Eye Exam for Patients with Diabetes

Approximately 34.1 million U.S. adults have diabetes. Diabetes is one of the most costly and highly prevalent chronic diseases in the United States.

Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision. Approximately 4.1 million adults are affected by diabetic retinopathy. Early diagnosis and treatment of diabetic retinopathy helps reduce the risk of vision loss.1

The National Committee for Quality Assurance (NCQA) developed the Healthcare Effectiveness Data and Information Set (HEDIS®) measures to monitor the quality of care as a part of a performance and accountability system. Some of the HEDIS® measures focus on monitoring diabetes are Hemoglobin A1c Control, Kidney Health Evaluation, Statin Therapy, and Eye Exam.

The following information is a quick reference on Eye Exam for Patients with Diabetes measure:

Metric Eligible Compliance
Eye Exam for Patients with Diabetes (EED) Patients age 18–75 with type I or type II diabetes Patients who received a retinal eye exam during the year or negative exam during the year prior

Exclude: Patients age 66 and older with frailty and advanced illness.

Any provider type can complete a retinal exam using a retinal scanner. Results must be interpreted by an eye care provider. Provider should bill one of the following CPT codes: 92250, 92227, or 92228 along with one of the following CPT II codes: 2022F, 2024F, or 2026F. Any provider can submit a retinopathy status using CPT II 3072F in the year following the eye exam to indicate "no retinopathy."

The following codes can be filed by any provider type:

CPT II 3072F, 2022F, 2023F, 2024F, 2025F, 2026F, 2033F

The following codes must be filed by an eye care provider to identify an eye exam:

CPT 67028, 67030, 67031, 67036, 67039, 67040–67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225–92228, 92230, 92235, 92240, 92250, 92260, 99203–99205, 99213–99215, 99242–99245

Please refer to MyCare Finder for a list of in-network eye care providers.

1 Centers for Disease Control and Prevention (CDC). 2020. Common Eye Disorders and Diseases.

Updated October 1, 2021