• Download a printable 2018 Claims Reporting Guide (PDF) with annotated pictures.

    The purpose of this guide is to educate ophthalmologists on how to meet the requirements of the quality category of the Merit-Based Incentive Payment System using Medicare claims reporting. Failure to successfully participate in MIPS in 2018 will lead to a 5 percent penalty on all Medicare Part B payments in 2020. This translates into an average penalty amount of $23,437 for an average ophthalmologist, so participation is in your best interest. Three things to consider before reading:

    1. Penalty vs. bonus: This guide is focused on helping ophthalmologists in small practices (≤ 15 clinicians) meet the minimum criteria to avoid a penalty under the MIPS program. If you would like to do more (either to prepare yourself for next year or to earn a bonus), see the MIPS Roadmaps and additional content available under the Academy's MIPS pages.
    2. Individual vs. group reporting: Only providers reporting as individuals may submit quality data via claims. To report by claims, you must be either:
      1. In a solo practice or
      2. In a group practice where every member of the group is reporting at the individual level.
      You cannot report via claims as a group.
    3. Is claims-based reporting the best option for you or your group: The Academy recommends its IRIS® Registry for quality reporting. It is a free member benefit and is tailored to ophthalmologists. In addition, the IRIS Registry Web Portal does not require reporting in real time as claims-based reporting does, and there is less uncertainty as you are able to track the patients and quality measures you report on. Under claims-based reporting, CMS only confirms on remittance advice that the submission was received, but not that it was successful.

    Minimum Reporting: Using the Quality Category to Avoid a Penalty

    1. Find the Right Measures

    For the quality category in the 2018 transition year (the second year of the MIPS program), all clinicians in small practices (≤ 15 clinicians) can avoid the payment penalty by simply reporting on six measures, including one outcome measure, for one patient each. Here’s how to meet the minimum reporting requirements:

    1. View the 16 ophthalmology-relevant measures that can be submitted via claims. Each measure is identified based on its Quality ID #. Make sure to select applicable measures (measures relevant to your services or care rendered) on which to report.
    2. View the basic description of the measures you want to report. The Instructions section will describe how often you have to include the measure's numerator/denominator codes in a claim for the patient (the frequency of reporting) and the key patient characteristics.

    Your measure score depends on two components: the numerator and the denominator.

    • Denominator: To include a patient in the denominator, the case must meet three criteria:
      1. Patient characteristics: Defined in the "Description" section.
      2. Diagnosis codes (ICD-10-CM): Codes located in “Diagnosis Codes.”
      3. Procedure codes (CPT or HCPCS): Codes located in “CPT Codes.”
      The quality measure may also have exclusions for the denominator.
    • Numerator: The numerator is based on CPTII codes; these QDC scores are organized into one of three categories.
      1. Performance met: Include patient in numerator and denominator
      2. Denominator exclusion: Do not include patient in numerator or denominator.
      3. Performance not met: Include patient in denominator, but not in the numerator.

    2. Report the Measures

    Once you have chosen the measures needed to meet the minimum MIPS reporting requirements, follow these steps to report by claims.

    1. Report on quality measures on a regular CMS 1500 Medicare Part B Claim.
    2. Identify a patient encounter that is relevant to your selected quality measure (or vice versa) and add the QDC to the “Procedures, Services, and Supplies” section of the Claim form. Follow these three steps for correct coding.
      • Submit the quality code as its own line item.
      • Include a value of $0.01 under the “$ Charge” section for the quality codeline.
      • Use the right QDCs! Some of these have changed for MIPS (see table, below). Do not use old PQRS or old MIPS QDCs.

    This sample CMS 1500 form shows how to correctly report the quality category for a patient seen for an office visit. The clinician is reporting on quality measure ID 117 (Diabetes: Eye Exam), using QDC 2022F.


    Claims Reporting Guide CMS 1500 Form Ophtho


    More-than-Minimum Reporting

    Clinicians in small practices (≤ 15 clinicians) will receive 3 out of 10 points for each quality measure reported on at least 1 patient (up to 6 measures, maximum). To be eligible to receive the remaining 7 out of 10 points for each quality measure, additional criteria must be met (see Basic Requirements below).

    Going beyond minimum reporting requirements requires more comprehensive reporting. The maximum number of points within the quality category is 60, and a clinician can report on up to 6 measures (6 measures x 10 points each = 60 points total). The quality category is weighted at 50 percent of the MIPS final score, meaning that a perfect quality score will contribute up to 50 points to the MIPS final score. 

