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EyeNet Magazine

/ April 2024

/ MIPS 2023—Quality Measure Benchmark Summaries

MIPS 2023—Quality Measure Benchmark Summaries

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

There are four varieties of quality measure—MIPS clinical quality measures (MIPS CQMs), electronic CQMs (eCQMs), claims-based measures, and Quality Clinical Data Registry (QCDR) measures—each with its own set of measure specifications. For example, measure 117: Diabetes Eye Exam exists as a MIPS CQM and an eCQM, each of which has its own benchmark.

Meet 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) and—if reporting manually via the IRIS Registry—you submit your data-completeness totals, 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).

Understand the measures. Detailed measure specifications are available as part of the 2023 IRIS Registry Preparation kit, which can be downloaded at aao.org/iris-registry/user-guide/getting-started.

There is 3-point floor for small practices but—new for 2023—not for large practices. If you are in a small practice, you score 3 points for a measure provided that you report on at least one patient and, if reporting manually via the IRIS Registry, you submit data-completeness totals.

See the full benchmarks. The tables below summarize how many points are available for each quality measure. For full benchmark data, see the Quality Measure Benchmarks table, which is available in EyeNet's MIPS Primer and in the IRIS Registry Preparation Kit.

Preventive Measures

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)	MIPS CQM	1-10 points	3-10 points	Interm. outcome measure, inverse measure
1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)	Claims	Large practices can’t report via claims	No benchmark	Interm. outcome measure, inverse measure
1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)	eCQM	1-10 points	3-10 points	Interm. outcome measure, inverse measure
117: Diabetes: Eye Exam	MIPS CQM	1-5.9 or, with a 100% performance rate, 7 points	3-5.9 or, with a 100% performance rate, 7 points	Topped out, 7-point cap
117: Diabetes: Eye Exam	eCQM	1-10 points	3-10 points
128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	MIPS CQM	1-7.9 or, with a 100% performance rate, 10 points	3-7.9 or, with a 100% performance rate, 10 points	Topped out
128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Claims	Large practices can’t report via claims	3-4.9 or, with a 100% performance rate, 7 points	Topped out, 7-point cap
128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	eCQM	No benchmark	No benchmark
130: Documentation of Current Medications in the Medical Record	MIPS CQM	1-7 points	3-7 points	High-priority measure, topped out, 7-point cap
130: Documentation of Current Medications in the Medical Record	eCQM	1-7 points	3-7 points	High-priority measure, topped out, 7-point cap
226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	MIPS CQM	1-8.9 or, with a 100% performance rate, 10 points	3-8.9 or, with a 100% performance rate, 10 points
226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims	Large practices can’t report via claims	3-4.9 or, with a 100% performance rate, 10 points	Topped out
226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	eCQM	1-10 points	3-10 points
236: Controlling High Blood Pressure	MIPS CQM	1-10 points	3-10 points	Interm. outcome measure, flat benchmark
236: Controlling High Blood Pressure	Claims	Large practices can’t report via claims	3-10 points	Interm. outcome measure, flat benchmark
236: Controlling High Blood Pressure	eCQM	1-10 points	3-10 points	Interm. outcome measure
238: Use of High-Risk Medications in Older Adults	MIPS CQM	1-4.9 or, with a 100% performance rate, 10 points	3-4.9 or, with a 100% performance rate, 10 points	High-priority measure, inverse measure, topped out
238: Use of High-Risk Medications in Older Adults	eCQM	1-7.9 or, with a 100% performance rate, 10 points	3-7.9 or, with a 100% performance rate, 10 points	High-priority measure, inverse measure, topped out
317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	MIPS CQM	1-10 points	3-10 points
317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims	Large practices can’t report via claims	3-6.9 or, with a 100% performance rate, 10 points	Topped out
318: Falls: Screening for Future Fall Risk	eCQM	1-10 points	3-10 points	High-priority measure
374: Closing the Referral Loop: Receipt of Specialist Report	MIPS CQM	1-5.9 or, with a 100% performance rate, 7 points	3-5.9 or, with a 100% performance rate, 7 points	High-priority measure, topped out, 7-point cap
374: Closing the Referral Loop: Receipt of Specialist Report	eCQM	1-10 points	3-10 points	High-priority measure
402: Tobacco Use and Help with Quitting Among Adolescents	MIPS CQM	1-6.9 or, with a 100% performance rate, 7 points	3-6.9 or, with a 100% performance rate, 7 points	Topped out, 7-point cap
493: Adult Immunization Status	MIPS CQM	No benchmark	No benchmark	New measure, which means it has a 7-point-floor

