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

Last updated: May 9, 2019

CMS Measure ID: CMS132v8
Version: 8
NQF Number: 564e
Measure Description:

Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract who 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 in the operative eye: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

Initial Population:

All cataract surgeries for patients aged 18 years and older who did not meet any exclusion criteria

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

Cataract surgeries in patients with any one of a specified list of significant ocular conditions that impact the surgical complication rate

Numerator Statement:

Cataract surgeries with one or more specified operative procedures for any of the following major complications within 30 days following cataract surgery in the operative eye: 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
Previous Version:
Measure Scoring: Proportion
Measure Type: Outcome
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 denominatorinfo-icon 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 specificityinfo-icon (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 professionalinfo-icon or eligible clinicianinfo-icon 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.

Quality ID: 192
Meaningful Measure: Management of Chronic Conditions

Specifications

Release Notes

Header

  • Updated eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Added 'e' to NQFinfo-icon number.

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated header statements to reflect the measure is episode-based, per cataract surgery, rather than patient-based.

    Measure Section: Description

    Source of Change: Expert Work Group Review

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated header statements to reflect the measure is episode-based, per cataract surgery, rather than patient-based.

    Measure Section: Initial Populationinfo-icon

    Source of Change: Expert Work Group Review

  • Updated header statements to reflect the measure is episode-based, per cataract surgery, rather than patient-based.

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: Expert Work Group Review

  • Updated header statements to reflect the measure is episode-based, per cataract surgery, rather than patient-based.

    Measure Section: Numeratorinfo-icon

    Source of Change: Expert Work Group Review

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Added data elements 'Glaucoma Associated with Congenital Anomalies, Dystrophies and Systemic Syndromes,' 'Other Endophthalmitis,' and 'Purulent Endophthalmitis' to align with measure intent and clinical expert recommendation.

    Measure Section: Denominator Exclusions

    Source of Change: Expert Work Group Review

  • Removed data elements 'Aphakia and Other Disorders of Lens,' 'Cysts of Iris, Ciliary Body and Anterior Chamber,' 'Enophthalmos,' and 'Prior Pars Plana Vitrectomy' to align with measure intent and clinical expert recommendation.

    Measure Section: Denominator Exclusions

    Source of Change: Expert Work Group Review

  • Added a constraint to ensure that two unique procedures would be required to satisfy the numerator logic.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA)info-icon: CQMinfo-icon-3215

  • Removed 'Prior Pars Plana Vitrectomy Performed' definition due to the removal of this denominator exclusioninfo-icon per clinical expert recommendation.

    Measure Section: Definitions

    Source of Change: Expert Work Group Review

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Acute and Subacute Iridocyclitis (2.16.840.1.113883.3.526.3.1241): Added 35 SNOMED CT codes and deleted 5 SNOMED CT codes (11226001, 186266008, 193493000, 23798003, 416449002).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Cataract Secondary to Ocular Disorders (2.16.840.1.113883.3.526.3.1410): Added 1 SNOMED CT code (766837000) and deleted 1 SNOMED CT code (21818003).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Cataract, Posterior Polar (2.16.840.1.113883.3.526.3.1414): Added 8 SNOMED CT codes (15639401000119105, 15639441000119107, 253225009, 15639481000119102, 15737881000119104, 15737921000119106, 15737961000119101, 342821000119103) and deleted 5 SNOMED CT codes (111515007, 1412008, 204124004, 204125003, 95723009). Added 3 ICD-10-CM codes (H25.041, H25.042, H25.043) and deleted 1 ICD-10-CM code (Q12.0).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Cloudy Cornea (2.16.840.1.113883.3.526.3.1417): Added 6 SNOMED CT codes (1099031000119105, 1099041000119101, 1099051000119104, 336501000119105, 342111000119101, 347271000119100).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Corneal Edema (2.16.840.1.113883.3.526.3.1418): Added 1 SNOMED CT code (373429003).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Corneal Opacity and Other Disorders of Cornea (2.16.840.1.113883.3.526.3.1419): Added 10 SNOMED CT codes (1099031000119105, 1099041000119101, 1099051000119104, 193795008, 314005007, 336501000119105, 342111000119101, 347271000119100, 422947009, 95726001).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set High Hyperopia (2.16.840.1.113883.3.526.3.1425): Added 2 SNOMED CT codes (334851000119100, 340461000119106).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hypotony of Eye (2.16.840.1.113883.3.526.3.1426): Deleted 4 SNOMED CT codes (193281006, 23360000, 420011000, 6777006).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Central Corneal Ulcer (2.16.840.1.113883.3.526.3.1428): Added 1 SNOMED CT code (7426009).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Open Wound of Eyeball (2.16.840.1.113883.3.526.3.1430): Deleted 2 ICD-10-CM codes (S05.91XA, S05.92XA).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Pathologic Myopia (2.16.840.1.113883.3.526.3.1432): Deleted 3 SNOMED CT codes (232133000, 232134006, 408757002).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Posterior Lenticonus (2.16.840.1.113883.3.526.3.1433): Deleted 4 SNOMED CT codes (253221000, 419281007, 95480008, 95481007).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Uveitis (2.16.840.1.113883.3.526.3.1444): Added 2 SNOMED CT codes (75315001, 75614007).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Vitreous Procedures (2.16.840.1.113883.3.526.3.1447): Added 13 SNOMED CT codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Glaucoma (2.16.840.1.113883.3.526.3.1423): Added 3 SNOMED CT codes (15374009, 15996831000119101, 232083008).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes (2.16.840.1.113883.3.526.3.1461): Added Glaucoma Associated with Congenital Anomalies, Dystrophies, and Systemic Syndromes.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set Other Endophthalmitis (2.16.840.1.113883.3.526.3.1473): Added Other Endophthalmitis.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set Purulent Endophthalmitis (2.16.840.1.113883.3.526.3.1477): Added Purulent Endophthalmitis.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set Aphakia and Other Disorders of Lens (2.16.840.1.113883.3.526.3.1407): Removed Aphakia and Other Disorders of Lens.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set Cysts of Iris, Ciliary Body, and Anterior Chamber (2.16.840.1.113883.3.526.3.1420): Removed Cysts of Iris, Ciliary Body, and Anterior Chamber.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set Enophthalmos (2.16.840.1.113883.3.526.3.1421): Removed Enophthalmos.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set Prior Pars Plana Vitrectomy (2.16.840.1.113883.3.526.3.1434): Removed Prior Pars Plana Vitrectomy.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

External Resources