141. Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% or Documentation of a Plan of Care

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the preintervention level) or if the most recent IOP was not reduced by at least 15% from the preintervention level, a plan of care was documented within the 12-month performance period. This is an outcome measure.

This measure is to be reported a minimum of once per performance period for glaucoma patients seen during the performance reporting. It is anticipated that eligible clinicians who provide the primary management of patients with POAG will submit this measure.

Document IOP reduction or plan of care:

  1. Open the Ocular Exam.
  2. Select a dilated exam.
  3. Select the appropriate findings on the Discs and Fundus tabs.
  4. Select a POAG diagnosis from Impressions.
  5. Select a counseling Plan.
  6. Select the appropriate IOP from the Quality 141 drop-down.
  7. Tap Done.
  8. 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 POAG tab.
  6. Select the appropriate IOP from the Quality 141 drop-down.
  7. Tap Done.
  8. Document the rest of the exam and Finalize.

Document IOP reduction or plan of care:

  1. In a patient’s exam record in ExamWRITER, record the office visit.
  2. Click the Surgery - Plan - Mgmt tab.
  3. Click the Impressions/Assessment category bar.
  4. Select Glaucoma and click Process.
  5. In the Impression/Glaucoma window, select one of the following options:
    • IOP Reduction is > 15% - 3284F
    • < 15% - 3285F and Glaucoma Plan of Care Documented - 0517F

  6. Click Process.

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

Quality 141
NQF 0563
CMS —
  • Claims
  • Registry (Eyefinity EHR only)

This topic describes how points are calculated for this measure. To learn more about scoring, go to Scoring.

Benchmarks are displayed here as both a chart and a table. The chart gives you a visual representation and helps you quickly compare benchmarks across different reporting methods. The table lists the specific benchmark criteria for each available reporting method.

Claims-based reporting for this measure is capped at a maximum of 7 points based on performance.

 

Submission Method 3rd Decile 4th Decile 5th Decile 6th Decile 7th Decile 8th Decile 9th Decile 10th Decile
Claims — — — — — — — 100
Registry (Eyefinity EHR only)
32.62–
60.31
60.32–
82.13
82.14–
93.47
93.48–
98.54
98.55–
99.99		 — — 100

Patients 18 years of age or older on date of encounter;

AND who had a diagnosis of POAG:

H40.1111, H40.1112, H40.1113, H40.1114, H40.1121, H40.1122, H40.1123, H40.1124, H40.1131, H40.1132, H40.1133, H40.1134, H40.1211, H40.1212, H40.1213, H40.1214, H40.1221, H40.1222, H40.1223, H40.1224, H40.1231, H40.1232, H40.1233, H40.1234, H40.151, H40.152, H40.153

AND who had a visit during the measurement period:

92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

Denominator Exclusions

Telehealth modifier:

GQ, GT 95, POS 02

Patients whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the preintervention level) or if the most recent IOP was not reduced by at least 15% from the preintervention level, a plan of care was documented within 12 months.

Performance Met

Intraocular pressure (IOP) reduced by a value of greater than or equal to 15% from the preintervention level:

3284F

OR

Glaucoma plan of care documented:

0517F

AND intraocular pressure (IOP) reduced by a value less than 15% from the preintervention level:

3285F

Performance Not Met

IOP measurement not documented, reason not otherwise specified:

3284F with 8P

OR

Glaucoma plan of care not documented, reason not otherwise specified:

0517F with 8P

AND intraocular pressure (IOP) reduced by a value less than 15% from the pre-intervention level:

3285F