CMS Measure ID 117: Diabetes: Eye Exam (CMS131v10)

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Description

Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.

Instructions

This measure is to be submitted a minimum of once per performance period for patients with diabetes mellitus seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS-eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator 

Patients 18 - 75 years of age on date of encounter. This information can be entered in DrChrono in the patient chart under the Demographics tab with the Patient Date of Birth. 

AND

• An ICD-10 diagnosis for diabetes documented in one of the ICD-10 entry points.  See your Healthmonix MIPSpro account, the attached document, or the CMS website for a full list.  
• A relevant CPT or HCPCS code: 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0438, G0439

DENOMINATOR NOTE: To assess the age for exclusions, the patient’s age at the end of the measurement period should be used.

*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 MIPS CQMs.

AND NOT

DENOMINATOR EXCLUSION:

Hospice services provided to patient any time during the measurement period: G9714

OR

Patient is using palliative care services any time during the measurement period: G9994
OR
Patients age 66 and older in Institutional Special Needs Plans (SNP) or residing in long-term care with a POS code 32, 33, 34, 54 or 56 for more than 90 consecutive days during the measurement period: G2105
OR
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND a dispensed medication for dementia during the measurement period or the year prior to the measurement period: G2106
OR
Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND either one acute inpatient encounter with a diagnosis of advanced illness or two outpatient, observation, ED or nonacute inpatient encounters on different dates of service with an advanced illness diagnosis during the measurement period or the year prior to the measurement period: G2107.

Please see your Healthmonix MIPSpro account, the attached document, or the CMS website for a full list of codes that identify frailty and/or advanced illness. 

Table: Dementia Exclusion Medications

Numerator 

Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following:
• Diabetic with a diagnosis of retinopathy that overlaps the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period
• Diabetic with no diagnosis of retinopathy overlapping the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period

Numerator Options: The CPT codes associated with the numerator can be entered in the billing section for the appointment. 

Performance Met:

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (2023F)

OR

Performance Met:

7 standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed (2024F)

OR

Performance Met:

7 standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (2025F)

OR

Performance Met:

Eye imaging validated to match diagnosis from 7 standard field stereoscopic photos results documented and reviewed (2026F)

OR

Performance Met:

Eye imaging validated to match diagnosis from 7 standard field stereoscopic photos results documented and reviewed, without evidence of retinopathy (2033F)

OR

Performance Met:

Low risk for retinopathy (no evidence of retinopathy in the prior year)* (3072F)

OR

Performance Not Met:

The dilated eye exam was not performed, reason not otherwise specified (2022F or 2024F or 2026F with 8P)