| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS133v10 |
| NQF Number | 0565e |
| MIPS Quality ID | 191 |
| Description |
Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery |
| Initial Population |
All cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria |
| Numerator |
Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Equals Initial Population |
| Denominator Exclusions |
Cataract surgeries in patients with significant ocular conditions impacting the visual outcome of surgery |
| Denominator Exceptions |
None |
| Steward | American Academy of Ophthalmology |
| Measure Scoring | Proportion measure |
| Measure Type | Outcome measure |
| Improvement Notation |
Higher score indicates better quality |
| Guidance |
This eCQM is an episode-based measure. An episode for this measure is defined as each cataract surgery during the measurement period, including instances where more than one cataract procedure was performed during the measurement period. Every cataract surgery during the measurement period should be counted as a measurable denominator event for the measure calculation.
Only procedures performed during January 1 - September 30 of the reporting period will be considered for this measure, in order to determine if 20/40 or better visual acuity has been achieved within the 90 days following the cataract procedure. Cataract procedures performed during October 1 - December 31 are excluded from the initial population. 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 measure is to be reported by the clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract patients are not eligible for this measure. Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible encounter codes. 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 |
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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 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery |
| CMS eCQM ID | CMS133v9 | CMS133v10 | CMS133v11 | CMS133v12 |
| NQF Number | 0565e | 0565e | 0565e | 0565e |
| Description |
Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery |
Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery |
Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery |
Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery |
| Initial Population |
All cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria |
All cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria |
All cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria |
All cataract surgeries performed between January and September of the measurement period for patients 18 years and older |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions | Cataract surgeries in patients with significant ocular conditions impacting the visual outcome of surgery | Cataract surgeries in patients with significant ocular conditions impacting the visual outcome of surgery | Cataract surgeries in patients with significant ocular conditions impacting the visual outcome of surgery | Cataract surgeries in patients with significant ocular conditions impacting the visual outcome of surgery |
| Numerator |
Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery |
Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery |
Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery |
Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
None |
None |
| 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 | Outcome measure | Outcome measure | Outcome measure | Outcome measure |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Guidance |
This eCQM is an episode-based measure, meaning there may be more than one reportable event for a given patient during the measurement period. The level of analysis for this measure is each cataract surgery during the measurement period, including instances where more than one cataract procedure was performed during the measurement period. Every cataract surgery during the measurement period should be counted as a measurable denominator event for the measure calculation.
Only procedures performed during January 1 - September 30 of the reporting period will be considered for this measure, in order to determine if 20/40 or better visual acuity has been achieved within the 90 days following the cataract procedure. Cataract procedures performed during October 1 - December 31 are excluded from the initial population. 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 measure is to be reported by the clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract patients are not eligible for this measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
This eCQM is an episode-based measure. An episode for this measure is defined as each cataract surgery during the measurement period, including instances where more than one cataract procedure was performed during the measurement period. Every cataract surgery during the measurement period should be counted as a measurable denominator event for the measure calculation.
Only procedures performed during January 1 - September 30 of the reporting period will be considered for this measure, in order to determine if 20/40 or better visual acuity has been achieved within the 90 days following the cataract procedure. Cataract procedures performed during October 1 - December 31 are excluded from the initial population. 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 measure is to be reported by the clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract patients are not eligible for this measure. Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible encounter codes. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
This eCQM is an episode-based measure. An episode for this measure is defined as each cataract surgery during the measurement period, including instances where more than one cataract procedure was performed during the measurement period. Every cataract surgery during the measurement period should be counted as a measurable denominator event for the measure calculation.
Only procedures performed during January 1 - September 30 of the reporting period will be considered for this measure, in order to determine if 20/40 or better visual acuity has been achieved within the 90 days following the cataract procedure. Cataract procedures performed during October 1 - December 31 are excluded from the initial population. 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 measure is to be reported by the clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract patients are not eligible for this measure. Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible encounter codes. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This eCQM is an episode-based measure. An episode for this measure is defined as each cataract surgery during the measurement period, including instances where more than one cataract procedure was performed during the measurement period. Every cataract surgery during the measurement period should be counted as a measurable denominator event for the measure calculation.
