This content is excerpted from EyeNet’s MIPS 2020; also see the Academy’s MIPS hub page.
Table: Reporting Quality Measures via IRIS Registry–EHR Integration
Two data submission thresholds. If your reporting for a quality measure satisfies both the case minimum requirement (20 patients) and the data completeness criteria (70% of denominator-eligible patients), your performance rate will be compared against a benchmark (if the measure has one), and you can earn the achievement points indicated below (see column 3).
What if you don’t meet the 70% data completeness criteria? If you are in a large practice, you will score zero points for the measure, but if you are in a small practice you will score 3 achievement points provided you report on at least one patient. If you meet the 70% data completeness criteria, but not the 20 patient–case minimum, you will earn 3 achievement points, regardless of practice size.
Make sure you understand the measures. Review the Academy guide to reading quality measures (PDF) and then click the links in column 1 for detailed descriptions of each measure. For more detailed benchmark information, click the links in column 3. To get started, read “Tips on Using This Table.”
Important Caveat: You can only report a measure if the relevant data elements are available for extraction from your EHR system. Check with IRIS Registry staff to work on mapping for any of these measures.
|
ID: Measure Name |
High-Priority Measure (Bonus Points) |
Achievement Points |
Notes |
Preventive Health Measures
|
110: Preventive Care and Screening: Influenza Immunization |
|
3-10 points |
|
111: Pneumonia Vaccination Status for Older Adults |
|
3-10 points |
|
117: Diabetes: Eye Exam |
|
3-8.9 points or, with a 100% performance rate, 10 points |
|
128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan |
|
3-10 points |
|
130: Documentation of Current Medications in the Medical Record |
Patient safety (+1 point) |
3-7 points |
Topped out, 7-point cap
|
226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
|
3-8.9 points, or, with a 100% performance rate, 10 points |
|
236: Controlling High Blood Pressure |
Intermediate outcome (+2 points) |
3-10 points |
Flat benchmark |
238: Use of High-Risk Medications in the Elderly |
Patient safety (+1 point) |
3-7 points |
Inverse measure, topped out, 7-point cap |
318: Falls: Screening for Future Fall Risk |
Patient safety (+1 point) |
3-10 points |
|
374: Closing the Referral Loop |
Care coordination (+1 point) |
3-10 points |
|
Resource Use and Opioid Management
|
IRIS26: Avoidance of Routine Antibiotic Use Before or After Intravitreal Injections |
Efficiency (+1 point) |
3-6.9 points or, with a 0% performance rate, 10 points |
Reintroduced measure, inverse measure |
IRIS52: Postoperative Opioid Management Following Ocular Surgery |
Opioid-related (+1 points) |
No benchmark yet |
Change of ID # (previously IRIS37) |
Cataract/Anterior Segment
|
191: Cataracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery |
Outcome (+2 points) |
3-7.9 points or, with a 100% performance rate, 10 points |
|
IRIS54: Complications After Cataract Surgery |
Outcome (+2 points) |
No benchmark yet |
Inverse measure, change of ID # (previously IRIS27) |
IRIS59: Regaining Vision After Cataract Surgery |
Outcome (+2 points) |
No benchmark yet |
Change of ID# (previously IRIS40) |
Also see IRIS55 and IRIS60, under “Glaucoma.” |
Cornea/External Disease
|
IRIS1: Endothelial Keratoplasty: Postoperative Improvement in Best Corrected Visual Acuity to 20/40 or Greater |
Outcome (+2 points) |
3-10 points |
|
IRIS38: Endothelial Keratoplasty: Dislocation Requiring Surgical Intervention |
Outcome (+2 points) |
No benchmark yet |
Inverse measure |
Also see IRIS 52 under “Resource Use and Opioid Management.” |
Glaucoma
|
12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation |
|
3-8.9 points or, with a 100% performance rate, 10 points |
|
IRIS2: Intraocular Pressure (IOP) Reduction |
Intermediate outcome (+2 points) |
3-10 points |
|
IRIS39: IOP Reduction Following Trabeculectomy or an Aqueous Shunt Procedure |
Outcome (+2 points) |
No benchmark yet |
|
IRIS43: IOP Reduction Following Laser Trabeculoplasty |
Outcome (+2 points) |
No benchmark yet |
|
IRIS44: Visual Field Progression in Glaucoma |
Outcome (+2 points) |
No benchmark yet |
Inverse measure |
IRIS55: Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery |
Outcome (+2 points) |
No benchmark yet |
New measure |
IRIS60: Visual Acuity Improvement Following Cataract Surgery Combined With a Trabeculectomy or an Aqueous Shunt Procedure |
Outcome (+2 points) |
No benchmark yet |
Change of ID# (previously IRIS36) |
Neuro-Ophthalmology
|
IRIS56: Adult Diplopia: Improvement of Ocular Deviation or Absence of Diplopia or Functional Improvement |
Outcome (+2 points) |
No benchmark yet |
New measure |
IRIS57: Idiopathic Intracranial Hypertension: Improvement of Mean Deviation or Stability of Mean Deviation |
Outcome (+2 points) |
No benchmark yet |
Reintroduced measure |
Oculofacial Plastics/Reconstructive
|
IRIS5: Surgery for Acquired Involutional Ptosis: Patients With an Improvement of Marginal Reflex Distance (MRD) |
Outcome (+2 points) |
No benchmark yet |
|
IRIS6: Acquired Involutional Entropion: Normalized Lid Position After Surgical Repair |
Outcome (+2 points) |
No benchmark yet |
|
Also see IRIS 52 under “Resource Use and Opioid Management.” |
Pediatric Ophthalmology and Strabismus
|
IRIS48: Adult Surgical Esotropia: Postoperative Alignment |
Outcome (+2 points) |
No benchmark yet |
|
IRIS49: Surgical Pediatric Esotropia: Postoperative Alignment |
Outcome (+2 points) |
No benchmark yet |
