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  • MIPS 2023—What’s New With Quality Measures

    This content is excerpted from “MIPS 2023, Part 1” (EyeNet, January 2023). EyeNet’s MIPS content, including its MIPS 2023 supplement, is being published online ahead of print as it becomes available.

    As in previous years, you can earn points for reporting a quality measure. Provided that you meet the two data submission thresholds and, if applicable, report the data-completeness totals, your score for a measure will depend on how your performance rate compares with the measure’s benchmark. CMS uses 2021 performance data to try to calcu­late 2023 benchmarks for clinician-reported quality measures. At time of press, CMS expected to publish those benchmarks in late December 2022. (Update: In a Jan. 17 Webinar, CMS said that it would publish the benchmarks "in January 2023 sometime.") (Update: On Jan. 25, CMS published the benchmarks in its QPP Resource Library.)

    Changes to Quality Measures

    Here are the changes to the quality measure inventory that are most likely to impact ophthalmology practices.

    CMS removed some quality mea­sures. For 2023, CMS removed some quality measures for one or more reporting options, including three that had been available for reporting via the IRIS Registry.

    Measure 265: Biopsy Follow-Up removed. CMS removed this measure because it has reached the end of its “topped out lifecycle.” (Topped out measures are those for which the average performance rate is so good that there is not much room for improvement. Measures that are topped out for a second consecutive year are capped at 7 points; measures that are topped out for three years can be eliminated in the fourth year.)

    Two preventive measures removed. The following two measures can no longer be reported via traditional MIPS (but they can be included in MVPs):

    • Measure 110: Preventive Care and Screening: Influenza Immunization
    • Measure 111: Pneumococcal Vacci­nation Status for Older Adults

    CMS has subsumed the above two measures within a new measure, 493: Adult Immuniza­tion Status.

    Measure 117: Diabetes Eye Exam is no longer available for claims reporting. Measure 117 has reached the end of its topped out lifecycle for claims-based reporting. It is still available for other collection types. 

    Update: Measure 130: Documentation of Current Medications in the Medical Record is no longer available for claims reporting. Measure 130 has reached the end of its topped out lifecycle for claims-based reporting. It is still available for other collection types. 

    For IRIS Registry users, there may be some extra mea­sures to choose from. The following measure can be reported via the IRIS Registry either manually or using IRIS Registry–EHR integration:

    • New measure 493: Adult Immu­nization Status. This new composite measure involves reporting vaccina­tion rates using the influenza, herpes zoster, pneumococcal, and Td or Tdap vaccines. You will be able to report it via the IRIS Registry but not via claims. It is significant because it replaces two preventive quality measures (see above) that had been reportable manually via the IRIS Registry, electronically via IRIS Registry–EHR integration, or via claims.

    The following two quality measures can be reported manually via the IRIS Registry (but not via IRIS Registry–EHR integration):

    • Measure 440: Skin Cancer: Biop­sy Reporting Time—Pathologist to Clinician.
    • New measure 487: Screening for Social Drivers of Health.

    CMS made changes to several qual­ity measures. Of the measures most relevant to ophthalmology, CMS has flagged the following as having under­gone substantive changes since 2022:

    • 1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
    • 12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
    • 19: Diabetic Retinopathy: Commu­nication With the Physician Managing Ongoing Diabetes Care
    • 117: Diabetes Eye Exam
    • 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
    • 130: Documentation of Current Medications in the Medical Record
    • 191: Cataracts: 20/40 or Better Vi­sual Acuity Within 90 Days Following Cataract Surgery
    • 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
    • 236: Controlling High Blood Pres­sure
    • 238: Use of High-Risk Medications in Older Adults
    • 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
    • 318: Falls: Screening for Future Fall Risk
    • 374: Closing the Referral Loop: Re­ceipt of Specialist Report

    Check the specs. Each year, you should review the specifications of the measures that you plan to report. At time of press, these hadn’t yet been published for 2023. CMS typically posts measure specifications at

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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).