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Johns Hopkins Health Plans

EED - Eye Exam for Patient with Diabetes

Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31
 
Description:
The percentage of persons 18–75 years of age with diabetes (type 1 or type 2) who had a retinal eye exam.

Provider Specialty: Ophthalmologist or Optometrist.

Stratifications: 
Report stratification by race and ethnicity.
Report Stratification by SES only for Advantage MD (Medicare product line). 

Measure Reporting:
CMS Start Rating Measure
HealthChoice Performance Measure reporting for Priority Partners.  

Improvement Notation:
Increased score indicates improvement.

Data Collection:

  • Administrative.
  • Supplemental.

Initial Population:

  • Measure Item Count: Person.
  • Age:18–75 years of age as of the last day of the measurement period.
  • Benefits: Medical.
  • Continuous Enrollment: The measurement period.
  • Allowable Gap: No more than one gap of ≤45 days during the measurement period. No gaps on the last day of the measurement period.

Denominator:
Persons with a diagnosis of diabetes. 

  • Claim/encounter data. At least two diagnoses of diabetes on different dates of service during the measurement period or the year prior to the measurement period. 
  • Pharmacy data. At least one diagnosis of diabetes and at least one diabetes medication dispensing event of insulin or a hypoglycemic/antihyperglycemic medication during the measurement period or the year prior to the measurement period. 

Numerator:
Retinal eye exam. 
Screening or monitoring for diabetic retinal disease. This includes persons with diabetes who had one of the following:

  • A retinal or dilated eye exam by an eye care professional (optometrist   or ophthalmologist) in the measurement period.
  • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement period.

Any of the following meet criteria:

  • Billed by an eye care professional (optometrist or ophthalmologist):
    • Any code in the Retinal Eye Exams Value Set billed by an eye care professional (optometrist or ophthalmologist) during the measurement period.
    • Any code in the Retinal Eye Exams Value Set billed by an eye care professional (optometrist or ophthalmologist) during the year prior to the measurement period, with a diagnosis of diabetes without complications (Diabetes Mellitus Without Complications Value Set). 
  • Billed by any provider type:
    • Any code in the Eye Exam With Evidence of Retinopathy Value Set, Eye Exam Without Evidence of Retinopathy Value Set billed by any provider type during the measurement period. 
    • Retinal imaging with interpretation and reporting by a qualified reading center (Retinal Imaging Value Set) billed by any provider type during the measurement period. 
    • Autonomous eye exam billed by any provider type during the measurement period. Either of the following meets criteria:
      • CPT code 92229.
      • LOINC code 105914-6 with a result (Autonomous Eye Exam Result or Finding Value Set). 
    • Any code in the Eye Exam Without Evidence of Retinopathy Value Set billed by any provider type during the year prior to the measurement period. 
    • Diabetic retinal screening negative in prior year (CPT-CAT-II code 3072F) billed by any provider type during the measurement period. 
    • Any combination that indicates findings from a retinal exam for diabetic retinopathy performed in both the left and right eye by any provider, or a combination that indicates one eye is enucleated and the other was examined.
      • Left eye: 
        • Retinal exam finding: Any level of retinopathy (LOINC code 71490-7 with Diabetic Retinopathy Severity Level Value Set) during the measurement period. 
        • Retinal exam finding: No retinopathy (LOINC code 71490-7 with LOINC code LA18643-9) in the year prior to the measurement period. 
        • Enucleation: ICD-10-PCS code 08T1XZZ any time during the person’s history through the last day of the measurement period.
      • Right eye: 
        • Retinal exam finding: Any level of retinopathy (LOINC code 71491-5 with Diabetic Retinopathy Severity Level Value Set) during the measurement period.
        • Retinal exam finding: No retinopathy (LOINC code 71491-5 with LOINC code LA18643-9) in the year prior to the measurement period.
        • Enucleation: ICD-10-PCS code 08T0XZZ any time during the person’s history through the last day of the measurement period. 

