• MIPS 2020—Changes to the Quality Measures

    Excerpted from MIPS—What’s New in 2020 for Ophthalmology (EyeNet, January 2020). Also see MIPS 2020: A Primer and Reference, which is being posted online ahead of print.


    QCDR measures available via the IRIS Registry. As a qualified clinical data registry (QCDR), the Academy’s IRIS Registry is able to develop its own subspecialty-specific QCDR quality measures. For 2020, the IRIS Registry had developed some new QCDR measures, and also had plans to withdraw four QCDR measures, but at time of press was waiting for CMS to approve these changes.  

    CMS removed some quality measures. For 2020, CMS removed dozens of quality measures, including three that had been available for reporting via the IRIS Registry:

    • Measure 192: Cataracts: Complications Within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
    • Measure 388: Cataract Surgery With Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)
    • Measure 474: Zoster (Shingles) Vaccination

    Diabetic retinopathy measure no longer available for claims-based reporting. In 2020, you can no longer use Medicare Part B claims to report measure 19: Diabetic Retinopathy: Communication With Physician Managing Ongoing Diabetes Care—though you will still be able to report it via the IRIS Registry. CMS said that the benchmark for claims-based reporting was extremely topped out. 

    CMS is making changes to some measures. Even if you plan to report the same quality measures as last year, you should still check those measures to see if CMS has added scoring limitations or changed the measure specifications.

    For example, CMS has implemented substantive changes to the specifications of these measures:

    • Measure 1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9). CMS added some extra exclusions.
    • Measure 110: Preventive Care and Screening: Influenza Immunization. CMS has updated the numerator instructions to allow for shared decision-making with the patient and to align with whatever the CDC/ACIP guidelines might be for the performance year.
    • Measure 111: Pneumococcal Vaccination Status for Older Adults. CMS expanded the denominator to include skilled nursing facilities and domiciliary settings.
    • Measure 117: Diabetes: Eye Exam. CMS has added some exclusions and changed some measure specifications to make it easier to extract the relevant data from EHR.
    • Measure 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. CMS added an exclusion for hospice patients and removed “or refused follow-up” from denominator exclusion language.
    • Measure 191: Cataracts 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery. In a move that was strongly opposed by the Academy, CMS has altered the denominator so that the measure is reported per eye rather than per patient.
    • Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. CMS has revised the denominator for one of the three population criteria in this measure.
    • Measure 236: Controlling High Blood Pressure. CMS made several updates to the numerator, denomina­tor, and list of exclusions.
    • Measure 238: Use of High-Risk Medications in the Elderly. CMS adjusted the numerator.
    • Measure 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented. The measure specifications now allow for the documentation of a reason for follow-up.
    • Measure 385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery. CMS added a denominator exclusion for patients with a preoperative visual acuity better than 20/40.

    Review the quality measures. These at-a-glance tables show which measures are outcome measures, which have high-priority bonus points, which are subject to scoring limitations, such as a 7-point cap; click on the measure title for more detailed information. 

    Previous: MIPS 2020—What’s New With Quality

    Next: MIPS 2020—What’s New With Promoting Interoperability

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