This article covers the Clinical Quality Measure Report "Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery". This report is used to meet Clinical Quality Measure requirements for MIPS and Medicaid reporting programs. We'll cover the structure of the report and how it works so you can meet your Clinical Quality Measure requirements.
Overview of Measure
The "Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery" report tracks the percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best- corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.
A patient will be in the denominator when they have all of the following:
- An age 18 years or older
- A Cataract Surgery during the reporting period (excluding the last 92 days)
A patient will be in the numerator when they have all of the following:
- A "Best Corrected Visual Acuity" SNOMED code (419775003) added to their EMR or EHR form in the SNOMED code section. This code will need a Start Date and End Date within 90 days after their Cataract Surgery and a "Visual Acuity 20/40 or Better" SNOMED code added in the CQM Value box
A patient will be in the exclusion when they have any of the following:
- The following diagnoses active before the Cataract Surgery is performed:
- Acute and Subacute Iridocyclitis
- Pathologic Myopia
- Retinal Detachment with Retinal Defect
- Retinal Vascular Occlusion
- Purulent Endophthalmitis
- Certain Types of Iridocyclitis
- Glaucoma Associated with Congenital Anomalies
- Systemic Syndromes
- Chronic Iridocyclitis
- Choroidal Degenerations
- Optic Neuritis
- Other Background Retinopathy and Retinal Vascular Changes
- Other Corneal Deformities
- Cloudy Cornea
- Other Retinal Disorders
- Prior Penetrating Keratoplasty
- Other and Unspecified forms of Chorioretinitis and Retinochoroiditis
- Corneal Edema
- Nystagmus and other Irregular Eye Movements
- Moderate or Severe Impairment
- Better Eye
- Profound Impairment Lesser Eye
- Hereditary Choroidal Dystrophies
- Hereditary Retinal Dystrophies
- Burn Confined to Eye and Adnexa
- Scleritis and Episcleritis
- Other Disorders of Sclera
- Focal Chorioretinitis and Focal Retinochoroiditis
- Degenerative Disorders of Globe Degeneration of Macula and Posterior Pole
- Disseminated Chorioretinitis and Disseminated Retinochoroiditis
- Diabetic Macular Edema
- Profound Impairment, Both Eyes
- Other Proliferative Retinopathy
- Cataract Secondary to Ocular Disorders
- Disorders of Visual Cortex
- Choroidal Detachment
- Disorders of Optic Chiasm
- Injury to Optic Nerve and Pathways
- Choroidal Hemorrhage and Rupture
- Other Disorders of Optic Nerve
- Chorioretinal Scars
- Hereditary Corneal Dystrophies
- Central Corneal Ulcer
- Corneal Opacity and other Disorders of Cornea
- Optic Atrophy
- Open Wound of Eyeball
- Other Endophthalmitis
- Separation of Retinal Layers
- Diabetic Retinopathy, or Visual Field Defects
- Filter Providers: This filter allows you to narrow the generated data to include and exclude specific providers. When checked, any selected providers will be included in the results.
- Filter Offices: This filter allows you to narrow the generated data to include and exclude specific Office references.
- Filter Ethnicities: This filter will allow you to narrow the generated results to specific ethnicities as designated in a patient's record under the Patients Ability > Patient Tab > Race/Ethnicity sub-tab.
- Filter Races: This filter will allow you to narrow the generated results to specific races as designated in a patient's record under the Patients Ability > Patient Tab > Race/Ethnicity sub-tab.
- Filter Sex: This filter will allow you to narrow the generated results to specific genders as designated by the "Sex" field in the Patients Ability > Patient Tab > Sex drop down menu.
- Filter Insurances: This filter allows you to narrow down results to patients that have the selected insurances added in the Patients Ability > Patient Tab > Insurance Sub-Tab.
- Filter Tax Identification Numbers: This filters narrows results based on the provider's Tax ID numbers. In this case, it will narrow down to patients with the associated providers.
- Filter National Provider Identifiers: This filters narrows results based on the provider's National Provider Identifier (NPI). In this case, it will narrow down to patients with the associated providers.
- Filter Provider Types: This filter will narrow results by the Provider Taxonomy codes present in References > User > Provider Tab > Provider Taxonomy. To be precise, it will narrow the results to patients associated with providers with the selected Taxonomy codes entered in the User Reference.
- Filter Problem Lists: This filter will narrow the results down to patients who have the selected diagnosis codes entered into their Problem Lists. You can find these in the Clinical Ability under the Problem List widget.
- Filter Practice Address: This filter will narrow results down to patients who are associated with the Office with an address that matches the selected address.
- Start/End Date: These fields allow you to narrow the range of the generated results to the specified date range.
- Start Age/End Age: These drop downs allow you to narrow results down to patients with ages in between the range.
- Group Name: For reports with multiple numerator requirements, this identifies the numerator that is being checked for. In this report's case, there is only one numerator requirement.
- Numerator: The number of patient that meet the numerator requirements described above.
- Denominator: The number of patients that meet the denominator requirements described above.
- Percentage: The percentage of patients meeting both the numerator and denominator requirements.
- Patient #: The Patient Account Number for the Patient in question.
- Patient Name: The name of the patient in question, formatted as last name/first name.
- Episode: The procedure code of the episode that qualifies the patient to be in the denominator results.
- Date: The date of the episode in question.
- In Numerator (Yes/No): This column identifies whether the patient in question meets the numerator requirements.