2017 MIPS Measure #385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
Registry Outcome Yes Effective Clinical Care Ophthalmology

Measure Description

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye

Instruction

This measure is to be calculated each time a procedure for primary rhegmatogenous retinal detachment is performed during the performance period. This measure is intended to reflect the quality of services provided for the patient receiving primary rhegmatogenous retinal detachment surgery.

Note: This is an outcome measure and will be calculated solely using registry data.

  • For patients who receive the surgical procedures specified in the denominator coding, it should be reported whether or not the patient achieved an improvement of their visual acuity within 90 days of surgery.
  • Include only procedures performed through September 30 of the performance period. This will allow the post- operative period to occur before registries must submit data to CMS.

Denominator

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on the date of the procedure
AND
Patient procedure during the performance period (CPT): 67107, 67108, 67110
AND NOT
DENOMINATOR EXCLUSION:
Surgical procedures that included the use of silicone oil: G9757

Numerator

Patients who achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye

Numerator Options:
Performance Met: Patient achieved an improvement in visual acuity, from their preoperative level, within 90 days of surgery (G9516)
OR
Performance Not Met: Patient did not achieve an improvement in visual acuity, from their preoperative level, within 90 days of surgery, reason not given (G9517)

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