Measure: CMS131
Diabetes: Eye Exam
Measure Versions
| eMeasure Code |
Measure Year |
Full Version Number |
Title |
| CMS131v12 |
2024 |
12.0.000 |
Diabetes: Eye Exam |
| CMS131v11 |
2023 |
11 |
Diabetes: Eye Exam |
| CMS131v10 |
2022 |
10.0.000 |
Diabetes: Eye Exam |
| CMS131v9 |
2021 |
9.2.000 |
Diabetes: Eye Exam |
| CMS131v8 |
2020 |
8.4.000 |
Diabetes: Eye Exam |
| CMS131v7 |
2019 |
7.2.000 |
Diabetes: Eye Exam |
| CMS131v6 |
2018 |
6.2.000 |
Diabetes: Eye Exam |
| CMS131v5 |
2017 |
5.0.000 |
Diabetes: Eye Exam |
Description
Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period
Guidance
Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included.
The eye exam must be performed by an ophthalmologist or optometrist, or there must be evidence that fundus photography results were read by a system that provides an artificial intelligence (AI) interpretation.
This eCQM is a patient-based measure.
This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Patient Group Definitions
| Group |
Description |
Instructions Links |
| Initial Population | Patients 18-75 years of age with diabetes with a visit during the measurement period | Webchart Instructions |
| Denominator | Equals Initial Population | Webchart Instructions |
| Denominator Exclusions | Exclude patients who are in hospice care for any part of the measurement period.
Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period.
Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria:
- Advanced illness with two outpatient encounters during the measurement period or the year prior
- OR advanced illness with one inpatient encounter during the measurement period or the year prior
- OR taking dementia medications during the measurement period or the year prior
Exclude patients receiving palliative care during the measurement period. | Webchart Instructions |
| Numerator | Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following:
•Diabetic with a diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period
•Diabetic with no diagnosis of retinopathy in any part of the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None | |
Details
| Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
| CMS131v10 |
|
2022 |
10.0.000 |
Not Applicable |
d90bdab4-b9d2-4329-9993-5c34e2c0dc66 |
| Steward |
Developer |
Endorsed By |
| National Committee for Quality Assurance |
National Committee for Quality Assurance |
|
| Scoring Method |
Measure Type |
Stratification |
Risk Adjustment |
| Proportion |
PROCESS |
None |
None |
Rate Aggregation
None
Improvement Notation
Higher score indicates better quality
Rationale
Diabetes is the seventh leading cause of death in the United States. In 2017, diabetes affected approximately 34 million Americans (10.5 percent of the U.S. population) and killed approximately 84,000 people (Centers for Disease Control and Prevention [CDC], 2020a). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (CDC, 2020b). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney damage, and amputation of feet or legs, and premature death (CDC, 2018).
In 2017, diabetes cost the U.S. an estimated $327 billion: $237 billion in direct medical costs and $90 billion in reduced productivity. This is a 34 percent increase from the estimated $245 billion spent on diabetes in 2012 (American Diabetes Association, 2018).
Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. It is the leading cause of blindness in adults between 20-74 years of age. Approximately 4.1 million adults are affected by diabetic retinopathy (CDC, 2020c).
