2021 MIPS Measure #434: Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair 

Measure Type High Priority Measure? Collection Type(s)
Outcome yes MIPS CQM


Measure Description

Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgery


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.


All patients undergoing anterior or apical pelvic organ prolapse (POP) surgery

Denominator Criteria (Eligible Cases):

All patients, regardless of age


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


The number of patients receiving a ureter injury with repair at the time of initial surgery or subsequently up to 30 days postoperatively 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, ureter injury is sustained as a result of the prolapse surgery.

Numerator Options:

Performance Met:

Patient sustained ureter injury at the time of surgery or discovered subsequently up to 30 days post-surgery (G9631)


Denominator Exception:

Documented medical reasons for not reporting ureter 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 ureter injury) (G9632)


Performance Not Met:

Patient did not sustain ureter injury at the time of surgery nor discovered subsequently up to 30 days post-surgery (G9633)


CMS-Obstetrics-Gynecology-2021, CMS-Urology-2021, Obstetrics/Gynecology-2021, Quality-2021, Urology-2021