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)
OR
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)