019. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

Examine the macula and fundus:

1. Open the Ocular Exam.
2. Select a dilated macular or fundus exam.
3. Select diabetic retinopathy from Impressions.
4. Tap ICD-10 Exp on the right side of the screen.
5. Select the appropriate conditions from the Severity and Macular Edema drop-downs.
6. Select a counseling Plan.
7. Tap the Diabetic Retinopaty tab.
8. Select the appropriate communication from the Quality 19A or Quality 19B drop-downs.
9. Tap Done.
10. Document the rest of the exam and Finalize.

Alternatively, code quality with a special plan:

1. Open the Ocular Exam.
2. Select a Diagnosis and Plan.
3. Tap Special Plans and select MIPS.
4. From Popular Plans, select MIPS Quality.
5. Tap the Diabetic Retinopathy tab.
6. Select the appropriate communication from the Quality 19A or Quality 19B drop-downs.
7. Tap Done.
8. Document the rest of the exam and Finalize.

Examine the macula and fundus:

1. In a patient’s exam record in ExamWRITER, record the office visit.
2. Click the Exam - Special Tests tab.
3. Click the Examination category bar.
4. Select the Retina - Vascular check box, select an eye, and click Process.
5. On the Retina/Vascular window, select the check boxes that correspond to the patient’s condition and click Process:
   • DEF performed (Diabetic Patient)
   • Macular edema WNI or Edema
   • Macular elevation
6. On the Impressions window, select the check boxes that correspond to the patient’s condition, select an eye, and click Process:
   • Indicate diabetes if applicable.
   • Select one of the options under Retinopathy, Background
   • Select a severity from the fourth column even if indicated in the retinopathy selection.
7. On the Treatment window, select one of the following:
   • Document Dilation and DR & ME
   • Document no Dilated Exam
8. Select Diabetes Managing Provider Report and click Process.

Eyefinity products and documentation refer to the MIPS quality numbers. Other measure numbering systems are listed here for your reference.

Quality	19
NQF	0089
CMS	142

• Claims (ExamWRITER only)
• EHR (ExamWRITER only)
• Registry (Eyefinity EHR only)

Reporting methods vary by measure and EHR system. For more information about how different measures and reporting methods are scored, refer to the topic that corresponds with your EHR:

• Eyefinity EHR Quality Scoring and Benchmarking
• ExamWRITER Quality Scoring and Benchmarking

Patients aged 18 years or older;

AND is diagnosed with diabetic retinopathy:

AND who had a visit during the measurement period:

AND who had dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy:

Denominator Exclusions

Telehealth modifier:

Denominator Exceptions

Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician or other qualified health care professional managing the ongoing care of the patient with diabetes:

OR

Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician or other qualified health care professional managing the ongoing care of the patient with diabetes:

Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient’s diabetic care.

Performance Met

Findings of dilated macular or fundus exam communicated to the physician or other qualified health care professional managing the diabetes care:

Performance Not Met

Findings of dilated macular or fundus exam were not communicated to the physician or other qualified health care professional managing the diabetes care, reason not otherwise specified: