Public Comment Summary Report · The contract name is CHIPRA Electronic Clinical Quality Measure...

MATHEMATICA POLICY RESEARCH

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PUBLIC COMMENT SUMMARY REPORT

Project Title: CHIPRA Electronic Clinical Quality Measure Validity Testing 2016

Dates:

The Call for Public Comment ran from August 9, 2017 to September 7, 2017.

The Public Comment Summary was made on January 8, 2018.

Project Overview:

The Office of the National Coordinator for Health Information Technology (ONC) has

contracted with Mathematica Policy Research to conduct testing on two pediatric electronic

clinical quality measures (eCQM) focused on the completion of pediatric screenings. The first

measure—Vision Screening and Referral in Children—calculates the percentage of 6-year-olds

who were screened for vision problems at least once between their third and sixth birthdays and,

if necessary, were referred to an eye care specialist. This measure aligns with clinical

recommendations that all children have their vision screened at least once between their third and

sixth birthdays and that children who fail the screening should be referred to an eye care

specialist. A summary of the Vision Screening and Referral in Children measure that was posted

for public comment is included in Appendix A.

The second measure – ADHD: Symptom Reduction in Follow-up Period – will be described

in detail in a future public comment call posting.

The contract name is CHIPRA Electronic Clinical Quality Measure Validity Testing 2016.

The contract number is HHSP233201600017I, task order HHSP23337006T. As part of its

measure development process, ONC requested that interested parties submit comments on the

Vision Screening and Referral in Children measure being tested under this project.

Project Objectives:

The project’s primary objectives include:

Complete feasibility, validity, and reliability testing on the two pediatric eCQMs;

Gather patient perspective on the importance and usability of the measures;

Revise measure specifications, as is necessary, based on the testing results.

Information About the Comments received:

The project team conducted outreach to notify stakeholders and the general public about the

comment period. Outreach included the following:

Posting on the CMS public comment website

Sending emails to the following stakeholders and stakeholder organizations:


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- Academic Pediatric Association

- American Academy of Family Physicians

- American Academy of Nursing

- American Academy of Ophthalmology

- American Academy of Optometry

- American Academy of Pediatricians

- American Association for Pediatric Ophthalmology and Strabismus

- American Association for Physician Leadership

- American Association of Certified Orthoptists

- American Board of Family Medicine

- American Board of Ophthalmology

- American Board of Pediatrics

- American College of Preventive Medicine

- American Health Information Management Association

- American Medical Association

- American Medical Group Association

- American Medical Informatics Association

- American Ophthalmology Society

- American Optometric Association

- American Pediatric Society

- American Society of Ophthalmic Registered Nurses

- Association of University Professors of Ophthalmology

- Council of Pediatric Subspecialties

- Family Voices

- Healthcare Information and Management Systems Society (HIMSS) Electronic Health

Record Association

- Hospital-MDM Patient Family Advisory Board

- Institute for Healthcare Improvement

- Institute for Patient- and Family-Centered Care

- National Association of Pediatric Nurse Practitioners

- National Institute for Children's Health Quality

- National Optometric Association

- National Patient Advocate Foundation


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- National Patient Safety Foundation

- Opticians Association of America

- Patient Voice Institute

- The Association for Research in Vision and Ophthalmology

Requesting information about the public comment posting be shared within the following

forums, workgroups, listservs, newsletters, or group meetings:

- C3 Forum

- eCQI Resource Center

- eHealth Provider Workgroup

- eHealth Vendor Workgroup

- HL7 CQI Listserv

- MMS ListServ

- MMS Newsletter

- Weekly Governance Call for Measure Developers

Stakeholder Comments―General and Measure-Specific

We received five unique comments about the Vision Screening and Referral in Children

measure. All of these submissions had multiple comments embedded. The following

organizations provided comments:

American Academy of Pediatrics

The American Academy of Optometry’s Section on Binocular Vision, Perception and

Pediatric Optometry

American Optometric Association

Joint comment made by: the National Center for Children’s Vision and Eye Health at

Prevent Blindness, the American Association for Pediatric Ophthalmology and Strabismus,

the American Academy of Optometry’s Section on Binocular Vision, Perception and

Pediatric Optometry, and the American Academy of Ophthalmology

The American Academy of Ophthalmology

The comments and responses listed below are those that were either expressed in more than one

public comment response, resulted in a revision to the measure specifications, or identified a

potential consideration for future measure updates. These comments and responses are summary

statements. Verbatim comments and associated responses can be found in the table at the end of

this document.

Support of the Vision Screening and Referral in Children measure

Four comments included expressions of support for the measure.


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Response: Thank you for your comments. We appreciate your support of the measure.

Vision Screenings and Vision Screening Tools

Two comments included requests to add Current Procedural Terminology (CPT) codes to the

measure to capture vision screenings as providers consistently capture these codes.

Response: Although we understand the desire to capture information in the most feasible way,

the ONC’s Health Information Technology Standards Committee developed a framework

regarding using the clinical terminology standards (for example, SNOMED, ICD-10) to

represent certain data types. The Measures Management System Blueprint v.13.0 outlines this

framework and indicates that diagnostic tests defined as “any kind of medical test performed as a

specific test or series of steps to aid in diagnosis or detecting disease” must be specified using a

LOINC code (CMS 2017, CMS and ONC 2016). Therefore, we cannot use CPT codes to capture

vision screenings.

Two comments included requests to consider the implications of screenings that are completed in

non-primary care settings such as schools. Commenters noted the measure may be

overestimating the population of patients who have not received a vision screening if other

settings are not considered.

Response: We sought the expert opinion of our in-house pediatrician and our expert workgroup

members to decide how to handle these screenings within the measure. These experts indicated

that no standardized process or reliable mechanism is currently available to share vision

screening results between schools and primary care practices and, as such, pediatricians should

complete vision screenings during patients’ visits. Therefore, given the current data-sharing

environment, we did not account for screenings completed at a child’s school. As interoperability

improves, measure developers may revisit this issue. In the meantime, if the provider received

some form of documentation of the screening and felt confident in the result, the provider could

document the screening result in the EHR and make a referral, as appropriate.

One comment suggested we consider and provide guidance regarding the age appropriateness of

various vision screening tools.

Response: Thank you for the suggestion. We integrated language into the measure’s header to

outline the age appropriateness of various vision screening tools.

One comment suggested that the measure allow all screenings that occur during the measurement

period to count towards the measure, even if they occur after the child turns 6 years old, to

provide the opportunity for pediatricians to screen new patients. This commenter expressed

concern that there may be some patients who switch pediatricians during the measurement period

after the child’s sixth birthday and this new patient would be in the pediatrician’s patient

population, but the pediatrician would not have the opportunity to screen the patient.

