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Comprehensive Diabetes Care: Diabetic Eye Exam

Advantage MD, EHP, Priority Partners, and USFHP. Members 18-75 years of age.

Percentage of diabetic members who had the following:

  • Eye Exam-A retinal or dilated eye exam to detect retinopathy performed by an ophthalmologist or optometrist. A diagnosis of retinopathy or an eye exam with an unknown retinal status requires an annual exam. If negative for retinopathy, a bi-annual exam meets criteria. Members with bilateral eye enucleation are considered compliant

Provider Specialty: Ophthalmologist or Optometrist.

Best Practice and Measure Tips

  • Provide member education on risks of Diabetic Eye Disease, and encourage to schedule annual exam.
  • Obtain eye exam reports. Notate eye care provider name and demographics in chart if report not available.
  • The dilated or retinal exam must be bilateral unless there is history of a unilateral eye enucleation.
  • 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 credentials.
    • Documentation example: “Last diabetic retinal eye exam with John Smith, OD, was June 201X 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 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.
  • Prior year exam results must indicate retinopathy was not present.

Not Acceptable:

  • Routine fundoscopic exam without examination of macula, vessels and periphery.
  • Documentation of "diabetes without complications."

Measure Exclusions

Required Exclusions:

  • Palliative Care
  • Hospice
  • Fraility
  • Fraility and Advanced Illness
  • Living in Long Term Care

Optional Exclusion: Members without a diagnosis of diabetes in any setting and a diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes during the measurement year or the year prior.

Measure Codes

  • Diabetic Retinal Screening with Eye Care Professional:
    • Current year dilated retinal screening with evidence of retinopathy:
      • CPT II: 2022F, 2024F, 2026F
    • Current year dilated retinal screening without evidence of retinopathy:
      • CPT II: 2023F, 2025F, 2033F
    • Prior year dilated negative retinal screening:
      • CPT II: 3072F
  • Diabetic Eye Exam
    • CPT/CPT II: 67028, 67030-31, 67036, 67039-43, 67101, 67105, 67107-08, 67110, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220-21, 67227-28, 92002, 92004, 92012, 92014, 92018-19, 92134, 92225-28, 92230, 92235, 92240, 92250, 92260, 99203-05, 99213-15, 99242-45
  • Unilateral Eye Enucleation
    • CPT/CPT II: 65091, 65093, 65101, 65103, 65105, 65110, 65112, 65114
  • Unilateral Eye Enucleation – Left
    • ICD-10: Diagnosis 08B10ZX, 08B10ZZ, 08B13ZX, 08B13ZZ, 08B1XZX, 08B1XZZ
  • Unilateral Eye Enucleation – Right
    • ICD-10: Diagnosis 08B00ZX, 08B00ZZ, 08B03ZX, 08B03ZZ, 08B0XZX, 08B0XZZ
  • Bilateral Modifier
    • CPT Modifier 50