2007 Physician Quality Reporting Initiative 

As of: 6/18/2007 43 *Measure #18: Diabetic Retinopathy: Documentation of Presence or Absence of Macular
Edema and Level of Severity of Retinopathy 

DESCRIPTION:

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a
dilated macular or fundus exam performed which included documentation of the level of severity of
retinopathy and the presence or absence of macular edema during one or more office visits within
12 months

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide the primary management of patients
with diabetic retinopathy (in either one or both eyes) will submit this measure. The medical reason
exclusion may be used if a clinician is asked to report on this measure but is not the clinician
providing the primary management for diabetic retinopathy.

This measure can be reported using CPT Category II codes:

ICD-9 diagnosis codes, CPT procedure codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, and
the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified. 

NUMERATOR:

Patients who had a dilated macular or fundus exam performed which included documentation of
the level of severity of retinopathy AND the presence or absence of macular edema during one or
more office visits within 12 months

Definition: Medical record must include: Documentation of the level of severity of
retinopathy (e.g., background diabetic retinopathy, proliferative diabetic retinopathy,
nonproliferative diabetic retinopathy) AND documentation of whether macular edema was
present or absent

Numerator Coding:

Macular or Fundus Exam Performed

CPT II 2021F: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy

OR

As of: 6/18/2007 44 Macular or Fundus Exam not Performed for Medical or Patient Reasons

Append a modifier (1P or 2P) to CPT Category II code 2021F to report documented
circumstances that appropriately exclude patients from the denominator.

• 1P: Documentation of medical reason(s) for not performing a dilated macular or fundus
examination

• 2P: Documentation of patient reason(s) for not performing a dilated macular or fundus
examination

OR

Macular or Fundus Exam not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 2021F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.

• 8P: Dilated macular or fundus exam was not performed, including documentation of
the presence or absence of macular edema AND level of severity of retinopathy,
reason not otherwise specified 

DENOMINATOR:

All patients aged 18 years and older with a diagnosis of diabetic retinopathy

Denominator Coding:

An ICD-9 diagnosis code to identify patients with a diagnosis of diabetic retinopathy and a
CPT code are required for denominator inclusion. The CPT code may be a CPT procedure
code for ophthalmologic services or a CPT E/M service code.

ICD-9 diagnosis codes: 362.01, 362.02, 362.03, 362.04, 362.05, 362.06

AND

CPT procedure codes: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245 

RATIONALE:

Several level 1 RCT studies demonstrate the ability of timely treatment to reduce the rate and
severity of vision loss from diabetes (Diabetic Retinopathy Study - DRS, Early Treatment Diabetic
Retinopathy Study - ETDRS). Necessary examination prerequisites to applying the study results
are that the presence and severity of both peripheral diabetic retinopathy and macular edema be
accurately documented. In the RAND chronic disease quality project, while administrative data
indicated that roughly half of the patients had an eye exam in the recommended time period, chart
review data indicated that only 19% had documented evidence of a dilated examination. (McGlynn,
2003). Thus, ensuring timely treatment that could prevent 95% of the blindness due to diabetes
requires the performance and documentation of key examination parameters. The documented
level of severity of retinopathy and the documented presence or absence of macular edema assists
with the on-going plan of care for the patient with diabetic retinopathy. 

CLINICAL RECOMMENDATION STATEMENTS:

Since treatment is effective in reducing the risk of visual loss, detailed examination is indicated to
assess for the following features that often lead to visual impairment: presence of macular edema,
optic nerve neovascularization and/or neovascularization elsewhere, signs of severe NPDR and
vitreous or preretinal hemorrhage. (Level A:III Recommendation) (AAO, 2003)