2021 MIPS Measure #384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

Measure Description

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery

Instructions

This measure is to be calculated each time a procedure for primary rhegmatogenous retinal detachment is performed during the performance period. This measure is intended to reflect the quality of services provided for the patient receiving primary rhegmatogenous retinal detachment surgery.

Note: This is an outcome measure and will be calculated solely using registry data.

• For patients who receive the surgical procedures specified in the denominator coding, it should be submitted whether or not the patient had to return to the operating room within 90 days of surgery.
• Include only procedures performed through September 30 of the performance period. This will allow the post- operative period to occur before registries must submit data to CMS.

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 aged 18 years or older who had surgery for primary rhegmatogenous retinal detachment

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter

AND

Patient procedure during the performance period (CPT): 67107, 67108, 67110

AND NOT

DENOMINATOR EXCLUSION:

Surgical procedures that included the use of silicone oil: G9756

Numerator

Patients who did not return to the operating room within 90 days for complications within the operative eye

Numerator Options:

Performance Met:

Patient did not require a return to the operating room within 90 days of surgery (G9515)

OR

Performance Not Met:

Patient required a return to the operating room within 90 days of surgery (G9514)