Clinical Recommendation Statement
American Diabetes Association (2020):
- Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (Level of evidence: B)
- Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. (Level of evidence: B)
-If there is no evidence of retinopathy for one or more annual eye exam and glycemia is well controlled, then screening every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight threatening, then examinations will be required more frequently. (Level of evidence: B)
Definition
None
Transmission Format
TBD
Applicable Value Sets
| Category |
Value Set |
OID |
| Diagnosis |
Diabetes |
2.16.840.1.113883.3.464.1003.103.12.1001 |
| Diagnosis |
Diabetic Retinopathy |
2.16.840.1.113883.3.526.3.327 |
| Diagnosis |
Frailty Diagnosis |
2.16.840.1.113883.3.464.1003.113.12.1074 |
| Encounter, Performed |
Acute Inpatient |
2.16.840.1.113883.3.464.1003.101.12.1083 |
| Encounter, Performed |
Annual Wellness Visit |
2.16.840.1.113883.3.526.3.1240 |
| Encounter, Performed |
Care Services in Long-Term Residential Facility |
2.16.840.1.113883.3.464.1003.101.12.1014 |
| Encounter, Performed |
Emergency Department Visit |
2.16.840.1.113883.3.464.1003.101.12.1010 |
| Encounter, Performed |
Encounter Inpatient |
2.16.840.1.113883.3.666.5.307 |
| Encounter, Performed |
Frailty Encounter |
2.16.840.1.113883.3.464.1003.101.12.1088 |
| Encounter, Performed |
Home Healthcare Services |
2.16.840.1.113883.3.464.1003.101.12.1016 |
| Encounter, Performed |
Nonacute Inpatient |
2.16.840.1.113883.3.464.1003.101.12.1084 |
| Encounter, Performed |
Nursing Facility Visit |
2.16.840.1.113883.3.464.1003.101.12.1012 |
| Encounter, Performed |
Observation |
2.16.840.1.113883.3.464.1003.101.12.1086 |
| Encounter, Performed |
Office Visit |
2.16.840.1.113883.3.464.1003.101.12.1001 |
| Encounter, Performed |
Ophthalmological Services |
2.16.840.1.113883.3.526.3.1285 |
| Encounter, Performed |
Outpatient |
2.16.840.1.113883.3.464.1003.101.12.1087 |
| Encounter, Performed |
Palliative Care Encounter |
2.16.840.1.113883.3.464.1003.101.12.1090 |
| Encounter, Performed |
Preventive Care Services - Established Office Visit, 18 and Up |
2.16.840.1.113883.3.464.1003.101.12.1025 |
| Encounter, Performed |
Preventive Care Services-Initial Office Visit, 18 and Up |
2.16.840.1.113883.3.464.1003.101.12.1023 |
| Encounter, Performed |
Telephone Visits |
2.16.840.1.113883.3.464.1003.101.12.1080 |
| Intervention, Order |
Hospice care ambulatory |
2.16.840.1.113762.1.4.1108.15 |
| Intervention, Performed |
Hospice care ambulatory |
2.16.840.1.113762.1.4.1108.15 |
| Intervention, Performed |
Palliative Care Intervention |
2.16.840.1.113883.3.464.1003.198.12.1135 |
| Medication, Active |
Dementia Medications |
2.16.840.1.113883.3.464.1003.196.12.1510 |
| Patient Characteristic Ethnicity |
Ethnicity |
2.16.840.1.114222.4.11.837 |
| Patient Characteristic Payer |
Payer |
2.16.840.1.114222.4.11.3591 |
| Patient Characteristic Race |
Race |
2.16.840.1.114222.4.11.836 |
| Patient Characteristic Sex |
ONC Administrative Sex |
2.16.840.1.113762.1.4.1 |
| Physical Exam, Performed |
Retinal or Dilated Eye Exam |
2.16.840.1.113883.3.464.1003.115.12.1088 |
| Symptom |
Frailty Symptom |
2.16.840.1.113883.3.464.1003.113.12.1075 |
References
CITATIONAmerican Diabetes Association. (2018). Economic costs of diabetes in the U.S. in 2017. Diabetes Care, 41, 917-928. Retrieved from http://care.diabetesjournals.org/content/early/2018/03/20/dci18-0007
CITATIONAmerican Diabetes Association. (2020). 11. Microvascular complications and foot care: Standards of Medical Care in Diabetes–2020. Diabetes Care 2020; 43(Suppl. 1):S135–S151. https://doi.org/10.2337/dc20-s011
CITATIONCenters for Disease Control and Prevention. (2020a). National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services. Retrieved from https://www.cdc.gov/diabetes/data/statistics-report/index.html
CITATIONCenters for Disease Control and Prevention. (2020b). Diabetes Basics. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html
CITATIONCenters for Disease Control and Prevention. (2018). Diabetes Report Card 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services. Retrieved from https://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2017-508.pdf
CITATIONCenters for Disease Control and Prevention. (2020c). Common eye disorders and diseases. Retrieved from https://www.cdc.gov/visionhealth/basics/ced/index.html
Disclaimer
The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Copyright
This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2020 National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.
CPT(R) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved.
Source:
https://ecqi.healthit.gov/ecqm/measures/cmsv1