Response: Thank you for the suggestion. We agree that this change should be considered for

future updates of the measure.


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Referrals

Two comments included requests to remove the referral requirement from the measure and focus

the measure on the completion of a vision screening. One of the two comments mentioned that

the measure does not cite literature that suggests there is a quality gap related to physicians

providing referrals for failed screenings.

Response: We developed the measure to capture the full screening-referral process in primary

care as recommended in the American Academy of Pediatrics policy statement coauthored by the

American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology

and Strabismus, and the American Association of Certified Orthoptists (2016). The yes/no

measure you suggest does not meet current guidance from CMS, which has signaled that it

discourages documentation or “check box” measures (CMS 2017). Future revisions of the

measure could incorporate any new evidence regarding the proportion of failed screenings that

result in an appropriate referral. Implementing this measure can add to the availability of data to

identify whether providers are referring children who fail vision screenings.

Two comments included requests to add optometrists to the eye care professionals explicitly

identified in the measure’s header. The commenters specifically suggested adding the italicized

text to the following statement: “…who are found to have an ocular abnormality or who fail

vision screening should be referred to a pediatric ophthalmologist, an optometrist, or an eye care

specialist appropriately trained to treat pediatric patients.”

Response: We agree with adding this to the header, and we have included a code in the referral

value set to capture referrals to optometrists. We have updated the header language accordingly.

One comment suggested we consider requiring a referral for patients whose vision screening

results indicate the patient has anisometropia.

Response: Thank you for the suggestion. We added guidance to the measure’s header to indicate

that physicians should refer patients whose screening results indicate the patient has

anisometropia—a condition where two eyes have different refractive power—even if both eyes

pass the age-specific visual acuity thresholds. The measure’s logic will not align with this

guidance as we need to present as tested results for consideration for National Quality Forum

endorsement.

One comment suggested we consider requiring the notification of the completion of the referred

care for pediatricians to receive credit for the referral to insure patients are receiving the

necessary care.

Response: Thank you for the suggestion. We agree that this change should be considered for

future updates of the measure.

Two comments suggested that we add exclusions to the measure to account for children who

should receive a direct referral to an eye care specialist regardless of their screening results.

Response: Thank you for your suggestion. Although we started with a limited number of

measure exclusions, we agree that future revisions might include integrating a direct referral


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pathway (in which certain patients must be referred to an eye care specialist regardless of

whether a screening was done) into the numerator criteria.

Exclusions

One comment suggested we consider expanding the blindness value set.

Response: Thank you for the suggestion. We added codes to the blindness value set to represent

unilateral blindness, cortical blindness, unqualified vision loss, and unspecified disorder of

binocular vision.

One comment suggested we consider excluding patients who are under the care of an

optometrist.

Response: Thank you for the suggestion. Current guidelines do not provide recommendations on

whether children with corrective eyewear should receive a vision or visual acuity screening

during their primary care visits. Therefore, the current specifications do not exclude these

patients from the measure. If guidelines are revised to exclude this population from vision or

visual acuity screening, this measure should be modified to align with the updated guidelines.

Numerator language

One comment suggested the language in the numerator statement be revised to focus on the

passing or failing result of the vision screening.

Response: Thank you for your suggestion. We modified the numerator language in the header so

that the text refers to passing or not passing the vision screening rather than referring to whether

the vision screening results indicated normal vision or worse-than-normal vision.

Preliminary Recommendations

The section above includes the recommendations that resulted in measure specification revisions

or in considerations for future measure updates. The full verbatim public comments and

associated responses can be found in the table at the end of this document.

Overall Analysis of the Comments and Recommendations

We found the feedback received to be constructive. In consultation with our expert work group,

we used the public comment feedback to update the measure and to identify considerations for

future updates.

References

American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and

Strabismus, and American Association of Certified Orthoptists. “Visual System Assessment

in Infants, Children, and Young Adults by Pediatricians.” American Academy of Pediatrics,

vol. 137, no. 1, 2016. Available at http://www.pediatrics.org/cgi/doi/10.1542/peds.2015-

3596. Accessed August 1, 2017.

http://www.pediatrics.org/cgi/doi/10.1542/peds.2015-3596

http://www.pediatrics.org/cgi/doi/10.1542/peds.2015-3596


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Centers for Medicare & Medicaid Services. “Blueprint for the CMS Measures Management

System Version 13.0.” May 2017. Available at https://www.cms.gov/Medicare/Quality-

Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-130.pdf. Accessed

September 12, 2017.

Centers for Medicare & Medicaid Services. “Medicare Program; CY 2018 Updates to the

Quality Payment Program.” Proposed Rule, 81 FR 77375. Federal Register, June 30, 2017.

Centers for Medicare & Medicaid Services, and Office of the National Coordinator for Health

Information Technology. “Quality Data Model, Version 4.3.” September 27, 2016.

Available at https://ecqi.healthit.gov/system/files/qdm_4_3_508_compliant.pdf. Accessed

September 26, 2017.

United States Preventive Services Task Force. “Vision Screening in Children Aged 6 Months to

5 Years – US Preventative Services Task Force Recommendation Statement.” Journal of the

American Medical Association, vol. 318, no. 9, 2017, pp. 836–844. Available at

http://jamanetwork.com/journals/jama/fullarticle/2652657. Accessed September 16, 2017.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-130.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-130.pdf

https://ecqi.healthit.gov/system/files/qdm_4_3_508_compliant.pdf

http://jamanetwork.com/journals/jama/fullarticle/2652657

APPENDIX A

VISION SCREENING AND REFERRAL IN CHILDREN

MEASURE SPECIFICATION SUMMARY

VISION SCREENING AND REFERRAL IN CHILDREN MEASURE SPECIFICATION SUMMARY TABLE MATHEMATICA POLICY RESEARCH

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Table 1. Vision Screening and Referral in Children measure specification summary

Title Description Denominator Denominator exclusion Numerator

Vision Screening and Referral in Children

The percentage of children who were screened for vision problems at least once between their 3rd and 6th birthdays; and if necessary, were referred to a specialist.

Children who turn 6 years of age during the measurement period and who had at least one visit during the measurement period.

Children with an active diagnosis of either blindness or amblyopia before or during the measurement period.

Children who received a vision screening to detect the presence of vision problems between their 3rd and 6th birthdays and either 1) the results of the most recent screening indicated normal vision, or 2) the results of the most recent screening indicated worse than normal vision and the child was referred to an eye care specialist.