Only procedures performed during January 1 - September 30 of the reporting period will be considered for this measure, in order to determine if 20/40 or better visual acuity has been achieved within the 90 days following the cataract procedure. Cataract procedures performed during October 1 - December 31 are excluded from the initial population. 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 measure is to be reported by the clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract patients are not eligible for this measure. Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible encounter codes. 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 | 191 | 191 | 191 | 191 |
| Telehealth Eligible | No | No | No | No |
| Next Version | CMS133v10 | CMS133v11 | CMS133v12 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
-
Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
-
Updated Measure Steward.
Measure Section: Measure Steward
Source of Change: Measure Lead
-
Updated Measure Developer.
Measure Section: Measure Developer
Source of Change: Measure Lead
-
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
-
Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Annual Update
-
Added clarifying language to guidance section indicating that the measure is not eligible for telehealth visits.
Measure Section: Guidance
Source of Change: Measure Lead
-
Added clarifying language to guidance section of episode-based measures to define the episode.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
-
Replaced the 'Episcleritis and Scleritis' value set with a 'Scleritis' value set to reflect updated guidance that episcleritis does not affect central visual acuity and is therefore not a valid exclusion for this measure.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
-
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.
Measure Section: Multiple Sections
Source of Change: Standards Update
-
Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.
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 Acute and Subacute Iridocyclitis (2.16.840.1.113883.3.526.3.1241): Added 6 SNOMED CT codes (332921000119107, 338531000119102, 344301000119109, 675361000119103, 675371000119109, 675381000119107) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Cataract Surgery (2.16.840.1.113883.3.526.3.1411): Added 3 SNOMED CT codes (172523009, 860930005, 860934001) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Cloudy Cornea (2.16.840.1.113883.3.526.3.1417): Added 3 SNOMED CT codes (333881000119109, 339481000119109, 344611000119101) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Corneal Edema (2.16.840.1.113883.3.526.3.1418): Added 3 SNOMED CT codes (336241000119105, 341851000119102, 347061000119104) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Hereditary Corneal Dystrophies (2.16.840.1.113883.3.526.3.1424): Deleted 2 SNOMED CT codes (418946006, 419087002) based on terminology update. Added 18 ICD-10-CM codes based on terminology update. Deleted 7 ICD-10-CM codes (H18.50, H18.51, H18.52, H18.53, H18.54, H18.55, H18.59) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Central Corneal Ulcer (2.16.840.1.113883.3.526.3.1428): Deleted 1 SNOMED CT code (95731004) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Pathologic Myopia (2.16.840.1.113883.3.526.3.1432): Added 5 SNOMED CT codes (16837461000119106, 16837521000119102, 335471000119108, 346481000119100, 846621001) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Uveitis (2.16.840.1.113883.3.526.3.1444): Added 7 SNOMED CT codes (870199008, 870273007, 870329005, 870331001, 870332008, 870333003, 870335005) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Visual Field Defects (2.16.840.1.113883.3.526.3.1446): Added 5 SNOMED CT codes (16059151000119108, 16059191000119103, 336171000119109, 341781000119100, 346991000119107). Added 14 ICD-10-CM codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Amblyopia (2.16.840.1.113883.3.526.3.1448): Added 4 SNOMED CT codes (335461000119102, 341071000119100, 343371000119101, 346331000119107) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Choroidal Detachment (2.16.840.1.113883.3.526.3.1451): Added 7 SNOMED CT codes (336071000119108, 334901000119109, 332111000119102, 343491000119109, 341681000119105, 340511000119109, 337721000119107) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Choroidal Hemorrhage and Rupture (2.16.840.1.113883.3.526.3.1452): Added 4 SNOMED CT codes (336051000119104, 336061000119102, 341661000119101, 341671000119107) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Degenerative