Meeting HEDIS Requirements For Comprehensive Diabetes Care

Categorized as Operations

Comprehensive diabetes care (CDC): 

  • HbA1c Testing
  • HbA1c Control
  • Retinal/Diabetic eye exam
  • Medical attention for Nephropathy
  • BP Control <140/90 mm Hg

Retinal/Diabetic eye exam: % of plan members with diabetes who had a retinal or dilated eye exam by an eye care professional during measurement year.

Age: Members age 18–75 with diabetes (type 1 or type 2).

Requirements for compliance

A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year OR a negative retinal / dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.

What to report for compliance

At a minimum, documentation in the medical record must include ONE of the following:

  • A note or letter prepared by an ophthalmologist, optometrist, primary care physician or other health care professional indicating that an ophthalmoscopic exam was completed by an eye care professional and includes date procedure was performed and Results of exam
  • A chart or photograph of retinal abnormalities indicating the date when the fundus photography was performed and evidence that an eye care professional reviewed the results. Alternatively, you can submit results that were read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.
  • Documentation of a negative retinal or dilated exam by an eye care professional in the year prior to the measurement year, where results indicate retinopathy was not present (that is, documentation of normal findings for a dilated or retinal eye exam performed by an eye care professional, optometrist or ophthalmologist).

Codes to use

CPT – 67028, 67030, 67031, 67036, 67039- 67043,67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245 

CPT II – 2022F, 2024F, 2026F, 3072F 

HCPCS – S0620, S0621, S0625, S3000

Exclusions from HEDIS Measure

  • Have gestational or steroid induced diabetes
  • Are in hospice care
  • Are living long term in an institution
  • Are enrolled in an institutional SNF
  • Are 66 and older with advanced illness or frailty

Do keep in mind that.

  • * Blindness is not an exclusion for a diabetic eye exam
  • * If documentation in a 2018 visit note indicates “No Diabetic Retinopathy as of Ophtho note on 9/2017,” does this meet criteria as a negative retinal exam? Yes. This meets criteria for HEDIS 2019 reporting
  • * Images for baseline doc of a healthy eye or as preventative medicine – not covered even if disease is identified

Reimbursements for FUNDUS photography

  • Patient presents with a complaint 
  • Adjunct to management and treatment of a known disease
    • Present the following for reimbursement
    • Test order w/ justification
    • Test Date
    • Test Reliability
    • Test findings
    • Diagnosis if applicable
    • Impact on treatment/prognosis
    • Prior test comparison, if possible
    • Physician signature

Use 92250 ($44.50 = technical, $22.25 = professional)

  • Subject to Medicare’s Multiple Procedure Payment Reduction
  • Bilateral code, part of patient chart

Bundled with ICG/92240, mutually exclusive with scanning computerized ophthalmic diagnostic imaging/92133 of the posterior segment/92134 if performed on same day

Needs only general supervision (physician’s presence not required)

Payer policies & reimbursements can differ widely, be sure to read each carrier’s NCD/LCD

2 ways to use 

  • the carrier NCD/LCD supports this, and,
  • test must be used in the medical decision-making for the patient.

Patient can also pay, get ABN signed

Reimbursements for FUNDUS photography (Retinal screening)

Use of CPT code 92250 and with the use of a modifier (e.g. 52)

52 modifier + 92250 does not require an interpretation or report.

Increase Access

Nonmydriatic fundus camera improves access by capture of single 45-degree macular-centered images in both eyes

Telescreening for diabetic retinopathy in primary care clinics reported increased screening rates from approximately 25% to 40% in rural and underserved patients.

Of the referred patients, 60% completed the referral

Improve Quality

Approx 30 MM Americans have diabetes.

>30% American adults have prediabetes.

90 percent prediabetics (> 75 million) don’t know they have it.

Approx 70% with prediabetes will develop type 2 diabetes.

NEI Research – yearly dilated eye exam with timely needed treatment prevents 90% of vision loss.

Current US Annual Diabetic Patient Eye Exam Rate:

  • Insured : As low as 30-40%
  • Un- or Underinsured : As low as 10-20%


PCP/Pharmacy etc

  • Intake
  • Assessment
  • Image capture


store at Reading Center

Remote Image reader (MD, OD)

  • Presence & Severity of Pathology
  • Suggested follow-up

Success of such programs in the country

US Urban & Rural Safety Net Clinics & Pharmacy

  • Nashville, TN: 495 offered eye care, 293 screened – Annual DRS Rate increase (23-59%), 69% screened by camera, 48% referred for further eye care
  • Western NY: 112 offered eye care, Annual DRS Rate INC (6-80%), 47% by camera, 53% by seeing eye doctor, 31% DR, 9% poor vision, 100% f/u
  • LA County, CA: 21,222 camera screened, Annual DRS Rate INC (41- 57%), decreased Wait Time 158 to 17 days, 20% with DR, 12% other pathology
  • Veteran Affairs 60% of eligible patients screened via teleophthalmology