More than 23 million Americans—almost 8% of the population—have diabetes, according to the American Diabetes Association. Diabetes is even more prevalent—as high as 11%—in Hispanics and blacks. Most disturbing, it is one of the fastest growing systemic diseases in teenagers. The economic burden this one disease places on the U.S. health care system is estimated at more than $218 million a year.
In eye care, complications from diabetes make it the leading cause of new cases of blindness in the 20 to 74 age bracket. Despite this, 26% to 36% of all individuals with diabetes have never had eye examinations, according to the American Optometric Association. Unfortunately, retinopathy complications from diabetes are often only a matter of time because 60% of people who’ve had diabetes more than 10 years exhibit some degree of retinopathy.1
These statistics should make us all ask: Are we doing all we can do to monitor this disease?
Care of Diabetes Patients
Recommended clinical protocols from the AOA and the American Academy of Ophthalmology (AAO) stress annual comprehensive evaluations with dilated retinal evaluations for all diabetes patients. As the disease progresses, more frequent monitoring may be indicated.
Staging the severity of the disease may be based on a complex system from the Early Treatment of Diabetic Retinopathy Study and the Diabetic Retinopathy Study. The AAO Preferred Practice Pattern for diabetic retinopathy (http://one.aao.org/CE/PracticeGuidelines/PPP.aspx) recommends a less complex international classification system and has an excellent table that presents guidelines for frequency of evaluations based on clinical signs and the severity of those signs. Optometrists should become familiar with these classification systems so they can remain comfortable in monitoring diabetes patients, and not refer for laser or surgical care unless truly indicated.
Both organizations also stress the importance of communicating the ocular status of diabetes patients with their primary care physician or endocrinologist.
Even in involutional or end-stage retinopathy patients, optometric low vision services become an essential element in the quality of life of many patients.
Tests for the Diabetes Patient
In addition to a comprehensive exam, several procedures may be indicated as medically necessary in the care of people with diabetes:
• Quality fundus photographs (92250) are indispensable in documenting and monitoring moderate to severe retinopathy. Some Medicare MACs payors actually encourage photodocumenation of every diabetic patient’s retina, even in the absence of retinopathy. Check your payor for their policy in this area.
• Scanning lasers (92135) have provided eye doctors with a significant tool for documenting overall retinal thinning or macular edema. It should be noted that the current criteria for clinically significant macular edema are based on subjective retinal evaluations. How scanning lasers can be used to define the severity of macular edema is still not established.
• Fluorescein angiography (92235) is still a useful tool in documentation focal or diffuse retinal ischemia as well as degree of vascular leakage or compromise. Currently, fluorescein’s role is more beneficial in the decision to treat diabetic retinas as opposed to establishing a diagnosis of retinopathy.
• Gonioscopy (92020) to detect iris neovascularization is an essential tool in monitoring more advanced retinopathy.
• Visual fields (92083), though less diagnostic, may be indicated to detect and document vision loss from this blinding disease.
Medicare and Diabetes
Medicare recognized the important role of eye doctors in monitoring diabetes patients by establishing a preventive annual diabetic eye examination for those with diabetes (with or without diabetic retinopathy) and eight potential Level II CPT quality reporting initiatives for 2010––more than any other ocular disease condition. The preventive exam can be done annually on Medicare patients who have diabetes, even in the absence of any diabetic retinopathy. These are generally coded using the 920x4 or 920X2 codes rather than the 992XX codes. The diagnosis must include the specific form of systemic diabetes 250.XX, and if they have diabetic retinopathy, the specific ICD-9 code for that as well.
Medicare’s Physician Quality Reporting Initiative (PQRI) items include: conducting a dilated retinal evaluation in a diabetes patient (2022F); photographic documentation of retinal findings (2024F); documenting the severity of retinopathy and presence of absence of macular edema (2021F); communicating findings of a dilated examination with patient’s primary care physician (5010F); objective evaluation of retinopathy and/or macular edema (G8397 if performed, G8398 if not performed); and documentation of low risk for retinopathy based on current and prior evaluations (3072F). Less commonly reported is evaluation and report of ocular images from another physician (2026F). Details on these quality reporting initiatives are on Medicare’s website and the AOA’s website for members.
Clearly, comprehensive management of diabetic patients should keep us all on our clinical toes.
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1. Klein R, Klein BE, Moss SE, et al. The Wisconsin epidemiologic study of diabetic retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Arch Ophthalmol. 1984 Apr;102(4):520-6.