CMS143v12 – Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

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

This diagnosis is to be established during a qualifying encounter, which in this case can be any of the following:

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

– NUMERATOR

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

-DENOMINATOR EXCEPTION

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

For Denominator:

• To record an encounter, navigate to Patient > Provider Note > Create Superbill. 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, add the diagnosis details and then click ‘Save’.

For Numerator:

The documentation of the diagnostic study can be done via Patient > Provider Note > Evaluations. Here, click ‘Add’ and search for the diagnostic study. Select ‘Performed’ from the ‘Status’ dropdown and enter a result in the ‘Result’ field. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.

Note: The result should not be null.

For Denominator Exceptions:

The medical reason should be documented during the primary open angle glaucoma encounter. To do so, use the workflow Patient > Provider Note > Evaluations. Click ‘Add’ and search for the diagnostic study. Select ‘Not Done’ from the ‘Status’ dropdown and select a reason from the ‘Reason’ dropdown. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.