CMS142v11 – Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

All patients aged 18 years and older with a diagnosis of Diabetic Retinopathy.

The diagnosis requires a face to face encounter. This qualifying visit can include any of the following:

• Office Visit
• Ophthalmological Services
• Outpatient Consultation
• Care Services in Long-Term Residential Facility
• Nursing Facility Visit

– DENOMINATOR

All patients aged 18 years and older with a diagnosis of diabetic retinopathy 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. The following things should be communicated to the physician:

• Level of Severity of Retinopathy Findings
• Macular Edema Absence/Presence

-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:

• To record an encounter, navigate to Patient > Provider Notes > Create Superbill. Under the ‘Procedures-CPTs’ heading, enter the relevant encounter code.

• To document the diabetic retinopathy diagnosis, use the workflow Patient > Provider Notes > Diagnoses. Click ‘Add’ and search for the relevant diagnosis. Once done, click ‘Save’.

• The documentation of the Macular or Fundus Exam procedure can be done via Patient > Provider Notes > Orders > Procedures. Click ‘Add’ and search for the exam. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.

Note: The result of the Macular/Fundus Exam must not be null.

For Numerator:

To document the communications, use the workflow Patient > Provider Notes > Evaluations. Search for the relevant macular exam or severity of retinopathy findings and from the Status drop down, select ‘Referred to Provider’. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.

For Denominator Exceptions:

To document medical and patient reasoning(s) for not communicating the findings, navigate to Patient > Provider Notes > Evaluations. Click ‘Add’ and search for the relevant exam or retinopathy finding. From the Status drop down, select ‘Not Referred to Provider’. Then from the ‘Reason’ drop-down, select the patient/medical reason for not referring. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.