MIPS Measures Relevant to Ophthalmology

  1. Quality - 40% of total score:  Report 6 measures, including one Outcome or other High Priority measure for 12 months on at least 70% of eligible encounters to possibly earn more than 3 points on a measure. Note: Small practices (less than 16 in the practice) can earn 3 points on a measure if at least 1 eligible case is reported.  Suggestions for your specialty include, but are not limited to, the following:   
    ID:
    012
    NQF:
    0086
    eMeasure ID:
    CMS143v9
    High Priority:
    No

    2021 MIPS Measure #012: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

    Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.
     

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
    ID:
    014
    NQF:
    0087
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #014: Age-Related Macular Degeneration (AMD): Dilated Macular Examination

    Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
    ID:
    019
    NQF:
    0089
    eMeasure ID:
    CMS142v9
    High Priority:
    Yes

    2021 MIPS Measure #019: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

    Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
    ID:
    117
    NQF:
    0055
    eMeasure ID:
    CMS131v9
    High Priority:
    No

    2021 MIPS Measure #117: Diabetes: Eye Exam

    Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Ophthalmology
    ID:
    130
    NQF:
    0419e
    eMeasure ID:
    CMS68v10
    High Priority:
    Yes

    2021 MIPS Measure #130: Documentation of Current Medications in the Medical Record

    Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Infectious Disease
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    141
    NQF:
    0563
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

    Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    191
    NQF:
    0565
    eMeasure ID:
    CMS133v9
    High Priority:
    Yes

    2021 MIPS Measure #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

    Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    226
    NQF:
    0028
    eMeasure ID:
    CMS138v9
    High Priority:
    No

    2021 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Neurosurgery
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Podiatry
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    238
    NQF:
    0022
    eMeasure ID:
    CMS156v9
    High Priority:
    Yes

    2021 MIPS Measure #238: Use of High-Risk Medications in the Elderly

    Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Ophthalmology
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    303
    NQF:
    1536
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

    Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    304
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

    Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    374
    NQF:
    eMeasure ID:
    CMS50v9
    High Priority:
    Yes

    2021 MIPS Measure #374: Closing the Referral Loop: Receipt of Specialist Report

    Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    384
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

    Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    385
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

    Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    389
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #389: Cataract Surgery: Difference Between Planned and Final Refraction

    Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
     
  2. PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Edition certification must be in place by October 3, 2021. There are exclusions available for most of the required measures. Please check your QPP Participation Status to see if you are automatically exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category making it 65% of your score.
  3. IA: Improvement Activities - 15% of total score:  Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area,  attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. A group can attest to an activity when at least 50% of the clinicians in the group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year. There are over 100 possible activities to choose from. The following are suggestions only:

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