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Public Comment Verbatim Report

Date

Posted Measure Text of Comments

Name,

Credentials, and

Organization of

Commenter Response

09/06/17 Vision Screening and Referral in Children

EHRs may include discrete results for tests, but these are unlikely to have been mapped to SNOMED or any clinical taxonomy.

American Academy of Pediatrics (AAP)

Thank you for the feedback on the feasibility of collecting the vision screening results through the use of SNOMED codes. The Office of the National Coordinator for Health Information Technology’s (ONC)’s Health Information Technology Standards Committee (HITSC) developed a framework regarding the clinical terminology standards (for example, SNOMED, ICD-10) to be used to represent certain datatypes. This framework is outlined in the Measures Management System (MMS) Blueprint v.13.0, which indicates that assessment instrument answers or responses must be specified using a SNOMED code. We acknowledge that SNOMED codes are not currently being used expansively by practices. When SNOMED codes are not used by a practice, that practice must create a crosswalk between the practice’s internal data and the SNOMED codes to calculate the measure. (Centers for Medicare & Medicaid Services [CMS] 2017)


Referrals are unlikely to appear in the EHR, as optometry does not require a referral in many cases... there is no universal way for EHRs to track “patient referred for specialty exam”.


Thank you for the feedback on the feasibility of collecting referral information from the electronic health record (EHR). We identified the challenges with collecting information on referrals in field testing. We understand that implementation of this measure might mean that providers must begin capturing referrals in a more systematic way. We acknowledge that some physicians might have to start capturing referrals to optometrists in a structured way even if the optometrist or the patient’s insurance does not require a referral.


Clinical conditions are likely to be identified using ICD/SNOMED.


Thank you for the feedback on the feasibility of collecting clinical conditions.


The AAP is concerned about having the detailed results (i.e., 20/30, 20/40) as part of the numerator because there are many ways results can be entered into a system. In many practices, it may be just a text entry, or may be typed in as “normal” instead of 20/30. This can be true for the vision chart as well as the photoscreener.


Thank you for the feedback regarding the feasibility of capturing the results of vision screenings. The measure provides two options for capturing responses to enable flexibility for providers’ documentation practices. The first option is to calculate the measure using the specific numerical results of the screening (for example, 20/30). The second option is to calculate the measure using broader categories (for example, vision normal or referral needed).


For data collection purposes, a Current Procedural Terminology (CPT) code based metric would be much better. For example: was vision screening done between ages 3 and 6 years, yes or no?


Thank you for the feedback regarding the potential for a measure focusing exclusively on CPT codes. The goal of this measure is twofold. The first goal is to assess the completion of vision screenings, and the second goal is to assess referrals for children who fail their screening, which is the necessary next step in a screening-referral care process. A metric based on CPT codes as described would only capture the first aspect of the measure. Future revisions of the measure could incorporate any new evidence regarding the proportion of failed screenings that result in an appropriate referral. The implementation of this measure can add to the availability of data to identify whether providers are referring children who fail vision screenings to eye care specialists.


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Date


Name,

Credentials, and

Organization of

Commenter Response


Specifically related to the numerator the AAP would like to suggest the following: Numerator: The AAP would like to see the numerator specifications include billing codes (99173, 99174, 99177). This may motivate payers who do not currently recognize these as non-bundled, preventive, separately payable services.


Thanks for the suggestion to add CPT codes to the vision screening value set. ONC’s HITSC developed a framework regarding the clinical terminology standards (for example, SNOMED, ICD-10) to be used to represent certain datatypes. This framework is outlined in the MMS Blueprint v.13.0, which indicates that diagnostic tests, defined as “any kind of medical test performed as a specific test or series of steps to aid in diagnosis or detecting disease,” must be specified using a LOINC code (CMS 2017; CMS and ONC 2016). Therefore, we cannot use CPT codes to capture vision screenings.


AAP’s Bright Futures recommends that not all children should be screened, but this measure only includes two conditions for exclusions. For example: children at-risk for retinopathy of prematurity, or children with developmental conditions with risk of eye complications may not be good candidates for screening.


Thank you for the feedback on adding exclusions to the measure. Although we started with a limited number of measure exclusions, we agree that future revisions might include integrating a direct referral pathway (in which certain patients must be referred to an eye care specialist regardless of whether a screening was done) into the numerator criteria.


Snellen is not a recommended screening procedure for children under 72 months of age. LEA and HOTV optotypes are the recommended chart-based screening tools. A clinician using Snellen to provide screening to a child at 48 months would not be providing the recommended care.


Thank you for the feedback on the age-appropriateness of the vision screening tools. We will integrate this guidance into the measure header. We agree that future revisions should consider excluding Snellen charts from the measure given the age range of the children included in the measure.


This measure is too aggressive. If screening rates are less than 50 percent this warrants a specific measure to drive screening in pediatric practice. There is nothing in the background to suggest that failed screens are not referred consistently by clinicians within the rationale. To that end, there should be a single yes/no measure to assess screening rates. If there is literature to support a referral measure, that should be separate.


Thank you for your suggestion. The measure was developed to capture the full screening-referral process in primary care as outlined by the United States Preventive Service Task Force (USPSTF) and recommended in the American Academy of Pediatrics policy statement coauthored by the American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists. The yes/no measure you suggest does not meet current guidance from CMS, which has signaled that documentation or “check box” measures are discouraged (USPSTF 2017; American Academy of Ophthalmology et al. 2016; CMS 2017).


Preventive visits are not required. Ideally physicians would screen children at any opportunity. As the measure is written, if a patient has not been seen for a well visit since age 3 and is now 5, she would count against the clinicians. Similarly, a 5-year-old transferring into the practice would count against the new clinician who did not screen because the patient’s record indicated that her previous provider had screened at age 4.


Thank you for sharing your concerns regarding potential circumstances in which a provider might not receive credit for completion of a screening. We aligned the measure with USPSTF’s recommendations that children should have their vision screened at least once from ages 3 to 5 to detect amblyopia or its risk factors (USPSTF 2017). In the measure, a patient must turn 6 years old and be seen by a pediatrician during the measurement period. The measure then looks back to see if the child had a screening completed between their third and sixth birthdays. In the first example provided, the measure does require a patient to be seen and a vision screening be completed within the three-year window between the child’s third and sixth birthdays. In the second example, if a child transfers into the provider’s practice, the provider must integrate the previous physician’s vision screening exam and results into the new provider’s EHR or complete another screening (if the patient is younger than 6) to receive credit for the screening.


