Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

Measure Information	2021 Performance Period
CMS eCQM ID	CMS143v9
NQF Number	0086e
MIPS Quality ID	012
Description	Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months
Initial Population	All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
Numerator	Patients who have an optic nerve head evaluation during one or more office visits within 12 months
Numerator Exclusions	Not Applicable
Denominator	Equals Initial Population
Denominator Exclusions	None
Denominator Exceptions	Documentation of medical reason(s) for not performing an optic nerve head evaluation
Steward	PCPI(R) Foundation (PCPI[R])
Measure Scoring	Proportion measure
Measure Type	Process measure
Improvement Notation	Higher score indicates better quality
Guidance	Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities. Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy. 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. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
Telehealth Eligible	No
Next Version	CMS143v10
Previous Version	No Version Available

Compare eCQM Versions

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Filter Measure By

Download

Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period	2024 Performance Period
Title	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
CMS eCQM ID	CMS143v9	CMS143v10	CMS143v11	CMS143v12
NQF Number	0086e	0086e	0086e	0086e
Description	Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months	Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months	Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months	Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months
Initial Population	All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma	All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma	All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma	All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	None	None	None	None
Numerator	Patients who have an optic nerve head evaluation during one or more office visits within 12 months	Patients who have an optic nerve head evaluation during one or more visits within 12 months	Patients who have an optic nerve head evaluation during one or more visits within 12 months	Patients who have an optic nerve head evaluation during one or more visits within 12 months
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	Documentation of medical reason(s) for not performing an optic nerve head evaluation	Documentation of medical reason(s) for not performing an optic nerve head evaluation	Documentation of medical reason(s) for not performing an optic nerve head evaluation	Documentation of medical reason(s) for not performing an optic nerve head evaluation
Measure Steward	PCPI(R) Foundation (PCPI[R])	American Academy of Ophthalmology	American Academy of Ophthalmology	American Academy of Ophthalmology
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process measure	Process measure	Process measure	Process measure
Improvement Notation	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality
Guidance	Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities. Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy. 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. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities. Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy. 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. 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 5.5. Please refer to the eCQI resource center for more information on the QDM.	Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities. Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy. 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. 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.	Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities. Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy. 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. 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.
MIPS Quality ID	012	012	012	012
Telehealth Eligible	No	No	No	No
Next Version	CMS143v10	CMS143v11	CMS143v12	No Version Available
Previous Version	No Version Available	CMS143v9	CMS143v10	CMS143v11
Notes

Download XML

Download CSV

Specifications

Attachment	Size
CMS143v9.html	54.17 KB
CMS143v9.zip	56.87 KB
CMS143v9-TRN.xlsx	22.29 KB

Data Element Repository

Data Elements contained within CMS143v9

Value Sets

Value Sets to be used with CMS143v9

CMS143v9-TRN.xlsx

Header

Updated eCQM Version Number.

Measure Section: eCQM Version Number

Source of Change: Standards Update
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated disclaimer.

Measure Section: Disclaimer

Source of Change: Standards Update
Revised rationale based upon most recent National Quality Forum (NQF) maintenance submission.

Measure Section: Rationale

Source of Change: Measure Lead
Updated in-text citations to align with American Psychological Association (APA) formatting.

Measure Section: Clinical Recommendation Statement

Source of Change: Measure Lead
Updated references to align with most recent NQF maintenance submission and APA formatting.

Measure Section: Reference

Source of Change: Measure Lead
Added text to identify the Quality Data Model (QDM) version used in the measure specification.

Measure Section: Guidance

Source of Change: Standards Update
Added text to indicate whether the measure is patient-based or episode-based.

Measure Section: Guidance

Source of Change: Standards Update
Revised guidance to remove reference to ICD-9-CM as this terminology is no longer included in the technical specifications.

Measure Section: Guidance

Source of Change: Measure Lead

Logic

Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Measure Section: Definitions

Source of Change: Standards Update
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Measure Section: Functions

Source of Change: Standards Update
QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

Measure Section: Multiple Sections

Source of Change: Standards 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.

Value set Medical Reason (2.16.840.1.113883.3.526.3.1007): Deleted 5 SNOMED CT codes 216952002, 274512008, 371133007, 416406003, 445528004 based on expert review and/or public feedback. Removed codes due to intent of concepts which do not indicate a medical contraindication, but rather a provider decision to discontinue something or change a course of treatment.

Measure Section: Terminology

Source of Change: Annual Update
Value set Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008): Deleted 1 SNOMED CT code (17436001) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012): Added 3 CPT codes 99315, 99316, 99318) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, to capture additional nursing facility visit encounter types.

Measure Section: Terminology

Source of Change: Annual Update
Value set Primary Open-Angle Glaucoma (2.16.840.1.113883.3.526.3.326): Deleted 4 ICD-9-CM codes 365.10, 365.11, 365.12, 365.15). Removed ICD-9 codes from all measures that do not have lookback periods or removed ICD-9 codes from all measures with lookback period for which the ICD-9 codes were no longer relevant.

Measure Section: Terminology

Source of Change: Annual Update
Removed ICD-9-CM extensional value sets from applicable Groupings due to ICD-9-CM no longer being maintained and the measure not requiring historical lookback period.

Measure Section: Terminology

Source of Change: Measure Lead