Medicare

Medicare Claims at a Glance

Medicare Claims at a Glance
Medicare Part B Fee for Service Claims
Data type 100% Medicare Part B Fee for Service Medical claims
Sample Convenience sample of Medicare beneficiaries, including nearly 89% of the US population aged 65 years and older, as well as 3.3% of the US population younger than 65, including persons disabled due to blindness
VEHSS Topics Included Service Utilization
Eye Health Conditions
Years Analyzed 2014, 2015, 2016, 2017
Approximate Size 30 million persons per year

The analysis of Medicare claims for the Vision and Eye Health Surveillance System (VEHSS) includes beneficiaries who were fully enrolled in Medicare Part B Fee-for-Service (FFS) for the duration of 2014, 2015, 2016, or 2017.

Medicare claims represent a convenience sample that includes approximately 30 million individuals annually. Data from patients enrolled in Medicare managed-care plans were not included, as these plans do not include individualized claims for services.  In 2018, 2.2 million Americans were enrolled in Medicare advantage plans.

Medicare covers ophthalmologic services for nearly the entire US population aged 65 and older, for people younger than 65 who have received social security benefits as a result of disability for 24 months; for people who have end stage renal disease and receive dialysis or a kidney transplant; and for people who have amyotropic lateral sclerosis (ALS). Like others with a disability, people with US defined blindness (a best corrected acuity of 20/200 or worse in the better-seeing eye) become eligible for Medicare after 24 months of social security enrollment. In 2015, approximately 42.5 million out of 47.8 million Americans aged 65 and older (88.9%) were enrolled in Medicare Part B (which covers outpatient services).[1] Because of this high coverage rate, those enrolled are roughly representative of the overall population aged 65 and older. In contrast, only 9 million out of 273.6 million Americans aged 0 to 64 (3.3%) were enrolled in Medicare, and because these individuals are primarily eligible via disability, they are disproportionately sicker and poorer than other Americans in this age group.[2]  Additionally, Medicare does not cover all services. Routine eye exams and optometry services are not covered by Medicare except in rare circumstances.

NORC and its subcontractor KPMG LLP obtained access to 100% Medicare FFS claims data through the Centers for Medicare and Medicaid Services (CMS) Virtual Research Data Center (VRDC). Medicare data included a number of analytic files containing FFS claims organized into files by type of care, such as carrier files (also known as the Physician/Supplier Part B claims files), outpatient files, as well as denominator files (with information on eligibility and enrollment).  Through the VRDC, the project team had access to 100% CMS research identifiable files (RIFs), including:

  • Inpatient.
  • Outpatient.
  • Skilled Nursing Facility.
  • Hospice.
  • Home Health.
  • Carrier.
  • Durable Medical Equipment (DME).
  • Master Beneficiary Summary File (MBSF) Base File.
    • MBSF Chronic Conditions segment file.
    • Part D Event data.
    • Part D Characteristics, including Drug, Pharmacy, Prescriber, and Plan characteristics.

Please see the Research Data Assistance Center websiteexternal icon for a CMS description of each file.

Analysis Overview

VEHSS analyzed the 2014, 2015, 2016, and 2017 100% Medicare FFS claims databases to estimate the annual prevalence rate of treated diagnoses and the rate of clinical procedures. KPMG analyzed the data and generated de-identified summary reports of frequencies and rates, summarized by state and by age group, race/ethnicity, and sex. NORC further analyzed the summary data files, mapping outcomes to VEHSS-defined categories, calculating confidence intervals, and cleaning data. Results were further suppressed if the numerator was <3 and the denominator was less than 30, or the numerator was ≥3 and the denominator was ≤30.

A detailed description of the analytical steps is described in the report “VEHSS Claims & Registry Data Analysis Plan pdf icon[PDF – 579 KB]external icon.” Full analysis documentation is included in the “VEHSS Medicare Data Report pdf icon[PDF – 1.5 MB]external icon.”

Service Utilization–Eye Exams

VEHSS currently analyzes one category of Service Utilization–the proportion of Medicare beneficiaries who have an eye exam annually. The Eye Exam indicators analyzed in Medicare claims data are listed in Table 1.