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Date


Name,

Credentials, and

Organization of

Commenter Response


This measure includes a look-back period of two years. So if a pediatrician sees a 3-year-old who then leaves the practice and this physician typically screens at age 4, this would count against the pediatrician.


Thanks for sharing your concerns regarding the three-year look-back period. To be included in the measure, the patient must be turning 6 years old and be seen by the pediatrician during the measurement period. The measure then looks back to see if a vision screening for that child was completed between his or her third and sixth birthdays. If a patient changes pediatricians before the age of 6, the new pediatrician can perform the vision screening. Then when the child turns 6, the new pediatrician will receive credit for that screening. The one scenario in which the pediatrician does not have control of his or her score is if a child turned 6 during the measurement period and the child transfers to the new pediatrician during this measurement period after the child has already turned 6. In this situation, the child will be in the new pediatrician’s patient population and the pediatrician’s score for this child will be based on care provided by the child’s previous pediatrician(s). Future iterations of the measure should consider revising the measure so that the provider has the full measurement period to complete the screening even if the patient has already turned 6 to account for these situations, which are expected to be rare.


The AAP also believes that there should be a denominator exclusion or exception for situations where a patient is not screened because the pediatrician is aware that the patient went to an optometrist (even if there is no diagnosis of amblyopia or blindness).


Thank you for your suggestion to remove patients who are under active care by an eye care specialist. Current guidelines do not provide recommendations on whether children with corrective eyewear should receive a vision or visual acuity screening during their primary care visits. Therefore, the current specifications do not exclude these patients from the measure. If guidelines are revised to exclude this population from vision or visual acuity screening, this measure should be modified to align with the updated guidelines.


Many children are screened as part of a preschool or child care program, which does not generate a claim nor an insurance record. A question arises if a pediatrician has received the screening results: does this physician put them into the patient’s record? Or does she have to administer the screening on-site regardless of the other result and generate her own 9917x? AAP recommends logic to indicate that a vision screening has been done by another provider.


Thank you for your feedback regarding how to address vision screenings that occur outside the pediatrician’s office. We discussed this topic with our expert work group, and they indicated that there is currently no standardized process or reliable mechanism to share vision screening results between schools and primary care practices. Pediatricians should complete vision screenings during patient’s visits. As interoperability improves, consideration of how best to integrate these screening into the measure could be explored. In the meantime, if the provider received some form of documentation of the screening and felt confident in the result, the provider could document the screening result in the EHR and could make a referral, as appropriate.


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Date


Name,

Credentials, and

Organization of

Commenter Response


The measure as written does not include logic to protect against a child aging out of the sample set. For example: A child is 5 years old at the start of the measurement period but was never seen by his pediatrician. The child turns 6 and is screened with a pass during the measurement period. His doctor does not make a referral. This patient should be included in the numerator as a pass, not a fail.


Thank you for your concern about the measure missing vision screenings. We aligned the measure with USPSTF’s recommendations that children should have their vision screened at least once from ages 3 to 5 to detect amblyopia or its risk factors (USPSTF 2017). To be included in the measure, the patient must be turning 6 and be seen by the pediatrician during the measurement period. The measure then looks back to see if a vision screening for that child was completed between his third and sixth birthdays. The measure would currently not capture screenings completed during the measurement period after the child has turned 6. There might be some cases in which a child has a visit with a new pediatrician after the child has turned 6 earlier in the measurement period. In this situation, the child will be in the new pediatrician’s patient population and the pediatrician’s score for this child will be based on care provided by the child’s previous pediatrician(s). Future iterations of the measure should consider revising the measure so that the provider has the full measurement period to complete the screening even if the patient has already turned 6 to account for these potentially rare situations.


The value sets are sparse, and therefore, the AAP recommends supplementing the code lists: The following codes are not included:

Unilateral blindness

Cortical blindness

Unqualified vision loss

Unspecified disorder of binocular vision


Thank you for the suggestion of additional blindness categories that should be added to the blindness value set. We have added these codes to the value set.


In the measure specifications, only LOINC is used for vision tests. CPT should also be used, as EHRs will generate this more consistently than LOINC. Current CPT codes would capture this measure:

99173: quantitative, such as Snellen

99174: remote instrument-based

99177: on-site instrument-based

0033T: automated VEP


Thank you for the suggestion to add CPT codes to the vision screening value set. ONC’s HITSC developed a framework regarding the clinical terminology standards (for example, SNOMED, ICD-10) to be used to represent certain datatypes. This framework is outlined in the MMS Blueprint v.13.0, which indicates that diagnostic tests, defined as “any kind of medical test performed as a specific test or series of steps to aid in diagnosis or detecting disease,” must be specified using a LOINC code (CMS 2017; CMS and ONC 2016). Therefore, we cannot use CPT codes to capture vision screenings.


Measuring vision screening, with the goal of identification and treatment of amblyogenic risk factors, is of key importance in early childhood. The AAP applauds the effort to identify a pediatric vision screening measure that works for clinicians in practice.


Thank you for expressing your support of the goal of the measure.


The AAP asks that CMS recognize that it is very difficult to do screening well without instrument-based screenings.


Thank you. The measure includes instrument-based screenings.


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Date


Name,

Credentials, and

Organization of

Commenter Response


If the vision screening is failed i.e. the result if “Refer”, the measure asks for “Referral to an eye care specialist.” The AAP is concerned that it is unclear what constitutes a referral. For example: Does this mean an appointment is recommended, an appointment was made, or that the appointment was actually followed through on? Most insurance plans do not require referrals to optometry so it is unlikely that many pediatricians (even those who consistently track referrals) generate a new e-form within the EHR.


Thank you for your question regarding what constitutes referrals within the context of the measure. The referral used in this measure is intended to capture the recommendation for an appointment or a formal referral. This level of referral is used so that the measure aligns with the goal of vision screening and appropriate referral within primary care. It is not intended to reflect the scheduling or completion of the referral appointment.


There is a referral reason that is not listed in the guidance: if there is a significant refractory difference between the two eyes. For example, if a 3-year-old screens as left eye 20/30, right eye 20/50, and binocular vision 20/30, all screens meet the threshold for a 3-year old of 20/50. The EHR says “left eye PASS, right eye PASS, binocular PASS” but there is still an “ALERT Anisometropia-refer!!” The AAP believes that CMS should clarify this guidance by determining, for the purposes of this measure, if this counts as a pass or fail.


Thank you for sharing this additional referral rationale. We agree with this recommendation and have added it to the guidance section of the measure’s header.


