Ophthalmological Exams - Diabetes

Important Note:

HMSA has partnered with EyeMed, service date effective January 1, 2022. HMSA transitioned our current vision portfolio to a new vision benefit with EyeMed for the following line of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees. HMSA will continue to be the administrators for non-routine vision services through the members medical plan(s). For more information, please contact EyeMed at www.eyemedinfocus.com.

Contact by phone:

For Providers 1-888-259-4344

For Patients with Diabetes Mellitus

The publication, Hawaii State Practice Recommendations for Diabetes Mellitus, recommends that dilated eye examinations be performed for patients with diabetes as follows:

• For patients with Type 1 diabetes: Annually, beginning five years after onset
• For patients with Type 2 diabetes: Annually, beginning at time of diagnosis

Billing Options for Office-based Examinations by an Ophthalmologist

In general, CPT guidelines recommend using codes that most specifically describe the services provided.

Ophthalmological service codes

CPT codes 92002 through 92004, and CPT codes 92012 and 92014

When billing for an ophthalmological evaluation and dilated eye exam for patients with diabetes, consider using ophthalmological service codes. These codes describe the evaluation of new or existing conditions of the eye only. They include history, medical observation, external ocular and adnexal examination and other diagnostic procedures, such as ophthalmoscopy or tonometry. The codes may also include the initiation of diagnostic and treatment programs, the prescription of medication, and arranging for special diagnostic and treatment services or laboratory and radiological services.

In many cases an ophthalmologist or optometrist examines the patient’s eyes only, but does not treat or manage the patient’s other medical conditions. In such cases, ophthalmological service codes may describe the services being rendered more accurately than office visit codes.

Evaluation and management (office visit) codes

CPT codes 99201 through 99205, and CPT codes 99211 through 99215

New patient and established office visit codes include three basic components: history, examination and medical decision making. Higher-level office visit codes generally include a detailed patient history and detailed single system or multi-system examination. These codes are often used when the ophthalmologist or optometrist is performing a follow-up examination that is limited and does not meet the minimum criteria established for CPT codes 92002 or 92012. Office visit codes may also be used to represent higher-level services in cases that are extremely complex and require a high level of medical decision making.

Selecting the appropriate coding option

If an ophthalmologist or optometrist performs an annual dilated eye examination to diagnose, monitor or treat the patient for diabetic retinopathy, HMSA and HPH would prefer that the provider bill using ophthalmological service codes (CPT 92002-92014). When providers bill in this way, Medicare Advantage and HPH will be able to gather more accurate data for quality studies about the number of members receiving appropriate services for their diabetes.

Note: CPT codes 92225 and 92226 (ophthalmoscopy, extended) may also be used by Medicare Advantage and HPH to gather data for NCQA studies. However, routine ophthalmoscopy is included in the ophthalmological service codes and should not be reported separately.

Benefits

Most HPH plans include benefits for routine vision services. Routine vision exams are limited to one per year and are distinguished from medical vision exams by the diagnosis code used on the claims. Please be sure to indicate an appropriate medical diagnosis code when billing for dilated eye exams for diabetic patients. If a routine exam diagnosis code is used (e.g., ICD-9: V72.0/ ICD-10: Z01.00-Z01.01), the claim may not be paid if the patient has already used his or her annual eye exam benefit.

Medicare Advantage members are eligible for vision exams when the services are appropriate for diagnosing and treating a medical condition. Please be sure to indicate an appropriate medical diagnosis code when billing for dilated eye exams for diabetic patients covered by Medicare Advantage.

For more information, see Ophthalmological Diagnosis Codes - Minor, Ophthalmological Diagnosis Codes - Major and Ophthalmological Diagnosis Codes - Refractive.

Revision History