Table 1. Service Utilization Indicators Analyzed in VEHSS
Category Subgroup
AMD treatment, among diagnosed AMD patients​ Any AMD procedure
Intravitreal injections (including anti-VEGF)
Laser surgery
Photodynamic therapy
Cataract surgery, among diagnosed cataract patients Any Cataract treatment
Cataract surgery
Diabetic retinopathy Treatment, among diagnosed diabetic retinopathy patients Any DR treatment
Intravitreal injections (including anti-VEGF)
Laser/photocoagulation
Retinal detachment repair
Victrectomy
Eye exams By any provider type
By an ophthalmologist or other physician
By an optometrist or optician
Glaucoma treatment, among diagnosed glaucoma patients Any glaucoma treatment
Drain
Glaucoma surgery
Laser surgery
Imaging or diagnostic test Any diagnostic eye test
Flourescein angiography
Gonioscopy
Optical coherence tomography
Stereo fundus exam
Tonometry test
Visual field testing
Screening Any eye or vision screening
Glaucoma screening
Vision screening
Diabetic Retinopathy Telemedicine Screening
Vision correction Any vision correction
Contact lens or fitting
Eyeglasses

Medical Diagnoses

VEHSS categorizes diagnosis codes into medical diagnosis categories and subgroups. Individual Medicare beneficiaries were assigned to diagnosis categories and subgroups based on International Classification of Diseases (ICD) 9 (permissible in 2014) or ICD10 diagnosis codes on any patient claim during the year of observation. As reported in the “VEHSS Diagnosis Code Categories and Crosswalk,” we identified all eye and vision related ICD10 diagnosis codes, and organized them into a two-level categorization structure, including 17 categories and 78 subgroups, as listed in Table 2.