Health Equity

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
487: Screening for Social Drivers of Health	MIPS CQM	No benchmark	No benchmark	New measure, which means it has a 7-point-floor

Cataract/Anterior Segment

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	MIPS CQM	1-6.9 or, with a 100% performance rate, 10 points	3-6.9 or, with a 100% performance rate, 10 points	Outcome measure
191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	eCQM	1-10 points	3-10 points	Outcome measure
389: Cataract Surgery: Difference Between Planned and Final Refraction	MIPS CQM	1-8.9 or, with a 100% performance rate, 10 points	3-8.9 or, with a 100% performance rate, 10 points	Outcome measure
IRIS54: Complications After Cataract Surgery	QCDR	1-8.9 or, with a 100% performance rate, 10 points	3-8.9 or, with a 100% performance rate, 10 points	Outcome measure, inverse measure
IRIS59: Regaining Vision After Cataract Surgery	QCDR	1-10 points	3-10 points	Outcome measure

For two additional measures, see IRIS55 and IRIS60 under “Glaucoma.”

Cornea/External Disease

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
IRIS1: Endothelial Keratoplasty: Postoperative Improvement in Best Corrected Visual Acuity to 20/40 or Better	QCDR	No benchmark	No benchmark	Outcome measure
IRIS38: Endothelial Keratoplasty: Dislocation Requiring Surgical Intervention	QCDR	No benchmark	No benchmark	Outcome measure, inverse measure

Glaucoma

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	eCQM	1-10 points	3-10 points
141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care	MIPS CQM	1-8.9 or, with a 100% performance rate, 10 points	3-8.9 or, with a 100% performance rate, 10 points	Outcome measure
141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care	Claims	Large practices can’t report via claims	3 or, with a 100% performance rate, 10 points	Outcome measure
IRIS2: Intraocular Pressure (IOP) Reduction	QCDR	1-10 points	3-10 points	Interm. outcome measure
IRIS39: IOP Reduction Following Trabeculectomy or an Aqueous Shunt Procedure	QCDR	No benchmark	No benchmark	Outcome measure
IRIS43: IOP Reduction Following Laser Trabeculoplasty	QCDR	1-10 points	3-10 points	Outcome measure
IRIS44: Visual Field Progression in Glaucoma	QCDR	1-10 points	3-10 points	Outcome measure, inverse measure
IRIS55: Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery	QCDR	1-10 points	3-10 points	Outcome measure
IRIS60: Visual Acuity Improvement Following Cataract Surgery Combined With a Trabeculectomy or an Aqueous Shunt Procedure	QCDR	No benchmark	No benchmark	Outcome measure

Neuro-Ophthalmology

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
419: Overuse of Imaging for the Evaluation of Primary Headache	MIPS CQM	1-7.9 or, with a 0% performance rate, 10 points		High-priority measure, inverse measure, topped out
IRIS56: Adult Diplopia: Improvement of Ocular Deviation or Absence of Diplopia or Functional Improvement	QCDR	No benchmark	No benchmark	Outcome measure
IRIS57: Idiopathic Intracranial Hypertension: Improvement of Mean Deviation or Stability of Mean Deviation	QCDR	No benchmark	No benchmark	Outcome measure

Oculofacial Plastics/Reconstruction

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
137: Melanoma: Continuity of Care—Recall System	MIPS CQM	1-2.9 or, with a 100% performance rate, 10 points	3 or, with a 100% performance rate, 10 points	High-priority measure
138: Melanoma: Coordination of Care	MIPS CQM	1-3.9 or, with a 100% performance rate, 7 points	3-3.9 or, with a 100% performance rate, 7 points	High-priority measure, topped out, 7-point cap
397: Melanoma Reporting	MIPS CQM	1-1.9 or, with a 100% performance rate, 7 points	3 or, with a 100% performance rate, 7 points	High-priority measure, topped out, 7-point cap
397: Melanoma Reporting	Claims	Large practices can’t report via claims	3-3.9 or, with a 100% performance rate, 7 points	High-priority measure, topped out, 7-point cap
440: Skin Cancer: Biopsy Reporting Time—Pathologist to Clinician	QCDR	1-4.9 or, with a 100% performance rate, 7 points	3-4.9 or, with a 100% performance rate, 7 points	High-priority measure, topped out, 7-point cap
IRIS6: Acquired Involutional Entropion: Normalized Lid Position After Surgical Repair	QCDR	No benchmark	No benchmark	Outcome measure

