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2021 MIPS Measure #429: Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy

Quality ID 429
High Priority Measure Yes
Specifications Registry
Measure Type Process
Specialty Obstetrics/Gynecology Urology

Measure Description

Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse

 

Instructions

This measure is to be submitted each time a prolapse organ 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.

 

Denominator

All patients undergoing surgery for pelvic organ prolapse involving vaginal closure/obliterative procedure

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Patient procedure during the performance period (CPT): 57106, 57110, 57120

AND NOT

DENOMINATOR EXCLUSION:

Patients who have had a hysterectomy: G9774

 

Numerator

Number of patients screened for uterine malignancy or those that had an ultrasound and/or endometrial sampling of any kind

Numerator Options:

Performance Met: Documentation of screening for uterine malignancy, or those that had an ultrasound and/or endometrial sampling of any kind (G9618)

OR

Performance Not Met: Patient not screened for uterine malignancy, or those that have not had an ultrasound and/or endometrial sampling of any kind, reason not given (G9620)

 

Rationale

This measure will promote screening of patients at risk for a uterine malignancy prior to obliterative vaginal surgery. The incidence of endometrial cancer found unsuspectingly in patients with POP ranges from 0.3- 3.2%. In a review of all surgical pathology reports for patients undergoing a hysterectomy for pelvic organ prolapse, 644 women were evaluated and 2 were diagnosed with endometrial cancer (0.3%). Ensuring that providers ask about possible symptoms that may hint at the need for further evaluation would increase the quality of care provided to these patients.


Clinical Recommendation Statements

This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to obliterative procedure and can be referred to a gynecologic oncologist for appropriate treatment for the malignancy. The incidence of endometrial cancer found unsuspectingly in patients with POP ranges from 0.3- 3.2%. In a review of all surgical pathology reports for patients undergoing a hysterectomy for pelvic organ prolapse, 644 women were evaluated and 2 were diagnosed with endometrial cancer (0.3%). Ensuring that providers ask about possible symptoms that may hint at the need for further evaluation would increase the quality of care provided to these patients.

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