Quality Measures
Eye exams are an important component of diabetes management and help to close gaps in care.
When submitting retinal or dilated eye exam claims for VSP patients with diabetes, include Current Procedural Terminology (CPT®) Category II codes to provide more complete information and support quality programs such as Medicare’s Merit-based Incentive Payment System (MIPS), Healthcare Effectiveness Data and Information Set® (HEDIS), and the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System.
Including CPT Category II codes on VSP claims strengthens the role doctors of optometry have in their patients' healthcare and highlights the impact they have on protecting their patients' vision and overall health. In addition, using CPT Category II codes reduces the number of medical records requested for quality measure reporting and gap closure attestation.
HEDIS Quality Measures
The Healthcare Effectiveness Data and Information Set (HEDIS®) is one of healthcare’s most widely used performance improvement tools. The National Committee for Quality Assurance (NCQA) collects HEDIS data from health plans and other healthcare organizations to create annual health outcome surveys. Plans use HEDIS data to measure performance and drive improvement efforts.
HEDIS includes more than 90 measures across multiple domains of care. These measures relate to public health issues, including asthma medication use, blood pressure control, cancer screening, diabetes care, heart disease, and smoking and tobacco use cessation.
Eye Exam for Patients With Diabetes
Eye Exam for Patients With Diabetes (EED) is a HEDIS effectiveness of care measure that evaluates the percentage of members 18 to 75 years of age with diabetes (types 1 and 2) who received a retinal or dilated eye exam.
The measure includes:
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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 dilation meets the criteria for a “retinal exam.”
Diabetic Retinal Exam Codes
Diabetic retinal exam codes valid for the Eye Exam for Patients With Diabetes (EED) measure are:
CPT Codes: 92002, 92004, 92012, 92014, 92134, 92201, 92202, 92227, 92228, 92250, 92260, 99203- 99205, 99213-99215, 99242-99245
HCPCS Codes: S0620, S0621
Submitting CPT Category II Codes
CPT Category II codes are informational codes that facilitate data collection regarding the quality of care for services (e.g., retinal or dilated eye exams) that support MIPS, HEDIS, and CMS performance measures.- CPT Category II codes are for reporting purposes only and are not separately reimbursable. Submit CPT Category II codes with a $0.00 amount.
- CPT Category II codes are not a substitute for Category I codes.
| Patients with Diabetes with Evidence of Retinopathy | |
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2022F |
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy |
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2023F |
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy |
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2024F |
Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy |
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2025F |
Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy |
| Patients with Diabetes without Evidence of Retinopathy | |
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2026F |
Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy |
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2033F |
Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy |
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3072F |
Low risk for retinopathy (no evidence of retinopathy in the prior year) |
Visit vspeyeondiabetes.com to download a diabetic eye exam CPT Category II codes reference sheet and find additional resources for your practice.
Reimbursement
VSP network doctors are eligible for an additional $5 reimbursement on VSP WellVision Exam claims by indicating the patient has diabetes or diabetic retinopathy via the diagnosis code or the checkbox in eClaim on eyefinity.com and including the appropriate CPT Category II code. Refer to the Submitting Patient Conditions Requirement for more information.
CPT® is a registered trademark of the American Medical Association.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
The codes and quality measure tips listed above are informational only, not clinical guidelines or standards of care, and do not guarantee reimbursement.