• Measure 19: Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care


    Updated January 2018.

    Reporting Options: 

    • IRIS Registry for EHR: groups and individuals
    • IRIS Registry manual data entry: groups and individuals
    • EHR through your vendor (if offered): groups and individuals
    • Claims-based reporting: individuals only

    Measure Type:  High Priority

    Description: This measure is to be reported a minimum of once per performance period for patients, aged 18 years and older, with a diagnosis of diabetic retinopathy seen during the performance period. This measure quantifies the percentage of these patients who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.

    It is anticipated that eligible clinicians who provide the primary management of patients with diabetic retinopathy (in either one or both eyes) will submit this measure.

    To Which Patients Does the Measure Apply?

    Denominator: All patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed.

    There are three criteria for inclusion of a patient into the denominator.

    1. Patient characteristics: Description located in “Instructions” (see above).
    2. Diagnosis codes (ICD-10-CM): Codes located in “Diagnosis Codes.”
    3. Procedure codes (CPT and HCPCS): Codes located in “CPT Codes” and "HCPCS Code."

    The quality measure also has exclusions for the denominator.

    Diagnosis Codes

    CMS has stated that ICD-10 should be coded to the greatest specificity and unspecified codes may be denied. Therefore, the codes listed below with a strikethrough should not be included on your claim or submitted with this quality measure.

    Diagnosis for diabetic retinopathy:  E08.311, E08.319, E08.3211, E08.3212, E08.3213, E08.3219, E08.3291, E08.3292, E08.3293, E08.3299, E08.3311, E08.3312, E08.3313, E08.3319, E08.3391, E08.3392, E08.3393, E08.3399, E08.3411, E08.3412, E08.3413, E08.3419, E08.3491, E08.3492, E08.3493, E08.3499, E08.3511, E08.3512, E08.3513, E08.3519, E08.3521, E08.3522, E08.3523, E08.3529, E08.3531, E08.3532, E08.3533, E08.3539, E08.3541, E08.3542, E08.3543, E08.3549, E08.3551, E08.3552, E08.3553, E08.3559, E08.3591, E08.3592, E08.3593, E08.3599, E09.311, E09.319, E09.3211, E09.3212, E09.3213, E09.3219, E09.3291, E09.3292, E09.3293, E09.3299, E09.3311, E09.3312, E09.3313, E09.3319, E09.3391, E09.3392, E09.3393, E09.3399, E09.3411, E09.3412, E09.3413, E09.3419, E09.3491, E09.3492, E09.3493, E09.3499, E09.3511, E09.3512, E09.3513, E09.3519, E09.3521, E09.3522, E09.3523, E09.3529, E09.3531, E09.3532, E09.3533, E09.3539, E09.3541, E09.3542, E09.3543, E09.3549, E09.3551, E09.3552, E09.3553, E09.3559, E09.3591, E09.3592, E09.3593, E09.3599, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599

    CPT Codes

    2018 additions in red.

    92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

    Without Telehealth Modifier: GQ, GT, 95, POS 2.

    Denominator note: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures.

    HCPCS Code

    G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy

    How to Report the Measure

    Claims and IRIS Registry Manual Reporting

    2018 additions in red.

    Numerator: Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient’s diabetic care.

    Numerator note: Denominator Exception(s) are determined on the date of the denominator eligible encounter.

    Measure reporting via registry: The listed numerator options are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

    Category II Codes:

    • Performance met (patient included in numerator and denominator): 5010F Findings of dilated macular or fundus exam communicated to the physician managing the diabetes care;
    • Denominator Exclusion (patient not included in numerator or denominator): 5010F 1P Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the on-going care of the patient with diabetes
      Or
      5010F 2P Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the on-going care of the patient with diabetes
    • Performance not met (patient not included in numerator, but included in denominator): 5010F 8P Findings of dilated macular or fundus exam was not communicated to the physician managing the diabetes care, reason not otherwise specified

    IRIS Registry EHR Reporting

    Instructions: Percentage of patients 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam within 12 months.

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

      • Evidence of a letter or call to the physician documenting severity of diabetic retinopathy and presence or absence of macular edema
      • Severity of diabetic retinopathy:
        • Mild NPDR
        • Moderate NPDR
        • Severe NPDR
        • Very Severe NPDR
        • Proliferative DR
      • Presence or absence of macular edema

    © 2015 PCPI® Foundation and American Medical Association. All Rights Reserved.

    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.

    Benchmarks

    Decile/PointsEHR (including IRIS integration)Registry (No EHR)Claims
    3 46.15 – 56.85 52.00 – 72.40 --
    4 56.85 – 65.13 72.41 – 81.47 --
    5 65.14 – 72.38 81.48 – 90.76 --
    6 73.39 – 78.21 90.77 – 96.54 --
    7 78.22 – 84.27 96.55 – 99.99 --
    8 84.28 – 89.93 -- --
    9 89.94 – 95.41 -- --
    10 >=95.42 100 100