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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
117 0055 Process Yes Effective Clinical Care Claims

Measure Description

Percentage of patients 18 – 75 years of age with diabetes who had a retinal or dilated eye exam by an eyecare professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy)in the 12 months prior to the measurement period

Instructions

This measure is to be submitted a minimum of once per performance period for patients with diabetes mellitus seen during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding.

NOTE: No notes for this Quality ID

Measure Submission

The listed denominator criteria is used to identify the intended patient population. The numerator quality-data codes included in this specification are used to submit the quality actions allowed by the measure. All measure-specific coding should be submitted on the claim(s) representing the eligible encounter.

Numerator

Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following:

A retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period

Numerator Instructions:

Data not available

Numerator Quality-Data Coding Options

Denominator Exclusion: G9714:

Patient receiving Hospice Services, Patient Not Eligible

Patient was provided hospice services any time during the measurement period

Performance Met: CPT II 2022F:
Retinal or Dilated Eye Exam Performed by an Eye Care Professional

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed

Performance Met: CPT II 2024F:

Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed

Performance Met: CPT II 2026F:

Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed

Performance Met: CPT II 3072F:

Low risk for retinopathy (no evidence of retinopathy in
the prior year)*

*Note: This code can only be used if the claim/encounter was during the measurement period because it indicates that the patient had “no evidence of retinopathy in the prior year”. This code definition indicates results were negative; therefore a result is not required.

Performance Not Met: CPT II 2022F or 2024F or 2026F with 8P:
Retinal or Dilated Eye Exam not Performed, Reason not Otherwise Specified

Append a submission modifier (8P) to CPT Category II code 2022F or 2024F or 2026F to submit circumstances when the action described in the numerator is not performed and the reason is not otherwise specified

Dilated eye exam was not performed, reason not otherwise specified

NUMERATOR NOTE:

The eye exam must be performed or reviewed by an ophthalmologist or optometrist.

Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.

Denominator

Patients 18 – 75 years of age with diabetes with a visit during the measurement period

Eligible cases are determined and must be reported, if either of the following conditions

Option 1 – Denominator Criteria (Eligible Cases):

Patients 18 to 75 years of age on date of encounter

AND

Diagnosis for diabetes (ICD-10-CM):
E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83

AND
Patient encounter during the performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

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Sunrise Women’s Medical Group

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