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)