Eye Condition Included subgroups Subgroup description
Table 2. Medical Diagnosis Indicators Analyzed in VEHSS
Retinal Detachment and Defects​ Retinal Detachment and Defects Retinal detachment and retinal breaks without detachment.
Diabetic eye diseases Early/mild diabetic retinopathy Early/Mild Diabetic Retinopathy includes diagnosis codes for background diabetic retinopathy, nonproliferative diabetic retinopathy, or mild nonproliferative diabetic retinopathy.
Moderate /severe non-proliferative diabetic retinopathy Moderate /Severe Non-proliferative Diabetic Retinopathy includes diagnosis codes indicating moderate or severe nonproliferative diabetic retinopathy, without macular edema.
Proliferative diabetic retinopathy Proliferative Diabetic Retinopathy includes diagnosis codes indicating proliferative diabetic retinopathy, without macular edema.
Diabetic macular edema (DME) Diabetic Macular Edema (DME, CSDME) includes diagnosis codes indicating diabetic retinopathy of any type with the presence of macular edema (DME), including clinically significant diabetic macular edema (CSDME).
Other/unspecified diabetes related eye conditions Other/unspecified diabetes related eye conditions includes diagnosis codes indicating diabetic retinopathy of unspecified type, other ophthalmic complications of diabetes including diabetic cataract, or diabetes mellitus with ophthalmic complication resolved after treatment.
Age related macular degeneration (AMD) AMD, unspecified Unspecified macular degeneration includes diagnosis codes indicating degeneration of macula and/or posterior pole, but does not specify stage.
Early AMD Early AMD includes diagnosis codes indicating the presence of drusen (degenerative) of the macula.
Dry-form AMD Dry-form AMD indicates the presence of diagnosis codes for nonexudative age-related macular degeneration.
Geographic atrophy AMD Geographic atrophy AMD indicates the presence of ICD10 codes indicating advanced atrophic stage of dry-form AMD.
Wet-form AMD Wet-form AMD indicates the presence of diagnosis codes for exudative age-related macular degeneration.
Choroidal neovascularization AMD Choroidal neovascularization AMD indicates the presence of ICD10 codes specifying active choroidal neovascularization; advanced wet-form AMD.
Other Retinal Disorders Retina vascular disease, Occlusive (arterial, venous) Retina vascular disease, Occlusive (arterial, venous) includes diagnosis codes indicating unspecified or transient retinal vascular occlusion.
Other/unspecified retinal disorders Other/unspecified retinal disorders include diagnosis codes indicating age-related choroidal atrophy, diffuse secondary atrophy of choroid, retinoschisis, retinal cysts, cyst of ora serrata, retinopathy of prematurity, non-diabetic proliferative retinopathy, unspecified separation of retinal layers, central serous chorioretinopathy, detachment of retinal pigment epithelium, macular cyst, hole, or pseudohole, toxic maculopathy, puckering of macula, various forms of retinal degeneration, retinal hemorrhage, and other or unspecified retinal disorders.
Central retinal vein occlusion Central retinal vein occlusion indicates diagnosis codes for central retinal vein occlusion, with or without macular edema or retinal neovascularization.
Branch retinal vein occlusion Branch retinal vein occlusion indicates diagnosis codes for tributary (branch) retinal vein occlusion, with or without macular edema or retinal neovascularization, or venous engorgement.
Central retinal arterial occlusion Central retinal arterial occlusion indicates diagnosis codes for central retinal arterial occlusion, with or without macular edema or retinal neovascularization.
Branch retinal artery occlusion Branch retinal artery occlusion indicates diagnosis codes for tributary (branch) retinal arterial occlusion.
Retina vascular disease, Non-Occlusive Retina vascular disease, Non-Occlusive includes diagnosis codes indicating hypertensive or exudative retinopathy, changes in retinal vascular appearance, retinal micro-aneurysms, retinal telangiectasis, neovascularization, or vasculitis, intraretinal microvascular abnormalities, or unspecified background retinopathy.
Macular edema (Cystoid or non-diabetic) Macular edema (Cystoid or non-diabetic) indicates diagnosis codes for cystoid macular degeneration.
Hereditary chorioretinal dystrophy Hereditary chorioretinal dystrophy includes diagnosis codes indicating various types of chiorioretinal dystrophy, including circumpapillary, central choroidal atrophy, and choroideremia.
Myopic degeneration Myopic degeneration includes diagnosis codes indicating progressive high (degenerative) myopia.
Glaucoma Open-angle glaucoma Open-angle glaucoma includes diagnosis codes indicating unspecified open-angle glaucoma, pigmentary glaucoma, or capsular glaucoma with pseudoexfoliation of lens.
Primary open-angle glaucoma Primary open-angle glaucoma includes diagnosis codes for primary open-angle glaucoma of any stage.
Low-tension glaucoma Low-tension glaucoma includes diagnosis codes for low-tension glaucoma of any stage.
Glaucoma suspect Glaucoma suspect indicates diagnosis codes for pre-glaucoma, open-angle with borderline findings, ocular hypertension, steroid responder, or primary angle closure without damage.
Primary angle-closure glaucoma Primary angle-closure glaucoma includes diagnosis codes indicating primary, acute, chronic, intermittent or unspecified angle-closure glaucoma.
Narrow-angle glaucoma Narrow-angle glaucoma includes diagnosis codes indicating narrow angle glaucoma, anatomical or secondary to eye trauma.
Congenital glaucoma Congenital glaucoma includes diagnosis codes for congenital glaucoma or buphthalmos (enlargement of the eye in children).
Neovascular glaucoma Neovascular glaucoma includes diagnosis codes indicating glaucoma associated with vascular disorders, phacolytic or other specified glaucoma.
Other/unspecified glaucoma Other/unspecified glaucoma includes diagnosis codes indicating unspecified glaucoma, glaucoma secondary to drugs, other eye disorders or inflammation, hypersecretion glaucoma, increased episcleral venous pressure, or aqueous misdirection.
Cataracts Age-related cataract Age-related cataract indicates the presence of diagnosis codes for age-related incipient, polar, cortical, nuclear, morgagnian, other or unspecified cataract
Other or unspecified cataract Other or unspecified cataract includes diagnosis codes for various cataracts not specified as age-related or congenital, including traumatic cataract, drug-induced cataract, cataract with neovascularization, cataract secondary to ocular disorders, or unspecified cataracts.
Congenital Cataract Congenital Cataract includes diagnosis codes indicating congenital cataract, congenital aphakia, coloboma of lens, spherophakia, congenital lens malformations, or infantile or juvenile cataracts of any type.
Posterior capsular opacity Posterior capsular opacity includes diagnosis codes indicating posterior capsular opacity, Soemmering’s ring, or other secondary cataract.
Pseudophakia Pseudophakia includes diagnosis codes indicating the presence of intraocular lens, aphakia
Aphakia and other disorders of lens Aphakia and other disorders of lens includes diagnosis codes indicating aphakia, subluxation of lens, anterior dislocation of lens, posterior dislocation of lens, or other disorders of lens
Refraction and accommodation Myopia Myopia includes diagnosis codes indicating myopia in one or both eyes.
