Diabetic Retinal Eye Exam | April 2022 | Clinical Corner

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April 1, 2022

Diabetic Retinal Eye Exam

HEDIS MEASURE:

The percentage of members 18–75 years of age with diabetes (types 1 and 2) who had a retinal eye exam.

 

BACKGROUND:

Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20–74 years in developed countries.

Type 1 Diabetes

Because retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia, patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the diagnosis of diabetes1.

Type 2 Diabetes

Patients with type 2 diabetes who may have had years of undiagnosed diabetes and have a significant risk of prevalent diabetic retinopathy at the time of diagnosis should have an initial dilated and comprehensive eye examination at the time of diagnosis1.

 

RECOMMENDATIONS:

  1. Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes.
  2. Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis.
  3. If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well controlled, then screening every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist.
  4. Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy.

 

TO CLOSE GAPS:

  1. A note or letter prepared by an ophthalmologist, optometrist, PCP or other healthcare
    professional indicating that an ophthalmoscopic exam was completed by an eye care
    professional, the date when the procedure was done and the results.
  2. A chart or photograph indicating the date when the fundus photography was performed and
    evidence that an optometrist or ophthalmologist reviewed the results.
  3. Documentation of a negative retinal or dilated eye exam by an optometrist or ophthalmologist in
    the year prior to the measurement year, results indicating retinopathy was not present.
  4. Documentation anytime in the member’s history of evidence that the member had bilateral eye
    enucleation or acquired absence of both eyes.
  5. CPT II codes may be used to document exam performed, results, exclusions:
    1. Eye exam without Evidence of Retinopathy: 2023F, 2025F, 2033F
    2. Eye Exam with Evidence of Retinopathy: 2022F, 2024F, 2026F
    3. Diabetic Retinal Screening Negative in the Prior Year: 3072F

 

REFERENCES:

American Diabetes Association. 11. Microvascular complications and foot care: Standards of Medical Care in Diabetes 2021