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    • EyeNet Magazine
    • / May 2022
    • / MIPS 2019—Reporting MIPS Quality Measures Manually via the IRIS Registry
  • MIPS 2019—Reporting MIPS Quality Measures Manually via the IRIS Registry

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    This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page. 


    If  you are using the IRIS Registry to manually report quality measures, you can choose from 29 MIPS clinical quality measures (MIPS CQMs) and 28 QCDR measures (the IRIS measures).

    In the chart below, those measures are grouped by area of focus. There are preventative health measures, cataract/anterior segment measures, cornea/external disease measures, glaucoma measures, neuro-ophthalmology measures, oculofacial plastics/reconstructive measures, pediatric ophthalmology and strabismus measures, refractive surgery measures, retina/vitreous measures, and uveitis/immunology measures. In addition to considering the measures in your subspecialty, you should review the measures in the other subspecialties in case any might be relevant to you. (And don’t forget to review "Tips on Using This Chart.")

    Harder to get a high score for quality. In 2019, if you report the same quality measures as you did in 2018 and get similar performance rates, you are likely to score fewer achievement points. Why? The benchmarks for most quality measures have become more demanding, more measures are in their second year of being topped out, which means they are subject to a 7-point cap (see Table 6A), and scoring for more measures “stalls” below the 10th decile (see Tables 6B and 6C). 

    Table 8: Manually Reporting Quality Measures via the IRIS Registry

    If your reporting for a quality measure satisfies both the case minimum requirement (20 patients) and the data completeness criteria (60% of denominator-eligible patients), your performance rate will be compared against a benchmark and you can earn the achievement points indicated below (column 3).

    If you meet the data completeness criteria but not the case minimum requirement, you earn 3 achievement points. If you don't meet the data completeness criteria, but report on at least one patient, you earn 1 achievement point or, if a special status applies to you—e.g., you are in a small practice—3 achievement points.

    ID: Measure Name High-Priority Measure (Bonus Points) Achievement Points Notes

    Preventive Health Measures

    1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Intermediate outcome (+2 bonus points) 3-10 points Inverse measure
    110: Preventive Care and Screening: Influenza Immunization   3-10 points  
    111: Pneumonia Vaccination Status for Older Adults   3-10 points  
    117: Diabetes: Eye Exam   3-7 points Topped out, 7-point cap
    128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan   3-8.9 points or, with a 100% performance rate, 10 points  
    130: Documentation of Current Medications in the Medical Record Patient safety (+1 bonus point) 3-7 points Topped out, 7-point cap
    154: Falls: Risk Assessment Patient safety (+1 bonus point) 3-7 points Topped out, 7-point cap
    226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention   No benchmark yet  
    236: Controlling High Blood Pressure Intermediate outcome (+2 bonus points) 3-10 points  
    238: Use of High-Risk Medications in the Elderly Patient safety (+1 bonus point) 3-5.9 points or, with a 0% performance rate, 7 points Inverse measure, topped out, 7-point cap
    317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented   3-10 points  
    374: Closing the Referral Loop Care coordination (+1 bonus point) 3-10 points  
    402: Tobacco Use and Help With Quitting Among Adolescents   3-8.9 points or, with a 100% performance rate, 10 points Topped out
    474: Zoster (Shingles) Vaccination   No benchmark yet  

    Cataract/Anterior Segment

    191: Cataracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery Outcome (+2 bonus points) 3-5.9 points or, with a 100% performance rate, 10 points Topped out
    192: Cataracts: Complications Within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Outcome (+2 bonus points) 3 points or, with a 0% performance rate, 7 points Inverse measure, topped out, 7-point cap
    388: Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) Outcome (+2 bonus points) 3 points or, with 0% performance rate, 7 points  Inverse measure, topped out, 7-point cap
    389: Cataract Surgery: Difference Between Planned and Final Refraction Outcome (+2 bonus points) 3-6.9 points or, with a 100% performance rate, 10 points  
    IRIS27: Adverse Events After Cataract Surgery Outcome (+2 bonus points) No benchmark yet Inverse measure
    IRIS40: Regaining Vision After Cataract Surgery Outcome (+2 bonus points) No benchmark yet Change of ID # (previously IRIS28)
    Also see IRIS36, under Glaucoma.      

