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)