Diabetes: Eye Exam

Measure Specification

Diabetes is the eighth leading cause of death in the United States. In 2021, diabetes affected more than 38 million Americans (11.6 percent of the U.S. population) and killed more than 103,000 people. Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly. People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney damage, amputation of feet or legs, and premature death.

In 2022, diabetes cost the U.S. an estimated $413 billion: $307 billion in direct medical costs and $106 billion in reduced productivity. The direct medical cost of diabetes increased by 7% between 2017 and 2022. Diabetes is the leading cause of new cases of blindness among adults aged 18–64 years. Diabetic retinopathy is progressive damage to the small blood vessels in the retina that may result in loss of vision.

Approximately 4.1 million adults are affected by diabetic retinopathy.

American Diabetes Association (2025): - Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (Level of evidence: B) - Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis.

(Level of evidence: B) -If there is no evidence of retinopathy for one or more annual eye exams and glycemic indicators are within goal range, i, then screening every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist.

If retinopathy is progressing or sight threatening, then examinations by an ophthalmologist will be required more frequently. (Level of evidence: B) - Programs that use retinal photography with remote reading or the use of U.S. Food and Drug Administration–approved artificial intelligence algorithms to improve access to diabetic retinopathy screening are appropriate screening strategies for diabetic retinopathy.

Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.

For Numerator Option: Performance Met: Low risk for retinopathy (no evidence of retinopathy in the prior year) 3072F This code can only be used if the claim/encounter was during the measurement period because it indicates that the patient had “no evidence of retinopathy in the prior year”. This code definition indicates results were negative; therefore, a result is not required.