    Cornea/External Disease

    IRIS1: Endothelial Keratoplasty: Postoperative Improvement in Best Corrected Visual Acuity to 20/40 or Greater Outcome (+2 bonus points) No benchmark yet  
    IRIS38: Endothelial Keratoplasty: Dislocation Requiring Surgical Intervention Outcome (+2 bonus points) No benchmark yet  

    Glaucoma

    12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation   3-4.9 points or, with a 100% performance rate, 7 points Topped out, 7-point cap
    141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% or Documentation of a Plan of Care Outcome (+2 bonus points) 3-6.9 points or, with a 100% performance rate, 10 points  
    IRIS2: Intraocular Pressure (IOP) Reduction Intermediate outcome (+2 bonus points) 3-5.9 points or, with a 100% performance rate, 10 points Topped out
    IRIS36: Visual Acuity Improvement Following Cataract Surgery Combined With a Trabeculectomy or an Aqueous Shunt Procedure Outcome (+2 bonus points) No benchmark yet  
    IRIS39: IOP Reduction Following Trabeculectomy or an Aqueous Shunt Procedure Outcome (+2 bonus points) No benchmark yet  
    IRIS43: IOP Reduction Following Laser Trabeculoplasty Outcome (+2 bous points) No benchmark yet Change of ID # (previously IRIS4)
    IRIS44: Visual Field Progression in Glaucoma Outcome (+2 bonus points) No benchmark yet Inverse measure, change of ID # (previously IRIS3)

    Neuro-Ophthalmology

    419: Overuse of Neuroimaging for Patients With Primary Headache and a Normal Neurological Examination Efficiency (+1 bonus point) No benchmark yet  
    IRIS21: Ocular Myasthenia Gravis: Improvement of Ocular Deviation or Absence of Diplopia or Functional Improvement Outcome (+2 bounus points) No benchmark yet  
    IRIS22: Giant Cell Arteritis: Absence of Fellow Eye Involvement After Treatment Outcome (+2 bonus points) No benchmark yet  

    Oculofacial Plastics/Reconstructive 

    137: Melanoma: Continuity of Care – Recall System Care coordination (+1 bonus point) 3-5.9 points or, with a 100% performance rate, 10 points  
    138: Melanoma: Coordination of Care Care coordination (+1 bonus point) 3-6.9 points or, with a 100% performance rate, 10 points  
    265: Biopsy Follow-Up Care coordination (+1 bonus point) 3-7 points Topped out, 7-point cap
    397: Melanoma Reporting Care coordination (+1 bonus point) 3-3.9 points or, with a 100% performance rate, 7 points Topped out, 7-point cap
    IRIS5: Surgery for Acquired Involutional Ptosis: Patients With an Improvement of Marginal Reflex Distance (MRD) Outcome (+2 bonus points) No benchmark yet  
    IRIS6: Acquired Involutional Entropion: Normalized Lid Position After Surgical Repair Outcome (+2 bonus points) No benchmark yet  
    IRIS37: Postoperative Opioid Management Following Oculoplastic Surgery Opioid-related measure (+1 bonus point) No benchmark yet  

    Pediatric Ophthalmology and Strabismus

    IRIS48: Adult Surgical Esotropia: Postoperative Alignment Outcome (+2 bonus points) No benchmark yet  
    IRIS49: Surgical Pediatric Esotropia: Postoperative Alignment Outcome (+2 bonus points) No benchmark yet Change of ID # (previously IRIS8)
    IRIS50: Amblyopia: Interocular Visual Acuity Outcome (+2 bonus points) No benchmark yet Change of ID # (previously IRIS7)

