On this page
- What Is the CPT Code for a Diabetic Eye Exam?
- Which Diagnosis Codes Go With a Diabetic Eye Exam?
- Which CPT II Codes Report the Diabetic Eye Exam Result?
- How Do Medicare and Vision Plans Treat a Diabetic Eye Exam?
- Which Tests Are Billed With a Diabetic Eye Exam?
- What Does a Diabetic Eye Exam Claim Look Like?
- Why Do Diabetic Eye Exam Claims Deny or Miss the Measure?
Key takeaways
- A diabetic eye exam is billed with 92002 to 92014 or an E/M code, not with a special diabetic exam code.
- The diabetes code goes first, such as E11.9 when there is no retinopathy or E11.3293 when there is.
- CPT II codes 2022F, 2023F, 2024F, 2025F, 2026F, 2033F and 3072F report the exam result for quality measures.
- Medicare covers a dilated diabetic eye exam as a medical service, so it is not billed as a routine exam.
What Is the CPT Code for a Diabetic Eye Exam?
There is no special CPT code for a diabetic eye exam, so it is billed with an eye exam code or an E/M code and the patient's diabetes diagnosis. The diagnosis, not the procedure code, shows the payer it was a diabetic exam.
The table lists the visit codes used most for diabetic eye exams. All of them are in the ophthalmology CPT codes list.
| Patient and exam | Code |
|---|---|
| New patient, complete dilated exam | 92004 |
| Established patient, complete dilated exam | 92014 |
| Established patient, focused follow-up | 92012 |
| Visit leveled by decision making or time | 99202 to 99215 |
A yearly diabetic exam is usually a complete dilated exam, billed with 92004 or 92014.
Which Diagnosis Codes Go With a Diabetic Eye Exam?
The first-listed diagnosis is the diabetes code that matches the exam findings, with a long-term drug code added when it applies. The code changes when retinopathy is found.
| Exam finding | Diagnosis codes |
|---|---|
| Type 2 diabetes, no retinopathy | E11.9 |
| Type 2 diabetes, mild retinopathy without macular edema, both eyes | E11.3293 |
| Type 1 diabetes, no retinopathy | E10.9 |
| Insulin use | Add Z79.4 |
| Oral diabetes drugs | Add Z79.84 |
The full set of retinopathy codes, with severity, edema and eye, is in the diabetic retinopathy ICD-10 codes guide.
Which CPT II Codes Report the Diabetic Eye Exam Result?
CPT II codes 2022F to 2026F, 2033F and 3072F report whether the exam or retinal images showed retinopathy, for the HEDIS Eye Exam for Patients With Diabetes measure and MIPS. They carry no payment but close the quality gap for the patient.
| Code | What it reports |
|---|---|
| 2022F | Dilated retinal exam read by an eye care provider, with retinopathy |
| 2023F | Dilated retinal exam read by an eye care provider, without retinopathy |
| 2024F | Seven standard field stereoscopic photos read by an eye care provider, with retinopathy |
| 2025F | Seven standard field stereoscopic photos read by an eye care provider, without retinopathy |
| 2026F | Eye imaging validated to match seven-field photos, with retinopathy |
| 2033F | Eye imaging validated to match seven-field photos, without retinopathy |
| 3072F | Low risk for retinopathy, no retinopathy in the prior year |
Health plans read these codes without modifiers 1P, 2P, 3P or 8P, which would mark the measure as not met or excluded. Check each plan's current measure year rules.
How Do Medicare and Vision Plans Treat a Diabetic Eye Exam?
Medicare and medical plans cover a diabetic eye exam as a medical service, while a vision plan covers only the routine part of a visit. The diabetes diagnosis moves the exam to medical insurance.
A diabetic patient who also wants new glasses can have both. The exam goes to medical insurance with the diabetes code, and refraction (92015) goes to the vision plan or the patient. Our vision plan billing team splits these visits between the right payers.
Which Tests Are Billed With a Diabetic Eye Exam?
OCT of the retina, fundus photography and retinal imaging are billed with a diabetic eye exam when the findings make them medically necessary. A normal exam with no retinopathy rarely supports extra tests.
- 92134 for OCT of the retina when macular edema is suspected or followed
- 92250 for fundus photos to document retinopathy
- 92229 for point-of-care AI retinal imaging, often used in primary care
- 92227 or 92228 for remote retinal imaging read by another provider
92250 and the remote imaging codes are not billed together on the same date.
What Does a Diabetic Eye Exam Claim Look Like?
A diabetic eye exam claim bills the exam with the diabetes diagnosis and adds the CPT II result code at a zero or one cent charge. The example shows a yearly exam with no retinopathy for an established patient on insulin.
| Claim line | Charge | Diagnosis |
|---|---|---|
| 92014 | Practice fee | E11.9, Z79.4 |
| 2023F | $0.00 or $0.01 | E11.9 |
A copy of the report sent to the patient's primary care provider helps both offices close the quality measure.
Why Do Diabetic Eye Exam Claims Deny or Miss the Measure?
Diabetic eye exam claims fail most often because of a routine diagnosis, a missing CPT II code or a CPT II code with an exclusion modifier. These checks prevent most of them.
- Z01.00 or Z01.01 used instead of the diabetes code for a medical exam
- No CPT II code, so the quality gap stays open
- A retinopathy result code that does not match the diagnosis
- An E11.3- code missing its eye character
Our ophthalmology medical coding services add the correct CPT II code to every diabetic eye exam claim.