CMS143v10 – Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma.

-DENOMINATOR EXCEPTION

Documentation of medical reason(s) for not performing an optic nerve head evaluation.

– NUMERATOR

Patients who have an optic nerve head evaluation during one or more office visits within 12 months.

For Denominator:

Include patients aged 18 years and older at the start of the measurement period with a primary open angle glaucoma encounter during the measurement period. The diagnosis of ‘Primary Open-Angle Glaucoma’ should overlap the face to face encounter.

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

• To document the primary open-angle glaucoma 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.

For Numerator:

Include patients fulfilling the following criteria:

1. Patients with ‘Cup to Disc Ratio’ diagnostic study performed with result. The diagnostic study should be performed during the primary open angle glaucoma encounter. To document a diagnostic study performed, use any of the following three workflows:

• Patient > Clinical > Evaluations. Click ‘+Add’ and search for the diagnostic study. Select ‘Performed’ from the ‘Status’ dropdown and enter a result in the ‘Result’ field. Then click ‘Sign’ or ‘Save’. The result of the evaluation must not be null.

• 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’. 

• Patient > Provide Note > Clinical > History > Medical History. Open the ‘Procedure/Tests tab’, search for Procedure/Test 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.

2. Patients with ‘Optic Disc Exam for Structural Abnormalities’ diagnostic study performed with result. The diagnostic study should be performed during the primary open angle glaucoma encounter. To document a diagnostic study performed, use any of the following three workflows:

• Patient > Clinical > Evaluations.
• Patient > Clinical > Orders & Results > Radiology.
• Patient > Provide Note > Clinical > History > Medical History.

For Denominator Exception:

Include patients fulfilling any of the following criteria:

• Patients with ‘Cup to Disc Ratio’ diagnostic study not performed with a medical reason recorded. The medical reason should be documented during the primary open angle glaucoma encounter. To document a diagnostic study not performed, use the workflow Patient > Clinical > Evaluations. Click ‘+Add’ and search for the diagnostic study. Select ‘Not Done’ from the ‘Status’ dropdown and select a reason from the ‘Reason’ dropdown. Then click ‘Sign’ or ‘Save’.

• Patients with ‘Optic Disc Exam for Structural Abnormalities’ diagnostic study performed with a medical reason recorded. The medical reason should be documented during the primary open angle glaucoma encounter. To document a diagnostic study not performed, use the workflow Patient > Clinical > Evaluations. Then click ‘Sign’ or ‘Save’.