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Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Measure Information 2023 Performance Period
CMS Measure ID CMS133v11
NQF Number 0565e
Measure 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

Denominator Statement

Equals Initial Population

Denominator Exclusions

Cataract surgeries in patients with significant ocular conditions impacting the visual outcome of surgery

Numerator Statement

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 Exceptions

None

Measure Steward American Academy of Ophthalmology
Quality Domain Effective Clinical Care
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 5.6. Please refer to the QDM page for more information on the QDM.

MIPS Quality ID 191
Meaningful Measure Management of Chronic Conditions
Telehealth Eligible No
Next Version No Version Available
Previous Version

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
CMS Measure ID CMS133v9 CMS133v10 CMS133v11
NQF Number 0565e 0565e 0565e
Measure 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

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

Denominator Statement

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
Numerator Statement

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

Denominator Exceptions

None

None

None

Measure Steward PCPI(R) Foundation (PCPI[R]) American Academy of Ophthalmology American Academy of Ophthalmology
Quality Domain Effective Clinical Care Effective Clinical Care Effective Clinical Care
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Outcome measure Outcome measure Outcome measure
Improvement Notation

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 (https://ecqi.healthit.gov/qdm) 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
Meaningful Measure Management of Chronic Conditions Management of Chronic Conditions Management of Chronic Conditions
Telehealth Eligible No No No
Next Version CMS133v10 CMS133v11 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards/Technical Update

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

Logic

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical 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 Pathologic Myopia (2.16.840.1.113883.3.526.3.1432): Deleted 2 SNOMED CT codes (3712000, 193276002) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Optic Neuritis (2.16.840.1.113883.3.526.3.1467): Deleted 1 SNOMED CT code (314787009) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Injury to Optic Nerve and Pathways (2.16.840.1.113883.3.526.3.1427): Deleted 1 SNOMED CT code (230515007) 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 1 ICD-10-CM code (H53.47) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Retinal Detachment with Retinal Defect (2.16.840.1.113883.3.526.3.1478): Added 3 ICD-10-CM codes (H33.41, H33.42, H33.43) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Other and Unspecified Forms of Chorioretinitis and Retinochoroiditis (2.16.840.1.113883.3.526.3.1468): Added 2 SNOMED CT codes (699515009, 699763005) based on terminology update. Deleted 1 SNOMED CT code (44674000) 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): Added 1 SNOMED CT code (231927007) based on terminology update. Deleted 1 SNOMED CT code (123670005) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Glaucoma Associated with Congenital Anomalies and Dystrophies and Systemic Syndromes (2.16.840.1.113883.3.526.3.1461): Added 1 SNOMED CT code (1137633000) based on terminology update. Deleted 1 SNOMED CT code (404634005) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Focal Chorioretinitis and Focal Retinochoroiditis (2.16.840.1.113883.3.526.3.1460): Added 3 SNOMED CT codes (373667006, 699515009, 699763005) based on terminology update. Deleted 1 SNOMED CT code (44674000) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Degeneration of Macula and Posterior Pole (2.16.840.1.113883.3.526.3.1453): Added 1 SNOMED CT code (4041005) based on terminology update. Deleted 1 SNOMED CT code (204179007) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Uveitis (2.16.840.1.113883.3.526.3.1444): Deleted 2 SNOMED CT codes (95706000, 95707009) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.526.3.1461): Renamed to Glaucoma Associated with Congenital Anomalies and Dystrophies and Systemic Syndromes based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.526.3.1414): Renamed to Cataract Posterior Polar based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.526.3.1413): Renamed to Cataract Mature or Hypermature based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.526.3.1412): Renamed to Cataract Congenital based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Glaucoma (2.16.840.1.113883.3.526.3.1423): Added 1 SNOMED CT code (15673041000119101) based on review by technical experts, SMEs, and/or public feedback. Added 2 SNOMED CT codes (1137633000, 1003657004) based on terminology update. Deleted 2 SNOMED CT codes (15673081000119106, 404634005) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 04, 2022