Diabetic Eye Exams: Reference Guide for Documentation and Claim Coding

Woman receiving an eye exam

As an eye care provider, you play a crucial role in the early detection and timely treatment of diabetes‑related eye diseases such as diabetic retinopathy. More than one in three adults with diabetes has signs of diabetic retinopathy, underscoring the importance of routine retinal evaluation for this population.* To ensure patients with evidence of retinopathy receive an annual eye exam, NCQA® developed the Eye Exam for Patients with Diabetes (EED) measure within the Healthcare Effectiveness Data and Information Set (HEDIS®). This measure evaluates the percentage of patients aged 18–75 with a diagnosis of diabetes (type 1 or type 2) who received a retinal eye exam.

What is the HEDIS® measure specific to diabetics and eye exams?

This measure assesses the percentage of persons 18–75 years of age with diabetes (type 1 or type 2) who had a retinal eye exam.

How is the diabetic eye exam identified and monitored?

Screening or monitoring for diabetic retinal disease is identified by one of the following:

  • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement period (January 1, 2026 – December 31, 2026).
  • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement period. (2025)

Procedural Notations

  • If your patient has diabetes and does not have retinal disease, one of the CPTII codes below must be added to your claim, OR, one of the three ICD-10 codes listed below must be the Primary Diagnosis code for the claim.

It is a critical claim submission component that CPT**, CPTII and ICD-10 codes be added to the claim to demonstrate the outcome of retinal exams related to the HEDIS® measure.

Code Type Code Definition With/Without Retinopathy
CPT 92229 Autonomous eye examination With/Without
CPT 92002/92004/92012/92014 Ophthalmological services With/Without
CPT 92018/92019 Ophthalmological examination under general anesthesia With/Without
CPT 92134/92137 Computerized ophthalmic diagnostic imaging With/Without
CPT 92201/92202 Ophthalmoscopy with interpretation and report With/Without
CPT 92227/92228 Imaging of retina for detection of disease With/Without
CPT 92235 Ophthalmic angiography With/Without
CPT 92230/92250 Ophthalmoscopy with medical diagnostic evaluation With/Without
CPT 99203/99204/99205 New patient office visit requiring 30+ minutes With/Without
CPT 99213/99214/99215 Established patient office visit With/Without
CPT 99242/99243/99244/99245 Office consultation for a new or established patient With/Without
CPTII 2022F

2024F

2026F

Dilated retinal eye exam

Seven standard field stereoscopic retinal photos

Eye imaging validated to match diagnosis from seven standard field

with evidence of retinopathy

With
CPTII 2023F

2025F

2033F

Dilated retinal eye

Seven standard field stereoscopic retinal photos

Eye imaging validated to match diagnosis from seven standard field

without evidence of retinopathy

Without
CPTII 3072F Low risk/negative for retinopathy in prior year (2025) Without
ICD10 E10.9, E11.9, E13.9 Type 1/Type 2/Other specified diabetes mellitus without complications Without

How to Document

At a minimum, documentation in the medical record must include one of the following:

  • A note or letter prepared by an ophthalmologist, optometrist, PCP, or other healthcare professional that an optometrist or ophthalmologist completed an ophthalmoscopic exam, the date when the procedure was performed, and the results of the procedure
  • A chart or photograph indicating the date when the fundus photography was performed and one of the following:
    • evidence that an optometrist/ophthalmologist reviewed the results
    • evidence results were read by a system that provides an artificial intelligence (AI) interpretation
    • evidence that the patient had bilateral eye enucleation of acquired absence of both eyes; look as far back as possible in the patient’s history through December 31, 2025

Documentation of a negative retinal or dilated eye exam by an optometrist/ophthalmologist in 2025, where results indicate that retinopathy was not present

*Centers for Disease Control and Prevention. Promoting Eye Health.
**CPT codes, descriptions, and two-digit numeric modifiers only are copyright of the 2026 American Medical Association. All rights reserved.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Measure specifications are from NCQA.

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