2023 MIPS Measure #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Measure Description

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.

Instructions

This measure is to be submitted each time a procedure for uncomplicated cataract is performed during the performance period. This measure is intended to reflect the quality of services provided for the patients receiving uncomplicated cataract surgery. This measure is to be submitted by the Merit-based Incentive Payment System (MIPS) eligible clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract surgery patients are not eligible for this measure.

NOTE: This is an outcome measure and can be calculated solely using third party intermediary data.

• For patients who receive the cataract surgical procedures specified in the denominator coding, it should be reported whether or not the patient had best-corrected visual acuity of 20/40 or better achieved in the operative eye within 90 days following cataract surgery.
• Cataract surgeries performed on patients who have any of the listed significant ocular conditions [comorbid] in the exclusion criteria should be removed from the denominator; these patients have existing ocular conditions that could impact the outcome of surgery and are not included in the measure calculation for those patients who have best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.
• Include only cataract surgery procedures performed through September 30th of the performance period. This will allow the post-operative period to occur within the performance period.

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 cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of procedure

AND

Procedure during the performance period (CPT): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984

WITHOUT

Modifier: 56 or 55

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

AND NOT

DENOMINATOR EXCLUSION:

Any of the following significant ocular conditions that impact the visual outcome of surgery (Patients with documentation of the presence of one or more of the following significant ocular conditions that impact the visual outcome of surgery prior to date of cataract surgery which is still active at the time of the cataract surgery are excluded from the measure calculation)

Table 1 - Significant Ocular Conditions

Numerator

Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery

Numerator Options:

Performance Met: Best-corrected visual acuity of 20/40 or better (distance or near) achieved within the 90 days following cataract surgery (4175F)

OR

Performance Not Met: Best-corrected visual acuity of 20/40 or better (distance or near) not achieved within the 90 days following cataract surgery, reason not otherwise specified (4175F with 8P)

Rationale

In the United States, cataracts affect more than 24 million adults over 40 years (National Eye Institute, 2019). According to the American Academy of Ophthalmology (Academy) (2021), cataract surgery has a substantial beneficial impact on visual function and on quality of life.

1. Scientific basis for measuring visual acuity outcomes after cataract surgery The only reason to perform cataract surgery (other than for a limited set of medical indications) is to improve a patient’s vision and associated functioning. The use of a 20/40 visual acuity threshold is based on several considerations. First, it is the level for unrestricted operation of a motor vehicle in the US. Second, it has been consistently used by the FDA in its assessment for approval of intraocular lens (IOL) and other vision devices. Third, it is the literature standard to denote success in cataract surgery. Fourth, work by West et al. in the Salisbury Eye Study suggests that 20/40 is a useful threshold for 50th percentile functioning for several vision- related tasks. Most patients achieve excellent visual acuity after cataract surgery (20/40 or better). This outcome is achieved consistently through careful attention through the accurate measurement of axial length and corneal power and the appropriate selection of an IOL power calculation formula. As such, it reflects the care and diligence with which the surgery is assessed, planned and executed. Failure to achieve this after surgery in eyes without comorbid ocular conditions that would impact the success of the surgery would reflect care that should be assessed for opportunities for improvement. The exclusion of patients with other ocular and systemic conditions known to increase the risk of an adverse outcome reflects the findings of the two published prediction rule papers for cataract surgery outcomes, by Mangione et al. (1995) and Steinberg et al. (1994). In both papers, the presence of comorbid glaucoma and macular degeneration negatively impacted the likelihood of successful outcomes of surgery. Further, as noted in the prior indicator, exclusion of eyes with ocular conditions that could impact the success of the surgery would NOT eliminate the large majority of eyes undergoing surgery while also minimizing the potential adverse selection that might otherwise occur relative to those patients with the most complex situations who might benefit the most from having surgery to maximize their remaining vision.

2. Evidence of a gap in care Cataract surgery successfully restores vision in the majority of people who have the procedure. Data from a study of 368,256 cataract surgeries show that corrected visual acuity (CDVA) of 0.5 (20/40) or better was achieved in 94.3% and CDVA of 1.0 (20/20) or better was achieved in 61.3% of cases (Lundstrom et al., 2013). Additionally, data from a UK multi-center Cataract National Dataset found a postoperative visual acuity of 6/12 (20/40) or better was achieved for 94.7% of eyes with no co-pathologies and in 79.9% of eyes with one or more co-pathologies (Jaycock et al., 2009). A rate of 85.5-94.7% of patients achieving a 20/40 or better visual acuity in the context of approximately 3 million cataract surgeries in the US annually would mean that between 160,000 to 435,000 individuals would not achieve a 20/40 or better visual acuity which suggests an opportunity for improvement.

Clinical Recommendation Statements

This is an outcome measure. As such, there is no statement in the guideline specific to this measurement topic.