Clearing up-coding confusion for retinal eye exams (DRE)
The Comprehensive Diabetes Care HEDIS® Measure Retinal Eye Exam (DRE) valuates the percent of adult members ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.
Changes to 3072F
The definition for the code 3072F (negative for retinopathy) has been redefined to: Low risk for retinopathy (no evidence of retinopathy in the prior year). This can be particularly confusing because it would not be used at the time of the exam. It would be used the following year, along with the exam coding for the current year, to indicate that retinopathy was not present the previous year.
A simpler coding solution
Using these three codes count toward the DRE measurement if they are billed in the current measurement year, or the prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years:
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)
7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy (DM)
Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed: without evidence of retinopathy (DM)
For more about diabetic retinopathy, visit CMS.gov or use this link to read more.
Meeting the measurement for all diabetes care
These exams are also important in evaluating the overall health of diabetic patients, as well as meeting the Comprehensive Diabetes Care HEDIS measure:
- Hemoglobin A1c (HbA1c) testing
- HbA1c poor control (>9.0%)
- HbA1c control (<8.0%)
- Retinal Eye exam performed
- Blood Pressure control (<140/90 mm Hg)
Record your efforts in the member’s medical records for the HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test and the estimated glomerular filtration rate test. Meeting the mark and closing gaps in care is key to good health outcomes.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
August 2021 Anthem Blue Cross Provider News - California