Measure Description
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 20% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 20% from the pre-intervention level, a plan of care was documented within the 12 month performance period.
Instructions
This measure is to be submitted a minimum of once per performance period for glaucoma patients 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 POAG 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 primary open-angle glaucoma
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for primary open-angle glaucoma (ICD-10-CM): H40.1111, H40.1112, H40.1113, H40.1114, H40.1121, H40.1122, H40.1123, H40.1124, H40.1131, H40.1132, H40.1133, H40.1134, H40.1211, H40.1212, H40.1213, H40.1214, H40.1221, H40.1222, H40.1223, H40.1224, H40.1231, H40.1232, H40.1233, H40.1234, H40.151, H40.152, H40.153
AND
Patient encounter during the performance period (CPT): 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
WITHOUT
Place of Service (POS): 12
Numerator
Patients whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 20% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 20% from the pre-intervention level, a plan of care was documented within the 12 month performance period
Definitions:
Plan of Care – May include: recheck of IOP at specified time, change in therapy, perform additional diagnostic evaluations, monitoring per patient decisions or health system reasons, and/or referral to a specialist.
Plan to Recheck – In the event certain factors do not allow for the IOP to be measured (e.g., patient has an eye infection) but the physician has a plan to measure the IOP at the next visit; the plan of care code should be submitted.
Glaucoma Treatment Not Failed – The most recent IOP was reduced by at least 20% in the affected eye or if both eyes were affected, the reduction of at least 20% occurred in both eyes from pre-intervention levels.
Numerator Instructions:
Pre-Intervention Level – The patient’s IOP in the affected eye prior to the initiation of therapy. For patients who have just begun management of their POAG, i.e., a newly diagnosed patient or a patient recently transferred to the care of the physician, a provider can meet the measure’s performance requirements by documenting a plan of care and submitting M1223. Patients whose POAG is well managed are assumed to have met the requirement to reduce their IOP by greater than or equal to 20% and should submit M1225.
Numerator Options:
Performance Met: Intraocular pressure (IOP) reduced by a value of greater than or equal to 20% from the pre-intervention level (M1225)
OR
Performance Met: Glaucoma plan of care documented (M1223)
AND
Intraocular pressure (IOP) reduced by a value less than 20% from the pre-intervention level (M1224)
OR
Performance Not Met: Glaucoma plan of care not documented, reason not otherwise specified (M1222)
AND
Intraocular pressure (IOP) reduced by a value less than 20% from the pre-intervention level (M1224)
OR
Performance Not Met: IOP measurement not documented, reason not otherwise specified (M1226)
Rationale
- Scientific basis for intraocular pressure (IOP) control as outcomes measure (intermediate)
In a recent randomized clinical trial comparing phaco/Kahook Dual Blade to phaco/iStent, success was defined as at least a 20% reduction in IOP or reduction of 1 or more glaucoma medications from baseline (Falenberry S et al 2020). In the only multicenter randomized clinical trial comparing minimally invasive glaucoma surgery standalone procedures, the COMPARE Study defined success as an unmedicated IOP reduction of at least 20% from baseline or unmedicated IOP less than or equal to 18 mmHg (Ahmed IIK et al. 2020). As such, an appropriate “failure” indicator is to NOT achieve at least a 20% IOP reduction. The rationales for a failure indicator are that 1) the results of different studies can lead experienced clinicians to believe that different levels of IOP reduction are appropriate; 2) to minimize the impact of adverse selection for those patients whose IOPs are more difficult to control; and 3) because each patient’s clinical course may require IOP reduction that may vary from 18 to 40+%.
In addition, “…several population-based studies have demonstrated that the prevalence of POAG as well as the incidence of POAG, increases as the level of IOP increases. These studies provide strong evidence that IOP plays an important role in the neuropathy of POAG. Furthermore, studies have demonstrated that reduction in the level of IOP lessens the risk of visual field progression in open-angle glaucoma. In addition, treated eyes that have a greater IOP fluctuation are at increased risk of progression.
Intraocular pressure is the intermediate outcome of therapy used by the FDA for approval of new drugs and devices and, as noted above, has been shown to be directly related to ultimate patient outcomes of vision loss. As such, failure to achieve minimal pressure lowering, absent an appropriate plan of care to address the situation, would constitute performance whose improvement would directly benefit patients with POAG. - Evidence for gap in care
Based on studies in the literature reviewing documentation of IOP achieved under care, the gap could be as great as 50% or more in the community of ophthalmologists and optometrists treating patients with primary open-angle glaucoma. Based on loose criteria for control, IOP was controlled in 66% of follow-up visits for patients with mild glaucoma and 52% of visits for patients with moderate to severe glaucoma.
Another study of a single comprehensive insurance plan suggested that a large proportion of individuals felt to require treatment for glaucoma or suspect glaucoma are falling out of care and are being monitored at rates lower than expected from recommendations of published guidelines.
Clinical Recommendation Statements
The goal of treatment is to maintain the IOP within a range at which visual field loss is unlikely to significantly reduce a patient’s health-related quality of life over his or her lifetime.
The estimated upper limit of this range is considered the “target pressure.” The initial target pressure is an estimate and a means toward the ultimate goal of protecting the patient’s vision. The target pressure should be individualized and may need adjustment further down or even up during the course of the disease.
When initiating therapy, the ophthalmologist assumes that the measured pretreatment pressure range contributed to optic nerve damage and is likely to cause additional damage in the future. Factors to consider when choosing a target pressure include the stage of overall glaucomatous damage as determined by the degree of structural optic nerve injury and/or functional visual field loss, baseline IOP at which damage occurred, age of patient, and additional risk factors (e.g., central corneal thickness (CCT), life expectancy, prior rate of progression). Lowering the pretreatment IOP by 25% or more has been shown to slow progression of POAG. Choosing a lower target IOP can be justified if there is more severe optic nerve damage, if the damage is progressing rapidly, or if other risk factors such as family history, age, or disc hemorrhages are present. Choosing a less aggressive target IOP may be reasonable if the risks of treatment outweigh the benefits (e.g., if a patient does not tolerate medical or laser therapy well and surgical intervention would be difficult or if the patient’s anticipated life expectancy is limited).
Gedde SJ, Vinod K, Wright MW et al and American Academy of Ophthalmology Glaucoma Panel. Preferred Practice Pattern® Guidelines. Primary Open-Angle Glaucoma. Ophthalmology. 2021;128:P71-P150.
Falenberry S et al. Excisional goniotomy vs trabecular microbypass stent implantation: A prospective randomized clinical trial in eyes with mild to moderate open-angle glaucoma. J Cataract Refract Surg. 2020;46:1165-1171.
Ahmed IIK et al. A prospective randomized trial comparing Hydrus and iStent microinvasive glaucoma surgery implants for standalone treatment of open-angle glaucoma: The COMPARE Study. Ophthalmology. 2020;127:52- 61.
The intent of this measure is to have this indicator apply to both optometrists and ophthalmologists (and any other physician who provides glaucoma care); the use of “ophthalmologists” only in the preceding verbatim section reflects the wording in the American Academy of Ophthalmology Preferred Practice pattern.