    Refractive Surgery

    IRIS23: Refractive Surgery: Patients With a Postoperative Uncorrected Visual Acuity (UCVA) of 20/20 or Better Outcome (+2 bonus points) No benchmark yet  
    IRIS24: Refractive Surgery: Patients With a Postoperative Correction Within ± 0.5 Diopter (D) of the Intended Correction Outcome (+2 bonus points) No benchmark yet  

    Retina/Vitreous

    Retina: Age-Related Macular Degeneration (AMD)
    14: AMD: Dilated Macular Examination   3-7 points Topped out, 7-point cap
    IRIS45: Exudative AMD: Loss of Visual Acuity Outcome (+2 bonus points) No benchmark yet Change of ID # (previously IRIS10)
    Retina: Diabetic Retinopathy (DR) and Diabetic Maculat Edema (DME)
    19: Diabetic Retinopathy: Communication With the Physician Managing On-going Diabetes Care Care coordination (+1 bonus point) 3-6.9 points or, with a 100% performance rate, 10 points Topped out
    IRIS13: Diabetic Macular Edema: Loss of Visual Acuity Outcome (+2 bonus points) No benchmark yet  
    Retina: Epiretinal Membrane
    IRIS41: Improved Visual Acuity After ERM Treatment Within 120 Days Outcome (+2 bonus points) No benchmark yet Change of ID # (previously IRIS29)
    IRIS42: Return to OR or Endophthalmitis Within 90 Days After ERM Surgical Treatment Outcome (+2 bonus points) No benchmark yet Inverse measure, change of ID # (previously IRIS30)
    Retina: Macular Hole
    IRIS46: Evidence of Anatomic Closure of Macular Hole Within 90 Days After Surgery as Documented by OCT Outcome (+2 bonus points) No benchmark yet Change of ID # (previously IRIS32)
    IRIS47: Return to OR or Endophthalmitis Within 90 Days After Macular Hole Surgery Outcome (+2 bonus points) No benchmark yet Inverse measure, change of ID # (previously IRIS33) 
    Retina:Retinal Detachment
    384: Adult Primary Rhegmatogenous Retinal Detachment: No Return to the Operating Room Within 90 Days of Surgery Outcome (+2 bonus points) No benchmark yet  
    385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery Outcome (+2 bonus points) No benchmark yet  

    Uveitis/Immunology

    IRIS18: Chronic Anterior Uveitis: Post-Treatment Visual Acuity Outcome (+2 bonus points) No benchmark yet  
    IRIS35: Improvement of Macular Edema in Patients with Uveitis Outcome (+2 bonus points) No benchmark yet  
    IRIS51: Acute Anterior Uveitis: Post-Treatment Visual Acuity Outcome (+2 bonus points) No benchmark yet Change of ID # (previously IRIS16)

    Tips on Using This Chart

    This chart shows the benchmarks for quality measures reported manually via the IRIS Registry. You also can report via IRIS Registry–EHR integration and via Medicare Part B claims.

    Column 1—ID: Measure Name

    Learn more about a measure by clicking on its name. Each measure’s name is linked to a detailed web page that explains which patients are denominator eligible, lists relevant ICD-10 and CPT codes, describes how to report the measure, and provides detailed benchmark information.

    Which measures should you report? Skim through this chart to see which measures you are most likely to (a) satisfy the case minimum requirement of 20 patients, (b) satisfy the 60%-data completeness criteria, and (c) achieve a high performance rate.

    Other factors to keep in mind are that you need to report at least one quality or intermediate quality measure (or if neither of those are available to you, some other type of high-priority measure); you can earn high-priority bonus points for some measures; and you should watch for measures where scoring stalls before the 10th decile (especially if they stall at a low decile), measures that are subject to a 7-point cap, and measures that don’t yet have a benchmark. 

    Column 2—High-Priority Measures (Bonus Points)

    Report at least one outcome measure. You need to report at least six quality measures, and at least one of them should be an outcome measure or an intermediate outcome measure (or if none is available, you must report another type of high-priority measure).

    Earn high-priority bonus points. After reporting the initial, mandatory outcome or other high-priority measure (see above), you earn bonus points for submitting additional high-priority measures.

