Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
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| Measure Information | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period | 2026 Performance Period |
|---|---|---|---|---|
| Title | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care |
| CMS eCQM ID | CMS142v11 | CMS142v12 | CMS142v13 | CMS142v14 |
| CBE ID* | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| MIPS Quality ID | 019 | 019 | 019 | 019 |
| Measure Steward | American Academy of Ophthalmology | American Academy of Ophthalmology | American Academy of Ophthalmology | American Academy of Ophthalmology |
| Description |
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months |
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the measurement period |
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the measurement period |
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the measurement period |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process | Process |
| Stratification | *See CMS142v11.html |
None |
None |
None |
| Risk Adjustment | *See CMS142v11.html |
None |
None |
None |
| Rationale | *See CMS142v11.html |
Diabetic retinopathy is a prevalent complication of diabetes, estimated to affect 28.5% of diabetic patients in the US (Zhang et al., 2010). Diabetic retinopathy is a key indicator of systemic complications of diabetes (Zhang et al., 2010). Coordination of care between the eye care specialist and the physician managing a patient’s ongoing diabetes care is essential in stemming the progression of vision loss. Communication from the eye care specialist to a primary care physician facilitates the exchange of information about the severity and progression of a patient’s diabetic retinopathy, adherence to recommended ocular care, need for follow-up visits, and treatment plans (Storey et al., 2016). Data from the Diabetes Control and Complications Trial showed that diabetic treatment and maintenance of glucose control delays the onset and slows the progression of diabetic retinopathy (Aiello & DCCT/EDIC Research Group, 2014). |
Diabetic retinopathy is a prevalent complication of diabetes, estimated to affect 28.5% of diabetic patients in the US (Zhang et al., 2010). Diabetic retinopathy is a key indicator of systemic complications of diabetes (Zhang et al., 2010). Coordination of care between the eye care specialist and the physician managing a patient’s ongoing diabetes care is essential in stemming the progression of vision loss. Communication from the eye care specialist to a primary care physician facilitates the exchange of information about the severity and progression of a patient’s diabetic retinopathy, adherence to recommended ocular care, need for follow-up visits, and treatment plans (Storey et al., 2016). Data from the Diabetes Control and Complications Trial showed that diabetic treatment and maintenance of glucose control delays the onset and slows the progression of diabetic retinopathy (Aiello & DCCT/EDIC Research Group, 2014). |
Diabetic retinopathy is a prevalent complication of diabetes, estimated to affect 28.5% of diabetic patients in the US (Zhang et al., 2010). Diabetic retinopathy is a key indicator of systemic complications of diabetes (Zhang et al., 2010). Coordination of care between the eye care specialist and the physician managing a patient’s ongoing diabetes care is essential in stemming the progression of vision loss. Communication from the eye care specialist to a primary care physician facilitates the exchange of information about the severity and progression of a patient’s diabetic retinopathy, adherence to recommended ocular care, need for follow-up visits, and treatment plans (Storey et al., 2016). Data from the Diabetes Control and Complications Trial showed that diabetic treatment and maintenance of glucose control delays the onset and slows the progression of diabetic retinopathy (Aiello & DCCT/EDIC Research Group, 2014). |
| Clinical Recommendation Statement | *See CMS142v11.html |
The ophthalmologist should refer patients with diabetes to a primary care physician for appropriate management of their systemic condition and should communicate examination results to the physician managing the patient's ongoing diabetes care (III; Good Quality; Strong Recommendation) (Flaxel et al., 2020). Ophthalmologists should communicate the ophthalmologic findings and level of retinopathy with the primary care physician as well as the need for optimizing metabolic control (III; Good Quality; Strong Recommendation) (Flaxel et al,, 2020). Close partnership with the primary care physician is important to make sure that the care of the patient is optimized (III; Good Quality; Strong Recommendation) (Flaxel et al., 2020). |
The ophthalmologist should refer patients with diabetes to a primary care physician for appropriate management of their systemic condition and should communicate examination results to the physician managing the patient's ongoing diabetes care (III; Good Quality; Strong Recommendation) (Flaxel et al., 2020). Ophthalmologists should communicate the ophthalmologic findings and level of retinopathy with the primary care physician as well as the need for optimizing metabolic control (III; Good Quality; Strong Recommendation) (Flaxel et al,, 2020). Close partnership with the primary care physician is important to make sure that the care of the patient is optimized (III; Good Quality; Strong Recommendation) (Flaxel et al., 2020). |
The ophthalmologist should refer patients with diabetes to a primary care physician or endocrinologist for appropriate management of their systemic condition and should communicate examination results to the physician managing the patient’s ongoing diabetes care (Lim et al., 2025). A goal is to achieve optimal control of blood glucose, blood pressure, and other risk factors through close communication with the patient’s primary care physician on the status of the DR and the need for optimal metabolic control (Lim et al., 2025). Establishing a close partnership between the ophthalmologist and the primary care physician is an important step to ensure optimal patient care. Furthermore, it is important to help educate patients with diabetes as well as their primary care physician about the ophthalmologic implications of controlling blood glucose (as monitored by HbA1c) to as near to normal as is safely possible (Lim et al., 2025). |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *See CMS142v11.html |
