Measure ID: MIPS 384|Ophthalmology|2026 Performance Year

Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.

Outcome – High PriorityOphthalmologyPatient Safety

Last updated: January 15, 2026

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Measure Specification

Denominator (Eligible Population)

Patients aged ≥ 18 years on the date of the procedure
ANDPatient procedure during the performance period

Denominator Exclusions1

G9756Surgical procedures that included the use of silicone oil

Numerator

Patients who did not return to the operating room within 90 days for complications within the operative eye. _NUMERATOR NOTE:_ For the purposes of meeting the numerator, complications are only those related to the following procedures: 67107, 67108, 67110

Submission Codes (QDCs)

✓ Performance Met
G9515Patient did not require a return to the operating room within 90 days of surgery
✗ Performance Not Met
G9514Patient required a return to the operating room within 90 days of surgery

Denominator Exceptions

None — this measure has no denominator exceptions.

🧮MIPS Score Simulator

Estimate only — actual CMS scoring may vary based on reporting method, data completeness, and annual rule updates.

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VBCA Insights

💡Why This Measure Matters

After retinal detachment surgery, did the patient need a second surgery within 90 days? A low rate of returns to OR means your surgical technique—cryotherapy or laser placement, retinopexy approach—is creating durable reattachment. Outcomes depend on careful preoperative planning, proper identification of all retinal breaks, and thorough treatment to the ora serrata. Low re-operation rates reflect technical excellence and patient satisfaction; high rates warrant review of case selection and operative technique.

📖Clinical Rationale

The goal of treatment for retinal breaks is to create a firm chorioretinal adhesion in the attached retina immediately adjacent to and surrounding the retinal tear using cryotherapy or laser photocoagulation to halt the progression of subretinal fluid from detaching the neurosensory retina. Treatment of peripheral horseshoe tears should be extended to the ora serrata if the tear cannot be surrounded using laser or cryotherapy.

The most common cause of failure in treating horseshoe tears is failure to adequately treat the tear, particularly the anterior border. Continued vitreous traction may extend the tear beyond the treated area and allow fluid to dissect through the subretinal space to cause a clinical retinal detachment. Treatment of dialyses must extend over the entire length of the dialysis, reaching the ora serrata beyond each horn or end of the dialysis.

Sufficient evidence exists for treating acute, symptomatic horseshoe tears. There is insufficient evidence for management of other vitreoretinal abnormalities. A Cochrane systematic review found that in making the decision to treat other vitreoretinal abnormalities, including lattice degeneration and asymptomatic retinal breaks, the risks that treatment will be unnecessary, ineffective, or harmful must be weighed against the possible benefit of reducing the rate of subsequent retinal detachment.

In a study published in 2011, Schall and colleagues studied the success rate with 4 surgical techniques. Initial success rate for retinal reattachment was 86% for scleral buckling only, 90% for vitrectomy only, 94% for the combination of scleral buckling and vitrectomy, and 63% for pneumatic retinopexy surgery. Patients undergoing pneumatic retinopexy had a lower initial success rate, however there was no statistically significant difference in initial reattachment rates between the other three groups.

In a 2002 study, Ling and colleagues reported an 85% success rate with a single procedure. Of the 15% that initially failed, 97% were successful with one additional surgery.

📝Clinical Recommendations

This is an outcome measure. As such, no clinical recommendations are included.

📋Implementation Notes

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed. This is an outcome measure and will be calculated solely using Merit-based Incentive Payment System (MIPS) eligible clinician, group, or third-party intermediary submitted data.

• For patients who receive the surgical procedures specified in the denominator coding, it should be submitted whether or not the patient had to return to the operating room within 90 days of surgery. • Include only procedures performed between January 1st and September 30th of the performance period. This will allow the post-operative period to occur before third-party intermediaries must submit data to CMS.

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