2016 Measures Group (MG) Flow Diabetic Retinopathy
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4 2016 Measures Group (MG) Flow Diabetic Retinopathy Please refer to the specific section of the 2016 PQRS Measures Groups Specifications Manual to identify specific coding and instructions to report the Diabetic Retinopathy Measures Group Patient Sample Criteria (denominator), individual measures, and numerator options information for use in reporting this Measures Group. 1. Start with G9671 Intent G-code if Utilized 2. Check Patient Age: a. If the Age is greater than or equal to 18 years and less than or equal to 75 years of age at Date of Service equals No, do not include in Eligible Population/Denominator. Stop Processing. b. If the Age is greater than or equal to 18 years and less than or equal to 75 years of age at Date of Service equals Yes, proceed to check Patient Diagnosis. 3. Check Patient Diagnosis: a. If Diagnosis of Diabetic Retinopathy as Listed in the MG Patient Sample Criteria equals No, do not include in Eligible Population/Denominator. Stop Processing. b. If Diagnosis of Diabetic Retinopathy as Listed in the MG Patient Sample Criteria equals Yes, proceed to check Encounter Performed. 4. Check Encounter Performed: a. If Encounter as Listed in the MG Patient Sample Criteria equals No, do not include in Eligible Population. Stop Processing. b. If Encounter as Listed in the MG Patient Sample Criteria equals Yes, include in the Eligible Population/Denominator. 5. Denominator Population a. Include in Eligible Population/Denominator all eligible patients who meet the Patient Sample Criteria (denominator) for the Measures Group. For each measure within the measures group each numerator option is represented by a letter which is used in the Scenarios for Reporting and Performance Algorithms at the end of this document. 6. Start Numerator Options for Measures within the Measures Group 7. Composite Quality Data Code (QDC) G9672 has been created for registries that utilize claims data. This QDC may be reported in lieu of individual QDCs when all quality clinical actions for all applicable measures within the group have been performed for this patient. 8. Measure 1 a. Measure #1 is an inverse measure. A lower calculated performance rate for this measure indicates better clinical control and care. b. Numerator option Performance Met is represented by letter a i. c. Numerator option Performance Not Met has an arrow pointing to G9672 Composite Quality Data Code (QDC) or Equivalent. Performance Not Met is represented by letter c i.
5 d. Numerator option Not Reported is represented by letter d i. 9. Measure 18 (QDC) or Equivalent. Performance Met is represented by letter a ii. b. Numerator option Performance Exclusion is represented by letter b ii. c. Numerator option Performance Not Met is represented by letter c ii. d. Numerator option Not Reported is represented by letter d ii. 10. Measure 19 a. Measure #19 does not need to be reported (is not applicable) when the reporting provider manages the patient s diabetes care. When measure #19 is Not Applicable it is represented by letter e iii in the Scenarios for Reporting Algorithms. b. Numerator option Performance Met has an arrow pointing to G9672 Composite Quality Data Code (QDC) or Equivalent. Performance Met is represented by letter a iii. c. Numerator option Performance Exclusion is represented by letter b iii. d. Numerator option Performance Not Met is represented by letter c iii. e. Numerator option Not Reported is represented by letter d iii. 11. Measure 117 (QDC) or Equivalent. Performance Met is represented by letter a iv. b. Numerator option Performance Not Met is represented by letter c iv. c. Numerator option Not Reported is represented by letter d iv. 12. Measure 130 (QDC) or Equivalent. Performance Met is represented by letter a v. b. Numerator option Performance Exclusion is represented by letter b v. c. Numerator option Performance Not Met is represented by letter c v. d. Numerator option Not Reported is represented by letter d v. 13. Measure 226 (QDC) or Equivalent. Performance Met is represented by letter a vi. b. Numerator option Performance Exclusion is represented by letter b vi. c. Numerator option Performance Not Met is represented by letter c vi.
6 d. Numerator option Not Reported is represented by letter d vi. 14. Measure 317 a. Measure #317 does not need to be reported (is not applicable) if the patient has an active diagnosis of hypertension. When measure #317 is Not Applicable it is represented by letter e vii in the Scenarios for Reporting Algorithms. b. Numerator option Performance Met has an arrow pointing to G9672 Composite Quality Data Code (QDC) or Equivalent. Performance Met is represented by letter a vii. c. Numerator option Performance Exclusion is represented by letter b vii. d. Numerator option Performance Not Met is represented by letter c vii. e. Numerator option Not Reported is represented by letter d vii. 15. Scenarios for Reporting and Performance Algorithms 16. Patient X a. Patient X Met Measure 1 (represented by a i ) b. Patient X Met Measure 18 (represented by a ii ) c. Patient X Met Measure 19 (represented by a iii ) d. Patient X Met Measure 117 (represented by a iv ) e. Patient X Met Measure 130 (represented by a v ) f. Patient X Met Measure 226 (represented by a vi ) g. Patient X Met Measure 317 (represented by a vii ) 17. Patient Y a. Patient Y Met Measure 1 (represented by a i ) b. Patient Y Not Met but Reported Measure 18 (represented by c ii ) c. Patient Y Not Applicable for Measure 19 (represented by e iii ) d. Patient Y Met Measure 117 (represented by a iv ) e. Patient Y Met Measure 130 (represented by a v ) f. Patient Y Exclusion Reported for 226 (represented by b vi ) g. Patient Y Met Measure 317 (represented by a vii ) 18. Patient Z a. Patient Z Not Met but Reported Measure 1 (represented by c i ) b. Patient Z Not Met but Reported Measure 18 (represented by c ii )
7 c. Patient Z Met Measure 19 (represented by a iii ) d. Patient Z did Not Report Measure 117 (represented by d iv ) e. Patient Z Met Measure 130 (represented by a v ) f. Patient Z Met Measure 226 (represented by a vi ) g. Patient Z Not Met but Reported Measure 317 (represented by c vii ) 19. Reporting Algorithm a. Reporting of all applicable measures contained in the measures group, per eligible patient, equals one b. Patient X Reporting equals 1 Plus Patient Y Reporting equals 1 Plus Patient Z Reporting equals 0 for a total of 2 of the Required 20 Patient Sample Reported 20. Performance Algorithms 21. Measure 1 a. Performance Met equals 2 divided by Reported QDC for 3 eligible patients equals 66.67% Performance Rate 22. Measure 18 a. Performance Met equals 1 divided by Reported QDC for 3 eligible patients minus 0 Performance Exclusions equals 33.33% Performance Rate 23. Measure 19 a. Performance Met equals 2 divided by Reported QDC for 2 eligible patients minus 0 Performance Exclusions equals 100% Performance Rate 24. Measure 117 a. Performance Met equals 2 divided by Reported QDC for 2 eligible patients equals 100% Performance Rate 25. Measure 130 a. Performance Met equals 3 divided by Reported QDC for 3 eligible patients minus 0 Performance Exclusion equals 100% Performance Rate 26. Measure 226 a. Performance Met equals 2 divided by Reported QDC for 3 eligible patients minus 1 Performance Exclusion equals 100% Performance Rate 27. Measure 317 a. Performance Met equals 2 divided by Reported QDC for 3 eligible patients minus 0 Performance Exclusion equals 66.67% Performance Rate
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