Updated December 2022. No changes for 2023.
The measure is approved for traditional MIPS submission pathway only.
Care Setting: Ambulatory Care: Clinician Office/Clinic
- 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 surgical entropion patients with normalized lid position within 90 days postoperatively.
Risk Adjusted: No
Performance Rate: 1
High Priority Measure: Yes
Inverse Measure: No
To Which Patients Does the Measure Apply?
Denominator: All patients aged 18 years or older with a diagnosis of involutional entropion who underwent a surgical procedure for the condition.
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.”
- Senile entropion (ICD-10: H02.031, H02.032, H02.033, H02.034, H02.035, H02.036, H02.039)
Entropion surgical procedure
- Lateral canthoplasty (CPT: 67950)
- Lateral tarsal strip (CPT: 67917)
- Entropion repair (CPT: 67924)
- Excision and repair of eyelid (CPT: 67961)
- Excision and repair of eyelid (CPT: 67966)
How to Report the Measure
Numerator: Patients with normalized lid position within 90 days postoperatively
EHR-IRIS Registry Integration
We have had difficulty identifying pre and post op lid position descriptions. To improve capture of this measures, it would be helpful if you could document these in your electronic health record notes:
- “Normal or normalized lid position” in your assessment and notes within 90 days of surgery OR
- “Abnormal or not normalized lid position” in your assessment and notes within 90 days of surgery
How CMS Scores Your Performance
See QPP resource library for benchmarks.
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.
© 2017-2023 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 2023 American Medical Association.