Diabetes: Eye Exam

Measure Information	2024 Performance Period	2025 Performance Period	2026 Performance Period	2027 Performance Period
Title	Diabetes: Eye Exam	Diabetes: Eye Exam	Diabetes: Eye Exam	Diabetes: Eye Exam
CMS eCQM ID	CMS131v12	CMS131v13	CMS131v14	CMS131v15
CBE ID*	Not Applicable	Not Applicable	Not Applicable	Not Applicable
MIPS Quality ID	117	117	117	117
Measure Steward	National Committee for Quality Assurance	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	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	Proportion	Proportion	Proportion
Measure Type	Process	Process	Process	Process
Stratification	None	None	None	None
Risk Adjustment	None	None	None	None
Rationale	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).	Diabetes is the eighth leading cause of death in the United States. In 2021, diabetes affected more than 38 million Americans (11.6 percent of the U.S. population) and killed more than 103,000 people (American Diabetes Association [ADA], 2024). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (Centers for Disease Control and Prevention [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 2022, diabetes cost the U.S. an estimated $413 billion: $307 billion in direct medical costs and $106 billion in reduced productivity. The direct medical cost of diabetes increased by 7% between 2017 and 2022 (Parker et al., 2022). Diabetes is the leading cause of new cases of blindness among adults aged 18–64 years (CDC, 2024). Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. Approximately 4.1 million adults are affected by diabetic retinopathy (CDC, 2020).	Diabetes is the eighth leading cause of death in the United States. In 2021, diabetes affected more than 38 million Americans (11.6 percent of the U.S. population) and killed more than 103,000 people (American Diabetes Association [ADA], 2024). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (Centers for Disease Control and Prevention [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 2022, diabetes cost the U.S. an estimated $413 billion: $307 billion in direct medical costs and $106 billion in reduced productivity. The direct medical cost of diabetes increased by 7% between 2017 and 2022 (Parker et al., 2022). Diabetes is the leading cause of new cases of blindness among adults aged 18–64 years (CDC, 2024). Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. Approximately 4.1 million adults are affected by diabetic retinopathy (CDC, 2020).
Clinical Recommendation Statement	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)	American Diabetes Association (2024): - 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)	American Diabetes Association (2024): 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	Higher score indicates better quality
Definition	None	None	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 analyzed by a system that provides an autonomous artificial intelligence (AI) calculation. 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 analyzed by a system that provides an autonomous artificial intelligence (AI) calculation. 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	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	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 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.	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. Exclude patients who have bilateral absence of eyes any time during the patient’s history through the end 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. Exclude patients who have bilateral absence of eyes any time during the patient’s history through the end 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 patients with diabetes who had one of the following: - 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 - 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 - An autonomous eye exam in the measurement period - A retinal exam finding with a retinopathy severity level in any part of the measurement period - A retinal exam finding with no retinopathy severity level in the year prior to the measurement period	Patients with an eye screening for diabetic retinal disease. This includes patients with diabetes who had one of the following: 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 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 An autonomous eye exam in the measurement period A retinal exam finding with a retinopathy severity level in any part of the measurement period A retinal exam finding with no retinopathy severity level in the year prior to the measurement period
Numerator Exclusions	Not Applicable	Not Applicable	None	None
Denominator Exceptions	None	None	None	None
Telehealth Eligible	Yes	Yes	Yes	Yes
Next Version	CMS131v13	CMS131v14	CMS131v15	No Version Available
Previous Version	No Version Available	CMS131v12	CMS131v13	CMS131v14

Measure Information

2024 Performance Period

2025 Performance Period

2026 Performance Period

2027 Performance Period

Title

Diabetes: Eye Exam

CMS eCQM ID

CMS131v12

CMS131v13

CMS131v14

CMS131v15

CBE ID*

Not Applicable

MIPS Quality ID

117

Measure Steward

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

Measure Scoring

Proportion

Measure Type

Process

Stratification

None

Risk Adjustment

None

Rationale

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 eighth leading cause of death in the United States. In 2021, diabetes affected more than 38 million Americans (11.6 percent of the U.S. population) and killed more than 103,000 people (American Diabetes Association [ADA], 2024). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (Centers for Disease Control and Prevention [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 2022, diabetes cost the U.S. an estimated $413 billion: $307 billion in direct medical costs and $106 billion in reduced productivity. The direct medical cost of diabetes increased by 7% between 2017 and 2022 (Parker et al., 2022).

Diabetes is the leading cause of new cases of blindness among adults aged 18–64 years (CDC, 2024). Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. Approximately 4.1 million adults are affected by diabetic retinopathy (CDC, 2020).

Clinical Recommendation Statement

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)

American Diabetes Association (2024):

- 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)

American Diabetes Association (2024):

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

Definition

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.

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 analyzed by a system that provides an autonomous artificial intelligence (AI) calculation.

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.

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

Denominator

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 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