Coding Diabetic Eye Exams
Diabetic eye exams play a critical role in the detection and management of retinopathy, a leading cause of vision loss among diabetic patients. Accurately tracking the results of dilated or retinal eye exams is essential not only for delivering high quality care but also for streamlining claims and reporting data. One of the most effective tools for this is the use of CPT Category II® codes.
- Improved Eye Health – Dilated or retinal eye exams are a cornerstone of diabetic care. CPT II® codes reflect whether retinopathy was detected and help ensure that patients receive the preventive care they need. Patients with a positive result (evidence of retinopathy) should have an annual eye exam. Patients with negative results (no evidence of retinopathy) should have an eye exam every two years.
- Accurate Reporting – CPT II® codes are also beneficial for accurate HEDIS ® performance reporting. When submitted via claims or supplemental data feeds, they can eliminate the need for medical record requests and chart reviews by providing a more complete picture of a patient’s health history.
A successful partnership between primary care providers and eye care professionals should include the following:
- Educating patients with diabetes on the importance of comprehensive eye exams
- Ensuring patients complete scheduled eye exams
- Exchanging eye exam reports
- Coordinating follow-up care.
In addition, optometrists and ophthalmologists should use the appropriate CPT II® code to report the eye exam result and submit a proper billing code to indicate the completion of an eye exam.
Since August 2024, LifeWise has been sending diabetic eye exam medical record requests to select providers who have performed eye exams for patients with diabetes without reporting results or diagnoses of diabetes without complications. If your office has received this request, please review the accompanying member list and CPT II® information, and email us if you have any questions about next steps.