Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero

Last updated: May 3, 2018

CMS Measure ID: CMS178v4
Version: 4
NQF Number: 0453
Measure Description:

Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero.

Initial Patient Population:

All hospital discharges for selective surgery with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital admission with a catheter in place postoperatively.

Denominator Statement:

All selected surgical patients 18 years of age and older with a catheter in place postoperatively with An ICD-9-CM Principal Procedure Code of selected surgeries.

Denominator Exclusions:
  • Patients enrolled in clinical trials.
  • Patients who had a urological, gynecological or perineal procedure performed.
  • Patients who expired perioperatively.
  • Patients whose length of stay was less than two days postoperatively.
  • Patients who had a urinary diversion or a urethral catheter or were being intermittently catheterized prior to hospital arrival.
  • Patients who did not have a catheter in place postoperatively.
  • Patients who had physician/APN/PA documentation of a reason for not removing the urinary catheter postoperatively.
Numerator Statement:

Number of surgical patients whose urinary catheter is removed on postoperative day (POD) 1 or postoperative day (POD) 2 with day of surgery being day zero.

Numerator Exclusions:

Not applicable

Denominator Exceptions:


Measure Steward: Centers for Medicare and Medicaid Services
Domain: Patient Safety
Short Name: SCIPInf9
Next Version:
Measure Score: Proportion
Score Type: Process
Improvement Notation:

Higher score indicates better quality.


The measurement period is one calendar year but the reporting period is 3 months as a calendar quarter; Q1 = Jan – Mar, Q2 = Apr – Jun, Q3 = Jul – Sep, Q4 is Oct – Dec.

General guidance:

In this measure the code lists that describe types of surgical procedures remain only in ICD-9 or ICD-10 because the concepts that apply are limited to a very specific subset of all surgical procedures.

Denominator element guidance:

The denominator in this measure specifically excludes surgical procedures that may be associated with post-operative indwelling urinary catheter usage and that occur in close time proximity to the index major surgical procedure.

Exclusion element guidance:

The exclusion for patients who are clinical trial participants is limited to patients participating in a clinical trial for the same conditions as covered by the measure. Other clinical trials are not valid reasons for exclusions.

By convention, discharge date post Encounter inpatient is used to describe the hospital discharge date. Where logic needs to indicate discharge (or transfer) from one inpatient location to another, the logic uses Transfer From or Transfer To as the QDS data type.


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