Diabetes Care – Eye Exam (EED)

What Is the Measure?

This measure looks at the percentage of enrolled members 18-75 years of age with type 1 or type 2 diabetes who had a comprehensive eye exam to screen/monitor for diabetic retinal disease using either of the following criteria:

• A retinal or dilated eye exam in the current measurement year

• A negative retinal or dilated eye exam (negative for retinopathy) in the year prior to measurement year

• Bilateral eye enucleation any time during the patient’s history through December 31 of the measurement year

Eye exam must be done by an eye care professional (optometrist or ophthalmologist).

Documentation

Documentation of retinal exam must be obtained from eye care provider if patient advises they have completed an eye exam. At a minimum, documentation in the medical record must include one of the following:

• A note or letter from an ophthalmologist, optometrist, PCP, or other health care professional indicating that an ophthalmoscopic exam was completed, the date when the procedure was performed, and the results.

• A chart or photograph indicating the date when the fundus photography was performed and that an optometrist or ophthalmologist reviewed the results.

• 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.

• Documentation anytime in the member’s history of bilateral eye enucleation or acquired absence of both eyes

Eligible Codes

92250 or 92227 or 92228

Must be submitted via claims by an eye care professional (optometrist or ophthalmologist); if submitted by PCP then must also apply a CPTII code as shown in the adjacent column. →

2.6

2.7

2.8

2022F, 2024F, 2026F (2023F and 2025F are current year codes to be used for when the member is without evidence of retinopathy. Thus, they meet numerator compliance for current year and the following year.)

2.9

2.10

To be used only for eye exams read by a system that provides an artificial intelligence (AI) interpretation of results.

Exclusions

• Hospice care

• Palliative care anytime in the measurement year

• Medicare patients 66 years of age and older as of December 31st of the measurement year who are either enrolled in an institutional special needs plan (I-SNP) or living long-term in an institution

• Patients 66 years of age and older as of December 31st of the measurement year who meet both frailty and advanced illness criteria

How to Improve Score

• Review chart notes to find evidence of retinal eye exam or statement from patient that they have completed within the year or year prior.

• Educate patient regarding importance of eye exam, especially with diabetes.

• Prepare standing referral to eye care professional; assist patient in making appointment if needed.

• Ensure proper billing codes are submitted by eye care professional.

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