast feeding before or at 8 weeks post-partum.
Post-Partum Depression Screening – Patients who were screened for post-partum depression before or at 8 weeks post-partum. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool (e.g., PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS).
Post-Partum Glucose Screening for Gestational Diabetes – Patients who were diagnosed with gestational diabetes during pregnancy who were screened with a glucose screen before or at 8 weeks post- partum.
Family and Contraceptive Planning – Patients who were provided family and contraceptive planning and education (including contraception, if necessary) before or at 8 weeks post-partum.
Numerator Instructions:
To satisfactorily meet the numerator ALL components (breast feeding evaluation and education, post-partum depression screening, family and contraceptive planning and post-partum glucose screening for patients with gestational diabetes) must be performed.
NUMERATOR OPTIONS:
Performance Met: Post-partum screenings, evaluations and education performed (G9357)
OR
Performance Not Met: Post-partum screenings, evaluations and education not performed (G9358)