    Column 3—Achievement Points

    For many quality measures, you can earn 3-10 achievement points. Your score will depend on how your performance rate compares against a measure’s benchmark, which is split into deciles. If your performance rate falls within the benchmark’s 10th decile, you earn 10 achievement points; if it falls within the benchmark’s ninth decile, you earn 9.0-9.9 achievement points; if it falls within the benchmark’s eighth decile, you earn 8.0-8.9 achievement points; etc. (Example: Benchmark for measure 374: Closing the Referral Loop.)

    Why does the point range for each measure start at 3 points? Provided you satisfy the 60%-data completeness criteria for a measure, there is a floor of 3 achievement points for reporting that measure. Thus, if your performance rate fell below the performance rate associated with the third decile, you would earn 3 achievement points. (If you didn’t satisfy the 60%-data completeness criteria, you would earn 3 achievement points if you are in a small practice, 1 point if you are in a large practice.)

    Why does the point range for some measures peak at 7 points? Some quality measures are subject to a 7-point cap (see below).

    Scoring for some quality measures temporarily “stalls” below the 10th decile. The benchmarks for some quality measures approach perfect performance before the 10th decile. For instance, the benchmark for measure 402: Tobacco Use and Help With Quitting Among Adolescents reaches a performance rate of 99.99% at the eighth decile. Consequently, if your performance rate is 99.99%, you would only earn 8.9 achievement points; however, a performance rate of 100% would earn you 10 achievement points (the chart indicates this in the “Achievement Points” column, by noting “3-6.9 points or, with a 100% performance rate, 10 points”). Some measures with stalled scoring also are subject to the 7-point cap.   

    What if a quality measure doesn’t yet have a benchmark? CMS used 2017 performance data to try and establish 2019 benchmarks for quality measures. If there isn’t enough 2017 performance data to establish a reliable benchmark for a measure, or if the measure didn’t exist in 2017, CMS will try to establish a benchmark retroactively using 2019 performance data. If it is still unable to establish a benchmark for a measure, you won’t be able to earn more than 3 achievement points for reporting that measure.

    Different benchmarks for different collection types. This chart refers to the benchmarks that would be used if you are reporting manually via the IRIS Registry. There can be other benchmarks for EHR-based reporting (which would apply if you are reporting via IRIS Registry–EHR integration or via your EHR vendor) and for for claims-based reporting.

    Column 4—Notes

    What are inverse measures? An inverse quality measure is one where you earn more achievement points for a lower performance rate. (Example: Measure 1: Diabetes: Hemoglobin A1c Poor Control [>9%].)

    What’s the 7-point cap? Once a quality measure is in its second year of being topped out, you won’t be able to score more than 7 achievement points for it (for example, see Table 6A and Table 6C).

    What are topped out measures? CMS considers a measure to be topped out when a lot of clinicians are attaining, or almost attaining, maximum performance for that measure (e.g., the average performance rate is 95% or higher). CMS had previously established a four-year life cycle for such measures—if they are topped out for at least two years, they would be subject to a 7-point cap; topped out for three consecutive performance years, they would be eliminated in the fourth year. 

    What are extremely topped out measures? If CMS considers a measure to be extremely topped out (e.g., the average performance rate is 98% or higher), it can be removed from MIPS the following year, even if it hasn’t been topped out for three consecutive years. (Note: Topped out QCDR measures also are on an accelerated timetable for removal from MIPS, even if they aren’t extremely topped out.)

    Previous: Table 7: Reporting Quality Measures via IRIS Registry–EHR Integration

    Next: Table 9: Reporting Quality Measures via IRIS Medicare Part B Claims

    DISCLAIMER AND LIMITATION OF LIABILITY: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

    COPYRIGHT© 2019, American Academy of Ophthalmology, Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry, among other marks, are trademarks of the American Academy of Ophthalmology®.

    All of the American Academy of Ophthalmology (AAO)–developed quality measures are copyrighted by the AAO’s H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).

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