Requirement reminder: Care and coding standards for patients with diabetes

April 2025

As a reminder, when rendering services to a patient with diabetes, dilation of the pupil for fundus examination is required. All providers must be licensed and capable to dilate the pupil and perform the physical retina examination. 

New patients 

All new patients require a detailed examination of the fundus. This can be accomplished with the pharmacological dilation of the pupil and examination with a binocular indirect ophthalmoscope and a slit lamp fundus lens, or the professional review of a wide-angle fundus image (Optos or equivalent). 

Established patients 

Patients who have been diagnosed with diabetes require dilation annually at a minimum, but more often if they have retinopathy. Although the retinal imaging method is acceptable in some cases, it is not a substitute for a physical binocular retina examination. 

Care for patients with diabetes 

The following actions will help ensure the required care for patients with diabetes is met:

• History should include the name and, if available, contact information of the primary care physician (PCP), or the provider managing the diabetes
• History should include a complete list of all diabetes medications 
• The HbA1c should be documented in the chart
  • This may come from the patient, a lab report or the PCP
• Dilation is required every year 
• All common eye changes resulting from diabetes should be documented in the medical record. These include, but are not limited to retinopathy, dry eye, blepharitis, cataract and low-tension glaucoma
• The retina examination must be detailed, and subtle background changes should be noted 
• Education and counseling about blood sugar control and the required numbers to prevent vision loss should be emphasized 

Communication and coordination with the PCP are required. Send a full report of the dilated eye examination results to the PCP and/or diabetes provider. You may contact the health plan or PCP to coordinate additional medical needs identified while providing vision services. 

Correct coding and billing are required. Include the correct codes for retinopathy on your claim. The appropriate ICD-10 codes related to the diagnosis of diabetes and CPT® II are 2022F, 2023F, 2024F, 2025F, 2026F, 2033F or 3072F.

For more detailed information, please review our Care and coding standards: Diabetesopen_in_new on our Provider Training Academy.