Diabetic Retinal Disease: Don't Forget To Document!
Date: 10/31/17
Louisiana Healthcare Connections is committed to helping our provider partners improve their Quality ratings in Comprehensive Diabetes Care. A key HEDIS measure, Comprehensive Diabetes Care includes performing eye exams on patients ages 18-75 with diabetes (Type 1 and Type 2).
Screening or monitoring for diabetic retinal disease refers to a retinal or dilated eye exam performed by an eye care professional (optometrist or ophthalmologist) in the measurement year, or a negative retinal or dilated eye exam performed by an eye care professional in the year prior to the measurement year. For providers, it is important to document that this screening was completed in the patient’s medical records.
What should documentation include?
At a minimum, documentation in the patient’s medical record should include:
- A note or letter prepared by an ophthalmologist, optometrist, Primary Care Provider (PCP) or other health care professional indicating that an ophthalmoscope exam was completed by an eye care professional
- The date when the procedure was performed
- The results of the procedure
What should the eye exam include?
Diabetic retinopathy and macular edema are detected during a comprehensive eye exam that includes:
- Visual acuity test
- Dilated eye exam
- Tonometry
Additional testing includes fluorescein angiography, optical coherence tomography and ophthalmoscopy.
Things To Remember:
- Hypertensive retinopathy is considered to be the same as diabetic retinopathy when reporting the eye exam indicator for this measure. Though clinically diagnosed different, an eye exam documented as positive or negative for hypertensive retinopathy is counted as positive or negative for diabetic retinopathy.
- Blindness is not an exclusion for the diabetic eye exam because it is difficult to distinguish between those are who legally blind.
Questions?
If you have questions about how to document this HEDIS measure in the patient’s medical record, contact a member of our Quality team by calling Provider Services at 1-866-595-8133.