2019 MIPS Measure #428: Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence

Quality ID 428
High Priority Measure No
Specifications Registry
Measure Type Process
Specialty Obstetrics/Gynecology Urology

Measure Description

Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines



This measure is to be submitted each time an anterior and/or apical pelvic organ prolapse repair surgery is performed during the performance period. There is no diagnosis associated with this measure. 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.



All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery

Denominator Criteria (Eligible Cases):

All patients, regardless of age


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



Number of patients undergoing preoperative assessment


Preoperative Assessment – Includes the following:

1) History asking about incontinence and its character.
2) Urinalysis documented.
3) Physical exam testing for stress incontinence whether or not a patient is symptomatic.

Numerator Options:

Performance Met: Preoperative assessment documented (G9615)


Denominator Exception: Documentation of reason(s) for not documenting a preoperative assessment (e.g., patient with a gynecologic or other pelvic malignancy noted at the time of surgery) (G9616)


Performance Not Met: Preoperative assessment not documented, reason not given (G9617)

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