Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months

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Diabetic retinopathy is a leading cause of new cases of legal blindness among working-age Americans and represents a leading cause of blindness in this age group worldwide. (Klein, 2007). In 2005-2008, the estimated prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy was 28.5 percent among persons with diabetes aged 40 years and older (Zhang, 2010). Approximately 1.5% of adults with diabetes had proliferative diabetic retinopathy and 2.7% had clinically significant macular edema (Zhang, 2010). 

Several level 1 RCT studies demonstrate the ability of timely treatment to reduce the rate and severity of vision loss from diabetes (Diabetic Retinopathy Study -- DRS, Early Treatment Diabetic Retinopathy Study -- ETDRS). Necessary examination prerequisites to applying the study results are that the presence and severity of both peripheral diabetic retinopathy and macular edema be accurately documented. In the RAND chronic disease quality project, while administrative data indicated that roughly half of the patients had an eye exam in the recommended time period, chart review data indicated that only 19% had documented evidence of a dilated examination (McGlynn, 2003). Thus, ensuring timely treatment that could prevent 95% of the blindness due to diabetes requires the performance and documentation of key examination parameters. The documented level of severity of retinopathy and the documented presence or absence of macular edema assists with the on-going plan of care for the patient with diabetic retinopathy.

Because treatment is effective in reducing the risk of visual loss, a detailed examination is indicated to assess for the following features that often lead to visual impairment: macular edema, signs of severe NPDR (extensive retinal hemorrhages/microaneurysms, venous beading, and IRMA), optic nerve head neovascularization and/or neovascularization elsewhere, and vitreous or preretinal hemorrhage. (Good evidence; Strong recommendation) (AAO, 2016)

Higher score indicates better quality

American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2016. Available at: www.aao.org/ppp.

Klein BE. Overview of epidemiologic studies of diabetic retinopathy. Ophthalmic Epidemiol. 2007;14:179-83. 

Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. 2010;304:649-56. 

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45.

Documentation - The medical record must include: documentation of the level of severity of retinopathy AND documentation of whether macular edema was present or absent.

Macular Edema - Acceptable synonyms for macular edema include: macular thickening, intraretinal thickening, serous detachment of the retina, or pigment epithelial detachment.

Severity of Retinopathy - Mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative.

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.

TBD

All patients aged 18 years and older with a diagnosis of diabetic retinopathy

Equals Initial Population

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Patients who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months

Not Applicable

Documentation of medical reason(s) for not performing a dilated macular or fundus examination.

Documentation of patient reason(s) for not performing a dilated macular or fundus examination.

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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