2024 MIPS Measure #499: Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: Process

Description

‌Percentage of patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservative-free triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant) who, within seven (7) weeks following the date of injection, are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP ≤ 25 mm Hg for injected eye OR if the IOP was > 25 mm Hg, a plan of care was documented.

Instructions

‌This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservative-free triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant) with a patient encounter during the measurement period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure specific denominator coding.

Measure Submission Type

‌Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. 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 by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

Patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservative-free triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant) with a patient encounter during the performance period

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

All patients regardless of age

AND

Patient encounters during the performance period (CPT): 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

AND

Denominator Exclusions:

‌Patients with a diagnosis of hypotony: M1326

Numerator

Number of patients who, within seven (7) weeks following the date of injection, are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP ≤ 25 mm Hg for injected eye listed in chart OR if the IOP was > 25 mm Hg, a plan of care was documented

Definition:

Plan of care – Plan of care includes one of the following: placement on IOP lowering medication (i.e., placement on a new medication, change in frequency or dose of an existing medication, or re- prescribing/renewing an existing medication), order for or performance of a IOP lowering procedure, referral to eye care provider for management of elevated IOP, or return within 4 weeks for IOP re-check.

Numerator Instructions:

For patients who receive more than one injection during the measurement period (12 months), screening only needs to occur once to meet the numerator.

Tonometry with documented IOP should occur for the same eye that was injected.

NUMERATOR NOTE: If the intravitreal or periocular corticosteroid injection occurs from November 12th – December 31st of the performance period and the patient is not able to be seen for follow-up within the performance period, it would be appropriate to report the denominator exception for inadequate time for follow-up.

Numerator Options:

Performance Met: Patients seen within 7 weeks following the date of injection AND are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP ≤ 25 mm Hg for injected eye (M1322)

Performance Met: Patients seen within 7 weeks following the date of injection AND are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP > 25 mm Hg AND a plan of care was documented (M1323)

Denominator Exception: Patients who were not seen for reasons documented by clinician for patient or medical reasons (e.g., inadequate time for follow-up, patients who received a prior intravitreal or periocular steroid injection within the last six (6) months and had a subsequent IOP evaluation with IOP < 25mm Hg within seven (7) weeks of treatment) (M1325)

Performance Not Met: Patients who were not seen within 7 weeks following the date of injection for follow up OR who did not have a documented IOP OR no plan of care documented if the IOP was > 25 mm Hg (M1321)

RATIONALE:

Patients treated with corticosteroid therapy are at increased risk for elevated IOP leading to steroid-induced glaucoma and their quality of life may be negatively impacted due to visual impairments (Breusegem, 2009; Haller, 2011; Iwao, 2007; Jonas, 2003; Phulke, 2017; Skalicky, 2012; Smithen, 2004; Vedantham, 2005).

Several randomized clinical trials and a systematic review identified that IOPs typically peak around 7-9 weeks (Haller, 2010; Kiddee, 2013; Aref, 2015). Ensuring that appropriate monitoring is conducted to detect and treat this complication is important to prevent significant visual morbidity. This measure encourages providers to screen and treat patients identified with an elevated IOP in a timely manner.

CLINICAL RECOMMENDATION STATEMENTS:

While current clinical guidelines do not address the need to assess for elevated IOP following corticosteroid injection, a systematic review completed by Kiddee and colleagues (Kiddee, 2013) identified that 10.9% to 79.0% of these patients will develop clinically significant IOP elevations with the large variation in incidence dependent largely on the specific steroid utilized and dose administered. The timing of IOP elevation also varies based on the type and dose; although, the available literature consistently shows IOP peaking in the 4-8 week range following injection with higher and earlier elevations following intravitreal triamcinolone injections as compared to intravitreal dexamethasone implants. This review recommended that IOP be assessed every two weeks in the first month and monthly for an additional six months at a minimum. Well-designed randomized controlled trials also support initial follow-up of no later than seven weeks. The Standard of Care vs. Corticosteroid for Retinal Vein Occlusion (SCORE) study where pressures peaked within 52.5 days following 4 mg intravitreal triamcinolone acetonide injection and the GENEVA study examining the effectiveness of dexamethasone intravitreal injections saw IOP peak within 60 days (Haller, 2010; Aref, 2015). For patients with a diagnosis of glaucoma, these symptoms can occur earlier and we would expect the follow up timeframe would occur sooner such as within the first four weeks following the injection (Vie, 2017).

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