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2020 MIPS Measure #448: Appropriate Workup Prior to Endometrial Ablation

Quality ID 448
NQF 0567
High Priority Measure Yes
Specifications Registry
Measure Type Process
Specialty Obstetrics/Gynecology

Measure Description

Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation

 

Instructions

This measure is to be submitted each time a procedure for endometrial ablation is performed during the measurement period. This measure is to 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 aged 18 years and older who undergo an endometrial ablation procedure during the measurement year

Definition:

Index Date (exclusive of the index date) – This date is in reference to the date of procedure for endometrial sampling or hysteroscopy with biopsy.

Denominator Criteria (Eligible Cases):

All patients, aged 18 years and older

AND

Codes for endometrial ablation (ICD-10-PCS): 0U5B0ZZ, 0U5B3ZZ, 0U5B4ZZ, 0U5B7ZZ, 0U5B8ZZ, 0UDB7ZZ, 0UDB8ZZ

AND/OR

Patient procedure during the performance period (CPT): 58353, 58356, 58563

AND NOT

DENOMINATOR EXCLUSION:

Patients who had an endometrial ablation procedure during the year prior to the index date (exclusive of the index date): G9822

 

Numerator

Patients who received endometrial sampling or hysteroscopy with biopsy and results documented during the year prior to the index date (exclusive of the index date) of the endometrial ablation

Numerator Options:

Performance Met: Endometrial sampling or hysteroscopy with biopsy and results documented (G9823)

OR

Performance Not Met: Endometrial sampling or hysteroscopy with biopsy and results not documented (G9824)

 

Rationale

The structure and histology of the endometrial cavity should be thoroughly evaluated, both to assess for malignancy or endometrial hyperplasia and to ensure that the length and configuration is suitable for endometrial ablation. These parameters will vary depending on the technique or system used. Endometrial sampling, typically with an outpatient technique, can be used to evaluate all women for hyperplasia or malignancy, and results should be reviewed before ablation is scheduled. Women with endometrial hyperplasia or uterine cancer should not undergo endometrial ablation. (ACOG Practice Bulletin 81, 2007, Reaffirmed 2013

Abnormal Uterine Bleeding (AUB) is a significant issue for women during their reproductive years, occurring in approximately 10-to 35% of women [1-3]. This condition can result in anemia, limit daily activities and raises concerns about uterine cancer. Five percent of women between the ages of 30 and 49 will seek medical attention for evaluation of menorrhagia [4-6]. Endometrial Ablation (AB) is a well-established, effective treatment for AUB, and is a less invasive alternative to hysterectomy, with lower complication rates. The procedure effectively reduces menstrual flow and results in high patient satisfaction [7]. Preoperative evaluations include endometrial sampling and assessment of the uterine cavity [7].

References
1. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, Number 81, May 2007, Reaffirmed 2013.
2. Côté I, Jacobs P, Cumming DC. Use of health services associated with increased menstrual loss in the United States. Am J Obstet Gynecol 2003; 188:343.
3. Santer M, Warner P, Wyke S. A Scottish postal survey suggested that the prevailing clinical preoccupation with heavy periods does not reflect the epidemiology of reported symptoms and problems. J Clin Epidemiol 2005; 58:1206.
4. Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract 2004; 54:359.
5. Warner P, Critchley HO, Lumsden MA, et al. Referral for menstrual problems: cross sectional survey of symptoms, reasons for referral, and management. BMJ 2001; 323:24.
6. Vessey MP, Villard-Mackintosh L, McPherson K, et al. The epidemiology of hysterectomy: findings in a large cohort study. Br J Obstet Gynaecol 1992; 99:402.
7. Dilley A, Drews C, Miller C, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol 2001; 97:630.
8. Laberge, P, Leyland, N., Murji, A. et al. Endometrial Ablation in the Management of Abnormal Uterine Bleeding. J. Obstet. Gynaecol. Can. 2015; 37(4):362-376.


Clinical Recommendation Statements

The Society of Obstetricians and Gynecologists of Canada published the Clinical Practice Guideline “Endometrial Ablation in the Management of Abnormal Uterine Bleeding in 2015” [1]. This guideline has various recommendations for indication and contraindication and preoperative assessments prior to Endometrial Ablation (EA). Table 2 of the guideline details indications and contraindication to EA. Indications include: AUB of benign origin, and candidates that are poor surgical candidates for hysterectomy [1]. Absolute contraindications for EA include pregnancy, desire to preserve fertility, endometrial hyperplasia or cancer, cervical cancer, and active pelvic infection [1].

The guideline goes on to recommend:

“3. Recommended evaluations for abnormal uterine bleeding, including but not limited to endometrial sampling and an assessment of the uterine cavity are necessary components of the preoperative assessment. (II-2B) [1].

The guideline then offers clinical tips which list required investigations prior to EA which include: a pregnancy test; Papanicolaou test within 2 years, cervical cultures if clinically appropriate, endometrial sampling; and, assessment of uterine cavity for Mullerian anomalies or intracavity pathology [1].

As cited above the American College of Gynecology states: “The structure and histology of the endometrial cavity should be thoroughly evaluated, both to assess for malignancy or endometrial hyperplasia and to ensure that the length and configuration is suitable for endometrial ablation. These parameters will vary depending on the technique or system used. Endometrial sampling, typically with an outpatient technique, can be used to evaluate all women for hyperplasia or malignancy, and results should be reviewed before ablation is scheduled. Women with endometrial hyperplasia or uterine cancer should not undergo endometrial ablation.” (ACOG Practice Bulletin 81, 2007, Reaffirmed 2013)

References
1. Laberge, P, Leyland, N., Murji, A. et al. Endometrial Ablation in the Management of Abnormal Uterine Bleeding. J. Obstet. Gynaecol. Can. 2015; 37(4):362-376.
2. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, Number 81, May 2007, Reaffirmed 2013.

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