|
IRIS50: Amblyopia: Interocular Visual Acuity |
Outcome (+2 points) |
No benchmark yet |
|
Refractive Surgery
|
IRIS23: Refractive Surgery: Patients With a Postoperative Uncorrected Visual Acuity (UCVA) of 20/20 or Better |
Outcome (+2 points) |
3-7.9 points or, with a 100% performance rate, 10 points |
|
IRIS24: Refractive Surgery: Patients With a Postoperative Correction Within ± 0.5 Diopter (D) of the Intended Correction |
Outcome (+2 points) |
No benchmark yet |
|
Retina/Vitreous
|
Retina: Age-Related Macular Degeneration (AMD) |
IRIS45: Exudative AMD: Loss of Visual Acuity |
Outcome (+2 points) |
No benchmark yet |
|
Also see IRIS 26, under “Resource Use and Opioid Management.” |
Retina: Diabetic Retinopathy (DR) and Diabetic Macula Edema (DME) |
19: Diabetic Retinopathy: Communication With the Physician Managing On-going Diabetes Care |
Care coordination (+1 point) |
3-8.9 points or, with a 100% performance rate, 10 points |
|
IRIS13: Diabetic Macular Edema: Loss of Visual Acuity |
Outcome (+2 points) |
3-10 points |
|
IRIS58: Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days |
Outcome (+2 points) |
No benchmark yet |
New measure |
Retina: Epiretinal Membrane |
IRIS41: Improved Visual Acuity After ERM Treatment Within 120 Days |
Outcome (+2 points) |
No benchmark yet |
|
Retina: Macular Hole |
IRIS46: Evidence of Anatomic Closure of Macular Hole Within 90 Days After Surgery as Documented by OCT |
Outcome (+2 points) |
No benchmark yet |
|
Uveitis/Immunology
|
IRIS17: Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells |
Outcome (+2 points) |
3-10 points |
Reintroduced measure |
IRIS35: Improvement of Macular Edema in Patients with Uveitis |
Outcome (+2 points) |
No benchmark yet |
|
IRIS51: Acute Anterior Uveitis: Post-Treatment Visual Acuity |
Outcome (+2 points) |
No benchmark yet |
|
IRIS53: Chronic Anterior Uveitis: Post-Treatment Visual Acuity |
Outcome (+2 points) |
No benchmark yet |
Change of ID # (previously IRIS18) |
Tips on Using This Chart
This chart shows the benchmarks for quality measures reported via IRIS Registry–EHR integration. You also can report manually via the IRIS Registry 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. To help you make the most of these pages, the Academy has developed a guide to reading quality measures (PDF).
Which measures should you report? If you are reporting quality via IRIS Registry–EHR integration, you don’t have to actively select which quality measures you want to report; after the performance year is over, an automated process will get you your optimal score by reviewing all applicable measures for which there are sufficient data. However, because some measures are subject to significant scoring limitations (see column 3), you should see which measures are not subject to such limitations and make sure that you are performing them and documenting them in line with the latest requirements.
Column 2—High-Priority Measure (Bonus Points)
Report at least one outcome measure. 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 some 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, depending on where it falls within that benchmark; if it falls within the benchmark’s eighth decile, you earn 8.0-8.9 achievement points; etc.
Why does scoring for a measure start at 3 points? Provided you satisfy the 70%-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 70%-data completeness criteria, you would earn 3 achievement points if you are in a small practice, 0 points if you are in a large practice.)
Why does scoring 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” before the 10th decile. The benchmarks for some quality measures approach perfect performance before the 10th decile. For example, measure 191, which is a cataract surgery measure, has a benchmark that reaches a performance rate of 99.99% at the seventh decile. Consequently, if your performance rate is 99.99%, you would only earn 7.9 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 “3-7.9 points or, with a 100% performance rate, 10 points”).
What if a quality measure doesn’t yet have a benchmark? CMS used 2018 performance data to try and establish 2020 benchmarks for quality measures. If there isn’t enough 2018 performance data to establish a reliable benchmark for a measure, or if the measure didn’t exist in 2018, CMS will try to establish a benchmark retroactively using 2020 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 via IRIS Registry–EHR integration. There are other benchmark charts to review if you are reporting manually via the IRIS Registry or via Medicare Part B claims.
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 238: Use of High-Risk Medications in the Elderly.)
What is 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
What is a flat benchmark? A flat benchmark is not based on performance data. Instead, it is based on a simple formula: A performance rate of 90% or more earns you 10 achievement points; a performance rate of 80%-88.9% earns you 9 achievement points, etc. For inverse measures that have a flat benchmark, such as measure 1, a performance rate of 10% or less earns you 10 achievement points, a performance rate of 10.1-20% earns you 9 achievement points, etc.
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).
Topped out measures have a limited life cycle. If a measure is topped out for at least two years, it is subject to a 7-point cap; topped out for three consecutive performance years, CMS will consider eliminating it 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.)
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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).