Specifically related to the denominator the AAP would like to suggest the following: Denominator: The AAP suggests the use of denominator exceptions rather than exclusions in most conditions, and an expansion of the exceptions. Blindness is an exclusion, but if the physician has a patient with glasses and does not perform screening because her patient has seen an ophthalmologist/optometrist, does that suffice? We recommend including “seen by ophthalmologist/optometrist, wears glasses” as an exception.


Thank you for your suggestion to remove patients who are under active care by an eye care specialist. Current guidelines do not provide recommendations on whether children with corrective eyewear should receive a vision or visual acuity screening during their primary care visits. Therefore, the current specifications do not exclude these patients from the measure. If guidelines are revised to exclude this population from vision or visual acuity screening, this measure should be modified to align with the updated guidelines.


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Date


Name,

Credentials, and

Organization of

Commenter Response


Health insurers who carve out vision and have that part of the plan managed by another vision services plan, may not be timely in reporting their claims back to the insurance carrier, or there may be differences in the claims platform between the vision services plan and the insurance carrier that impedes the insurance carrier from having data for its quality program that utilizes claims data and quality metrics. Pediatricians see something similar in fluoride varnish quality programs where Medicaid has a dental benefit manager and the Medicaid Managed Care Organizations (MCOs) who are doing the reporting only know who is reporting 99188 to the MCO not D0190/D1206 to the dMCO. The AAP urges CMS to take this scenario into account when continuing to develop this measure.


Thanks for your comment on the availability of data. This measure is an electronic clinical quality measure, and therefore the data comes from a practice’s EHR system and not the insurance company’s claims.


We are writing to comment on and express support for the CHIPRA Electronic Clinical Quality Measure: Vision Screening and Referral in Children. In clinical practice we frequently encounter young children with complicated visual problems for whom we conclude, if only this child had received a comprehensive eye exam at a younger age. Untreated vision problems such as high refractive error, strabismus, and amblyopia interfere with vision and overall development. Moreover, the longer they go untreated, the more difficult it is to ameliorate the functional defects. Vision screenings done correctly by trained personnel in a timely manner will be a step towards identifying needy children sooner. This CHIPRA Electronic Clinical Quality Measure is a worthy undertaking to provide factual data regarding the regularity of vision screenings of children age 3 to 5 years.

The American Academy of Optometry’s Section on Binocular Vision, Perception and Pediatric Optometry

Thank you for expressing your support of the measure.


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Date


Name,

Credentials, and

Organization of

Commenter Response


Additionally, we agree with the recommendation highlighted in the document regarding the clinical statement in the Performance Measure Detail document titled “Vision Screening and Referral in Children.” Specifically, as pediatric optometrists are specifically trained to treat these patients, and are widely dispersed throughout the country, including rural and communities of low income families, we agree with the recommendation to change the text that current reads “…who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients” be changed to the following text“…who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist, an optometrist, or an eye care specialist appropriately trained to treat pediatric patients.” As stated in the letter, we too believe this revision will promote wider opportunities for eye care referral following a failed vision screening, ultimately leading to better patient care for these needy individuals.

The American Academy of Optometry’s Section on Binocular Vision, Perception and Pediatric Optometry

Thank you for this suggestion. We will add this language to the measure header. Referrals to optometrists are included in the referral value set.


Although the draft measure specifications may intend to limit reporting to pediatricians, it is important to recognize that even when done in a pediatrician's or primary care physician's office, the scope of vision screening may be limited by the type of testing equipment available. Factors such as training of the individual conducting the screening, room lighting, testing distances, and maintenance of the testing equipment can also affect test results. Ambiguity and inconsistency remains in these and other related factors, primarily due to the lack of clearly identified targeted outcomes.


Thank you for expressing your concerns regarding the completion of vision screenings within the primary care practice. We aligned the measure with USPSTF’s recommendations that children should have their vision screened at least once from ages 3 to 5 to detect amblyopia or its risk factors (USPSTF 2017).


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In addition to the lack of a universally accepted definition of “vision screening”, it is unclear as to which specific problems this measure will effectively identify and accurately reflect. This measure as currently written will result in a variety of negative downstream consequences relative to children in the utility, analysis, and subsequent strength of data and findings arising from the imprecision. Many childhood eye and vision conditions/disorders will go undocumented and/or untreated if referral to the eye doctor lacks follow through and eye examination is not completed. Any anticipated subsequent outcomes, including comparative analyses related to effectiveness and cost, will be compromised in strength and specificity. Any resulting workforce data will be limited in scope. From the population health perspective, the measure poses great difficulty in accurately representing targeted health outcomes of this group of individuals. Ultimately, it adversely affects proper assessment of the distribution of outcomes within this targeted group. Without clear metrics, the measure as written only provides a limited opportunity to view results from following a subjective referral approach to accessing eye care, instead of objectively identifying a targeted health problem/condition for intervention as is customary with recommended health screening.


Thank you for your feedback on your concerns regarding this measure. The level of analysis for this measure is not intended to be at the population level, but the individual physician level. We aligned the measure with USPSTF’s recommendations that all children ages 3 to 5 should have their vision screened at least once to detect amblyopia or its risk factors. The measure captures many of the vision screening assessments outlined in USPSTF’s recommendations, such as visual acuity screenings and instrument-based vision screening completed with autorefractors and photoscreeners. (USPSTF 2017).


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While it is valuable for CMS to focus on children’s eye care issues, it is critically important to recognize the limitations of vison screenings. Many vision screenings test only for distance visual acuity. While the ability to see clearly at a distance is important, it does not indicate how well the eyes focus up-close or work together. In addition to appropriately interpreting what the eyes see, the foundational visual skills children need to succeed in the classroom include the ability to focus the eyes at distance and at near, to use both eyes together as a team, and to move the eyes efficiently and effectively. When discussing screenings, it is important to understand the distinction between 1) the accepted use of screenings as traditionally referenced from a public health perspective that are evidence-based for a specific individual biomarker/procedure/metric (i.e., colonoscopy, a1c, BP) and 2) a recognized series of procedures, assessments, and tests (like a wellness physical or other exam sequence) that requires clinical decision making based on evidence and patient presentation. There’s no one individual test, metric or finding that can rule in or rule out a healthy eye/visual system. If this measure does not specify the exact problem being targeted, then it is poised to fail on multiple levels.


Thank you for your feedback on your concerns regarding this measure. The level of analysis for this measure is not intended to be at the population level, but the individual physician level. We aligned the measure with USPSTF’s recommendations that all children ages 3 to 5 should have their vision screened at least once to detect amblyopia or its risk factors. The measure captures many of the vision screening assessments outlined in the USPSTF’s recommendations, such as visual acuity screenings and instrument-based vision screening completed with autorefractors and photoscreeners (USPSTF 2017).