Communication - May include documentation in the medical record indicating that the findings of the dilated macular or fundus exam were communicated (e.g., verbally, by letter) with the clinician managing the patient's diabetic care OR a copy of a letter in the medical record to the clinician managing the patient's diabetic care outlining the findings of the dilated macular or fundus exam. Findings - Includes level of severity of retinopathy (e.g., mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative) AND the presence or absence of macular edema. |
Communication - May include documentation in the medical record indicating that the findings of the dilated macular or fundus exam were communicated (e.g., verbally, by letter) with the clinician managing the patient's diabetic care OR a copy of a letter in the medical record to the clinician managing the patient's diabetic care outlining the findings of the dilated macular or fundus exam. Findings - Includes level of severity of retinopathy (e.g., mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative) AND the presence or absence of macular edema. |
Communication - May include documentation in the medical record indicating that the findings of the dilated macular or fundus exam were communicated (e.g., verbally, by letter) with the clinician managing the patient's diabetic care OR a copy of a letter in the medical record to the clinician managing the patient's diabetic care outlining the findings of the dilated macular or fundus exam. Findings - Includes level of severity of retinopathy (e.g., mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative) AND the presence or absence of macular edema. |
| Guidance |
The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but SNOMED-CT does not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible professional or eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality. The communication of results to the primary care physician providing ongoing care of a patient's diabetes should be completed soon after the dilated exam is performed. Eligible professionals or eligible clinicians reporting on this measure should note that all data for the reporting year is to be submitted by the deadline established by CMS. Therefore, eligible professionals or eligible clinicians who see patients towards the end of the reporting period (i.e., December in particular), should communicate the results of the dilated macular exam as soon as possible in order for those patients to be counted in the measure numerator. Communicating the results as soon as possible after the date of the exam will ensure the data are included in the submission to CMS. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but SNOMED-CT does not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality. The communication of results to the primary care physician providing ongoing care of a patient's diabetes should be completed soon after the dilated exam is performed. Eligible clinicians reporting on this measure should note that all data for the reporting year is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who see patients towards the end of the reporting period (i.e., December in particular), should communicate the results of the dilated macular exam as soon as possible in order for those patients to be counted in the measure numerator. Communicating the results as soon as possible after the date of the exam will ensure the data are included in the submission to CMS. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but SNOMED-CT does not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality. The communication of results, including the level of severity of diabetic retinopathy and presence or absence of macular edema to the primary care physician providing ongoing care of a patient's diabetes should be completed soon after the dilated exam is performed. Eligible clinicians reporting on this measure should note that all data for the measurement period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who see patients towards the end of the measurement period (i.e., December in particular), should communicate the results of the dilated macular exam as soon as possible in order for those patients to be counted in the measure numerator. Communicating the results as soon as possible after the date of the exam will ensure the data are included in the submission to CMS. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but SNOMED-CT does not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality. The communication of results, including the level of severity of diabetic retinopathy and presence or absence of macular edema to the primary care physician providing ongoing care of a patient's diabetes should be completed soon after the dilated exam is performed. Eligible clinicians reporting on this measure should note that all data for the measurement period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who see patients towards the end of the measurement period (i.e., December in particular), should communicate the results of the dilated macular exam as soon as possible in order for those patients to be counted in the measure numerator. Communicating the results as soon as possible after the date of the exam will ensure the data are included in the submission to CMS. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Initial Population |
All patients aged 18 years and older with a diagnosis of diabetic retinopathy |
All patients aged 18 years and older with a diagnosis of diabetic retinopathy |
All patients aged 18 years and older with a diagnosis of diabetic retinopathy |
All patients aged 18 years and older with a diagnosis of diabetic retinopathy during the measurement period |
| Denominator |
Equals Initial Population who had a dilated macular or fundus exam performed |
Equals Initial Population who had a dilated macular or fundus exam performed |
Equals Initial Population who had a dilated macular or fundus exam performed |
Equals Initial Population who had a dilated macular or fundus exam performed during the measurement period |
