2023 # 191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

CMS Measure ID: #191

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a procedure for uncomplicated cataract is performed during the performance period. This measure is intended to reflect the quality of services provided for the patients receiving uncomplicated cataract surgery. This measure is to be submitted by the Merit-based Incentive Payment System (MIPS) eligible clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract surgery patients are not eligible for this measure.

Note: This is an outcome measure and can be calculated solely using third party intermediary data.

For patients who receive the cataract surgical procedures specified in the denominator coding, it should be reported whether or not the patient had best-corrected visual acuity of 20/40 or better achieved in the operative eye within 90 days following cataract surgery.
Cataract surgeries performed on patients who have any of the listed significant ocular conditions [comorbid] in the exclusion criteria should be removed from the denominator; these patients have existing ocular conditions that could impact the outcome of surgery and are not included in the measure calculation for those patients who have best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.
Include only cataract surgery procedures performed through September 30th of the performance period. This will allow the post-operative period to occur within the performance period.

Measure Reporting:

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 for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 0 – 23.54
Decile 1: 23.55 – 85.7
Minimum: 85.71 – 92.9
Decile 3: 92.91 – 97.02
Decile 4: 97.03 – 98.35
Decile 5: 98.36 – 99.17
Decile 6: 99.18 – 99.99
Decile 10: 100 – 100

eCQM

Topped out: No
Capped at 7: No

Decile 0: 0 – 17.23
Decile 1: 17.24 – 74.47
Minimum: 74.48 – 88.07
Decile 3: 88.08 – 92.66
Decile 4: 92.67 – 95.13
Decile 5: 95.14 – 96.76
Decile 6: 96.77 – 97.85
Decile 7: 97.86 – 98.62
Decile 8: 98.63 – 99.26
Decile 9: 99.27 – 99.99
Decile 10: 100 – 100

Denominator

All cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria

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

AND

Patient encounter during the performance period (CPT): 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984

WITHOUT

Modifier: 56 or 55

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

AND NOT

DENOMINATOR EXCLUSION:

Any of the following significant ocular conditions that impact the visual outcome of surgery (Patients with documentation of the presence of one or more of the following significant ocular conditions that impact the visual outcome of surgery prior to date of cataract surgery which is still active at the time of the cataract surgery are excluded from the measure calculation)

