Diabetes is becoming one of the most common diseases in the United States. And, diabetic retinopathy (DR) is one of the nation’s leading causes of blindness. Patients with diabetes also have other ocular problems, including vision fluctuations, early cataract development, dry eye and glaucoma. The most important method of detecting and monitoring sight-threatening ocular complications from diabetes is direct observation of the anterior segment structures and the retinal structure and vasculature.
Medicare and most payors fully recognize the essential role the eye care provider plays in the detection and management of this debilitating disease. For optometrists, systemic diabetes codes, even without ocular complications, are included in the allowable diagnostic list for the EM and Ophthalmologic codes. In fact, in 2008, CMS allowed an annual eye exam for those with diabetes, even in the absence of diabetic retinopathy. Properly managing patients with diabetes often requires other diagnostic tests administered in the optometrist’s office.
• Fundus Photography. Photo-documentation of retinal pathology is often the most important aspect of monitoring retinal complications from diabetes. Coverage varies across the country, from allowing photodocumentation of even healthy retinas to severity and frequency limitations. Check with your individual payors or online resources (such as www.LCDPlus.com) for coverage guidelines specific to your practice. Although a sound medical decision in many cases, reimbursement for routine, repeat photos are typically not allowed unless you are documenting change in the tissue.
• Blood Glucose Measurement. Office blood glucose screening is a common service in many optometric practices. While any single blood glucose reading may have limited diagnostic implications, it is one more valuable piece of information optometrists can use to make diagnostic and management decisions. Keep in mind that blood, exudates, fluid and vessel changes in the deeper retinal layers are only findings and do not constitute the diagnosis of diabetic retinopathy unless associated with blood glucose dysregulation.
• Scanning Laser. Laser coherence tomography has become an essential element of managing retinal complications from diabetes. While direct observation is usually sufficient to detect most diabetic retinal vascular aberrations, evaluation of potential neovascularization and especially retinal edema is often detected and/or quantified by the imaging capabilities of scanning lasers. Remember that retinal edema can occur in the absence of observed vascular changes.
On January 1, 2011, the scanning laser code for retinal evaluation changed to 92134, and is billed as one unit whether performed on one eye or both. While reimbursement for this imaging test was reduced, it is still an essential element of monitoring diabetic retinal disease.
Clinical Coding Committee
• John Rumpakis, O.D., M.B.A.,
Clinical Coding Editor
• Joe DeLoach, O.D.
• David Mills, O.D., M.B.A.
• Laurie Sorrenson, O.D.
• Rebecca Wartman, O.D.
• Fluorescein Angiography. While scanning lasers have decreased the role of fluorescein angiography in managing diabetic retinal complications, they have far from eliminated the need for this essential test. Potential neovascular changes, areas of vascular non-perfusion and the severity of retinal edema are often still best detected by fluorescein imaging. Other than detecting and quantifying retinal non-perfusion, oral fluorescein angiography can be very beneficial in evaluating suspicious vascular aberrations, especially neovascularization.
• Dry Eye Evaluation. There’s a strong link between diabetes and dry eye. As many as 50% of all people with diabetes suffer from dry eye symptoms––most due to decreased aqueous deficiency and meibomian gland compromise. Although often limited to reimbursement by the patient, tear function tests can provide important information in the management of diabetic dry eye problems.
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