Measure Description
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
Instructions
This measure is to be submitted a minimum of once per performance period for all patients with diabetic retinopathy seen during the performance period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians who provide the primary management of patients with diabetic retinopathy (in either one or both eyes) will submit this measure.
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 aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis of diabetic retinopathy (ICD-10-CM): E08.311, E08.319, E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533, E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E09.311, E09.319, E09.3211, E09.3212, E09.3213, E09.3291, E09.3292, E09.3293, E09.3311, E09.3312, E09.3313, E09.3391, E09.3392, E09.3393, E09.3411, E09.3412, E09.3413, E09.3491, E09.3492, E09.3493, E09.3511, E09.3512, E09.3513, E09.3521, E09.3522, E09.3523, E09.3531, E09.3532, E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E09.3591, E09.3592, E09.3593, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391,E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.3591, E10.3592, E10.3593, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, E11.3512, E11.3513, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542, E11.3543, E11.3551, E11.3552, E11.3553, E11.3591, E11.3592, E11.3593, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3291, E13.3292, E13.3293, E13.3311, E13.3312, E13.3313, E13.3391, E13.3392, E13.3393, E13.3411, E13.3412, E13.3413, E13.3491, E13.3492, E13.3493, E13.3511, E13.3512, E13.3513, E13.3521, E13.3522, E13.3523, E13.3531, E13.3532, E13.3533, E13.3541, E13.3542, E13.3543, E13.3551, E13.3552, E13.3553, E13.3591, E13.3592, E13.3593
AND
Patient encounter during the performance period (CPT): 92002, 92004, 92012, 92014, 99201, 9202,99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304,99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,99337
WITHOUT
Telehealth Modifier: GQ, GT, 95, POS 02
AND
Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy: G8397
Numerator
Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient’s diabetic care
Definitions:
Communication – May include documentation in the medical record indicating that the findings of the dilated macular or fundus exam were communicated (e.g., verbally, by letter) with the clinician managing the patient’s diabetic care OR a copy of a letter in the medical record to the clinician managing the patient’s diabetic care outlining the findings of the dilated macular or fundus exam.
Findings – Includes level of severity of retinopathy (e.g., mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative) AND the presence or absence of macular edema.
NUMERATOR NOTE: Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met: Findings of dilated macular or fundus exam communicated to the physician or other qualified health care professional managing the diabetes care (5010F)
OR
Denominator Exception: Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician or other qualified health care professional managing the ongoing care of the patient with diabetes (5010F with 1P)
OR
Denominator Exception: Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician or other qualified health care professional managing the ongoing care of the patient with diabetes (5010F with 2P)
OR
Performance Not Met: Findings of dilated macular or fundus exam were not communicated to the physician or other qualified health care professional managing the diabetes care, reason not otherwise specified (5010F with 8P)
Rationale
The primary care physician that manages the ongoing care of the patient with diabetes should be aware of the patient’s dilated eye examination and severity of retinopathy to manage the ongoing diabetes care. Such communication is important in assisting the physician to better manage the diabetes. Several studies have shown that better management of diabetes is directly related to lower rates of development of diabetic eye disease (Diabetes Control and Complications Trial – DCCT, UK Prospective Diabetes Study – UKPDS).
Clinical Recommendation Statements
The ophthalmologist should refer patients with diabetes to a primary care physician for appropriate management of their systemic condition and should communicate examination results to the physician managing the patient’s ongoing diabetes care (III; Good Quality; Strong recommendation) (American Academy of Ophthalmology, 2017).
Ophthalmologists should communicate the ophthalmologic findings and level of retinopathy with the primary care physician as well as the need for optimizing metabolic control (III; Good Quality; Strong Recommendation) (American Academy of Ophthalmology, 2017).
Close partnership with the primary care physician is important to make sure that the care of the patient is optimized (III; Good Quality; Strong Recommendation) (American Academy of Ophthalmology, 2017).