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  • MIPS 2023—Quality: Four Varieties of Measure

    This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.

    Here’s a quick overview of MIPS clinical quality measures (MIPS CQMs), electronic CQMs (eCQMs), Medicare Part B claims-based measures, and qualified clinical data registry (QCDR) measures.

    There can be more than one way to report a quality measure. Measure 236: Controlling High Blood Pressure, for example, can be reported as a MIPS CQM, an eCQM, or a claims-based measure. For each of these three approaches—also known as collection types—you’ll need to follow a different set of measure specifications and you’ll be scored against a different benchmark.

    MIPS CQMs can be reported via qualified registries and qualified clinical data registries (QCDRs), such as the IRIS Registry. The reporting can be done manually or electronically. Data for MIPS CQMs can be pulled from a paper chart or from an electronic source, such as an EHR.

    eCQMs are reported electronically (e.g., via IRIS Registry–EHR integration). Measure specifications feature programming code, which helps the developers of regis­tries and EHR systems to capture and report the requisite data. New this year: Your EHR system must have 2015-edi­tion Cures Update certification.

    Claims-based measures can only be used by clinicians in small practices. They are reported using the CMS-1500 claims form.

    QCDR measures are in a class of their own. As a QCDR, the IRIS Registry has been able to develop its own quality measures. These ophthalmology-specific measures have an “IRIS” prefix (e.g., IRIS1) and can be reported only via the IRIS Registry.

    Up to 26 QCDR measures available to IRIS Registry users. You can report on any of the 26 QCDR registers manually via the IRIS Registry, but the measures available for integrated IRIS Registry–EHR reporting may depend on what data can be extracted from your EHR system. For QCDR measures, the same benchmark applies whether you are reporting it manually or electronically.

    Benchmarks are already available for 12 QCDR measures. There are already benchmarks for the following IRIS Registry QCDR measures:

    • IRIS2: Intraocular Pressure (IOP) Reduction
    • IRIS13: Diabetic Macular Edema: Loss of Visual Acuity
    • IRIS17: Acute Anterior Uveitis: Post-Treatment Grade 0 Anterior Chamber Cells
    • IRIS23: Refractive Surgery: Patients With a Postoperative Uncorrected Visual Acuity (UCVA) of 20/20 or Better Within 30 Days
    • IRIS43: IOP Reduction Following Laser Trabeculoplasty
    • IRIS44: Visual Field Progression in Glaucoma
    • IRIS46: Evidence of Anatomic Closure of Macular Hole Within 90 Days After Surgery as Documented by OCT
    • IRIS51: Acute Anterior Uveitis: Post-Treatment Visual Acuity
    • IRIS53: Chronic Anterior Uveitis: Post-Treatment Visual Acuity
    • IRIS54: Complications After Cataract Surgery
    • IRIS55: Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery
    • IRIS59: Regaining Vision After Cataract Surgery

    What if there isn’t yet a benchmark? After 2023 is over, CMS will see if there is enough 2023 performance year data to calculate benchmarks for the IRIS Registry’s other 14  QCDR measures.

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