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


    Reporting Option: 

    • IRIS Registry EHR
    • EHR through your vendor
    • IRIS Registry group reporting
    • IRIS Registry manual data entry
    • Claims based reporting

    Measure Type: Process- High Priority

    Description: 
    Percentage of patients aged 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 at least once within 12 months.

    CPT Codes:

    Denominator note: *Signifies that this CPT Category I code is a non-covered service under the PFS (Physician Fee Schedule). These non-covered services will not be counted in the denominator population for claims-based measures.

    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

    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

    Claims based and IRIS Registry Manual Reporting

    Category II and HCPCS Codes:

    Note:  There are four options for reporting this measure. Each requires a Category II code and one HCPCS G code.

    5010F Findings of dilated macular or fundus exam communicated to the physician managing the diabetes care;
    and
    G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy;
    or
    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
    and
    G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy
    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
    and
    G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy ,
    or
    G8398 Dilated macular or fundus exam not performed.
    or
    5010F 8P Findings of dilated macular or fundus exam was not communicated to the physician managing the diabetes care, reason not otherwise specified
    and
    G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy

    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

    How CMS Scores Your Performance

    • If you report this measure for at least 50 percent of applicable patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
    • If you successfully report a measure for less than 50 percent of your patients, you will earn 3 points.
    • You can also earn bonus points because of the measure type and if you electronically report this measure (i.e., through an integrated EHR system).
    Decile/Points eCQM Benchmark (Integrated EHR) Web Portal Benchmark (No EHR)
    3 20.00 - 29.78 36.21 - 59.99
    4 29.79 - 38.35 60.00 - 78.56
    5 38.36 - 45.70 78.57 - 89.80
    6 45.71 - 52.53 89.81 - 96.22
    7 52.54 - 60.79 96.23 - 99.99
    8 60.80 - 68.80 --
    9 68.81 - 79.30 --
    10 >= 79.31 100