It is clear from the draft measure specifications that CMS is working to capture the various vision screening protocols that are available and leave the screening approach up to the pediatrician by indicating, “pediatricians should choose the most cognitively difficult test that the child is capable of performing.” The specifications also indicate, “Instrument-based screenings are an acceptable method of vision screening…practices that use these instruments will have to use screening guidance that accompanies the device to determine if a patient has passed the screening or requires a referral.” The variances in screening approaches and the potential for differences in instrument-based screening products complicate this measure and cast significant doubt on its usefulness. Research has found that when Snellen visual


Thank you for expressing concern about the accuracy and scope of vision screening. We aligned the measure with USPSTF’s recommendations that all children ages 3 to 5 should have their vision screened at least once to detect amblyopia or its risk factors. The measure captures many of the vision screening assessments outlined in the USPSTF’s recommendations, such as visual acuity screenings and instrument-based vision screening completed with autorefractors and photoscreeners. The USPSTF “found adequate evidence that vision screening tools are accurate in detecting vision abnormalities, including refractive errors, strabismus, and amblyopia” (USPSTF 2017).


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acuity alone was used as a screening tool, it was 100 percent specific for identifying reduced acuity due to myopia (nearsightedness), but missed 75.5 percent of the children found to have, hyperopia, and or binocular and oculomotor vision problems when given a complete visual examination.1 Additionally, a study of 1,992 school-age children found that 41 percent of children who failed the State University of New York screening battery would not have been identified if the screening was based on visual acuity alone.2 The U.S. Preventive Services Task Force (USPSTF) has concluded that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children 3 years of age and younger.3 While the USPSTF concluded with moderate certainty that vision screening for children 3 to 5 years of age has moderate net benefit compared with no screening, they did not compare the benefit of screening to a comprehensive eye examination.4 Vision screening procedures lack the evidence needed, with proven high sensitivity and specificity, for identifying the targeted vision problems present in the population of children being screened.5 6, The sensitivity of a wide variety of screening techniques was evaluated by the Vision in Preschoolers (VIP) study, which unlike standard screenings, used licensed eye doctors who had completed VIP study specific training and certification.7 In the study, the sensitivity of 11 vision screening techniques used for detecting clinically significant vision problems in children 3 to 5 years of age varied from 16 percent to 64 percent, with specificities ranging from 62 percent to 98 percent. These tests were compared again with a specificity of 94 percent, and the sensitivity dropped even further,8 the most common being Lea Symbols Visual Acuity (49 percent sensitivity), HOTV Visual Acuity ((36 percent sensitivity), MTI Photoscreener (37 percent sensitivity), Retinomax Autorefractor (52 percent sensitivity) and SureSight Vision Screener (51 percent sensitivity).9 It also remains unclear as to if access to instruments with high sensitivity is readily available for pediatricians and primary care providers. In addition to the resulting variability from a limited clinical decision making perspective, these well proven concerns regarding the specificity of procedural screening methods and resulting low granularity data from which outcomes


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will be assessed raise serious concerns regarding the usefulness of this measure for America’s children and for CMS quality programs.


An additional complicating factor for this quality measure is the intersection of this draft measure and current state laws regarding eye examinations, vision screenings, school-based screening programs and screening programs offered by organizations, such as Head Start. Many states have vision screening and eye examination requirements and some states specify the vision screening protocols that must be used. The individuals who provide these screenings vary widely in training and background. Other states, such as Illinois, Nebraska, Kentucky, and Missouri, recognize the importance and value of a comprehensive eye examination and state law mandates that each child has an eye exam prior to entering kindergarten or entering a public, private or parochial school for the first time. For example, the state of Kentucky requires proof of a vision examination by an optometrist or ophthalmologist be submitted to the child’s school no later than January 1 of the first year that a three to six year old child is enrolled in public school, public preschool, or Head Start program.


Thank you for expressing your concerns of variability of state laws regarding vision exams. This measure was developed as measure of vision screening in primary care settings for children and was aligned with USPSTF’s 2017 recommendation that all children should have their vision screened at least once from ages 3 to 5 to detect amblyopia or its risk factors (USPSTF 2017). The measure is not intended to reflect vision screening or comprehensive eye exams at the population level, including those outside primary care. The measure includes options for multiple screening tools and is agnostic to the specific screening tool used. In states where comprehensive eye exams are required, primary care physicians can document the occurrence of the eye exam and the exam results to make sure children are getting their vision screened. This documentation could be used to calculate the measure.


There are also a number of state-based vision screening initiatives, such as the North Carolina school nurses program; mobile eye clinics used in Los Angeles; and Head Start and Early Head Start programs. Because of the number of initiatives already underway, the measure as currently constructed would capture data that is inaccurate and, more importantly, would do little to improve eye care for children.


Thank you for your feedback regarding how to address vision screenings that occur outside the pediatrician’s office. We discussed this topic with our expert work group, and they indicated that there is currently no standardized process or reliable mechanism to share vision screening results between schools and primary care practices. Pediatricians should complete vision screenings during patient’s visits. Therefore, given the current data sharing environment, we did not account for screenings completed at a child’s school. As interoperability improves, consideration of how best to integrate these screening into the measure could be explored. In the meantime, if the provider received some form of documentation of the screening and felt confident in the result, the provider could document the screening result in the EHR and could make a referral as appropriate.


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While more must be done to ensure that children are receiving appropriate and necessary eye care, we strongly believe that the CMS measure must be refined and revised in order to develop a quality measure that truly meets the CMS goal to assure quality health care through accountability and public disclosure. As an initial step, we would encourage CMS to review the AOA’s “Evidence-based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination” housed in the National Guideline Clearinghouse.10 The guidelines combine the best available current scientific evidence and research with expert clinical opinion following an approved Institute of Medicine process to recommend appropriate steps in the diagnosis, management, and treatment of infants and children with various eye and vision conditions. The body of research that CMS relied upon the development of this measure is rather limited and we would strongly encourage CMS to review the 251 pieces of research evaluated in development of the AOA’s pediatric clinical practice guidelines.


Thank you for your suggestion. This measure was developed as a measure of vision screening in primary care settings for children and was aligned with USPSTF’s 2017 recommendation that all children should have their vision screened at least once from ages 3 to 5 to detect amblyopia or its risk factors (USPSTF 2017). The measure is not intended to reflect vision screening or comprehensive eye exams at the population level, including those outside primary care.


