Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

Last updated: May 3, 2018

CMS Measure ID: CMS132v6
Version: 6
NQF Number: 0564
Measure Description:

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

Initial Patient Population:

All patients aged 18 years and older who had cataract surgery and did not meet any exclusion criteria

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

Patients with any one of a specified list of significant ocular conditions that impact the surgical complication rate

Numerator Statement:

Patients who had one or more specified operative procedures for any of the following major complications within 30 days following cataract surgery: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: PCPI(R) Foundation (PCPI[R])
Domain: Patient Safety
Next Version:
Previous Version:
Improvement Notation:

Lower score indicates better quality

Guidance:

This 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. Every cataract surgery during the measurement period should be counted as a measurable denominator event for the measure calculation.

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 ICD-9-CM and SNOMED-CT do 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.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • ​​Updated Rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated Guidance.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Removed 'no significant ocular conditions impacting the surgical complication rate' and added 'did not meet any exclusion criteria' to align Initial Population language across similar cataracts measures.

    Measure Section: Initial Population

    Source of Change: Expert Work Group Review

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 Cysts of Iris, Ciliary Body, and Anterior Chamber (2.16.840.1.113883.3.526.3.1420): Added 4 ICD10CM codes (H21.331, H21.332, H21.333, H21.339).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Use of Systemic Sympathetic alpha-1a Antagonist Medication for Treatment of Prostatic Hypertrophy (2.16.840.1.113883.3.526.3.1442): Added 2 RXNORM codes (199797, 199798).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hereditary Corneal Dystrophies (2.16.840.1.113883.3.526.3.1424): Added 1 SNOMEDCT code (129623003).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Pathologic Myopia (2.16.840.1.113883.3.526.3.1432): Added 18 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources