Patients with diabetes are at an increased risk for serious eye complications, including diabetic retinopathy and vision loss. Annual eye exams are a key component of diabetes management—and they’re also an essential quality measure in healthcare.
Here is what’s changing: Starting in 2025, the Eye Exam for Patients with Diabetes HEDIS® measure changed from a hybrid measure to an administrative measure. This means health plans will rely primarily on administrative claims data—rather than manual chart review—to determine whether diabetic patients received their annual eye exam.
What does this mean for you as an eye care professional?
The use of CPT® Category II (CPT II) codes is now critical to ensure your patients’ eye exams are properly captured. Each of these codes provides confirmation of an eye exam and its outcome, ensuring accurate quality reporting:
| Codes for Diabetic Patients WITH Evidence of Retinopathy | |
| 2022F | Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed |
| 2024F | Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed |
| 2026F | Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed |
| Codes for Diabetic Patients WITHOUT Evidence of Retinopathy | |
| 2023F | Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed |
| 2025F | Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed |
| 2033F | Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed |
| Codes for Diabetic Patients who had no evidence of retinopathy in the prior year | |
| 3072F | Low risk for retinopathy (no evidence of retinopathy in the prior year), photos results documented and reviewed |
Why It Matters
- Avoid Inaccurate Quality Scores: If an exam isn’t reflected in claims data, it could negatively impact the quality measure—and the performance scores of health plans who rely on that data.
- Support Population Health Goals: Accurate documentation helps ensure patients with diabetes are receiving appropriate preventive care.
- Streamline Your Workflow: Proper use of CPT II codes means fewer burdensome record requests and chart audits.
Action Steps for Eye Care Professionals
- Verify you’re submitting the appropriate CPT II codes along with your claims for diabetic patients. These codes are billed the same way your office bills for regular CPT codes and are placed in the same location on the claim form.
- Train staff and billing teams to understand the importance of these codes and when to use them.
Correct documentation can make a difference—not just in quality measures, but in the lives of diabetic patients. Accurate CPT II coding ensures your care is counted and your patients are protected.