CMS 131v12: Diabetes: Eye Exam

Measure: Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period

Measure Type High Priority Measure Scoring
Process No A higher percentage indicates better quality
Denominator Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period
Numerator

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

  • Diabetic with a diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period
  • Diabetic with no diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period
Denominator Exceptions None
Denominator Exclusions
  • Patients in hospice care for any part of the measurement period
  • Patients receiving palliative care for any part of the measurement period
  • Patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period
  • Patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
    • Advanced illness with two outpatient encounters during the measurement period or the year prior
    • OR advanced illness with one inpatient encounter during the measurement period or the year prior
    • OR taking dementia medications during the measurement period or the year prior

Patients who meet the following criteria will be included in the denominator:

  • Age is 18 years to 75 years at the end of the Measurement Period

    AND

  • Have an active diagnosis of Type 1 or Type 2 diabetes during the Measurement Period

    AND

  • Have at least one eligible encounter during the Measurement Period finalized by the EC

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99395, 99396, 99397, 99385, 99386, 99387, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 92002, 92004, 92012, 92014, 98966, 98967, 98968, 99441, 99442, 99443

HCPCS: G0438, G0439

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for diabetes can be located here.

A patient will be excluded from the measure if they meet any of the following conditions:

  • Is in hospice care for any part of the Measurement Period
  • Is receiving palliative care for any part of the Measurement Period
  • Age is ≥ 66 at the end of the Measurement Period and are living long term in a nursing home any time on or before the end of the Measurement Period
  • Age is ≥ 66 at the end of the Measurement Period and has evidence of frailty and advanced illness

To document hospice care ambulatory services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

CPT: 99377, 99378

HCPCS: G0182

Order Status must be marked as Pending or Complete.

To document hospice care encounter services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9996, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046

Order Status must be marked as Complete.

Palliative care services can be documented using the FACIT-Pal Questionnaire flowsheet, as an order, or as a diagnosis.

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard

  2. Click Add New Flowsheet

  3. Select the FACIT-Pal Questionnaire flowsheet and click Add

  4. Click Add Column

  5. Populate the patient's responses to the questions as appropriate

  6. Click OK to save

Go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9054, M1017

Order Status must be marked as Complete.

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis code for palliative care is:

ICD-10: Z51.5

To document a nursing home stay:

  1. Go to Chart > Demographics > Patient Info

  2. Click Update

  3. Click Additional Info tab

  4. Populate the Date field in the Pop. Info section

  5. Select Patient lives in nursing home for Housing Status

  6. Click Save

A patient has evidence of frailty if they meet any of the following criteria:

  • Has an active diagnosis of Frailty during the Measurement Period
  • Has an active diagnosis of Frailty Symptom during the Measurement Period
  • Is using a frailty device during the Measurement Period
  • Has a frailty encounter during the Measurement Period

"Frailty" refers to a range of conditions that includes falls and problems affecting mobility.

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for frailty can be located here.

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis codes for frailty symptoms are:

ICD-10: R26.2, R26.89, R26.9, R53.1, R53.81, R54, R62.7, R63.4, R63.6, R64

To document the patient's use of a frailty device:

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard
  2. Click Add New Flowsheet
  3. Select the Frailty Device flowsheet and click Add
  4. Click Add Column
  5. Select a Device and the type (Value) of device
  6. Populate a usage Start Date for the device
  7. Optional: populate a usage Stop Date for the device
    1. The Stop Date cannot occur prior to the start of the Measurement Period
  8. Optional: populate a Reason for use of the device
  9. Click OK to save

CPT: 99504, 99509

HCPCS: G0162, G0299, G0300, G0493, G0494, S0271, S0311, S9123, S9124, T1000, T1001, T1002, T1003, T1004, T1005, T1019, T1020, T1021, T1022, T1030, T1031

A patient has evidence of advanced illness if they meet any of the following criteria:

  • Had an inpatient encounter with an active diagnosis of Advanced Illness during the Measurement Period or in the year prior
  • Had 2 or more outpatient encounters with an active diagnosis of Advanced Illness during the Measurement Period or in the year prior
    • Encounters must have different dates of service
    • Diagnosis must be active during all eligible encounters
  • Was prescribed medication for dementia during the Measurement Period or in the year prior

"Advanced illness" refers to a wide range of conditions and includes diseases such as Alzheimer's disease, cancer, and heart failure.

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for advanced illness can be located here.

CPT: 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 99291, 99236, 99234, 99235

CPT: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99455, 99456, 99483, 99217, 99218, 99219, 99220, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

HCPCS: G0402, G0438, G0439, G0463, T1015

To prescribe a medication, go to Encounter > Medications > Manage/Prescribe Meds > New Prescription or Chart > Medications/Assessments > Modify. A comprehensive list of eligible dementia medications can be located here.

A patient will be counted in the numerator if they received a retinal eye exam or a dilated eye exam.

  • Patients with an active diagnosis of diabetic retinopathy during the Measurement Period must receive their exam during the Measurement Period
  • Patients who do not have an active diagnosis of diabetic retinopathy during the Measurement Period must receive their exam during the Measurement Period or in the 12 months prior to the start of the Measurement Period

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

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for diabetic retinopathy can be located here.

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard
  2. Click Add New Flowsheet
  3. Select the Diabetes Care flowsheet and click Add
  4. Click Add Column
  5. Populate a Date and Value for the Dilated Eye Exam or Retinal Eye Exam
  6. Click OK to save

https://ecqi.healthit.gov/ecqm/ec/2024/cms0131v12

 

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