    Basic Requirements

    1. Performance Period: Quality reporting must be done for a full calendar year within the 2018 performance year.
    2. Data Completeness: For each measure, the clinician must report on at least 60% of all Medicare Part B denominator-eligible patients seen during the performance year (this number is the data completeness numerator for the measure).
      • For example, for the Diabetic Retinopathy measures, the denominator-eligible patients are all patients between the ages of 18 and 75 years with diabetes.
    3. Case Minimum: For any quality measure, at least 20 patients must be included in the denominator.


    Apart from the 3 base points for participation, CMS bases the additional 7 out of 10 points on your performance rate, which the agency calculates based on the following formula:

    Performance Met


    Data Completeness Numerator - Denominator Exclusion - Denominator Exception


    • CMS compares this performance-rate percentage to a benchmark. Each measure has an individual benchmark based on collective performance.
    • Your points earned, out of 10, depends on the decile in which your performance rate falls. Note: Since clinicians in small practices receive a base score of 3 points, the first three deciles are pooled into Decile 3.
    • See the measure specification for performance required for each measure in order to earn more than 3 points.


    Decile Range Category Points
    Decile 3 3-3.9
    Decile 4 4-4.9
    Decile 5 5-5.9
    Decile 6 6-6.9
    Decile 7 7-7.9
    Decile 8 8-8.9
    Decile 9 9-9.9
    Decile 10 10

    Quality Data Codes Changes for 2018 MIPS Claims-Eligible Measures

    MeasureQDC Changes
    14 - Age-Related Macular Degeneration (AMD): Dilated Macular Examination

    Performance Met: G9974 (Dilated macular exam performed, including documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage and the level of macular degeneration severity)
    Denominator Exclusion: G9975 (Documentation of medical reason(s) for not performing a dilated macular examination)
    Denominator Exclusion: G9892 (Documentation of patient reason(s) for not performing a dilated macular examination)
    Performance Not Met: G9893 (Dilated macular exam not performed)

    226 - Preventive Care and Screening: Tobacco use: Screening and Cessation Intervention

    Major Changes:  This is now a 3-Part Measure

    Patient is Tobacco User: All parts required; Non-Users: Part I and III.

    Part I - Patients screened for tobacco use at least once within 24 months

    Performance Met: G9902 or G9903 (Patient screened and identified as a tobacco user or non-user, respectively)
    Denominator Exclusion: G9904 (Documentation of medical reason(s) for not screening for tobacco use*)
    Performance Not Met: G9905 (Patient not screened for tobacco use, reason not given)

    Part II - Identified tobacco users receive tobacco cessation intervention

    Performance Met: G9906 (Patient identified as a tobacco user received tobacco cessation intervention (counselling and/or pharmacotherapy)
    Denominator Exclusion: G9907 AND G9902 (Documentation of medical reason(s) for not providing tobacco cessation intervention*)
    Performance Not Met: G9908 AND G9902 (Patient identified as tobacco user did not receive tobacco cessation intervention, reason not given)

    Part III - Patients screened AND either non-tobacco user or received tobacco cessation intervention, if positive

    Performance Met: CPTII 4004F or CPTII 1036F (Patient screened and identified as a tobacco user AND received intervention; or non-user, respectively)
    Denominator Exclusion 1: CPTII 4004F + 1P (Tobacco screening not performed OR tobacco cessation intervention not provided, for medical reasons*)
    Denominator Exclusion 2: G9909 (Documentation of medical reason(s) for not providing tobacco cessation intervention if identified as a tobacco user*)
    Performance Not Met: CPTII 4004F + 8P
    (Tobacco screening not performed OR tobacco cessation intervention not provided, reason not otherwise specified)

    *e.g., limited life expectancy, other medical reason
    236 - Controlling High Blood Pressure Denominator Exclusion: G9910 Patients age 65 or older in Institutional Special Needs Plans (SNP) or residing in long-term care with POS code 32, 33, 34, 54, or 56 any time during the measurement period)

    No 2018 QDC Changes to the Following MIPS Claims-Eligible Measures:

    • Measure 1: Diabetes: Hemoglobin A1c Poor Control
    • Measure 12: Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
    • Measure 19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
    • Measure 47: Care Plan
    • Measure 110: Preventive Care and Screening: Influenza Immunization
    • Measure 111: Pneumonia Vaccination Status for Older Adults
    • Measure 117: Diabetes: Eye Exam
    • Measure 128: Preventive Care and Screening: Body Mass Index
    • Measure 130: Documentation of Current Medications
    • Measure 140: Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
    • Measure 141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
    • Measure 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
    • Measure 397: Melanoma Reporting