Measure Description
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bladder or bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.
Instructions
This measure is to be submitted each time an anterior, posterior, or apical prolapse repair surgery is performed from December 1st of the previous performance period through November 30th of the current 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.
This measure will be calculated with 2 performance rates:
1) Percentage of patients undergoing prolapse repair who sustain a bladder injury that necessitates repair either intraoperatively or within 30 days after surgery .
2) Percentage of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within 30 days after surgery.
Submission of the two performance rates is required for this measure. A simple average, which is the sum of the performance rates divided by the number of the performance rates will be used to calculate performance.
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.
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
1) All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery who sustain a bladder injury.
2) All patients undergoing anterior, posterior, or apical pelvic organ prolapse (POP) surgery who sustain a bowel injury.
DENOMINATOR (SUBMISSION CRITERIA 1):
All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery.
Definitions:
Denominator identification period – the twelve month period in which eligible patients have a procedure, which December 1st of the previous performance period through November 30th of the current performance period.
Denominator Criteria (Eligible Cases)
All patients, regardless of age
AND
Patient procedure during the denominator identification period (CPT): 57106, 57110, 57120, 57240, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57423, 57425, 57556, 58263, 58270, 58280, 58292, 58294, 58400
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10
NUMERATOR (SUBMISSION CRITERIA 1):
Percentage of patients undergoing prolapse repair who sustain a bladder injury that necessitates repair either intraoperatively or within 30 days after 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)
DENOMINATOR (SUBMISSION CRITERIA 2)
All patients undergoing anterior, posterior, or apical pelvic organ prolapse (POP) surgery.
Definitions:
Denominator identification period – the twelve month period in which eligible patients have a procedure, which December 1st of the previous performance period through November 30th of the current performance period.
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient procedure during the denominator identification period (CPT): 45560, 57106, 57110, 57120, 57200, 57210, 57240, 57250, 57260, 57265, 57268, 57270, 57280, 57282, 57283, 57284, 57285, 57289, 57423, 57425, 57545, 57555, 57556, 58263, 58270, 58280, 58292, 58294, 58400, 58410
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10
NUMERATOR (SUBMISSION CRITERIA 2):
Percentage of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within 30 days after 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, bowel injury is sustained as a result of the prolapse surgery.
Numerator Options:
Performance Met: Patient sustained bowel injury at the time of surgery or discovered subsequently up to 30 days post-surgery (G9628)
OR
Denominator Exception: Documented medical reasons for not reporting bowel injury (e.g. gynecologic or other pelvic malignancy documented, planned (e.g. not due to an unexpected bowel injury) resection and/or re-anastomosis of bowel, or patient death from non-medical causes not related to surgery, patient died during procedure without evidence of bowel injury) (G9629)
OR
Performance Not Met: Patient did not sustain a bowel injury at the time of surgery nor discovered subsequently up to 30 days post-surgery (G9630)
Rationale
There are numerous approaches to surgical correction of pelvic organ prolapse- vaginal, open, laparoscopic and robotic. The incidence of visceral injury ranges from 0.1-4% (SGS Systemic Review Obstet Gynecol 2008: 112: 1131- 1142), depending on the approach, with high potential for morbidity. Unrecognized injury to the intestine increases the risk of mortality from 2 to 23% (Chapron et al. J Am Coll Surg. 1991;185:461-465, Baggish, MSJ Gynecol Surg. 2003;19:63-73). It is critically important for surgeons who are performing these procedures to recognize and repair any visceral injuries intraoperatively, in order to minimize postoperative morbidity, includingthe need for subsequent surgical intervention to address these complications. Surgeons benefit from interventions to improve the quality of their surgical care if they have a higher than expected rate of visceral injury during pelvic organ prolapse repair.
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
There are numerous approaches to surgical correction of pelvic organ prolapse- vaginal, open, laparoscopic and robotic. The incidence of visceral injury ranges from 0.1-4% (SGS Systemic Review Obstet Gynecol 2008: 112: 1131- 1142) depending on the approach with high potential for morbidity. Unrecognized injury to the intestine increases the risk of mortality from 2 to 23 % (Chapron et al. J Am Coll Surg. 1991;185:461-465, Baggish, MS J Gynecol Surg. 2003;19:63-73).
1. SGS Systemic Review Obstet Gynecol 2008: 112: 1131- 1142
2. Chapron et al. J Am Coll Surg. 1991;185:461-465,
3. Baggish, MS J Gynecol Surg. 2003;19:63-73
4. Husch, T et al Int J Surg 2016; 33 Pt A:36-41