Coding, compliance, and care for your patients with diabetes.

While it would be easy to simply lay out all of the CPT codes typically associated with care of the ophthalmic patient with diabetes, it would also be irresponsible. Compliance rules require that we only provide care that is medically necessary and appropriate for the stage of disease.  The patient’s medical record must clearly demonstrate that the service, procedure, or test ordered and performed was absolutely necessary in order to diagnose, treat, or monitor the patient’s condition.

Diabetes is one of the few disease states for which the Centers for Medicare & Medicaid Services (CMS) has adopted a real philosophy of preventive care. In 2008, CMS allowed the provision of an annual comprehensive eye examination (92004/92014) solely with the systemic diagnosis of diabetes even in the absence of diabetic retinopathy. Special ophthalmic tests such as retinal photography, OCT, and visual fields are commonly associated with the care of the patient with diabetes, but proper documentation specifying the necessity of any additional testing is critical rather than just assuming you can perform the test because of a diabetic diagnosis.

CPT and ICD-10 specificity today is also closely tied together with claims data analysis. Ordering and performing special tests in the absence of establishing medical necessity for those tests in the medical record is simply inappropriate, and the monies paid by a carrier are definitely recoverable in a post-payment review.

A typical care profile for a patient with diabetes who has  non-proliferative disease, but with macular edema (for example, ICD-10 E11.321), would look similar to the chart below:

92004 Opthalmological services:
medical examination and…
1 $149.58
92014 Opthalmological services:
medical examination and…
0 $124.47
99213 Office or other outpatient
visit for the evaluation…
2 $73.04
92250 Fundus photography with
interpretation and report…
1 $79.68
92083 Visual field examination,
unilateral or bilateral…
0 $64.95
92134 Scanning computerized oph-
thalmic diagnostic imaging…
1 $45.55
*Reimbursements stated are the 2015 CMS National Average for Each Procedure. Source:

Caring for patients with diabetes can generate $400 to $500 per patient, per year in gross receipts for the practice, particularly if the patient requires special ophthalmic testing. However, this is not to mean that every comprehensive exam is going to be paid by a medical carrier, particularly if the patient has a managed vision care plan that also pays for an annual comprehensive exam, nor should it mean that every patient will get exactly the same care. The exam frequency and the tests that you order for a patient should be based upon that individual patient and their stage of disease ““ not a clinical care protocol to be followed without regard to this.

Our role in providing primary optometric care is critical to both early detection of the disease as well as preserving the eyesight of our patients. Done properly, the care of patients with diabetes can, and should, be a significant part of the success of your practice.

John Rumpakis, OD, MBA, is a leading authority on medical coding and compliance issues in eyecare.


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