2007 Physician
Quality Reporting Initiative
As of: 6/18/2007 45 *Measure #19: Diabetic Retinopathy: Communication
with the Physician Managing
Ongoing Diabetes Care
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of
diabetic retinopathy who had a
dilated macular or fundus exam performed with documented communication
to the physician who
manages the ongoing care of the patient with diabetes regarding the
findings of the macular or
fundus exam at least once 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 codes OR the CPT Category II code(s)
with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P-
patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients with documentation, at least once within 12 months, of the
findings of the dilated macular
or fundus exam via communication to the physician who manages the
patient’s diabetic care
Definition: Communication may include: Documentation in the medical
record indicating
that the results of the dilated macular or fundus exam were
communicated (e.g., verbally,
by letter) with the clinician managing the patient’s diabetic
care OR a copy of a letter in the
medical record to the clinician managing the patient’s
diabetic care outlining the findings of
the dilated macular or fundus exam.
Numerator Coding:
Dilated Macular or Fundus Exam Findings Communicated
CPT II 5010F: Findings of dilated macular or fundus exam communicated
to the physician
managing the diabetes care
AND
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 46 Dilated Macular or Fundus Exam Findings not
Communicated for Medical or Patient
Reasons
Append a modifier (1P or 2P) to CPT Category II code 5010F to report
documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not communicating
the findings of the
dilated macular or fundus exam to the physician who manages the ongoing
care of the
patient with diabetes
• 2P: Documentation of patient reason(s) for not communicating
the findings of the
dilated macular or fundus exam to the physician who manages the ongoing
care of the
patient with diabetes
AND
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
If patient does not meet denominator inclusion because:
Patient did not have dilated macular or fundus exam performed:
Append a reporting modifier (8P) to CPT Category II code 2021F to
report circumstances
when the action described does not meet denominator inclusion and the
reason is not
otherwise specified.
• 8P: Dilated macular or fundus exam not performed, including
documentation of the
presence or absence of macular edema AND level of severity of
retinopathy, reason
not otherwise specified
OR
Dilated Macular or Fundus Exam Findings not Communicated, Reason Not
Specified
Append a reporting modifier (8P) to CPT Category II code 5010F to
report circumstances
when the action described in the numerator is not performed and the
reason is not
otherwise specified.
• 8P: Findings of dilated macular or fundus exam was not
communicated to the
physician managing the diabetes care, reason not otherwise specified
AND
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.
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetic
retinopathy who had a dilated
macular or fundus exam performed
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
As of: 6/18/2007 47 CPT procedure codes: 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
The physician that manages the ongoing care of the patient with
diabetes should be aware of the
patient’s dilated eye examination and severity of retinopathy
to manage the on-going diabetes
care. Such communication is important in assisting the physician to
better manage the diabetes.
Several studies have shown that better management of diabetes is
directly related to lower rates of
development of diabetic eye disease. (Diabetes Control and
Complications Trial - DCCT, UK
Prospective Diabetes Study - UKPDS)
CLINICAL RECOMMENDATION STATEMENTS:
While it is clearly the responsibility of the ophthalmologist to manage
eye disease, it is also the
ophthalmologist’s responsibility to ensure that patients with
diabetes are referred for appropriate
management of their systemic condition. It is the realm of the
patient’s family physician, internist or
endocrinologist to manage the systemic diabetes. The ophthalmologist
should communicate with
the attending physician. (Level A: III Recommendation) (AAO, 2003)