This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page.
If you have integrated your EHR system with the IRIS Registry, there may be as many as 42 quality measures for you to report, including up to 14 electronic clinical quality measures (eCQMs) and up to 28 QCDR quality measures (the IRIS measures).
The IRIS Registry uses a data mapping process to establish which of these 42 measures you are able to report. You will only be able to report a measure if the IRIS Registry can extract the relevant data elements from your EHR system.
In the chart below, the 42 measures are grouped by area of focus. There are preventive health measures, cataract/anterior segment measures, cornea/external disease measures, glaucoma measures, neuro-ophthalmology measures, oculofacial plastics/reconstructive measures, pediatric ophthalmology and strabismus measures, refractive surgery measures, retina/vitreous measures, and uveitis/immunology measures.
Harder to get a high score for quality. In 2019, if you report the same quality measures as you did in 2018, and get similar performance rates, your likely to score fewer achievement points. Why? The benchmarks for most quality measures have become more demanding, more measures have been topped out for two or more years, which means they are subject to a 7-point cap (see Table 6A), and scoring for more measures “stalls” below the 10th decile (see Tables 6B and 6C).
Which quality measures should you report? An advantage of IRIS Registry–EHR integration is that you don’t have to select which ones to report; after the performance year is over, an automated process determines which measures would give you the best score. However, because some of the measures that you reported last year may now be subject to significant scoring limitations (see above), 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.
Table 7: Reporting Quality Measures via IRIS Registry–EHR Integration
If your reporting for a quality measure satisfies both the case minimum requirement (20 patients) and the data completeness criteria (60% of denominator-eligible patients), your performance rate will be compared against a benchmark and you can earn the achievement points indicated below (column 3).
If you meet the data completeness criteria but not the case minimum requirement, you earn 3 achievement points. If you don't meet the data completeness criteria, but report on at least one patient, you earn 1 achievement point or if a special scorings status applies to you—e.g., you are in a small practice—3 achievement points.
|
ID: Measure Name |
High-Priority Measure (Bonus Points) |
Achievement Points |
Notes |
Important Caveat: You can only report a measure if the IRIS Registry can extract the relevant data elements from your EHR system. Check your IRIS Registry dashboard to see which of the measures below are available for you to report.
|
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 |
|
3-10 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 bonus point) |
3-7 points |
Topped out, 7-point cap |
226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
|
No benchmark yet |
|
236: Controlling High Blood Pressure |
Intermediate outcome (+2 bonus points) |
3-10 points |
|
238: Use of High-Risk Medications in the Elderly |
Patient safety (+1 bonus point) |
3-7 points |
Inverse measure, topped out, 7-point cap |
318: Falls: Screening for Future Fall Risk |
Patient safety (+1 bonus point) |
3-10 points |
|
374: Closing the Referral Loop |
Care coordination (+1 bonus point) |
3-10 points |
|
Cataract/Anterior Segment
|
191: Cataracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery |
Outcome (+2 bonus points) |
3-10 points |
|
192: Cataracts: Complications Within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures |
Outcome (+2 bonus points) |
3 points or, with a 0% performance rate, 7 points |
Inverse measure, topped out, 7-point cap |
IRIS27: Adverse Events After Cataract Surgery |
Outcome (+2 bonus points) |
No benchmark yet |
Inverse measure |
IRIS40: Regaining Vision After Cataract Surgery |
Outcome (+2 bonus points) |
No benchmark yet |
Change of ID # (previously IRIS28) |
Also see IRIS36, under Glaucoma |
Cornea/External Disease
|
IRIS1: Endothelial Keratoplasty: Postoperative Improvement in Best Corrected Visual Acuity to 20/40 or Greater |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS38: Endothelial Keratoplasty: Dislocation Requiring Surgical Intervention |
Outcome (+2 bonus points) |
No benchmark yet |
|
Glaucoma
|
12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation |
|
3-10 points |
|
IRIS2: Intraocular Pressure (IOP) Reduction |
Outcome (+2 bonus points) |
3-5.9 points or, with a 100% performance rate, 10 points |
Topped out |
IRIS36: Visual Acuity Improvement Following Cataract Surgery Combined With a Trabeculectomy or an Aqueous Shunt Procedure |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS39: IOP Reduction Following Trabeculectomy or an Aqueous Shunt Procedure |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS43: IOP Reduction Following Laser Trabeculoplasty |
Outcome (+2 bonus points) |
No benchmark yet |
Change of ID # (previously IRIS4) |
IRIS44: Visual Field Progression in Glaucoma |
Outcome (+2 bonus points) |
No benchmark yet |
Inverse measure, change of ID # (previously IRIS3) |
Neuro-Ophthalmology
|
IRIS21: Ocular Myasthenia Gravis: Improvement of Ocular Deviation or Absence of Diplopia or Functional Improvement |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS22: Giant Cell Arteritis: Absence of Fellow Eye Involvement After Treatment |
Outcome (+2 bonus points) |
No benchmark yet |
|
Oculofacial Plastics/Reconstructive
|
