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Measure: CMS131

Diabetes: Eye Exam

Measure Versions

eMeasure Code Measure Year Full Version Number Title
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 overlapping 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 overlapping 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.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationPatients 18-75 years of age with diabetes with a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsExclude patients whose hospice care overlaps the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 days during the measurement period. Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.Webchart Instructions
NumeratorPatients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: •Diabetic with a diagnosis of retinopathy that overlaps 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 overlapping 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 periodWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS131v8 131 2020 8.4.000 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

As the seventh leading cause of death in the U.S., diabetes kills approximately 79,500 people a year and affects more than 30 million Americans (9.4 percent of the U.S. population) (Centers for Disease Control and Prevention [CDC], 2017a, 2017b ). 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, 2017c). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet or legs, and premature death (CDC, 2016). 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, 2018a). 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, 2015).

Clinical Recommendation Statement

American Diabetes Association (2018b):

- 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 exams 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 ED 2.16.840.1.113883.3.464.1003.101.12.1085
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 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
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
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

American Diabetes Association. (2018a). 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
American Diabetes Association. (2018b). 10. Microvascular complications and foot care: Standards of Medical Care in Diabetes—2018. Diabetes Care, 41(Suppl. 1), S105-S118.
Centers for Disease Control and Prevention. (2017a). Health, United States, 2016: With chartbook on long-term trends in health. Retrieved from https://www.cdc.gov/nchs/data/hus/hus16.pdf
Centers for Disease Control and Prevention. (2017b). National diabetes statistics report, 2017. Atlanta, GA: U.S. Department of Health and Human Services, CDC. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
Centers for Disease Control and Prevention. (2017c). About diabetes. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html
Centers for Disease Control and Prevention. (2016). At a glance 2016: Diabetes—Working to reverse the U.S. epidemic. Atlanta, GA: Author.
Centers for Disease Control and Prevention. (2015). Common eye disorders: Diabetic retinopathy. 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) 2012-2019 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 2004-2018 American Medical Association. LOINC(R) copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organisation. ICD-10 copyright 2018 World Health Organization. All Rights Reserved.

Source: https://ecqi.healthit.gov/ecqm/measures/cms131v8