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
American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
National Committee for Quality Assurance
American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
National Quality Forum
Finalized Date/Time
Copyright 2013 National Committee for Quality Assurance (NCQA) and American Medical Association. All Rights Reserved.
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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
NQF ID Number
Disclaimer
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eMeasure Identifier
167
measureStartDate
measureEndDate
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.
Transmission Format
TBD
Initial Patient Population
All patients aged 18 years and older with a diagnosis of diabetic retinopathy
Denominator
Equals Initial Patient Population
Denominator Exclusions
None
Numerator
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
Numerator Exclusions
Not Applicable
Denominator Exceptions
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
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.
None
Population criteria
-
Initial Patient Population =
- AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Measurement Period"
- AND:
- OR:
- AND: "Occurrence A of Encounter, Performed: Ophthalmological Services" during "Measurement Period"
- AND: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" starts before or during "Occurrence A of Encounter, Performed: Ophthalmological Services"
- AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" ends before start of "Occurrence A of Encounter, Performed: Ophthalmological Services"
- OR:
- AND: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility" during "Measurement Period"
- AND: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" starts before or during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
- AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" ends before start of "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
- OR:
- AND: "Occurrence A of Encounter, Performed: Nursing Facility Visit" during "Measurement Period"
- AND: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" starts before or during "Occurrence A of Encounter, Performed: Nursing Facility Visit"
- AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" ends before start of "Occurrence A of Encounter, Performed: Nursing Facility Visit"
- OR:
- AND: "Occurrence A of Encounter, Performed: Office Visit" during "Measurement Period"
- AND: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" starts before or during "Occurrence A of Encounter, Performed: Office Visit"
- AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" ends before start of "Occurrence A of Encounter, Performed: Office Visit"
- OR:
- AND: "Occurrence A of Encounter, Performed: Outpatient Consultation" during "Measurement Period"
- AND: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" starts before or during "Occurrence A of Encounter, Performed: Outpatient Consultation"
- AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" ends before start of "Occurrence A of Encounter, Performed: Outpatient Consultation"
- OR:
- AND: "Occurrence A of Encounter, Performed: Face-to-Face Interaction" during "Measurement Period"
- AND: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" starts before or during "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
- AND NOT: "Occurrence A of Diagnosis, Active: Diabetic Retinopathy" ends before start of "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
-
Denominator =
- AND: "Initial Patient Population"
-
Denominator Exclusions =
- None
-
Numerator =
- AND:
- AND: "Occurrence A of Diagnostic Study, Result: Macular Exam (result: 'Level of Severity of Retinopathy Findings')"
- AND:
- OR: "Occurrence A of Diagnostic Study, Result: Macular Exam (result: 'Macular Edema Findings Absent')"
- OR: "Occurrence A of Diagnostic Study, Result: Macular Exam (result: 'Macular Edema Findings Present')"
- during
- OR: "Occurrence A of Encounter, Performed: Ophthalmological Services"
- OR: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
- OR: "Occurrence A of Encounter, Performed: Nursing Facility Visit"
- OR: "Occurrence A of Encounter, Performed: Office Visit"
- OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
- OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
-
Denominator Exceptions =
- AND:
- OR: "Diagnostic Study, Performed not done: Medical Reason" for "Macular Exam"
- OR: "Diagnostic Study, Performed not done: Patient Reason" for "Macular Exam"
- during
- OR: "Occurrence A of Encounter, Performed: Ophthalmological Services"
- OR: "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
- OR: "Occurrence A of Encounter, Performed: Nursing Facility Visit"
- OR: "Occurrence A of Encounter, Performed: Office Visit"
- OR: "Occurrence A of Encounter, Performed: Outpatient Consultation"
- OR: "Occurrence A of Encounter, Performed: Face-to-Face Interaction"
Patient Characteristic Birthdate: birth date
Measurement Period
Occurrence A of Encounter, Performed: Ophthalmological Services
Measurement Period
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Ophthalmological Services
