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2021 MIPS Measure #335: Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse)

Quality ID 335
High Priority Measure Yes
Specifications Registry
Measure Type Outcome
Specialty Obstetrics/Gynecology

Measure Description

Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries by cesarean section (C-section), or early inductions of labor, without medical indication.

 

Instructions

This measure is to be submitted each time a procedure is performed for patients undergoing delivery by C-section, or induction of labor, at less than 39 weeks gestation 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 delivering a live singleton at < 39 weeks of gestation completed

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Single live birth (ICD-10-CM): Z37.0

AND

Patient procedure during performance period (CPT): 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622

AND

Delivery at < 39 weeks gestation

 

Numerator

Patients who had elective deliveries by C-section, or early inductions of labor, without medical indication

Numerator Options:

Performance Met: Early elective delivery by C-section, or early elective induction, not performed (< 39 weeks gestation) (G9355)

OR

Denominator Exception: Medical indication for induction [Documentation of reason(s) for elective delivery (C-section) or early Induction) (e.g., hemorrhage and placental complications, hypertension, preeclampsia and eclampsia, rupture of membranes (premature or prolonged), maternal conditions complicating pregnancy/delivery, fetal conditions complicating pregnancy/delivery, late pregnancy, prior uterine surgery, or participation in clinical trial)] (G9361)

OR

Performance Not Met: Early elective delivery by C-section, or early elective induction, performed (< 39 weeks gestation) (G9356)

 

Rationale

Elective delivery or early induction often leads to prematurity, increased costs, and an increased incidence of cesarean section. Studies have determined that elective delivery or elective cesarean section prior to the gestational age of 39 weeks may result in significant short-term neonatal morbidity (neonatal intensive care unit admission rates of 13%– 21%). Among women undergoing induction, women with their first pregnancies have a higher rate of cesarean delivery than women with prior vaginal births. Recent research shows that infants born prior to 39 weeks face a higher risk of breathing disorders and other problems than those who remain in the womb longer.

 

Clinical Recommendation Statements

The below evidence statements are quoted from the following clinical practice bulletins: the American College of Obstetrics and Gynecologists (ACOG) “Induction of Labor” (issued in August 2009 and reaffirmed in 2016); the ACOG Medically Indicated Late-Preterm and Early-Term Deliveries Committee Opinion (2019); and the ACOG Avoidance of Nonmedically Indicated Early-Term Deliveries and Associated Neonatal Morbidities Committee Opinion (2019).

Decisions regarding maternal delivery are complex and must take into account maternal and newborn risks, practice environment, and patient preferences. The goal of induction of labor is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor. Generally, induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. Labor may also be induced for logistic reasons, e.g., rapid labor, distance, or psychosocial reasons.

However, indications for induction of labor are not absolute but should take into account maternal and fetal conditions, gestational age, cervical status, and other factors. ACOG and the Society for Maternal-Fetal Medicine have long discouraged nonindicated delivery before 39 weeks of gestation because the neonatal risks of late pre-term (34 0/7–36 6/7 weeks of gestation) and early term (37 0/7–38 6/7 weeks of gestation) births are well-established, and the potential neonatal complications associated with elective delivery at less than 39 0/7 weeks are well described. Based on these and other data, timing of elective delivery at 39 weeks of gestation or later is recommended. However, deferring delivery to 39 weeks of gestation is not recommended if there is a medical or obstetric indication for early delivery.

In some cases, health providers will need to weigh competing risks and benefits for the woman and her fetus. The following are examples of maternal or fetal conditions that may be indications for elective delivery by cesarean section, or early induction of labor:

  • Placenta previa*
  • Suspected accrete, increate, or percreta*
  • Vasa previa* • Prior classical cesarean*
  • Prior myomectomy requiring cesarean delivery* 
  • Previous uterine rupture*
  • Oligohydramnios
  • Polyhydramnios
  • Growth restriction
  • Multiple gestations—uncomplicated
  • Multiple gestations—complicated
  • Alloimmunization
  • Hypertensive disorders of pregnancy
  • Diabetes
  • HIV
  • Intrahepatic cholestasis of pregnancy
  • PROM (prelabor rupture of membranes)

    * These conditions may be indications for early delivery by cesarean section; they are not indications for early induction of labor.

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