| 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 | |
| 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.
| 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 |
Data Element Repository
Header
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Updated eCQM Version Number.
Measure Section: eCQM Version Number
Source of Change: Standards Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Standards Update
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Revised rationale based upon most recent National Quality Forum (NQF) maintenance submission.
Measure Section: Rationale
Source of Change: Measure Lead
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Updated in-text citations to align with American Psychological Association (APA) formatting.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
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Updated references to align with most recent NQF maintenance submission and APA formatting.
Measure Section: Reference
Source of Change: Measure Lead
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Added text to identify the Quality Data Model (QDM) version used in the measure specification.
Measure Section: Guidance
Source of Change: Standards Update
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Added text to indicate whether the measure is patient-based or episode-based.
Measure Section: Guidance
Source of Change: Standards Update
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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