Updated January 2019. This measure is not available for MIPS reporting beginning in 2020.
- IRIS Registry manual data entry: groups and individuals
Measure Type: Outcome
NQS Domain: Patient Safety
Meaningful Measure Area: Preventable Healthcare Harm
Description: Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy
Instructions: This measure is to be calculated each time a procedure for cataracts is performed during the performance period. This measure is intended to reflect the quality of services provided for the patient receiving cataract surgery.
To Which Patients Does the Measure Apply?
Denominator: All patients aged 18 years and older who had cataract surgery
There are two criteria for inclusion of a patient into the denominator.
- Patient characteristics: Description located in “Denominator” (see above).
- Procedure codes (CPT and HCPCS): Codes located in “CPT Codes” and "HCPCS Code."
The quality measure also has exclusions for the denominator.
This measure does not require a specific diagnosis to be submitted during the encounter.
66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
Without modifiers: 55, 56
Exclusion (patient ineligible):
G9759 History of preoperative posterior capsule rupture
How to Report the Measure
IRIS Registry Manual Reporting
Numerator: Patients who experienced an unplanned rupture of the posterior capsule requiring vitrectomy during cataract surgery.
Inverse measure - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.
- Performance met (patient included in numerator and denominator): G9389 Unplanned rupture of the posterior capsule requiring vitrectomy during cataract surgery
- Performance not met (patient not included in numerator, but included in denominator): G9390 No unplanned rupture of the posterior capsule requiring vitrectomy during cataract surgery
Rationale: Although there are numerous complications that can occur after cataract surgery, those resulting in permanent loss of vision are rare. Unplanned anterior vitrectomies are performed following cataract surgery when vitreous inadvertently prolapses into the anterior segment of the eye. This may result in poor visual outcome and additional complications, including retinal detachment. Studies have shown unplanned vitrectomy rates ranging from 1 percent to 4 percent. The literature indicates that this complication can occur more commonly for inexperienced surgeons.
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 performance period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
- Note: For those reporting this measure via IRIS Registry manual/web portal, there is a 7 point cap.
||IRIS Registry web portal (No EHR)
*Capped at 7 points*
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