Table 1 – Significant Ocular Conditions

Significant Ocular Condition	Corresponding ICD-10-CM Codes
Acute and Subacute Iridocyclitis	H20.00, H20.011, H20.012, H20.013, H20.021, H20.022, H20.023, H20.031, H20.032, H20.033, H20.041, H20.042, H20.043, H20.051, H20.052, H20.053
Amblyopia	H53.001, H53.002, H53.003, H53.011, H53.012, H53.013, H53.021, H53.022, H53.023, H53.031, H53.032, H53.033, H53.041, H53.042, H53.043
Burn Confined to Eye and Adnexa	T26.01XA, T26.02XA, T26.11XA, T26.12XA, T26.21XA, T26.22XA, T26.31XA, T26.32XA, T26.41XA, T26.42XA, T26.51XA, T26.52XA, T26.61XA, T26.62XA, T26.71XA, T26.72XA, T26.81XA, T26.82XA, T26.91XA, T26.92XA
Cataract Secondary to Ocular Disorders	H26.211, H26.212, H26.213, H26.221, H26.222, H26.223
Cataract, Congenital	Q12.0
Cataract, Mature or Hypermature	H26.9
Cataract, Posterior Polar	H25.041, H25.042, H25.043
Central Corneal Ulcer	H16.011, H16.012, H16.013
Certain Types of Iridocyclitis	H20.21, H20.22, H20.23, H20.811, H20.812, H20.813, H20.821, H20.822, H20.823, H20.9
Choroidal Degenerations	H35.33
Choroidal Detachment	H31.401, H31.402, H31.403, H31.411, H31.412, H31.413, H31.421, H31.422, H31.423
Choroidal Hemorrhage and Rupture	H31.301, H31.302, H31.303, H31.311, H31.312, H31.313, H31.321, H31.322, H31.323
Chronic Iridocyclitis	A18.54, H20.11, H20.12, H20.13, H20.9
Cloudy Cornea	H17.01, H17.02, H17.03, H17.11, H17.12, H17.13, H17.811, H17.812, H17.813, H17.821, H17.822, H17.823
Corneal Edema	H18.11, H18.12, H18.13, H18.20, H18.221, H18.222, H18.223, H18.231, H18.232, H18.233, H18.421, H18.422, H18.423, H18.43
Corneal Opacity and Other Disorders of Cornea	H17.01, H17.02, H17.03, H17.11, H17.12, H17.13, H17.89, H17.9
Degeneration of Macula and Posterior Pole	H35.30, H35.3110, H35.3111, H35.3112, H35.3113, H35.3114, H35.3120, H35.3121, H35.3122, H35.3123, H35.3124, H35.3130, H35.3131, H35.3132, H35.3133, H35.3134, H35.3210, H35.3211, H35.3212, H35.3213, H35.3220, H35.3221, H35.3222, H35.3223, H35.3230, H35.3231, H35.3232, H35.3233, H35.341, H35.342, H35.343, H35.351, H35.352, H35.353, H35.361, H35.362, H35.363, H35.371, H35.372, H35.373, H35.381, H35.382, H35.383
Degenerative Disorders of Globe	H44.2A1, H44.2A2, H44.2A3, H44.2B1, H44.2B2, H44.2B3, H44.2C1, H44.2C2, H44.2C3, H44.2D1, H44.2D2, H44.2D3, H44.2E1, H44.2E2, H44.2E3, H44.21, H44.22, H44.23, H44.311, H44.312, H44.313, H44.321, H44.322, H44.323, H44.391, H44.392, H44.393
Diabetic Macular Edema	E08.311, E08.3211, E08.3212, E08.3213, E08.3311, E08.3312, E08.3313, E08.3411, E08.3412, E08.3413, E08.3511, E08.3512, E08.3513, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533, E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.37X1, E08.37X2, E08.37X3, E09.311, E09.3211, E09.3212, E09.3213, E09.3311, E09.3312, E09.3313, E09.3411, E09.3412, E09.3413, E09.3511, E09.3512, E09.3513, E09.3521, E09.3522, E09.3523, E09.3531, E09.3532, E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E09.37X1, E09.37X2, E09.37X3, E10.311, E10.3211, E10.3212, E10.3213, E10.3311, E10.3312, E10.3313, E10.3411, E10.3412, E10.3413, E10.3511, E10.3512, E10.3513, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.37X1, E10.37X2, E10.37X3, E11.311, E11.3211, E11.3212, E11.3213, E11.3311, E11.3312, E11.3313, E11.3411, E11.3412, E11.3413, E11.3511, E11.3512, E11.3513, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542, E11.3543, E11.3551, E11.3552, E11.3553, E11.37X1, E11.37X2, E11.37X3, E13.311, E13.3211, E13.3212, E13.3213, E13.3311, E13.3312, E13.3313, E13.3411, E13.3412, E13.3413, E13.3511, E13.3512, E13.3513, E13.3521, E13.3522, E13.3523, E13.3531, E13.3532, E13.3533, E13.3541, E13.3542, E13.3543, E13.3551, E13.3552, E13.3553, E13.37X1, E13.37X2, E13.37X3
