NCQA retired the Hybrid Method; this measure is now reported using the Administrative Method only.

Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Eligible Population:
Members 18-75 years old as of December 31 of the measurement year. This includes HealthChoice Performance Measure reporting for Priority Partners.

Definition:
Percentage of diabetic (types 1 and 2) members who had the following:

• Eye Exam:
  • A retinal or dilated eye exam to detect retinopathy performed by an ophthalmologist or optometrist.
  • A diagnosis of retinopathy or an eye exam with an unknown retinal status requires an annual exam.
  • If negative for retinopathy, a bi-annual exam meets criteria.

Provider Specialty: Ophthalmologist or Optometrist.

Report Stratification by race and ethnicity.
Report Stratification by SES only for Advantage MD (Medicare product line).


Continuous Enrollment:

• The measurement year.

Best Practice and Measure Tips

• Provide member education on risks of Diabetic Eye Disease, and encourage scheduling annual exam.
• Obtain eye exam reports. Notate eye care provider name and demographics in chart if report not available.
• The dilated or retinal exam:  it is best practice to have a bilateral retinal exam unless there is history of a unilateral eye enucleation.
  • In some instances a unilateral retinal / dilated exam may be used if it meets guidelines for acceptable documentation. 
• Documentation can be in the form of a note or letter prepared by an ophthalmologist, optometrist, PCP or other health care professional. Include: date of service, the test (indicate a dilated or retinal exam) or result, and the care provider’s credentials.
  • Documentation example: “Last diabetic retinal eye exam with John Smith, OD, was June 20XX with no retinopathy.”
• Must indicate performed by Optometrist or Ophthalmologist.
• 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 eye dilation meets criteria for a "retinal exam."
• A chart or photograph with date of fundus photography or retinal imaging (Example: Computerized Ophthalmic Imaging such as Optical Coherence Tomography - OCT) and one of the following is acceptable:
  • Results read by a qualified reading center or by a system that provides an artificial intelligence (AI) interpretation.
  • Results reviewed by an eye care professional.
  • Results read by a qualified reading center operating under the direction of a medical director who is a retinal specialist.
• Prior year exam results must indicate retinopathy was not present.
• AI Reports:
  • Acceptable: “Negative for more than mild diabetic retinopathy”: This is only considered a negative result when it is a result of an exam read by AI (IDx-DR imaging system).
  • Documentation of Provider type for AI Reports:
    • If it is noted that an Optometrist or Ophthalmologist reviewed the AI results, then choose the appropriate provider type in the dropdown.
    • Some of the reports state they were read by AI and do not list a provider. If so, choose the provider dropdown option, “Results read by a system that provides an artificial intelligence (AI) interpretation.

Not Acceptable:

• Routine fundoscopic exam without examination of macula, vessels and periphery.
• Documentation of "diabetes without complications."
• Exams performed by PCP or non-eye care professionals (optician)
• Refractive only exams
• Exams in which only the anterior (A) chamber of the eye is examined
• Glaucoma pressure checks
• Unilateral post-op eye exams which do not meet guidelines for acceptable documentation

Measure Exclusions

Required Exclusions:

• Palliative Care
• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year.
• Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness.
• Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
  • Enrolled in an Institutional SNP (I-SNP).
  • Living in Long Term Care.
• Bilateral eye enucleation any time during the member’s history through December 31 of the measurement year
  
  

NOTE: Blindness is not an exclusion for a diabetic eye exam because it is difficult to distinguish between individuals who are legally blind but require a retinal exam and those who are completely blind and therefore do not require an exam.

Exclusion Codes:

• Unilateral Eye Enucleation
  • CPT: 65091, 65093, 65101, 65103, 65105, 65110, 65112, 65114
• Unilateral Eye Enucleation – Left
  • ICD10PCS: Diagnosis 08T1XZZ
• Unilateral Eye Enucleation – Right
  • ICD10PCS: Diagnosis 08T0XZZ
• Bilateral Modifier
  • CPT Modifier 50

Measure Codes

Codes that can only be bill by an Eye Care Professional (optometrist or ophthalmologist):

• Retinal Eye Exams
  • CPT: 92235, 92230, 92250, 99245, 99243, 99244, 99242, 99205, 99203, 99204, 99215, 99213, 99214, 92018, 92019, 92004, 92002, 92014, 92012, 92202, 92201, 92134,
  • HCPCS: S3000, S0621, S0620
• Diabetes Mellitus Without Complications
  • ICD-10-CM: E10.9, E11.9, E13.9

Codes that can be bill by ANY provider type:

• Eye Exam With Evidence of Retinopathy
  • CPT-CAT-II: 2022F, 2024F, 2026F
• Eye Exam Without Evidence of Retinopathy during current year or prior year
  • CPT-CAT-II: 2023F, 2025F, 2033F
• Diabetic retinal screening negative in prior year:
  • CPT-CAT-II: 3072F
• Automated Eye Exam:
  • CPT: 92229
• Retinal Imaging
  • CPT: 92227, 92228
• Any combination that indicates findings from a retinal exam for diabetic retinopathy performed in both the left and right eye:
  •  Left Eye:
    •  During the measurement year: Any level of retinopathy LOINC code 71490-7 with Diabetic Retinopathy Severity Level LOINC code LA18644-7, LA18645-4, LA18643-9, LA18648-8, LA18646-2.
    • In the year prior to the measurement year: No retinopathy LOINC code 71490-7 with LOINC code LA18643-9.
  • Right Eye:
    • During the measurement year: Any level of retinopathy LOINC code 71491-5 with Diabetic Retinopathy Severity LA18644-7, LA18645-4, LA18643-9, LA18648-8, LA18646-2.
    • In the year prior to the measurement year: No retinopathy LOINC code 71491-5 with LOINC code LA18643-9.

Medication List: Diabetes Medications