BCBSRI is committed to making it easier for your practice to be successful in all areas of quality improvement. Together, we can achieve our shared goal of improving health outcomes by identifying and addressing open gaps in care. Hints for HEDIS (and more) is a reference tool to help better understanding of:
- Definitions, specifications, and exclusions of the many quality measures
- Billing codes used to report gap closure
- Collection and reporting methodologies
- Tips and best practices to maximize gap closure
Our Quality Concierge Team (QCT) is also available to answer questions, provide updates, assist in the interpretation of monthly gaps in care reports and detail summaries, research member attribution issues, and provide overall HEDIS support to you and your practice. Our QCT nurses can be reached at QualityHEDIS@bcbsri.org or at (401) 459-1005.
Understanding HEDIS for ophthalmology
How do ophthalmology and optometry play a role in HEDIS scores?
The “Comprehensive Diabetes Care” measure requires health plans to gather data showing that their members with diabetes get recommended screenings and exams. The measure includes a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a negative retinal exam or dilated eye exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement year.
Because a retinal exam is required to meet this quality measure, ophthalmologists and optometrists are an integral part of achieving the quality measure.
How does BCBSRI know that our members have received these services?
Claims submission data provides the necessary information to BCBSRI to validate meeting the HEDIS measure. For example, a claim for a lab test with CPT 83036 or 83037 confirms that the patient’s A1c was tested. There are several other ways that the health plan confirms performance of an eye exam. Per HEDIS, any provider may submit codes to substantiate the retinal exam. Eye exam codes (920xx) or evaluation and management codes (992xx), paired with a diabetes ICD-10 code, as well as the CPT Category II codes used for reporting of this measure, all suffice to support that this component of the measure was satisfied. The Category II codes are:
- CPT II 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed;
- CPT II 2024F: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed;
- CPT II 2026F: Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed; and
- CPT II 3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year).
In addition, BCBSRI requests provider medical records and conducts chart reviews to gather necessary data to report to NCQA.
How can eye care professionals help with this measure?
- Educate your patients with diabetes on the importance of having an annual retinal eye exam.
- Send reminders to those patients who are due or overdue for an annual exam.
- Ask your patients, at every visit, to document the name and address of their PCP.
- Send a letter or report of the eye exam to the patient’s PCP in a timely manner.