CMS142v9 – Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

All patients aged 18 years and older with a diagnosis of diabetic retinopathy and who had a dilated macular or fundus exam performed.

– NUMERATOR

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.

-DENOMINATOR EXCEPTION

• 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.
• 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.

For Denominator:

Include patients aged 18 years and older at the start of the measurement period with a ‘Diabetic Retinopathy Encounter’ and a macular exam performed during the measurement period. For diabetic retinopathy encounter the patient should have a face to face encounter overlapping diabetic retinopathy diagnosis.

• To record an encounter, navigate to Patient > Provider Note > eSuperbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

• To document the diabetic retinopathy diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.

• The macular exam should be performed during the diabetic retinopathy encounter. The result of the macular exam must not be null. To document the diagnostic study, use the workflow Patient > Provide Note > Clinical > History > Medical History. Open the ‘Procedure/Tests tab’, search for macular exam and click on the ‘Accept’ button.

Note:

Please ensure that the LOINC code is mapped to Medical Test from the Settings. To map a LOINC with the Radiology Test, navigate to Settings > EHR > Medical Tests. Click on the ‘Add’ button. Enter the Medical Test Name, Description, Code System (LOINC), LOINC Code and Category (Radiology). Once done, click on the ‘Save’ button.

The macular exam can also be recorded via the workflow, Patient > Clinical > Evaluations. Click ‘+ Add’ and search for the macular exam. Select ‘Performed’ from the ‘Status’ dropdown and a result from the ‘Result’ dropdown. Then click ‘Sign’ or ‘Save’.

Additionally, the macular exam can be documented using the workflow Patient > Clinical > Orders & Results > Radiology. Click ‘+ Order’ and add the radiology order details. Then hover over ‘Sign’ and click ‘Queue’.

Mark the radiology order as completed by clicking the ‘Mark As Completed’ button.

Note:

For LOINC Codes Based Labs: Please ensure that the test code is mapped to a LOINC Code from the Settings. To map a LOINC with the radiology test code, navigate to Settings > EHR > Radiology. Select the radiology test and navigate to the ‘Code’ tab. Then, click on a code. Under the ‘Result Codes and LOINCS’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’. 

For CPT Codes Based Labs: When a CPT code is added to a test order, please ensure that the CPT code is present in the ‘Procedures’. 

Moreover, the CPT code should be mapped to a LOINC Code from the Settings. To map a LOINC with the CPT code, navigate to Settings > Billing > Procedure. Select the CPT code and navigate to the ‘Edit Procedure’ tab. Under the ‘Procedure Components’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’. 

For Numerator:

Include patients fulfilling any of the following criteria:

• Patients with ‘Level of Severity of Retinopathy Findings Communicated’ and ‘Macular edema absence communicated’. The level of severity of retinopathy findings and macular edema absence communications should be performed with diabetic retinopathy encounter. Additionally, both the communications should be performed after the start of the diabetic retinopathy encounter. To record a communication performed, use the workflow Patient > Clinical > Evaluations. Click ‘+ Add’ and search for the communication. Select ‘Performed’ from the ‘Status’ dropdown and then click ‘Sign’ or ‘Save’.
• Patients with ‘Level of Severity of Retinopathy Findings Communicated’ and ‘Macular edema presence communicated’. The level of severity of retinopathy findings and macular edema presence communications should be performed with diabetic retinopathy encounter. Additionally, both the communications should be performed after the start of the diabetic retinopathy encounter. To record a communication performed, use the workflow Patient > Clinical > Evaluations.

For Denominator Exceptions:

Include patients satisfying any of the following conditions:

• Patients with medical or patient reason for not communicating level of severity of retinopathy. The communication should be documented as not performed during the diabetic retinopathy encounter. To record the communication not performed, use the workflow Patient > Clinical > Evaluations. Click ‘+ Add’ and search for the communication. Select ‘Not Performed’ from the ‘Status’ dropdown and select a reason from the ‘Reason’ dropdown. Then click ‘Sign’ or ‘Save’.
• Patients with medical or patient reason for not communicating absence of macular edema. The communication should be documented as not performed during the diabetic retinopathy encounter. To record the communication not performed, use the workflow Patient > Clinical > Evaluations.
• Patients with medical or patient reason for not communicating presence of macular edema. The communication should be documented as not performed during the diabetic retinopathy encounter. To record the communication not performed, use the workflow Patient > Clinical > Evaluations.