Retinal Eye Exams and CPT II Coding

We appreciate the care and services you provide to our Blue Cross and Blue Shield of Texas (BCBSTX) members. Many primary care providers (PCPs) refer diabetic patients to eye care specialists for annual eye examinations. PCPs need to know details about the care their patients receive and to receive communications from their patients’ eye care specialists. We want to encourage eye care specialists to share results routinely and promptly with PCPs. There is a specific Current Procedural Terminology CPT II code that indicates the documented communication of the eye exam findings to the PCP managing the diabetes care. This is a good example of evidence of continuity and coordination of care between providers.

Why it matters: Using the proper CPT® Category II codes when filing claims can help streamline your administrative processes and ensure gaps in care are closed.

CPT II codes are tracked for certain performance measures. We use these measures to monitor and improve the quality of care our members receive. CPT II codes are more specific than CPT I codes and can help:

  • Provide more accurate medical data
  • Identify and close gaps in care more accurately and quickly
  • Track member screenings to help you monitor care and avoid sending unnecessary reminders


Diabetic Retinal Exam


Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care


Members ages 18-75 diagnosed with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed, had documented communication to the physician who manages the ongoing care of the patient with diabetes regarding the findings of the dilated macular or fundus exam at least once within 12 months




Code description:

Findings of dilated macular or fundus exam communicated to the physician managing the diabetes care


Diabetic Eye Exam without Evidence of Retinopathy in Prior Year


Diabetic Eye Exam without Evidence of Retinopathy

2023F, 2025F, 2033F

Diabetic Eye Exam with Evidence of Retinopathy

2022F, 2024F, 2026F

Automated Eye Exam


Diabetic Eye Exam

67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92201, 92202, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, 99245

CPT copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. HEDIS is a registered trademark of the National l Committee for Quality Assurance (NCQA).

The material presented here is for informational/educational l purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment  based  upon  their  evaluation  of  their  patients'  conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third- party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.