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Although comprehensive pediatric eye examinations are essential for timely diagnosis and treatment of eye disease and to maintenance of good vision, the Centers for Disease Control and Prevention (CDC) reported that less than 15 percent of preschoolers receive an eye examination by an eye care professional. Many children who fail a screening do not receive the necessary treatment of their conditions. A study of public school children reported only 38.7 percent who failed the vision screening received follow-up care after screenings.11 Due to a lack of follow-through, screenings alone may not lead to the earlier diagnosis and treatment of eye and vision problems. While screenings may identify some children at risk for vision problems, a comprehensive eye exam is necessary for definitive diagnosis and appropriate treatment.12 While we appreciate that CMS has included the need for a referral in the draft quality measure, we believe that this portion of the measure must be strengthened with aspects from the CMS “Closing the Referral Loop” quality measure. In the “Closing the Referral Loop” measure rationale, CMS fully recognized the challenges in the referral process and specifically noted: Problems in the outpatient referral and consultation process have been documented, including lack of timeliness of information and inadequate provision of information between the specialist and the requesting physician (Gandhi, 2000; Forrest, 2000; Stille, 2005). In a study of physician satisfaction with the outpatient referral process, Gandhi et al. (2000) found that 68% of specialists reported receiving no information from the primary care provider prior to referral visits, and 25% of primary care providers had still not received any information from specialists 4 weeks after referral visits. In another study of 963 referrals (Forrest, 2000), pediatricians scheduled appointments with specialists for only 39% and sent patient information to the specialists in only 51% of the time.13


Thank you for your suggestion to capture the completed referral. Although we agree it is important for the referred care to be provided, this additional step of checking that the appointment was completed was not included in pilot testing and thus is currently beyond the scope of the validation of this measure. The measure’s steward could consider incorporating a requirement for notification of the completion of the referral into future revisions of the measure.


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It is clear that to actually improving care requires tracking whether children are receiving the follow up care needed and whether the referring physician received a report back from the referred to physician. To ensure that appropriate follow up care is received and communication between the physicians exists, we recommend that the electronic specifications be expanded to capture instances in which a referral has occurred and when a report was received from the physician to whom the patient was referred. In the quality measure specifications, this could be achieved through the use of the value sets currently included in the Closing the Referral Loop quality measure, including "Communication: From Provider to Provider: Consultant Report" using the "Consultant Report Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1006)." CMS must work to integrate aspects of the “Closing the Referral Loop” measure in any vision screening measure that is further pursued. In development of the closing the referral loop measure, CMS specifically noted concerns related to referrals from pediatric practices; to ignore those realities in the development of the vision screening quality measure intended to be reported by pediatricians is unacceptable. After all, the purpose of any screening tool is to identify individuals at high risk for having or developing a given condition. Failure to complete the referral to a comprehensive eye exam with an eye doctor all but ensures a failure to diagnose and treat a plethora of eye conditions that significantly impact the health and development of a child.


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CMS must also consider how children who have coverage for comprehensive eye exams under Medicaid or private insurance would be impacted by this measure. The National Academies of Sciences, Engineering and Medicine in their 2016 report recognized that comprehensive eye examinations are “the gold standard in clinical vision care to most accurately identify and diagnose eye and vision problems.”14 To encourage the provision of a vision screening when a child has true, readily-available access to care is unacceptable. Our nation's children all deserve a clear future. CMS should work to ensure that children have the tools needed to succeed in school and later in life. If children are not assessed early and regularly, through comprehensive eye examination, greater levels of preventable disease disparity and disability will result.


Thank you for your suggestion to consider coverage for comprehensive examinations. This measure was developed as a measure of vision screening in primary care settings for children and was aligned with USPSTF’s 2017 recommendation that all children should have their vision screened at least once from ages 3 to 5 to detect amblyopia or its risk factors (USPSTF 2017). The measure is not intended to reflect vision screening or comprehensive eye exams at the population level, including those outside primary care.


Currently, the measure numerator is defined as, “Children who received a vision screening to detect the presence of vision problems between their 3rd and 6th birthdays and either 1) the results of the most recent screening indicated normal vision, or 2) the results of the most recent screening indicated worse than normal vision and the child was referred to an eye care specialist.” If CMS moves forward with a measure focused on vision screening, this language must be revised. The term “normal vision” is not appropriate terminology and is lacking in precision. The term “normal visual acuity at distance”15 would be more accurate terminology as this measure as drafted would not assess any vision conditions outside of visual acuity at distance.


Thank you for your comment on the definition of normal vision. We will modify the language used in the measure’s header to read “Children who received a vision screening to detect the presence of vision problems between their third and sixth birthdays and either 1) passed her or his most recent vision screening, or 2) did not pass her or his most recent vision screening and was referred to an eye care specialist.”


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The current denominator exclusions for the measure are quite limited, only excluding children with an active diagnosis of either blindness or amblyopia before or during the measurement period. If CMS continues to develop this quality measure and focus on vision screenings, additional denominator exclusions must be added. While there is much robust discussion regarding the overall value and reliability of vision screenings, the general consensus among the eye care community is that if vision screening must be used, there are children who should bypass a vision screening and must go directly to an eye exam. We urge CMS to consider these recommendations from various eye care organizations. Including the following: (For brevity we include only AOA’s suggested list of children who should receive direct referrals). Based on the concerns of various eye care organizations and stakeholders, the AOA recommends the following additional exclusions be added to the measure specifications:

Children with observable ocular abnormalities

Children reporting symptoms

Children with first-degree relatives with strabismus or amblyopia

Children with systemic conditions with associated ocular abnormalities

Children with neurodevelopmental disorders

Children who were born prematurely and/or low birth weight

Children with motor abnormalities such as Cerebral Palsy

Children with Down Syndrome

Children with cognitive impairment

Children with hearing impairments

Children with speech/language delays

Children with autism spectrum disorders

Children whose parents believe their child may have a vision problem

Children whose teachers believe their student may have a vision problem

Children diagnosed with ADHD

Children with Individualized Education Plans (IEPs)

Children with a family history of vision impairment/vision loss


Thank you for the feedback to add exclusions to the measure. Although we started with a limited number of measure exclusions, we agree that future revisions might include integrating a direct referral pathway (in which certain patients must be referred to an eye care specialist regardless of whether a screening was done) into the numerator criteria.


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Without an expansion of the children that should be directly referred to an eye doctor and excluded from the measure, the value and accuracy of the quality measure is significantly decreased. With the general agreement from various organizations related to the children that should go directly to care, there should be no reason for CMS to continue with the limited exclusions for the measure as currently drafted.


