Who is eligible for MIPS 384?

Patients aged 18 years or older who had surgery for primary rhegmatogenous retinal detachment.

Is MIPS 384 the same as MIPS 384?

Yes. CMS uses zero-padded three-digit Quality IDs (384) in official specifications, while clinicians often search for MIPS 384 or Quality ID 384 without the leading zero. Both refer to the same 2026 MIPS quality measure reported through the Quality Payment Program (QPP).

How do I report MIPS Measure 384 in 2026?

MIPS Measure 384 (Quality ID 384) is reported through the Quality Payment Program (QPP) as a MIPS Clinical Quality Measure (CQM) via qualified registry, or Medicare Part B claims where applicable.

Is MIPS 384 a topped-out measure?

Yes, MIPS 384 is currently topped out, which means most clinicians perform well on this measure and it may be subject to a 7-point scoring cap.

Measure ID: MIPS 384|Ophthalmology|2026 Performance Year

2026 MIPS Measure #384: 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

Measure ID:MIPS 384 (Quality ID 384)

Collection:MIPS CQM

Topped Out:Yes

View CMS Spec ↗

Measure Specification

Eligible Population

Patients aged ≥ 18 years on the date of the procedure

ANDPatient procedure during the performance period

Exclusions

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

Reporting Codes

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

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.

VBCA is a CMS-approved Qualified Clinical Data Registry (QCDR) that submits MIPS Measure 384 to the Quality Payment Program (QPP). Practices can report this measure as a MIPS Clinical Quality Measure (CQM) or through qualified registry submission.

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Specialty Measure Sets

Ophthalmology

Related Measures

Ophthalmology

MIPS 117: Diabetes: Eye Exam MIPS 141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR MIPS 191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery MIPS 303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract MIPS 304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery MIPS 385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement MIPS 389: Cataract Surgery: Difference Between Planned and Final Refraction MIPS 499: Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following MIPS 500: Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up MIPS 501: Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate

Patient Safety

MIPS 130: Documentation of Current Medications in the Medical Record MIPS 145: Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy MIPS 155: Falls: Plan of Care MIPS 164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation MIPS 168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration MIPS 181: Elder Maltreatment Screen and Follow-Up Plan MIPS 259: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured MIPS 275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before MIPS 286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia MIPS 351: Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk MIPS 354: Anastomotic Leak Intervention MIPS 355: Unplanned Reoperation within the 30-Day Postoperative Period MIPS 357: Surgical Site Infection (SSI)MIPS 374: Closing the Referral Loop: Receipt of Specialist Report MIPS 385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement MIPS 392: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation MIPS 393: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation,MIPS 413: Door to Puncture Time for Endovascular Stroke Treatment MIPS 422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse MIPS 432: Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic MIPS 513: Patient Reported Falls and Plan of Care

Official Resources

📄 CMS Measure Specification (PDF)🔗 QPP Quality Payment Program

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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