Hypermetropia Hypermetropia includes diagnosis codes indicating hypermetropia in one or both eyes.
Astigmatism Astigmatism includes diagnosis codes indicating regular, irregular, or unspecified astigmatism in one or both eyes.
Presbyopia Presbyopia includes diagnosis codes indicating presbyopia in one or both eyes.
Other disorder of refraction and accommodation Other disorder of refraction and accommodation includes diagnosis codes indicating anisometropia and aniseikonia, disorders of accommodation, internal ophthalmoplegia, paresis of accommodation, or spasm of accommodation.
Diagnosed Blindness and low vision Unqualified visual loss, both eyes Unqualified vision loss, both eyes includes a diagnosis code indicating unqualified visual loss in both eyes.
Unqualified vision loss in one eye, or unspecified visual loss Unqualified vision loss in one eye or unspecified vision loss includes diagnosis codes indicating unqualified vision loss in one eye, unspecified visual loss, or problems with sight.
Low vision or blindness, one eye Low vision or blindness in one eye includes diagnosis codes indicating low vision or blindness in one eye, normal vision in the other eye.
Blindness one eye, low vision other eye Blindness in one eye, low vision in other eye includes diagnosis codes indicating blindness in one eye, low vision in other eye.
Low vision, both eyes Low vision, both eyes includes diagnosis codes indicating low vision in both eyes.
Blindness, both eyes, including legal blindness Blindness, both eyes, including legal blindness includes diagnosis codes indicating blindness in both eyes, legal blindness, or cortical blindness.
Strabismus and amblyopia Strabismus Strabismus includes diagnosis codes indicating monocular or binocular strabismus, including esotropia, exotropia, heterophoria and other types, nerve palsy of the eye, ophthalmoplegia, Brown’s sheath syndrome, disorders of convergence or binocular movement, or other unspecified disorders of binocular vision.
Amblyopia Amblyopia includes diagnosis codes indicating amblyopia, including deprivation, strabismic, refractive, or unspecified amblyopia type, or ablyopia suspect.
Injury, burns and surgical complications of the eye Injury Injury includes diagnosis codes indicating injury to the eye or ocular adnexa, due to trauma, foreign bodies, penetrating wounds, bites, abrasions or other causes, or injury secondary to other ocular disorders.
Burn Burn includes diagnosis codes indicating any type of burn or corrosion of the eye or ocular adnexa.
Surgical complication Surgical complication includes diagnosis codes indicating or typically associated with surgical complications, including postprocedural inflammation or infection, mechanical complications, cataract fragments, and other conditions usually associated with procedures.
Disorders of optic nerve and visual pathways Optic nerve disorders Optic nerve disorders includes diagnosis codes indicating optic neuritis and other disorders of the optic nerve.
Disorders of the visual pathway and visual cortex Disorders of the visual pathway and visual cortex includes diagnosis codes indicating disorders of visual pathways and visual cortex.
Other visual disturbances Visual field defect Visual field defect includes diagnosis codes indicating defects of the visual field, including scotoma, sector or arcuate defects, localized visual field defects, homonymous bilateral field defects or contraction of the visual field.
Color blindness Color blindness included diagnosis codes indicating color vision deficiencies.
Night blindness Night blindness includes diagnosis codes indicating night blindness, abnormal dark adaptation and glare sensitivity.
Other/unspecified visual disturbances Other/unspecified visual disturbances includes other disturbances or defects of sight including subjective visual disturbances, diplopia, other and unspecified disorders of binocular vision, and vision sensitivity deficiencies.
All Infectious and inflammatory diseases Infectious diseases Infectious diseases includes diagnosis codes indicating an infection of the eye or ocular adnexa.
Keratitis Keratitis includes diagnosis codes indicating keratitis, including corneal ulcer, other and unspecified superficial keratitis without conjunctivitis, keratoconjunctivitis, corneal neovascularization, or other or unspecified forms of keratitis.
Conjunctivitis Conjunctivitis includes diagnosis codes indicating most forms of conjunctivitis, including mucopurulent, acute, chronic, blepharoconjunctivitis, or other disorders of conjunctiva, including pterygium, conjunctival degenerations and deposits, or conjunctival scars, hemorrhage, vascular disorders, or cysts.
Eyelid disorders Eyelid disorders includes diagnosis codes indicating hordeolum and chalazion or other inflammation of the eyelid, including Blepharitis, noninfectious dermatosis or other inflammation of the eyelid.
Other inflammatory conditions Other inflammatory conditions includes diagnosis codes indicating inflammation of the eye or ocular adnexa not otherwise classified.
Lacrimal system and orbit inflammation Lacrimal system and orbit inflammation includes diagnosis codes indicating disorders of the lacrimal system and inflammatory disorders of the orbit.
Endophthalmitis Endophthalmitis includes diagnosis codes indicating enophthalmitis and disorders of the globe including degenerative myopia and uveitis.
Orbital and external disease Congenital anomalies Congenital anomalies includes diagnosis codes indicating congenital malformations of the eye and ocular adnexa.
Other/unspecified orbital or external disease Other/unspecified orbital or external disease includes diagnosis codes indicating non-inflammatory disorders of the orbit.
Lacrimal diseases Lacrimal diseases includes diagnosis codes indicating disorders of the lacrimal system, including dacryoadenitis, epiphora, stenosis and insufficiency of lacrimal passages, or other changes or disorders of the lacrimal system.
Eyelid disorders Eyelid disorders includes diagnosis codes indicating non-inflammatory disorders of the eyelid, including entropion, ectropion, lagophthalmos, ptosis, blepharochalasis, xanthelasma disorders of the eyelid, or other non-specified, non-inflammatory eyelid disorders.
Dry eye syndrome Dry eye syndrome includes diagnosis codes indicating dry eye syndrome.
Disorders of the globe Disorders of the globe includes diagnosis codes indicating disorders of the globe, excluding endoophthalmitis, degenerative myopia, and hypotony of the eye.
Cancer and neoplasms of the eye diseases Malignant neoplasm of the eye Malignant neoplasm of the eye includes diagnosis codes indicating malignant neoplasm of the eye, or carcinoma in situ of the eye.
Benign neoplasm of the eye Benign neoplasm of the eye includes diagnosis codes indicating benign neoplasm of the eye.
Cornea disorders Keratoconus Keratoconus includes diagnosis codes indicating keratoconus or conical cornea conditions.
Endothelial dystrophy (inc Fuchs) Endothelial dystrophy includes diagnosis codes indicating Endothelial or Fuchs dystrophy.
Other Corneal disorders Other Corneal disorders includes diagnosis codes indicating corneal scars, opacities and other disorders of the cornea.
All Other eye disorders Other eye disorders Other eye disorders includes diagnosis codes related to vision, the eye and ocular adnexa that are not otherwise classified.

