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  • Quality Measures for Merit-Based Incentive Payment System

  • Using the 2022 Clinical Quality Measure Specification and Benchmark Table

    If you're submitting data for the Merit-Based Incentive Payment System (MIPS), you'll first need to determine which reporting mechanism you’ll be using.

    After you've decided, review the measures available on the table below for that reporting mechanism (you’ll want to report at least six). The more measure achievement points you earn, the more likely you are to avoid any penalty.

    1. On the first pass of this chart, pick as many measures that allow you to earn up to 10.0 measure achievement points without any gaps (no stalled measures and no capped measures).
    2. Make sure at least one of them is classified as outcome or intermediate outcome.
    3. On second pass, pay attention to the collection type. The easiest and most reliable way to report is through the IRIS Registry®, but you can also report through other collection types. See EyeNet®'s MIPS 2022 Primer and Reference explanation of collection types. Coming soon, EyeNet®'s MIPS 2022 Primer and Reference will publish tables for EHR integration, manual web entry and claims-based reporting for your review.
    4. On your third and final pass, if reporting through IRIS Registry®-EHR integration or manual web entry, consider reporting IRIS QCDR measures that are without benchmarks in addition to your main selection. If you choose to report them, you will be assisting with the benchmarking for future years. This will give ophthalmic practices a greater selection of measures that reflect their everyday practice and can provide potentially more points than many other MIPS measures that are topped out.

    Download the Table (PDF)

    1. To earn achievement points based on your performance rate, you must first meet the two data submission thresholds. When selecting quality measures, look for measures where you are most likely to a) satisfy the case minimum of 20 patients, b) satisfy the 70% data submission threshold, and c) achieve a high performance rate.
    2. Make sure you’re using the current version of this chart. If you’ve printed this table, always check aao.org/medicare/benchmarks in order to make sure you’re using the most current version. Otherwise take advantage of the table’s electronic version for live links, including those in column 2 for the measure specifications. Remember, the specifications vary depending on which reporting pathway you are using.
    3. Check your data mapping. If you are reporting via IRIS Registry - EHR integration, you can only report a measure if the relevant data elements can be extracted from the EHR system. There is a June 1 deadline to select measures for data mapping, and Sept. 30 is the last day to request mapping refinements for those measures. If mapping is successful, you should check your mapping regularly throughout the year. 

    Based on the Centers for Medicare & Medicaid Services 2022 Quality Benchmarks (updated 02/15/2022), 2022 Clinical Quality Measure Specifications and Supporting Documents (created 12/08/2021), 2022 Medicare Part B Claims Measure Specifications and Supporting Documents (created 12/08/2021), and the 2022 Eligible Professional/Eligible Clinician eCQMs found at the eCQI Resource Center (accessed 12/31/2021). These files, links, and more can be found in the QPP Resource Library.  

    DISCLAIMER AND LIMITATION OF LIABILITY: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

    Copyright © 2022, American Academy of Ophthalmology Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry, among other marks, are trademarks of the American Academy of Ophthalmology®.

    All of the American Academy of Ophthalmology-developed quality measures are copyrighted by the Academy's H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).

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    IRIS1: Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or greater (better)
    in Qualified Clinical Data Registry, Registry Web Portal, EHR-IRIS Integration, Outcome, Cornea
    Percentage of endothelial keratoplasty patients with a best corrected visual acuity of 20/40 or better at 90 days after surgery
    • Comments 0
    • Views 389
    IRIS2: Glaucoma – Intraocular Pressure Reduction
    in EHR-IRIS Integration, Registry Web Portal, Qualified Clinical Data Registry, Glaucoma, Outcome
    Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis.
    • Comments 0
    • Views 972
    IRIS5: Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD)
    in Qualified Clinical Data Registry, Registry Web Portal, Oculoplastic, EHR-IRIS Integration, Outcome
    Percentage of surgical ptosis patients with an improvement of MRD postoperatively
    • Comments 0
    • Views 342
    IRIS6: Acquired Involutional Entropion: Normalized lid position after surgical repair
    in Oculoplastic, EHR-IRIS Integration, Registry Web Portal, Qualified Clinical Data Registry, Outcome
    Percentage of surgical entropion patients with normalized lid position within 90 days postoperatively
    • Comments 0
    • Views 306
    IRIS13: Diabetic Macular Edema: Loss of Visual Acuity
    in Qualified Clinical Data Registry, Registry Web Portal, EHR-IRIS Integration, Outcome, Retina
    Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) within the past 12 months.
    • Comments 0
    • Views 710
    IRIS17: Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells
    in Uveitis, Registry Web Portal, Qualified Clinical Data Registry, EHR-IRIS Integration, High Priority
    Percentage of patients with acute anterior uveitis post-treatment with Grade 0 anterior chamber cells.
    • Comments 0
    • Views 338
    IRIS23: Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 days
    in Refractive Surgery, Registry Web Portal, Qualified Clinical Data Registry, Outcome, EHR-IRIS Integration
    Percentage of patients with an uncorrected visual acuity of 20/20 or better within 30 days
    • Comments 0
    • Views 280
    IRIS24: Refractive Surgery: Patients with a postoperative correction within ± 0.5 Diopter (D) of the intended correction
    in Registry Web Portal, Refractive Surgery, EHR-IRIS Integration, Outcome, Qualified Clinical Data Registry
    Percentage of patients with an actual spherical equivalent within ± 0.5 D of the intended correction or SE
    • Comments 0
    • Views 162
    IRIS26: Avoidance of routine antibiotic use in patients before or after intravitreal injections
    in EHR-IRIS Integration, Retina, Registry Web Portal, Qualified Clinical Data Registry
    The percentage of patients, aged 18 years and older, who received topical or systemic antibiotics before or after intravitreal injections.
    • Comments 0
    • Views 362
    IRIS35: Improvement of Macular Edema in Patients with Uveitis
    in Outcome, Uveitis, EHR-IRIS Integration, Registry Web Portal, Qualified Clinical Data Registry
    Percentage of patients with uveitis and macular edema with a reduction of 20% or greater in the central subfield thickness on OCT within 90 days after treatment.
    • Comments 0
    • Views 399
    1-10 of 29 results
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