Measure description

Screening or monitoring for retinal disease in members who have diabetes as identified as one of the following:

  • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year.
  • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.
  • Bilateral eye enucleation any time during the member’s history through December 31 of the measurement year.

CPT codes to close the gap

Diabetic retinal screening

  • 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012,92014, 92018, 92019, 92134, 92201, 92202, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 92203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, 99245, S0620, S0621, S3000.

Unilateral eye enucleation value set with bilateral modifier

  • 65091, 65093, 65101, 65103, 65105, 65110, 65112, 65114. Must be billed with bilateral modifier ‘50’ unless there are codes with service dates 14 days or more apart.

CPT II codes to close the gap (can be billed by any provider type)

Eye exam with evidence of retinopathy

  • 2022F, 2024F, 2026F

Eye exam without evidence of retinopathy

  • 2023F, 2025F, 2033F

Diabetic retinal screening negative in prior year

  • 3072F

Diagnosis codes to close the gap

Diabetes mellitus without complications

  • E10.9, E11.9,E13.9

Unilateral eye enucleation left

  • 08T1XZZ

Unilateral eye enucleation right

  • 08T0XZZ

Supplemental data requirements to close the gap

The medical record must include documentation of one of the following:

  • A note or letter prepared by a healthcare professional indicating that an ophthalmoscopic exam was completed by an eye care professional (optometrist or ophthalmologist), the date the procedure was performed, and the result.
  • A chart or photograph of retinal abnormalities, indicating the date when the fundus photography was performed and one of the following:
    • Evidence that an eye care professional (optometrist or ophthalmologist) reviewed the result.
    • Evidence that results were read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.
    • Evidence that results were read by a system that provides an artificial intelligence (AI) interpretation.
    • Evidence that the member had bilateral eye enucleation or acquired absence of both eyes.
    • Documentation of a negative retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the year prior to the measurement year, where results indicate retinopathy was not present (for example, documentation of normal findings for a dilated or retinal eye exam performed by an eye care professional meets criteria). Documentation does not have to state specifically “no diabetic retinopathy” to be considered negative for retinopathy; however, it must be clear that the patient had a dilated or retinal eye exam by an eye care professional and that retinopathy was not present. A notation limited to a statement that indicates “diabetes without complications” does not meet criteria.

Notes specific to this submeasure.

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 do not require an exam.