Diabetic Retinopathy	E08.311, E08.319, E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533, E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E09.311, E09.319, E09.3211, E09.3212, E09.3213, E09.3291, E09.3292, E09.3293, E09.3311, E09.3312, E09.3313, E09.3391, E09.3392, E09.3393, E09.3411, E09.3412, E09.3413, E09.3491, E09.3492, E09.3493, E09.3511, E09.3512, E09.3513, E09.3521, E09.3522, E09.3523, E09.3531, E09.3532, E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E09.3591, E09.3592, E09.3593, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.3591, E10.3592, E10.3593, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, E11.3512, E11.3513, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542, E11.3543, E11.3551, E11.3552, E11.3553, E11.3591, E11.3592, E11.3593, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3291, E13.3292, E13.3293, E13.3311, E13.3312, E13.3313, E13.3391, E13.3392, E13.3393, E13.3411, E13.3412, E13.3413, E13.3491, E13.3492, E13.3493, E13.3511, E13.3512, E13.3513, E13.3521, E13.3522, E13.3523, E13.3531, E13.3532, E13.3533, E13.3541, E13.3542, E13.3543, E13.3551, E13.3552, E13.3553, E13.3591, E13.3592, E13.3593
Disorders of Optic Chiasm	H47.41, H47.42, H47.43, H47.49
Disorders of Visual Cortex	H47.611, H47.612, H47.621, H47.622, H47.631, H47.632, H47.641, H47.642
Disseminated Chorioretinitis and Disseminated Retinochoroiditis	A18.53, H30.101, H30.102, H30.103, H30.111, H30.112, H30.113, H30.121, H30.122, H30.123, H30.131, H30.132, H30.133, H30.141, H30.142, H30.143
Focal Chorioretinitis and Focal Retinochoroiditis	H30.001, H30.002, H30.003, H30.011, H30.012, H30.013, H30.021, H30.022, H30.023, H30.031, H30.032, H30.033, H30.041, H30.042, H30.043
Glaucoma	H40.10X0, H40.10X1, H40.10X2, H40.10X3, H40.10X4, H40.1110, H40.1111, H40.1112, H40.1113, H40.1114, H40.1120, H40.1121, H40.1122, H40.1123, H40.1124, H40.1130, H40.1131, H40.1132, H40.1133, H40.1134, H40.1210, H40.1211, H40.1212, H40.1213, H40.1214, H40.1220, H40.1221, H40.1222, H40.1223, H40.1224, H40.1230, H40.1231, H40.1232, H40.1233, H40.1234, H40.1310, H40.1311, H40.1312, H40.1313, H40.1314, H40.1320, H40.1321, H40.1322, H40.1323, H40.1324, H40.1330, H40.1331, H40.1332, H40.1333, H40.1334, H40.1410, H40.1411, H40.1412, H40.1413, H40.1414, H40.1420, H40.1421, H40.1422, H40.1423, H40.1424, H40.1430, H40.1431, H40.1432, H40.1433, H40.1434, H40.151, H40.152, H40.153, H40.20X0, H40.20X1, H40.20X2, H40.20X3, H40.20X4, H40.211, H40.212, H40.213, H40.2210, H40.2211, H40.2212, H40.2213, H40.2214, H40.2220, H40.2221, H40.2222, H40.2223, H40.2224, H40.2230, H40.2231, H40.2232, H40.2233, H40.2234, H40.231, H40.232, H40.233, H40.241, H40.242, H40.243, H40.31X0, H40.31X1, H40.31X2, H40.31X3, H40.31X4, H40.32X0, H40.32X1, H40.32X2, H40.32X3, H40.32X4, H40.33X0, H40.33X1, H40.33X2, H40.33X3, H40.33X4, H40.41X0, H40.41X1, H40.41X2, H40.41X3, H40.41X4, H40.42X0, H40.42X1, H40.42X2, H40.42X3, H40.42X4, H40.43X0, H40.43X1, H40.43X2, H40.43X3, H40.43X4, H40.51X0, H40.51X1, H40.51X2, H40.51X3, H40.51X4, H40.52X0, H40.52X1, H40.52X2, H40.52X3, H40.52X4, H40.53X0, H40.53X1, H40.53X2, H40.53X3, H40.53X4, H40.61X0, H40.61X1, H40.61X2, H40.61X3, H40.61X4, H40.62X0, H40.62X1, H40.62X2, H40.62X3, H40.62X4, H40.63X0, H40.63X1, H40.63X2, H40.63X3, H40.63X4, H40.811, H40.812, H40.813, H40.821, H40.822, H40.823, H40.831, H40.832, H40.833, H40.89, Q15.0
Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes	H40.31X0, H40.31X1, H40.31X2, H40.31X3, H40.31X4, H40.32X0, H40.32X1, H40.32X2, H40.32X3, H40.32X4, H40.33X0, H40.33X1, H40.33X2, H40.33X3, H40.33X4, H40.41X0, H40.41X1, H40.41X2, H40.41X3, H40.41X4, H40.42X0, H40.42X1, H40.42X2, H40.42X3, H40.42X4, H40.43X0, H40.43X1, H40.43X2, H40.43X3, H40.43X4, H40.51X0, H40.51X1, H40.51X2, H40.51X3, H40.51X4, H40.52X0, H40.52X1, H40.52X2, H40.52X3, H40.52X4, H40.53X0, H40.53X1, H40.53X2, H40.53X3, H40.53X4, H40.811, H40.812, H40.813, H40.821, H40.822, H40.823, H40.831, H40.832, H40.833, H40.89, H40.9, H42
Hereditary Choroidal Dystrophies	H31.20, H31.21, H31.22, H31.23, H31.29
