Not approved for MIPS reporting, but available for quality improvement purposes
Updated December 2024. No changes for 2024.
The measure is approved for traditional MIPS submission pathway only.
Care Setting: Ambulatory Care: Clinician Office/Clinic
Reporting Options:
- IRIS Registry QCDR for EHR: groups and individuals
- IRIS Registry QCDR manual data entry: groups and individuals
Measure Type: Outcome
NQS Domain: Effective Clinical Care
Meaningful Measure Area: Management of Chronic Conditions
Description: Percentage of patients with a 20% improvement in visual acuity within 120 days following epiretinal membrane treatment
Risk Adjusted: No
Performance Rate: 1
High Priority Measure: Yes
Inverse Measure: No
Proportional Measure
To Which Patients Does the Measure Apply?
Denominator: All patients aged18 years or older with a diagnosis of epiretinal membrane and had a procedure to treat epiretinal membrane.
This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. It is anticipated that clinicians who provide the primary management of patients with epiretinal membrane will submit this measure.
There are three criteria for inclusion of a patient into the denominator.
- Patient characteristics: Description located in “Denominator” (see above).
- Diagnosis codes (ICD-10-CM): Codes located in “Diagnosis Codes.”
- Procedure codes (CPT): Codes located in “CPT Codes.”
The quality measure also has exclusions for the denominator.
Diagnosis Codes
- Diagnosis of epiretinal membrane (ICD-10: H35.373, H35.379, H35.371, H35.372)
CPT Codes
- Had procedure to treat epiretinal membrane (CPT: 67041, 67042)
How To Report the Measure
Numerator: Patients with a 20% improvement in visual acuity within 120 days following epiretinal membrane treatment
Denominator Exclusions:
- Cystoid macular edema (ICD-10: H59.031, H59.032, H59.033, H59.039, H35.351, H35.352, H35.353, H35.359)
- Uveitis (ICD-10: H20.00, H20.011, H20.012, H20.013, H20.019, H20.021, H20.022, H20.023, H20.029, H20.11, H20.12, H20.13)
Notes: 20% improvement is defined as an improvement compared to the preoperative logMAR (-log(Snellen fraction)). The following table shows the 20% visual acuity improvement threshold.
|
logMAR
|
Preop Snellen
|
20% improve logMAR
|
20% improve Postop Snellen
|
|
0.1
|
20/25
|
0.08
|
20/25 +1
|
|
0.176
|
20/30
|
0.1408
|
20/25 -2
|
|
0.2
|
20/32
|
0.16
|
20/32 +2
|
|
0.3
|
20/40
|
0.24
|
20/32 -2
|
|
0.4
|
20/50
|
0.32
|
20/40 -1
|
|
0.477
|
20/60
|
0.3816
|
20/50 +1
|
|
0.5
|
20/63
|
0.4
|
20/50
|
|
|
0.544
|
20/70
|
0.4352
|
20/50 -2
|
|
0.6
|
20/80
|
0.48
|
20/63 +1
|
|
0.7
|
20/100
|
0.56
|
20/80 +2
|
|
0.8
|
20/125
|
0.64
|
20/80 -2
|
|
0.9
|
20/160
|
0.72
|
20/100 -1
|
|
1
|
20/200
|
0.8
|
20/125
|
|
|
1.1
|
20/250
|
0.88
|
20/160 +1
|
|
1.18
|
20/300
|
0.944
|
2/160 -2
|
|
1.2
|
20/320
|
0.96
|
20/200 +2
|
|
1.3
|
20/400
|
1.04
|
20/200 -2
|
|
1.5
|
20/640
|
1.2
|
20/320
|
|
|
1.6
|
20/800
|
1.28
|
20/400 +1
|
How CMS Scores Your Performance
See the QPP resource library for benchmarks.
Copyright
This measure has been developed by the H. Dunbar Hoskins Jr. MD Center for Quality Eye Care of the American Academy of Ophthalmology. The measure is not a clinical guideline and does not establish a medical standard. It has not been tested in all possible applications.
The measure, while copyrighted, can be reproduced and distributed with appropriate credit, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. The American Academy of Ophthalmology encourages use of the measure by other health care professionals, where applicable.
Commercial use is defined as the sale, license or distribution of the measures for commercial gain, or incorporation of some or all of a measure into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the measures require a license agreement between the user and the American Academy of Ophthalmology. Neither the Academy nor its members shall be responsible for any use of the measures.
THE MEASURE AND SPECIFICATIONS ARE PROVIDED “AS IS,” WITHOUT WARRANTY OF ANY KIND.
© 2017-24 American Academy of Ophthalmology. All rights reserved. Limited proprietary coding from Current Procedural Terminology (CPT®) is contained in the measure specifications. Users of this code set should obtain all necessary licenses. The Academy disclaims all liability for use or accuracy of the coding contained in these measure specifications. CPT® contained in the measures specifications is copyright 2004-2023 American Medical Association.