Measure Description
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.
Instructions
This measure is to be submitted each time an anterior and apical prolapse repair surgery is performed during the performance period ending November 30th. 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 anterior or apical pelvic organ prolapse (POP) surgery
Denominator Criteria (Eligible Cases)
All patients, regardless of age
AND
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
Numerator
Total number of patient's receiving a bladder injury at the time of surgery to repair a pelvic organ prolapse with repair during the procedure or subsequently up to 30 days post-surgery
Numerator Instructions:
INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
NUMERATOR NOTE: In order to meet the measure, bladder injury is sustained as a result of the prolapse surgery.
Numerator Options:
Performance Met: Patient sustained bladder injury at the time of surgery or discovered subsequently up to 30 days post-surgery (G9625)
OR
Denominator Exception: Documented medical reasons for not reporting bladder injury (e.g. gynecologic or other pelvic malignancy documented, concurrent surgery involving bladder pathology, injury that occurs during a urinary incontinence procedure, patient death from non-medical causes not related to surgery, patient died during procedure without evidence of bladder injury) (G9626)
OR
Performance Not Met: Patient did not sustain bladder injury at the time of surgery nor discovered subsequently up to 30 days post-surgery (G9627)
Rationale
Bladder injury is a common and potentially debilitating complication of pelvic surgery but more common in surgery for pelvic organ prolapse. Surgeons may benefit from interventions to improve the quality of their surgical care if they have a higher than expected rate of bladder injury during pelvic organ prolapse repair.
Clinical Recommendation Statements
Bladder injury is a common and potentially debilitating complication of pelvic surgery but more common in surgery for pelvic organ prolapse. Surgeons may benefit from interventions to improve the quality of their surgical care if they have a higher than expected rate of bladder injury during pelvic organ prolapse repair.