Best Practice and Measure Tips

  • Provide member education on risks of Diabetic Eye Disease, and encourage scheduling annual exam.
  • Obtain eye exam reports. Notate eye care provider name and demographics in chart if report not available.
  • Use measure codes on claims to indicate retinopathy status. Since this measure is administrative only, there will be no medical record review during annual. This will capture the compliance from the claim. For members who do not have retinopathy, will capture the compliance for 2 years.
  • Exams must be dilated or retinal exam or fundus photography.
  • The dilated or retinal exam:  it is best practice to have a bilateral retinal exam.
    • In some instances, a unilateral retinal / dilated exam may be used if there is documented enucleation and / or blindness in the un-examined eye.
  • Documentation can be in the form of a note or letter prepared by an ophthalmologist, optometrist, PCP or other health care professional. Include: date of service, the test (indicate a dilated or retinal exam) or result, and the care provider’s name and credentials.
    • Documentation example: “Last diabetic retinal eye exam with John Smith, OD, was June 20XX with no retinopathy.”
  • Must indicate performed by Optometrist or Ophthalmologist.
  • A slit-lamp examination must have documentation of dilation or evidence that the retina was examined to be considered compliant.
  • Examination of macula, vessels and periphery without eye dilation meets criteria for a "retinal exam."
  • A chart or photograph with date of fundus photography or retinal imaging (Example: Computerized Ophthalmic Imaging such as Optical Coherence Tomography - OCT) and one of the following is acceptable:
    • Results read by a qualified reading center or by a system that provides an artificial intelligence (AI) interpretation.
    • Results reviewed by an eye care professional.
    • Results read by a qualified reading center operating under the direction of a medical director who is a retinal specialist.
  • Prior year exam results must indicate retinopathy was not present. Be sure to add the retinopathy status codes to claims in order to capture compliance for 2 years.
  • AI Reports:
    • Acceptable: “Negative for more than mild diabetic retinopathy”: This is only considered a negative result when it is a result of an exam read by AI (Example: IDx-DR imaging system, AEYE-DS, EyeArt).

Not Acceptable:

  • Routine fundoscopic exam without examination of macula, vessels and periphery.
  • Documentation of "diabetes without complications."
  • Exams performed by PCP or non-eye care professionals (optician)
  • Refractive only exams
  • Exams in which only the anterior (A) chamber of the eye is examined
  • Glaucoma pressure checks
  • Unilateral post-op eye exams which do not meet guidelines for acceptable documentation

Measure Exclusions

Denominator Exclusions:

  • Persons receiving Palliative Care or had an encounter for Palliative Care any time during the intake period through the last day of the measurement period. Members in hospice or using hospice services anytime during the measurement year.
  • Persons in hospice or using hospice services any time during the measurement period.
  • Persons who died any time during the measurement period.
  • Persons 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness. 
  • Medicare enrollees, 66 years of age and older by the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI).  
  • Persons with bilateral absence of eyes or eye enucleation. 
    • Bilateral absence of eyes (SNOMED CT code 15665641000119103) any time during the person’s history through the last day of the measurement period.
    • Bilateral eye enucleation any time during the person’s history through the last day of the measurement period:
      • Unilateral eye enucleation (Unilateral Eye Enucleation Value Set) with a bilateral modifier (CPT Modifier code 50).
      • Two unilateral eye enucleations (Unilateral Eye Enucleation Value Set) with service dates 14 days or more apart. 
      • Left unilateral eye enucleation (ICD-10-PCS code 08T1XZZ) and right unilateral eye enucleation (ICD-10-PCS code 08T0XZZ) on the same or different dates of service.
      • A unilateral eye enucleation (Unilateral Eye Enucleation Value Set) and a left unilateral eye enucleation (ICD-10-PCS code 08T1XZZ) with service dates 14 days or more apart.
      • A unilateral eye enucleation (Unilateral Eye Enucleation Value Set) and a right unilateral eye enucleation (ICD-10-PCS code 08T0XZZ) with service dates 14 days or more apart.
  • Diagnosis code on a laboratory claim (POS 81) for:
    • Diabetes 
    • Frailty
    • Advance illness
    • Palliative care 

Note: Blindness is not an exclusion for a diabetic eye exam because it is difficult to distinguish between individuals who are legally blind but require a retinal exam and those who are completely blind and therefore do not require an exam.

Numerator Exclusions:
For CPT Category II codes do not include CPT CAT II Modifier. 

Exclusion Codes

Unilateral Eye Enucleation

  • CPT: 65091, 65093, 65101, 65103, 65105, 65110, 65112, 65114
  • SNOMED CT US Edition: 59590004, 172132001, 205336009, 397800002, 397994004, 398031005, 1303651001, 1303652008 

Unilateral Eye Enucleation – Left

  • ICD-10-PCS: 08T1XZZ

Unilateral Eye Enucleation – Right

  • ICD-10-PCS: 08T0XZZ

Bilateral Modifier

  • CPT Modifier 50

Bilateral absence of eyes 

  • SNOMED CT code: 15665641000119103 

Measure Codes

Codes that can only be bill by an Eye Care Professional (optometrist or ophthalmologist):

