• Measure 18 (NQF #0088): Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy


    Updated January 2018.

    Reporting Options: 

    • IRIS Registry for EHR: groups and individuals
    • EHR through your vendor (if offered): groups and individuals

    eMeasure Identifier: CMS167v6

    Measure Type:  Process

    Instructions:  Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.

    IRIS Registry EHR Reporting

    These are the required elements to be documented at least once a year to meet the measure performance requirements.  

    • Documentation of the level of severity of retinopathy AND
      • Mild NPDR
      • Moderate NPDR
      • Severe NPDR
      • Very Severe NPDR
      • Proliferative DR
    • Documentation of whether macular edema was present or absent

    Macular edema: Acceptable synonyms for macular edema include intraretinal thickening, serous detachment of the retina, or pigment epithelial detachment

    Denominator exceptions

    • Documentation of medical reason(s) for not performing a dilated macular or fundus examination
    • Documentation of patient reason(s) for not performing a dilated macular or fundus examination

    How CMS Scores Your Performance

    • If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
      • Small practices (≤ 15 clinicians) will receive 3 points,
      • Larger practices (> 15 clinicians) will receive 1 point.
    • If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
    • If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
    Decile/Points EHR (including EHR-IRIS integration)
    3 57.14 – 65.83
    4 65.84 – 72.72
    5 72.73 – 78.21
    6 78.22 – 83.12
    7 83.13 – 88.17
    8 88.18 – 92.30
    9 92.31 – 96.32
    10 >= 96.33