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Ophthalmological Services
Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility
Measurement Period
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility
Occurrence A of Encounter, Performed: Nursing Facility Visit
Measurement Period
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Nursing Facility Visit
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Nursing Facility Visit
Occurrence A of Encounter, Performed: Office Visit
Measurement Period
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Office Visit
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Office Visit
Occurrence A of Encounter, Performed: Outpatient Consultation
Measurement Period
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Outpatient Consultation
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Outpatient Consultation
Occurrence A of Encounter, Performed: Face-to-Face Interaction
Measurement Period
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Face-to-Face Interaction
Occurrence A of Diagnosis, Active: Diabetic Retinopathy
Occurrence A of Encounter, Performed: Face-to-Face Interaction
Initial Patient Population
Denominator
Diagnostic Study, Performed not done: Medical Reason
Diagnostic Study, Performed not done: Patient Reason
Occurrence A of Encounter, Performed: Ophthalmological Services
Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility
Occurrence A of Encounter, Performed: Nursing Facility Visit
Occurrence A of Encounter, Performed: Office Visit
Occurrence A of Encounter, Performed: Outpatient Consultation
Occurrence A of Encounter, Performed: Face-to-Face Interaction
Denominator
Occurrence A of Diagnostic Study, Result: Macular Exam (result: 'Level of Severity of Retinopathy Findings')
Occurrence A of Diagnostic Study, Result: Macular Exam (result: 'Macular Edema Findings Absent')
Occurrence A of Diagnostic Study, Result: Macular Exam (result: 'Macular Edema Findings Present')
Occurrence A of Encounter, Performed: Ophthalmological Services
Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility
Occurrence A of Encounter, Performed: Nursing Facility Visit
Occurrence A of Encounter, Performed: Office Visit
Occurrence A of Encounter, Performed: Outpatient Consultation
Occurrence A of Encounter, Performed: Face-to-Face Interaction
Data criteria (QDM Data Elements)
-
"Diagnosis, Active: Diabetic Retinopathy" using "Diabetic Retinopathy Grouping Value Set (2.16.840.1.113883.3.526.3.327)"
-
"Diagnostic Study, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"
-
"Diagnostic Study, Performed not done: Patient Reason" using "Patient Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1008)"
-
"Diagnostic Study, Performed: Macular Exam" using "Macular Exam Grouping Value Set (2.16.840.1.113883.3.526.3.1251)"
-
"Diagnostic Study, Result: Macular Exam" using "Macular Exam Grouping Value Set (2.16.840.1.113883.3.526.3.1251)"
-
"Encounter, Performed: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1014)"
-
"Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"
-
"Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1012)"
-
"Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"
-
"Encounter, Performed: Ophthalmological Services" using "Ophthalmological Services Grouping Value Set (2.16.840.1.113883.3.526.3.1285)"
-
"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"
-
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"
-
Attribute: "Result: Level of Severity of Retinopathy Findings" using "Level of Severity of Retinopathy Findings Grouping Value Set (2.16.840.1.113883.3.526.3.1283)"
-
Attribute: "Result: Macular Edema Findings Absent" using "Macular Edema Findings Absent Grouping Value Set (2.16.840.1.113883.3.526.3.1284)"
-
Attribute: "Result: Macular Edema Findings Present" using "Macular Edema Findings Present Grouping Value Set (2.16.840.1.113883.3.526.3.1320)"
Patient Characteristic Birthdate: birth date
Care Services in Long-Term Residential Facility
Diabetic Retinopathy
Face-to-Face Interaction
Macular Exam
Diagnostic Study, Performed: Macular Exam
Diagnostic Study, Performed not done: Medical Reason
Diagnostic Study, Performed not done: Patient Reason
Nursing Facility Visit
Office Visit
Ophthalmological Services
Outpatient Consultation
Encounter, Performed: Care Services in Long-Term Residential Facility
Diagnosis, Active: Diabetic Retinopathy
Encounter, Performed: Face-to-Face Interaction
Diagnostic Study, Result: Macular Exam
Encounter, Performed: Nursing Facility Visit
Encounter, Performed: Office Visit
Encounter, Performed: Ophthalmological Services
Encounter, Performed: Outpatient Consultation
Reporting Stratification
- None
Supplemental Data Elements
-
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"
-
"Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"
-
"Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"
-
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeSex Value Set (2.16.840.1.113762.1.4.1)"
Patient Characteristic Ethnicity: Ethnicity
Patient Characteristic Sex: ONC Administrative Sex
Patient Characteristic Payer: Payer
Patient Characteristic Race: Race