HEDIS Training and Tips 

Partner with Envolve Vision to Improve the Health of Diabetic Members

Current Procedural Terminology (CPT) II codes are a set of supplemental tracking codes that are used to measure performance. Reporting a Category II code for performance measurement decreases the need for record abstraction and chart review. This helps minimize administrative burden on physicians and staff.

Envolve Vision is committed to improving the health of our community by helping people with diabetes lead healthier lives. Vision is a vital part of diabetic care.

We are asking for your help to ensure our diabetic members receive both preventive and ongoing quality eye care. To help us identify those patients who are compliant with their diabetic retinal evaluations, please remember to report the following with claims:

1. Submit ICD-10 code indicating the eye(s) involved and ensure code meets the highest level of specificity, as unspecified codes are often denied
   
2. An appropriate examination, screening or diagnostic test code (CPT)
3. An appropriate tracking code for performance measurement (CPT II)

Envolve also offers incentives for reporting CPT II codes:

• When applicable, Envolve will reimburse providers up to $10 – once per member, per calendar year – for filing one of the qualifying HEDIS CPT II codes. 
• You must bill a dollar amount to receive reimbursement; see your fee schedule for details.

Diabetic retinal evaluation CPT II codes are listed below:

Routine retinal evaluation is recommended to reduce the risk of diabetes-related blindness. Exams do not require pre-authorization. Some health plans and products may require referral by a primary care physician (PCP) for specialty care. 

Did you know that using the appropriate CPT, HCPCS, ICD-10 codes below could also reduce the need for medical record review? 

CPT:

67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110,
67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228,
92002, 92004, 92012, 92014, 92018, 92019, 92134, 92201, 92202, 92227-92230,
92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245

HCPCS:

S0620, S0621, S3000

Diagnosis Code (Indicator for diabetes without complications):

E10.3-E10.39, E10.9, E11.3-11.39, E11.9, E13.3-E13.39, E13.9

Documentation to include:

• Date of Retinal Exam
• Type of Exam (dilated, retinal) - must be bilateral
  
• Result of exam (negative or positive for retinopathy)
  
• Eye care professional performing and reading exam(optometrist or ophthalmologist)
  

While exams do not require prior authorization, please adhere to Envolve Vision’s clinical policies regarding medical necessity.

Please visit envolvevision.com/logon to view medical necessity guidelines and to verify member benefits and eligibility. For questions regarding diabetic care coordination, contact Envolve Vision’s Customer Service Center at (800) 531-2818.

Please see plan specifics and applicable billing guidelines when selecting the most appropriate CPT code for services rendered.

*As a reminder, 3072F should be included in your claim filing to indicate no evidence of diabetic retinopathy in the prior year, when applicable. This code may be separately reimbursable, please reference plan specifics and applicable billing guidelines when selecting the most appropriate CPT code for services rendered.

**Please note that 3072F corresponds to the result of a test result performed during the year prior to the measurement period and not the present year. For tests performed this year, please report 2022F-2033F when applicable.