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

Measure Information	2023 Performance Period
CMS eCQM ID	CMS143v11
NQF Number	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 visits within 12 months
Initial Population	All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
Denominator	Equals Initial Population
Denominator Exclusions	None
Numerator	Patients who have an optic nerve head evaluation during one or more visits within 12 months
Numerator Exclusions	Not Applicable
Denominator Exceptions	Documentation of medical reason(s) for not performing an optic nerve head evaluation
Measure Steward	American Academy of Ophthalmology
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. 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
Telehealth Eligible	No
Next Version	No Version Available
Previous Version	CMS143v10

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Measure Information	2021 Performance Period	2022 Performance Period	2023 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
CMS eCQM ID	CMS143v9	CMS143v10	CMS143v11
NQF Number	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
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
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	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
Numerator Exclusions	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
Measure Steward	PCPI(R) Foundation (PCPI[R])	American Academy of Ophthalmology	American Academy of Ophthalmology
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process measure	Process measure	Process measure
Improvement Notation	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.
MIPS Quality ID	012	012	012
Telehealth Eligible	No	No	No
Next Version	CMS143v10	CMS143v11	No Version Available
Previous Version	No Version Available	CMS143v9	CMS143v10

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CMS143v11.html	61.63 KB
CMS143v11.zip	62.57 KB
CMS143v11-TRN.xlsx	20.52 KB

Data Element Repository

Data Elements contained within CMS143v11

Value Sets

Value Sets to be used with CMS143v11

Release Notes

CMS143v11-TRN.xlsx

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

Updated logic using the new QDM 5.6 'Encounter, Performed' class attribute to exclude telehealth (or virtual) encounters using the logical representation (class !~ virtual), for measures containing telehealth-eligible codes, where telehealth is not appropriate. For more information, please refer to the 2023 Telehealth Guidance document.

Measure Section: Multiple Sections

Source of Change: Standards/Technical Update
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 Medical Reason (2.16.840.1.113883.3.526.3.1007): Deleted 1 SNOMED CT code (397745006) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Primary Open-Angle Glaucoma (2.16.840.1.113883.3.526.3.326): Deleted 1 SNOMED CT code (193533000) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
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
Added direct reference code ActCode code (VR) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead