2023 # 385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

CMS Measure ID: #385

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 achieved an improvement of their visual acuity 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 and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 0 – 6.51
Decile 1: 6.52 – 16.8
Minimum: 16.81 – 21.89
Decile 3: 21.9 – 34.77
Decile 4: 34.78 – 38.77
Decile 5: 38.78 – 56.93
Decile 6: 56.94 – 62.27
Decile 7: 62.28 – 64.7
Decile 8: 64.71 – 77.28
Decile 9: 77.29 – 81.47
Decile 10: 81.48 – 100

Denominator

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

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

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:

Patients with a pre-operative visual acuity better than 20/40

OR

Surgical procedures that included the use of silicone oil: G9757

Numerator

Patients who achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye

Numerator Options:

Performance Met:

Patient achieved an improvement in visual acuity, from their preoperative level, within 90 days of surgery (G9516)

Performance Not Met:

Patient did not achieve an improvement in visual acuity, from their preoperative level, within 90 days of surgery, reason not given (G9517)