Hereditary Corneal Dystrophies	H18.501, H18.502, H18.503, , H18.511, H18.512, H18.513, H18.521, H18.522, H18.523, H18.531, H18.532, H18.533, , H18.541, H18.542, H18.543, H18.551, H18.552, H18.553, H18.591, H18.592, H18.593
Hereditary Retinal Dystrophies	H35.50, H35.51, H35.52, H35.53, H35.54, H36
Hypotony of Eye	H44.40, H44.411, H44.412, H44.413, H44.421, H44.422, H44.423, H44.431, H44.432, H44.433, H44.441, H44.442, H44.443
Injury to Optic Nerve and Pathways	S04.011A, S04.012A, S04.02XA, S04.031A, S04.032A, S04.041A, S04.042A
Macular Scar of Posterior Polar	H31.011, H31.012, H31.013
Morgagnian Cataract	H25.21, H25.22, H25.23
Nystagmus and Other Irregular Eye Movements	H55.00, H55.01, H55.02, H55.03, H55.04, H55.09, H55.81, H55.89
Open Wound of Eyeball	S05.11XA, S05.12XA, S05.21XA, S05.22XA, S05.31XA, S05.32XA, S05.51XA, S05.52XA, S05.61XA, S05.62XA, S05.71XA, S05.72XA, S05.8X1A, S05.8X2A
Optic Atrophy	H47.20, H47.211, H47.212, H47.213, H47.22, H47.231, H47.232, H47.233, H47.291, H47.292, H47.293
Optic Neuritis	H46.01, H46.02, H46.03, H46.11, H46.12, H46.13, H46.2, H46.3, H46.8, H46.9
Other and Unspecified Forms of Chorioretinitis and Retinochoroiditis	H30.21, H30.22, H30.23, H30.811, H30.812, H30.813, H30.891, H30.892, H30.893, H30.91, H30.92, H30.93
Other Background Retinopathy and Retinal Vascular Changes	H35.021, H35.022, H35.023, H35.051, H35.052, H35.053, H35.061, H35.062, H35.063
Other Disorders of Optic Nerve	H47.011, H47.012, H47.013
Other Endophthalmitis	H16.241, H16.242, H16.243, H21.331, H21.332, H21.333, H33.121, H33.122, H33.123, H44.111, H44.112, H44.113, H44.121, H44.122, H44.123, H44.131, H44.132, H44.133, H44.19
Other Proliferative Retinopathy	H35.101, H35.102, H35.103, H35.111, H35.112, H35.113, H35.121, H35.122, H35.123, H35.131, H35.132, H35.133, H35.141, H35.142, H35.143, H35.151, H35.152, H35.153, H35.161, H35.162, H35.163, H35.171, H35.172, H35.173
Pathologic Myopia	H44.2A1, H44.2A2, H44.2A3, H44.2B1, H44.2B2, H44.2B3, H44.2C1, H44.2C2, H44.2C3, H44.2D1, H44.2D2, H44.2D3, H44.2E1, H44.2E2, H44.2E3, H44.21, H44.22, H44.23, H44.30
Posterior Lenticonus	Q12.2, Q12.4, Q12.8
Prior Penetrating Keratoplasty	H18.601, H18.602, H18.603, H18.611, H18.612, H18.613, H18.621, H18.622, H18.623
Purulent Endophthalmitis	H44.001, H44.002, H44.003, H44.011, H44.012, H44.013, H44.021, H44.022, H44.023
Retinal Detachment with Retinal Defect	H33.001, H33.002, H33.003, H33.011, H33.012, H33.013, H33.021, H33.022, H33.023, H33.031, H33.032, H33.033, H33.041, H33.042, H33.043, H33.051, H33.052, H33.053, H33.41, H33.42, H33.43, H33.8
Retinal Vascular Occlusion	H34.11, H34.12, H34.13, H34.231, H34.232, H34.233, H34.8110, H34.8111, H34.8112, H34.8120, H34.8121, H34.8122, H34.8130, H34.8131, H34.8132, H34.8310, H34.8311, H34.8312, H34.8320, H34.8321, H34.8322, H34.8330, H34.8331, H34.8332
Retrolental Fibroplasias	H35.171, H35.172, H35.173
Scleritis and Episcleritis	H15.021, H15.022, H15.023, H15.031, H15.032, H15.033, H15.041, H15.042, H15.043, H15.051, H15.052, H15.053, H15.091, H15.092, H15.093
Separation of Retinal Layers	H35.711, H35.712, H35.713, H35.721, H35.722, H35.723, H35.731, H35.732, H35.733
Traumatic Cataract	H26.101, H26.102, H26.103, H26.111, H26.112, H26.113, H26.121, H26.122, H26.123, H26.131, H26.132, H26.133
Uveitis	H44.111, H44.112, H44.113, H44.131, H44.132, H44.133
Vascular Disorders of Iris and Ciliary Body	H21.1X1, H21.1X2, H21.1X3
Visual Field Defects	H53.411, H53.412, H53.413, H53.421, H53.422, H53.423, H53.431, H53.432, H53.433, H53.451, H53.452, H53.453, H53.461, H53.462, H53.47, H53.481, H53.482, H53.483

Numerator

Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery

Numerator Options:

Performance Met:

Best-corrected visual acuity of 20/40 or better (distance or near) achieved within the 90 days following cataract surgery (4175F)

Performance Not Met:

Best-corrected visual acuity of 20/40 or better (distance or near) not achieved within the 90 days following cataract surgery, reason not otherwise specified (4175F with 8P)