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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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, detailed examination is indicated to assess for the following features that often lead to visual impairment: presence of macular edema, optic nerve neovascularization and/or neovascularization elsewhere, signs of severe NPDR (extensive retinal hemorrhages/microaneurysms, venous beading, and IRMA), and vitreous or preretinal hemorrhage. (A:III) (AAO, 2008)

Higher score indicates better quality

American Academy of Ophthalmology. Preferred Practice Pattern: Diabetic Retinopathy. 2008.

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 Jun 26;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: 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 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 Patient Population

None

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

Not Applicable

Not Applicable

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