  • Retinal Eye Exams
    • CPT: 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92137, 92201, 92202, 92230, 92235, 92250, 99203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, 99245 
    • HCPCS: S0621, S0620, S3000
    • SNOMED CT US Edition: 6615001, 18188000, 21593001, 30842004, 36844005, 53524009, 56072006, 56204000, 252779009, 252780007, 252781006, 252782004, 252783009, 252784003, 252788000, 252789008, 252790004, 252846004, 274795007, 274798009, 308110009, 314972008, 391999003, 392005004, 410441007, 410450009, 410451008, 410452001, 410453006, 410455004, 416369006, 417587001, 420213007, 425816006, 427478009, 700070005, 722161008 
  • Diabetes Mellitus Without Complications
    • ICD-10-CM: E10.9, E11.9, E13.9
    • SNOMED CT US Edition: 111552007, 190412005, 290002008, 313436004, 443694000, 444073006, 444074000, 444110003, 445353002, 870528001, 1217044000, 1217068008, 1290118005, 1481000119100, 31321000119102, 164971000119101, 721111000124107, 721121000124104, 721201000124104 

Codes that can be bill by ANY provider type:

  • Eye Exam With Evidence of Retinopathy CPT-CAT-II: 2022F, 2024F, 2026F
  • Eye Exam Without Evidence of Retinopathy during current year or prior year CPT-CAT-II: 2023F, 2025F, 2033F
  • Diabetic retinal screening negative in prior year CPT-CAT-II: 3072F
  • Autonomous Eye Exam:
    • CPT: 92229
    • LOINC code 105914-6 with a result (Autonomous Eye Exam Result or Finding Value Set).
      • LA34398-0 ETDRS Level 20 or lower, without macular edema
      • LA34399-8 ETDRS Level 35 or higher, with or without macular edema
  • Retinal Imaging CPT: 92227, 92228, 92137
  • Retinal exam finding: 
    • Left Eye LOINC: 71490-7
    • Right Eye LOINC: 71490-7
    • With Diabetic Retinopathy Severity Level LOINC:
      • LA18643-9 No apparent retinopathy
      • LA18644-7 Mild non-proliferative retinopathy
      • LA18645-4 Moderate non-proliferative retinopathy
      • LA18646-2 Severe non-proliferative retinopathy
      • LA18648-8 Proliferative retinopathy
    • Or a combination that indicates one eye is enucleated and the other was examined: 
      • Enucleation ICD-10-PCS: 08T1XZZ (Resection of Left Eye, External Approach)
      • Enucleation ICD-10-PCS: 08T0XZZ (Resection of Right Eye, External Approach)  

Measure Medications

Diabetes Medications List

Alpha-glucosidase inhibitors

  • Acarbose
  • Miglitol

Amylin analogs

  • Pramlintide

Antidiabetic combinations

  • Alogliptin-metformin 
  • Alogliptin-pioglitazone
  • Canagliflozin-metformin
  • Dapagliflozin-metformin
  • Dapagliflozin-saxagliptin
  • Empagliflozin-linagliptin
  • Empagliflozin-metformin
  • Empagliflozin-linagliptin-metformin
  • Ertugliflozin-metformin
  • Ertugliflozin-sitagliptin
  • Glimepiride-pioglitazone
  • Glipizide-metformin
  • Glyburide-metformin
  • Linagliptin-metformin 
  • Metformin-pioglitazone
  • Metformin-rosiglitazone
  • Metformin-saxagliptin
  • Metformin-sitagliptin

Insulin

  • Insulin aspart 
  • Insulin aspart-insulin aspart protamine
  • Insulin degludec 
  • Insulin degludec-liraglutide
  • Insulin detemir
  • Insulin glargine
  • Insulin glargine-lixisenatide 
  • Insulin glulisine 
  • Insulin isophane human
  • Insulin isophane-insulin regular
  • Insulin lispro
  • Insulin lispro-insulin lispro protamine 
  • Insulin regular human
  • Insulin human inhaled

Meglitinides

  • Nateglinide
  • Repaglinide

Biguanides

  • Metformin

Glucagon-like peptide-1 (GLP1) agonists

  • Albiglutide
  • Dulaglutide
  • Exenatide
  • Liraglutide
  • Lixisenatide 
  • Semaglutide
  • Tirzepatide

Sodium glucose cotransporter 2 (SGLT2) inhibitor

  • Canagliflozin
  • Dapagliflozin
  • Empagliflozin
  • Ertugliflozin

Sulfonylureas

  • Chlorpropamide
  • Glimepiride
  • Glipizide
  • Glyburide
  • Tolazamide
  • Tolbutamide

Thiazolidinediones

  • Pioglitazone
  • Rosiglitazone

Dipeptidyl peptidase-4 (DDP-4) inhibitors

  • Alogliptin
  • Linagliptin
  • Saxagliptin
  • Sitagliptin