Disorders of Globe (2.16.840.1.113883.3.526.3.1454): Deleted 3 SNOMED CT codes (247178009, 30523006, 3712000) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Disorders of Visual Cortex (2.16.840.1.113883.3.526.3.1458): Added 6 ICD-10-CM codes (H47.621, H47.622, H47.631, H47.632, H47.641, H47.642) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes (2.16.840.1.113883.3.526.3.1461): Added 5 SNOMED CT codes (15673041000119101, 15679801000119105, 333151000119108, 338761000119103, 370504007) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Hereditary Choroidal Dystrophies (2.16.840.1.113883.3.526.3.1462): Deleted 1 SNOMED CT code (715417002) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Optic Atrophy (2.16.840.1.113883.3.526.3.1466): Added 6 SNOMED CT codes (348051000119102, 348501000119108, 680991000119108, 838307002, 838345001, 870319003) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Other and Unspecified Forms of Chorioretinitis and Retinochoroiditis (2.16.840.1.113883.3.526.3.1468): Added 14 SNOMED CT codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Other Disorders of Optic Nerve (2.16.840.1.113883.3.526.3.1471): Added 4 SNOMED CT codes (838324008, 838363001, 860808008, 860884007) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Prior Penetrating Keratoplasty (2.16.840.1.113883.3.526.3.1475): Added 7 SNOMED CT codes (334551000119102, 334561000119100, 340151000119101, 340161000119104, 345511000119103, 345521000119105, 349321000119104) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Retinal Detachment with Retinal Defect (2.16.840.1.113883.3.526.3.1478): Added 2 SNOMED CT codes (331831000119109, 337451000119106) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Separation of Retinal Layers (2.16.840.1.113883.3.526.3.1482): Added 3 SNOMED CT codes (334891000119105, 340501000119106, 345811000119101) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Degeneration of Macula and Posterior Pole (2.16.840.1.113883.3.526.3.1453): Added 5 SNOMED CT codes (247200005, 335531000119109, 341141000119106, 346401000119108, 789220007) based on terminology update. Deleted 2 SNOMED CT codes (247145002, 247148000) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Retinal Vascular Occlusion (2.16.840.1.113883.3.526.3.1479): Added 11 SNOMED CT codes (15997911000119103, 15997951000119102, 16279401000119108, 16279441000119105, 16711111000119100, 16711631000119103, 333281000119108, 337421000119103, 338891000119100, 677771000119102, 680941000119100) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Diabetic Retinopathy (2.16.840.1.113883.3.526.3.327): Added 1 SNOMED CT code (870420005) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Glaucoma (2.16.840.1.113883.3.526.3.1423): Added 1 SNOMED CT codes (15679801000119105) based on terminology update. Deleted 6 SNOMED CT codes (10100008, 193546005, 193549003, 367360002, 55129006, 66990007) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Cataract, Congenital (2.16.840.1.113883.3.526.3.1412): Added 8 SNOMED CT codes (335841000119103, 341451000119100, 346711000119101, 346731000119106, 349281000119109, 679911000119104, 679931000119109, 681041000119106) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Cataract, Posterior Polar (2.16.840.1.113883.3.526.3.1414): Added 2 SNOMED CT codes (15737681000119103, 16477021000119103) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Posterior Lenticonus (2.16.840.1.113883.3.526.3.1433): Added 3 SNOMED CT codes (15987911000119102, 840458000, 15987871000119100) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Traumatic Cataract (2.16.840.1.113883.3.526.3.1443): Added 1 SNOMED CT code (866114005) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Macular Scar of Posterior Polar (2.16.840.1.113883.3.526.3.1559): Added 1 SNOMED CT code (344341000119106) based on terminology update. Deleted 1 SNOMED CT code (246181000119100) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Value set Open Wound of Eyeball (2.16.840.1.113883.3.526.3.1430): Added 4 SNOMED CT codes (10942751000119100, 10942791000119105, 735657000, 870312007) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
-
Value Set Nystagmus and Other Irregular Eye Movements (2.16.840.1.113883.3.526.3.1465): Added 1 ICD-10-CM codes (H55.82) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
-
Added value set Scleritis (2.16.840.1.113762.1.4.1226.1) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
-
Removed value set Scleritis and Episcleritis (2.16.840.1.113883.3.526.3.1481) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead