2023 # 384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

CMS Measure ID: #384

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 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:

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

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

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 75.75
Decile 1: 75.76 – 89.13
Minimum: 89.14 – 95.09
Decile 3: 95.1 – 96.76
Decile 4: 96.77 – 98.25
Decile 5: 98.26 – 99.99
Decile 10: 100 – 100

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

WITHOUT

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

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)