CMS142v13: Diabetic Retinopathy: Communication with the Physician managing ongoing Diabetes Care

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the measurement period.

Numerator

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

• Text in Chart: This should be noted in the Assessment or Plan of the patient's encounter using either of the following phrases:
  • communicated findings of dilated macular exam to patient's managing physician. Macular edema absence communicated
  • communicated findings of dilated macular exam to patient's managing physician. Macular edema presence communicated
  • communicated findings of dilated fundus exam to patient's managing physician. Macular edema absence communicated
  • communicated findings of dilated fundus exam to patient's managing physician. Macular edema presence communicated
    

Denominator

All patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed. Patient must meet all the following criteria:

• Encounter: The patient has an encounter within the measurement period. An office visit CPT code must be entered into the superbill for this note. 
• Diagnosis of Diabetic Retinopathy with an appropriate ICD-10 code assigned to the patient
• Exam performed: Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema AND level of severity of retinopathy. This should be noted in the Physical Exam, Assessment or Plan sections of the patient's encounter using either of the following phrases:
  • dilated macular exam performed
  • dilated fundus exam performed

Denominator Exceptions

• Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes:
  • Text in Chart: Free text in Plan or Assessment any of the following phrases:
    • Macular exam not tolerated
    • Macular exam contraindicated
    • Fundus exam not tolerated
    • Fundus exam contraindicated
    • Absent response to dilating eye drops
• Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes.
  • Text In Chart: Free text in Plan or Assessment any of the following phrases:
    • Refuses Macular exam
    • Macular exam refused
    • Dissatisfied with result of Macular exam
    • Refuses fundus exam
    • Fundus exam refused
    • Dissatisfied with result of fundus exam