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)