Pediatric Ophthalmology and Strabismus

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
IRIS48: Adult Surgical Esotropia: Postoperative Alignment	QCDR	No benchmark	No benchmark	Outcome measure
IRIS49: Surgical Pediatric Esotropia: Postoperative Alignment	QCDR	No benchmark	No benchmark	Outcome measure
IRIS50: Amblyopia: Interocular Visual Acuity	QCDR	No benchmark	No benchmark	Outcome measure

Refractive Surgery

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
IRIS23: Refractive Surgery: Patients With a Postoperative Uncorrected Visual Acuity (UCVA) of 20/20 or Better Within 30 Days	QCDR	1-10 points	3-10 points	Outcome measure
IRIS24: Refractive Surgery: Patients With a Postoperative Correction Within ± 0.5 Diopter (D) of the Intended Correction	QCDR	No benchmark	No benchmark	Outcome measure

Retina: AMD

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
14: AMD: Dilated Macular Examination	MIPS CQM	1-7 points	3-7 points	Topped out, 7-point cap
19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	MIPS CQM	1-4.9 or, with a 100% performance rate, 7 points	3-4.9 or, with a 100% performance rate, 7 points	High-priority measure, topped out, 7-point cap
19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	eCQM	1-10 points	3-10 points	High-priority measure
IRIS13: Diabetic Macular Edema: Loss of Visual Acuity	QCDR	1-10 points	3-10 points	Outcome measure
IRIS58: Improved Visual Acuity After Vitrectomy for Complications of Diabetic Retinopathy Within 120 Days	QCDR	No benchmark	No benchmark	Outcome measure

Retina: Epiretinal Membrane

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
IRIS41: Improved Visual Acuity After ERM Treatment Within 120 Days	QCDR	No benchmark	No benchmark	Outcome measure

Retina: Macular Hole

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
IRIS46: Evidence of Anatomic Closure of Macular Hole Within 90 Days After Surgery as Documented by OCT	QCDR	1-10 points	3-10 points	Outcome measure

Retina: Retinal Detachment

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery	MIPS CQM	1-5.9 or, with a 100% performance rate, 7 points	3-5.9 or, with a 100% performance rate, 7 points	Outcome measure, topped out, 7-point cap
385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery	MIPS CQM	1-10 points	3-10 points	Outcome measure

Uveitis/Immunology

ID: Measure Title	Type	Points (Large Practice)	Points (Small Practice)	Notes
IRIS17: Acute Anterior Uveitis: Post-Treatment Grade 0 Anterior Chamber Cells	QCDR	1-10 points	3-10 points	Outcome measure
IRIS35: Improvement of Macular Edema in Patients With Uveitis	QCDR	No benchmark	No benchmark	Outcome measure
IRIS51: Acute Anterior Uveitis: Post-Treatment Visual Acuity	QCDR	1-10 points	3-10 points	Outcome measure
IRIS53: Chronic Anterior Uveitis: Post-Treatment Visual Acuity	QCDR	1-10 points	3-10 points	Outcome measure

Previous: Four Varieties of Measure
Next: PI: An Overview

DISCLAIMER AND LIMITATION OF LIABILITY: All information provided by the American Academy of Ophthalmology, its employees, agents, or representatives participating in the Academy’s efforts to explain regulatory and reimbursement issues is as current and reliable as reasonably possible. The Academy does not provide legal or accounting services or advice. You should seek legal and/or accounting advice if appropriate to your situation.
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 either 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© 2023, 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 Ophthalmology ®, American Academy of Ophthalmic Executives®, IRIS®, the Focus logo, and Protecting Sight. Empowering Lives ®, among other marks, are trademarks of the American Academy of Ophthalmology®.

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).

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