| Denominator Exclusions |
None |
None |
None |
None |
| Numerator |
Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care |
Patients with documentation, at least once within the measurement period, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care |
Patients with documentation, at least once within the measurement period, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care |
Patients with documentation, at least once within the measurement period, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
None |
| Denominator Exceptions |
Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes. Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes. |
Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes. Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes. |
Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes. Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes. |
Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes |
| Telehealth Eligible | No | No | No | No |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS142v14
Header
TRN | Measure Section | Source of Change |
|---|---|---|
Changed the 'eCQM Identifier (Measure Authoring Tool)' field name to 'CMS ID' based on tooling updates. | CMS ID | Standards/Technical Update |
Updated the eCQM version number. | eCQM Version Number | Annual Update |
Updated the generic measurement period from 'January 1, 20XX through December 31, 20XX' to specify 'January 1, 2026 through December 31, 2026' based on tooling updates. | Measurement Period | Standards/Technical Update |
Removed 'PCPI(R) Foundation (PCPI[R])' as a Measure Developer to reflect active Measure Developers. | Measure Developer | Annual Update |
Updated copyright. | Copyright | Annual Update |
Updated disclaimer. | Disclaimer | Annual Update |
Revised clinical recommendation statement related to communication between the ophthalmologist and patient's primary care physician to align with updated guidance. | Clinical Recommendation Statement | Measure Lead |
Updated references and measure header to reflect current evidence and new or updated literature. | Multiple Sections | Measure Lead |
Updated the denominator to clarify that only patients who had a dilated macular or fundus exam performed during the measurement period should be included in the measure, aligning with logic. | Denominator | Measure Lead |
Changed 'Numerator Exclusions' field to read 'None' instead of 'Not Applicable' when no exclusions are present. | Numerator Exclusions | Standards/Technical Update |
Logic
TRN | Measure Section | Source of Change |
|---|---|---|
Updated Measure Primary CQL Library Name from 'DRCommunicationWithPhysicianManagingDiabetes' to 'CMS142DRCommWithPhysicianManagingDiabetesQDM' for alignment with the CQL Style Guide. | Definitions | Standards/Technical Update |
Updated the version number of the Global Common Functions Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM.' | Definitions | Annual Update |
Updated the timing comparison precision in the definitions by adding 'day of' operator to align with the measure intent and address time zone differences. | Definitions | Measure Lead |
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide. | Definitions | Standards/Technical Update |
Updated Measure Primary CQL Library Name from 'DRCommunicationWithPhysicianManagingDiabetes' to 'CMS142DRCommWithPhysicianManagingDiabetesQDM' for alignment with the CQL Style Guide. | Functions | Standards/Technical Update |
Updated the version number of the Global Common Functions Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM.' | Functions | Annual Update |
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
TRN | Measure Section | Source of Change |
|---|---|---|
Value Set 'Diabetic Retinopathy' (2.16.840.1.113883.3.526.3.327): Added 2 SNOMEDCT codes (1306699009, 1306700005) based on code system/terminology updates. | Terminology | Annual Update |
Value Set 'Level of Severity of Retinopathy Findings' (2.16.840.1.113883.3.526.3.1283): Added 68 SNOMEDCT codes (138901000119108, 138941000119105, 16746901000119101, 16746941000119104, 16747021000119109, 16747101000119101, 16747141000119104, 16747341000119101, 399863006, 399872003, 399873008, 399877009, 769187006, 769188001, 769190000, 769191001, 870420005, 138891000119109, 138921000119104, 16697421000119103, 16697471000119102, 16697521000119104, 16746131000119105, 16746261000119108, 16746341000119103, 769185003, 769186002, 138881000119106, 138911000119106, 16745411000119104, 16745531000119108, 16745611000119102, 16745651000119101, 16745891000119105, 16745931000119102, 368711000119106, 769183005, 769184004, 16749781000119101, 16749661000119102, 16748741000119101, 16748141000119100, 16747901000119104, 16747741000119100, 1501000119109, 1306700005, 1306699009, 232021008, 232022001, 312906006, 312907002, 312908007, 312909004, 368721000119104, 399862001, 399865004, 399869005, 399870006, 399874002, 399875001, 60971000119101, 677741000119109, 770766000, 816961009, 816962002, 97341000119105, 769191001, 770765001) based on SME/expert recommendations. | Terminology | Annual Update |
Value Set 'Macular Edema Findings Present' (2.16.840.1.113883.3.526.3.1320): Added 15 SNOMEDCT codes (870421009, 335551000119103, 341161000119105, 346421000119104, 1217634001, 15639131000119107, 15639181000119108, 15639231000119102, 232042005, 232045007, 769221001, 769222008, 97331000119101, 399872003, 399877009) based on SME/expert recommendations. | Terminology | Annual Update |
Value Set 'Office Visit' (2.16.840.1.113883.3.464.1003.101.12.1001): Added 1 SNOMEDCT code (185349003) based on review by technical experts, SMEs and/or public feedback. | Terminology | Annual Update |
Replaced Value Set 'ONC Administrative Sex' (2.16.840.1.113762.1.4.1) with Value Set 'Federal Administrative Sex' (2.16.840.1.113762.1.4.1021.121) to represent Supplemental Data Element 'SDE Sex' based on revised standards. | Terminology | Standards/Technical Update |
Value Set 'Patient Reason' (2.16.840.1.113883.3.526.3.1008): Added 1 SNOMEDCT code (1296859006) based on code system/terminology updates. Added 1 SNOMEDCT code (31021000119100) based on public comment/implementer feedback. Deleted 2 SNOMEDCT codes (281399006, 105480006) based on code system/terminology updates. | Terminology | Annual Update |