Denominators used to Calculate Prevalence Rates

The denominator for each estimated rate is the total number of beneficiaries in that demographic category who were fully enrolled in the Medicare Part B program for all 12 months during the year of observation.

Potential Limitations

The VEHSS analysis of Medicare claims is subject to a number of potential limitations:

  • Medicare claims are intended for billing purposes only. Diagnosis information included on claims is intended to justify payment. Therefore, diagnosis data on claims may suffer from bias or limited detail.
  • Medicare FFS does not cover all healthcare services, such as routine eye exams or optometry care. Medicare patients may utilize these services using a different payer, and thus these services are not captured in Medicare FFS claims.
  • Patients may be insured by multiple insurers, such as a supplemental, medigap or Medicare managed care plans. Thus, even normally covered ophthalmology services may not be indicated in FFS claims if services were reimbursed by another plan.
  • Many Medicare patients move seasonally. We report patient residence using the last location of observation. This may skew patient numbers towards “sun belt” states.
  • Medicare is not nationally representative for individuals younger than 65 years. These patients may obtain Medicare coverage due to medical need, such as legally recognized disability, or other specially defined benefit, such as end-stage renal disease. Individuals who become disabled for reasons of blindness cannot be distinguished from others who are disabled unless their visual condition of low vision and blindness is recording in their medical claims.
  • Medicare FFS is nearly representative of the population aged 65 and older, but does not include beneficiaries with Medicare advantage plans, people who defer Medicare coverage, or services paid out of pocket.

[1] US Census Bureau. Profile america facts for features: CB17-FF.08. Washington, DC: Economics and Statistics Administration; 2017. https://www.census.gov/content/dam/Census/newsroom/facts-for-features/2017/cb17-ff08.pdf. Accessed March 1, 2018.

[2] State Health Facts: Menlo Park, CA: Kaiser Family Foundation. https://www.kff.org/statedata/. Accessed March 1, 2018.