IRIS5: Surgery for Acquired Involutional Ptosis: Patients With an Improvement of Marginal Reflex Distance (MRD) |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS6: Acquired Involutional Entropion: Normalized Lid Position After Surgical Repair |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS37: Postoperative Opioid Management Following Oculoplastic Surgery |
Opioid-related (+1 bonus point) |
No benchmark yet |
|
Pediatric Ophthalmology and Strabismus
|
IRIS48: Adult Surgical Esotropia: Postoperative Alignment |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS49: Surgical Pediatric Esotropia: Postoperative Alignment |
Outcome (+2 points) |
No benchmark yet |
Change of ID # (previously IRIS8) |
IRIS50: Amblyopia: Interocular Visual Acuity |
Outcome (+2 bonus points) |
No benchmark yet |
Change of ID # (previously IRIS7) |
Refractive Surgery
|
IRIS23: Refractive Surgery: Patients With a Postoperative Uncorrected Visual Acuity (UCVA) of 20/20 or Better |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS24: Refractive Surgery: Patients With a Postoperative Correction Within ± 0.5 Diopter (D) of the Intended Correction |
Outcome (+2 bonus points) |
No benchmark yet |
|
Retina/Vitreous
|
Retina: Age-Related Macular Degeneration (AMD) |
IRIS45: Exudative AMD: Loss of Visual Acuity |
Outcome (+2 bonus points) |
No benchmark yet |
Change of ID # (previously IRIS10) |
Retina: Diabetic Retinopathy (DR) and Diabetic Macula Edema (DME) |
19: Diabetic Retinopathy: Communication With the Physician Managing On-going Diabetes Care |
Care coordination (+1 bonus point) |
0-10 points |
|
IRIS13: Diabetic Macular Edema: Loss of Visual Acuity |
Outcome (+2 bonus points) |
No benchmark yet |
|
Retina: Epiretinal Membrane |
IRIS41: Improved Visual Acuity After ERM Treatment Within 120 Days |
Outcome (+2 bonus points) |
No benchmark yet |
Change of ID # (previously IRIS29) |
IRIS42: Return to OR or Endophthalmitis Within 90 Days After ERM Surgical Treatment |
Outcome (+2 bonus points) |
No benchmark yet |
Inverse measure, change of ID # (previously IRIS30) |
Retina: Macular Hole |
IRIS46: Evidence of Anatomic Closure of Macular Hole Within 90 Days After Surgery as Documented by OCT |
Outcome (+2 bonus points) |
No benchmark yet |
Change of ID # (previously IRIS32) |
IRIS47: Return to OR or Endophthalmitis Within 90 Days After Macular Hole Surgery |
Outcome (+2 bonus points) |
No benchmark yet |
Inverse measure, change of ID # (previously IRIS33) |
Uveitis/Immunology
|
IRIS18: Chronic Anterior Uveitis: Post-Treatment Visual Acuity |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS35: Improvement of Macular Edema in Patients with Uveitis |
Outcome (+2 bonus points) |
No benchmark yet |
|
IRIS51: Acute Anterior Uveitis: Post-Treatment Visual Acuity |
Outcome (+2 bonus points) |
No benchmark yet |
Change of ID # (previously IRIS16) |
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 (no EHR needed) or report 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.
Column 2—High-Priority Measures (Bonus Points)
Report at least one outcome measure. You need to 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 many 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; if it falls within the benchmark’s eighth decile, you earn 8.0-8.9 achievement points; etc.
Why does the point range for each measure start at 3 points? Provided you satisfy the 60%-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 60%-data completeness criteria, you would earn 3 achievement points if you are in a small practice, 1 point if you are in a large practice.)
Why does the point range 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” below the 10th decile. The benchmarks for some quality measures approach perfect performance before the 10th decile. For instance, suppose a benchmark for a measure reaches a performance rate of 99.99% at the sixth decile. In that case, if your performance rate is 99.99%, you would only earn 6.9 achievement points, however, a performance rate of 100% would earn you 10 achievement points (the chart would indicate this in the “Achievement Points” column, by noting “3-6.9 points or, with a 100% performance rate, 10 points”). Some measures with stalled scoring also are subject to the 7-point cap.
What if a quality measure doesn’t yet have a benchmark? CMS used 2017 performance data to try and establish benchmarks for the 2019 quality benchmarks. If there isn’t enough 2017 performance data to establish a reliable benchmark for a measure, or if the measure didn’t exist in 2017, CMS will try to establish a benchmark retroactively using 2019 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 using integrated IRIS Registry–EHR reporting. (There can be other benchmarks for reporting manually via the IRIS Registry and for reporting 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’s the 7-point cap? If 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 (for example, see Table 6A and Table 6C).
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). CMS had previously established a four-year life cycle for such measures—if they are in their second year of being topped out, they would be subject to a 7-point cap; topped out for three consecutive performance years, they would be eliminated 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.)
Previous: Table 6: Some Quality Measures Are Subject to Scoring Limitations
Next: Table 8: Manually Reporting Quality Measures via the IRIS Registry
DISCLAIMER AND LIMITATION OF LIABILITY: 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 regulators and 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© 2019, 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 Ophthalmic Executives® and IRIS® Registry, among other marks, are trademarks of the American Academy of Ophthalmology®.
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).