Diabetes: Eye Exam
Compare Versions of: "Diabetes: Eye Exam"
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| Measure Information | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period |
|---|---|---|---|
| Title | Diabetes: Eye Exam | Diabetes: Eye Exam | Diabetes: Eye Exam |
| CMS eCQM ID | CMS131v11 | CMS131v12 | CMS131v13 |
| CBE ID* | Not Applicable | Not Applicable | Not Applicable |
| MIPS Quality ID | 117 | 117 | 117 |
| Measure Steward | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| Description |
Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period |
Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period |
Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process |
| Stratification | *See CMS131v11.html |
None |
None |
| Risk Adjustment | *See CMS131v11.html |
None |
None |
| Rationale | *See CMS131v11.html |
Diabetes is the seventh leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2022a). In 2019, diabetes affected more than 37 million Americans (11.3 percent of the U.S. population) and killed more than 87,000 people (American Diabetes Association [ADA], 2022a). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (CDC, 2022a). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney damage, amputation of feet or legs, and premature death (CDC, 2022b). In 2017, diabetes cost the U.S. an estimated $327 billion: $237 billion in direct medical costs and $90 billion in reduced productivity. This is a 34 percent increase from the estimated $245 billion spent on diabetes in 2012 (ADA, 2018). Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. It is the leading cause of blindness in adults between 20-74 years of age. Approximately 4.1 million adults are affected by diabetic retinopathy (CDC, 2020). |
Diabetes is the seventh leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2022a). In 2019, diabetes affected more than 37 million Americans (11.3 percent of the U.S. population) and killed more than 87,000 people (American Diabetes Association [ADA], 2022a). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (CDC, 2022a). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney damage, amputation of feet or legs, and premature death (CDC, 2022b). In 2017, diabetes cost the U.S. an estimated $327 billion: $237 billion in direct medical costs and $90 billion in reduced productivity. This is a 34 percent increase from the estimated $245 billion spent on diabetes in 2012 (ADA, 2018). Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. It is the leading cause of blindness in adults between 20-74 years of age. Approximately 4.1 million adults are affected by diabetic retinopathy (CDC, 2020). |
| Clinical Recommendation Statement | *See CMS131v11.html |
American Diabetes Association (2022b): - Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (Level of evidence: B) - Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. (Level of evidence: B) - If there is no evidence of retinopathy for one or more annual eye exam and glycemia is well controlled, then screening every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight threatening, then examinations will be required more frequently. (Level of evidence: B) |
American Diabetes Association (2023): - Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (Level of evidence: B) - Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. (Level of evidence: B) - If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well controlled, then screening every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight threatening, then examinations will be required more frequently. (Level of evidence: B) |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *See CMS131v11.html |
None |
None |
| Guidance |
The eye exam must be performed by an ophthalmologist or optometrist, or there must be evidence that fundus photography results were read by a system that provides an artificial intelligence (AI) interpretation. This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The eye exam must be performed by an ophthalmologist or optometrist, or there must be evidence that fundus photography results were read by a system that provides an artificial intelligence (AI) interpretation. This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The eye exam must be performed by an ophthalmologist or optometrist, or there must be evidence that fundus photography results were read by a system that provides an artificial intelligence (AI) interpretation. This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Initial Population |
Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period |
Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period |
Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions |
Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care for any part of the measurement period. |
Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients receiving palliative care for any part of the measurement period. |
Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness diagnosis during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients receiving palliative care for any part of the measurement period. |
| Numerator |
Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: •Diabetic with a diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period •Diabetic with no diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period |
Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: - Diabetic with a diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period - Diabetic with no diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period |
Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: - Diabetic with a diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period - Diabetic with no diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
None |
| Telehealth Eligible | Yes | Yes | Yes |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Additional Resources for CMS131v13
Header
Updated the eCQM version number.
Measure Section:
eCQM Version Number
Source of Change:
Annual Update
Changed all references from NQF to CBE to identify the consensus-based entity role.
Measure Section:
CBE Number
Source of Change:
Annual Update
Updated copyright.
Measure Section:
Copyright
Source of Change:
Annual Update
Aligned order of exclusions listed in the narrative and logic to improve overall readability.
Measure Section:
Source of Change:
Measure Lead
Reduced the complexity of advanced illness criteria by removing the requirement to have at least two outpatient encounters or one inpatient encounter with the advanced illness diagnosis.
Measure Section:
Denominator Exclusions
Source of Change:
Measure Lead
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section:
Multiple Sections
Source of Change:
Annual Update
Updated references and measure header to reflect current evidence and new or updated literature.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Logic
Updated the timing comparison precision in the definitions from datetime to date by adding 'day of' operator to align with the measure intent and address time zone issues.
Measure Section:
Initial Population
Source of Change:
Measure Lead
Reduced the complexity of advanced illness criteria by removing the requirement to have at least two outpatient encounters or one inpatient encounter with the advanced illness diagnosis.
Measure Section:
Definitions
Source of Change:
Measure Lead
Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.
Measure Section:
Definitions
Source of Change:
Standards/Technical Update
Updated the timing comparison precision in the definitions from datetime to date by adding 'day of' operator to align with the measure intent and address time zone issues.
Measure Section:
Definitions
Source of Change:
Measure Lead
Updated the version number of the Advanced Illness and Frailty Exclusion ECQM Library to v9.0.000 and the library name from 'AdvancedIllnessandFrailtyExclusionECQM' to 'AdvancedIllnessandFrailtyQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Updated the version number of the Hospice Library to v6.0.000 and the library name from 'Hospice' to 'HospiceQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Updated the version number of the Palliative Care Exclusion Library to v4.0.000 and the library name from 'PalliativeCareExclusionECQM' to 'PalliativeCareQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Functions
Source of Change:
Annual 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.
Removed value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083) based on change in measure requirements/measure specification.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Advanced Illness (2.16.840.1.113883.3.464.1003.110.12.1082): Added 69 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Deleted 5 ICD-10-CM codes (F01.51, F02.81, F03.91, J84.17, K74.0) based on review by technical experts, SMEs, and/or public feedback. Added 109 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 22 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
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Measure Lead
Value set Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240): Added 3 SNOMED CT codes (86013001, 90526000, 866149003) based on review by technical experts, SMEs, and/or public feedback. Added 1 HCPCS code (G0402) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Deleted 1 SNOMED CT code (314904008) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Removed value set Emergency Department Evaluation and Management Visit (2.16.840.1.113883.3.464.1003.101.12.1010) based on change in measure requirements/measure specification.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Added 12 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 14 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074): Deleted 7 SNOMED CT codes (414188008, 414189000, 16728003, 162845004, 699215008, 699218005, 459821000124104) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Deleted 10 SNOMED CT codes (267031002, 272062008, 314109004, 271875007, 394616008, 163600007, 163695007, 268964003, 272036004, 225612007) based on review by technical experts, SMEs, and/or public feedback.
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Terminology
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Measure Lead
Value set Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016): Deleted 1 CPT code (99343) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584): Added 2 SNOMED CT codes (170935008, 170936009) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (385765002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Removed value set Nonacute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1084) based on change in measure requirements/measure specification.
Measure Section:
Terminology
Source of Change:
Measure Lead
Removed value set Observation (2.16.840.1.113883.3.464.1003.101.12.1086) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Deleted 2 SNOMED CT codes (30346009, 37894004) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (99201) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Removed value set Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087) based on change in measure requirements/measure specification.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090): Added 3 SNOMED CT codes (305686008, 305824005, 441874000) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.
Measure Section:
Terminology
Source of Change:
Annual Update