Careful and uniform implementation of this measure will provide much-needed data that will drive improvements in vision screening practice, reduce disparities in receipt of preventive vision services, and guide uniform best practices in children’s vision health. It is our desire that our combined voices on these comments demonstrate the importance that the Vision Screening and Referral Performance Measure will have on the children’s vision and eye health community. (Additional support of this measure was provided but was excluded from this table for brevity.)

The National Center for Children’s Vision and Eye Health at Prevent Blindness, the American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Optometry’s Section on Binocular Vision, Perception and Pediatric Optometry, and the American Academy of Ophthalmology



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The purpose of vision screening is to increase the number of individuals in need of care who ultimately receive comprehensive eye exams and necessary treatment. As such, in the Performance Measure Detail document titled, “Vision Screening and Referral in Children,” we would recommend that the clinical statement be revised from the current text which reads as, “…who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients“ be changed to the following text “…who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist, an optometrist, or an eye care specialist appropriately trained to treat pediatric patients.“ This revision will promote wider opportunities for eye care referral following a failed vision screening, which can be an access issue for children covered by Medicaid in areas with no or few pediatric specialty-trained eye professionals.

The National Center for Children’s Vision and Eye Health at Prevent Blindness, the American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Optometry’s Section on Binocular Vision, Perception and Pediatric Optometry, and the American Academy of Ophthalmology

Thank you. We will add this language to the measure header. Referrals to optometrists are included in the referral value set.


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The American Academy of Ophthalmology supports the measure: Vision Screening and Referral in Children. This measure would encourage early vision screening for visual impairments in children so that they can be appropriately referred to eye care specialists. The American Academy of Ophthalmology (AAO), the American Academy of Pediatrics (AAP), and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) recommend timely screening for the early detection and treatment of eye and vision problems in America's children, including during preschool years. Effective vision screening maximizes the rate of problem detection while minimizing unnecessary referrals and cost. Common eye conditions that can be detected include reduced vision in one or both eyes from amblyopia, uncorrected refractive errors, misalignment of the eyes (strabismus), or other eye defects. Early detection of treatable eye disease in childhood can have far-reaching implications for vision and, in some cases, for general health.




There is nothing in the background to suggest that failed screens are not referred consistently by clinicians within the rationale. Therefore, we support the removal of the referral requirement of the measure. The measure should only be whether or not a vision screening was performed.


Thank you for your suggestion to consider removing the referral aspect of the measure. The measure was developed to capture the full screening-referral process in primary care as recommended in the American Academy of Pediatrics policy statement coauthored by the American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists (American Academy of Ophthalmology et al. 2016). The yes/no measure you suggest does not meet current guidance from CMS, which has signaled that documentation or “check box” measures are discouraged (CMS 2017). Future revisions of the measure could incorporate any new evidence regarding the proportion of failed screening that result in an appropriate referral. The implementation of this measure can add to the availability of data to identify whether providers are referring children who fail vision screenings.


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While the Academy supports the measure, we encourage the measure developer to include CPT codes to this measure to ensure vision screening is captured in situations in which LOINC codes are not used or when EHR systems are not able to handle the new LOINC codes. The CPT codes that should be added to this measure include: 99173, 99174, 99177, and 0033T. While a LOINC code, could be beneficial in that they are agnostic to the screening method, there is uncertainty regarding the degree to which EHR systems would incorporate these new codes, and including the four CPT codes, in addition to the LOINC codes, would ensure screenings are captured.


Thank you for the suggestion to add CPT codes to the vision screening value set. ONC’s HITSC developed a framework regarding the clinical terminology standards (for example, SNOMED, ICD-10) to be used to represent certain datatypes. This framework is outlined in the MMS Blueprint v.13.0, which indicates that diagnostic tests, defined as “any kind of medical test performed as a specific test or series of steps to aid in diagnosis or detecting disease,” must be specified using a LOINC code (CMS 2017; CMS and ONC 2016). Therefore, we cannot use CPT codes to capture vision screenings.

Source: Vision Screening and Referral in Children measure’s public comment period than spanned from August 9 to September 7, 2017. Comments were captured in JIRA.

Note: Citations indicated in the comments column are copied verbatim from the public comment submission. 1 Lieberman S, Cohen AH, Stolzberg M, Ritty JM. Validation study of the New York State Optometric Association (NYSOA) Vision Screening Battery. Am J Optom Physiol Opt 1985; 62:165-68. 2 Bodack MI, Chung I, Krumholtz I. An analysis of vision screening data from New York City public schools. Optometry 2010; 81:476-84. 3 https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/vision-in-children-ages-6-months-to-5-years-screening 4 https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/vision-in-children-ages-6-months-to-5-years-screening 5 Schmidt P, Maguire M, Dobson V, et al. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision In Preschoolers Study. Ophthalmology 2004; 111:637-50. 6 Ying GS, Kulp MT, Maguire M, et al. Sensitivity of screening tests for detecting vision in preschoolers-targeted vision disorders when specificity is 94%. Optom Vis Sci 2005; 82:432-38. 7 Schmidt P, Maguire M, Dobson V, et al. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision In Preschoolers Study. Ophthalmology 2004; 111:637-50. 8 Ying GS, Kulp MT, Maguire M, et al. Sensitivity of screening tests for detecting vision in preschoolers-targeted vision disorders when specificity is 94%. Optom Vis Sci 2005; 82:432-38. 9 http://www.visionandhealth.org/documents/Child_Vision_Report.pdf 10 http://aoa.uberflip.com/i/807465-cpg-pediatric-eye-and-vision-examination 11 Jacobson J. Why can’t Johnny read? Abell Report 2010; 23:1-8. 12 Atkinson J, Nardini M, Anker S, et al. Refractive errors in infancy predict reduced performance on the movement assessment battery for children at 3 1/2 and 5 1/2 years. Dev Med Child Neurol 2005; 47:243-51. 13 https://ecqi.healthit.gov/system/files/ecqm/measures/CMS50v6_0.html 14 https://www.nap.edu/read/23471/chapter/9#330 15 https://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/visual-acuity?sso=y

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/vision-in-children-ages-6-months-to-5-years-screening

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/vision-in-children-ages-6-months-to-5-years-screening

http://www.visionandhealth.org/documents/Child_Vision_Report.pdf

http://aoa.uberflip.com/i/807465-cpg-pediatric-eye-and-vision-examination

https://ecqi.healthit.gov/system/files/ecqm/measures/CMS50v6_0.html

https://www.nap.edu/read/23471/chapter/9%23330

https://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/visual-acuity?sso=y

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