2026 MIPS Measure #117: Diabetes: Eye Exam

Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.

This measure is to be submitted a minimum of once per performance period for patients with diabetes mellitus seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.

Patients 18 - 75 years of age with diabetes with a visit during the measurement period

DENOMINATOR NOTE: To assess the age for exclusions, the patient’s age on the date of the encounter should be used.

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

DIABETES EYE EXAM (DEE) MEASURE – SUMMARY:

INCLUSION (DENOMINATOR):
- Age: 18 to 75 years on date of encounter
- Diagnosis: Diabetes (ICD-10-CM: E10.xx, E11.xx, E13.xx, O24.xx – see full list)
- Encounter during performance period using eligible CPT/HCPCS codes (see full list)

DENOMINATOR EXCLUSIONS (EXCLUDE FROM MEASURE IF ANY):
1. G9714 – Hospice services anytime during measurement period
2. G9994 – Palliative care services anytime during measurement period
3. G2105 – Age ?66 in Institutional SNP OR residing in long-term care (POS 32,33,34,54,56) for >90 consecutive days during measurement period
4. G2106 – Age ?66 with frailty (claim/encounter) AND dementia medication dispensed during measurement period OR prior year
5. G2107 – Age ?66 with frailty (claim/encounter) AND advanced illness diagnosis during measurement period OR prior year
6. M1428 – Bilateral absence of eyes anytime during patient's history through end of measurement period

FRAILTY CODES (for G2106 & G2107):
- HCPCS/CPT: 99504, 99509, E0100–E0171, E0250–E0304, E0424–E0472, E0561–E0562, E1130–E1298, G0162, G0299–G0300, G0493–G0494, S0271, S0311, S9123–S9124, T1000–T1031
- ICD-10-CM: L89.000–L89.96 (pressure ulcers), M62.50, M62.81, M62.84, R26.2, R26.89, R26.9, R29.6, R53.1, R53.81, R54, R62.7, R63.4, R63.6, R64, W01.0XXA–W19.XXXS (falls), Y92.199, Z59.3, Z73.6, Z74.01–Z74.9, Z91.81, Z99.11, Z99.3, Z99.81, Z99.89

ADVANCED ILLNESS CODES (for G2107):
- ICD-10-CM: A81.00–A81.09 (Prion disease), C25.0–C25.9 (Pancreatic cancer), C71.0–C71.9 (Brain cancer), C77.0–C79.9 (Metastatic cancer), C91.00–C94.32 (Leukemias), F01.50–F04 (Dementia/Alzheimer's with various complications), F10.27, F10.96–F10.97 (Alcohol-related), G10 (Huntington's), G12.21, G20.A1–G20.C (Parkinson's), G30.0–G31.83 (Alzheimer's/other degeneration), G35.A–G35.D (Multiple sclerosis), I09.81, I11.0, I12.0, I13.0–I13.2 (Hypertensive kidney disease), I50.1–I50.9 (Heart failure), J43.0–J43.9 (Emphysema), J68.4, J84.10–J84.178 (Interstitial lung disease), J96.10–J96.92 (Respiratory failure), J98.2–J98.3 (Interstitial emphysema/compensatory emphysema), K70.10–K74.69 (Liver disease/cirrhosis), N18.5–N18.6 (CKD stage 4-5)

DEMENTIA EXCLUSION MEDICATIONS (for G2106):
- Cholinesterase inhibitors: Donepezil, Galantamine, Rivastigmine
- Miscellaneous CNS agents: Memantine
- Dementia combinations: Donepezil-memantine

KEY TAKEAWAY:
Patient qualifies for measure if age 18-75 + diabetes Dx + eligible visit – EXCLUDE if any of G9714 (hospice), G9994 (palliative), G2105 (long-term care >90d), G2106 (frailty + dementia meds), G2107 (frailty + advanced illness), M1428 (bilateral absence of eyes), or POS for long-term care exclusions.

Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following:

Diabetic with a diagnosis of retinopathy during the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period
Diabetic with no diagnosis of retinopathy during the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period
NUMERATOR NOTE: The eye exam must be performed or reviewed by an ophthalmologist or optometrist, or there must be evidence that fundus photography results were read by a system that provides an artificial intelligence (AI) interpretation and documented as with or without retinopathy (reporting of CPT 92229 meets the intent of the quality action for performance met). Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.

Performance Met: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist or artificial intelligence (AI) interpretation documented and reviewed; with evidence of retinopathy (M1220)

OR

Performance Met: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist or artificial intelligence (AI) interpretation documented and reviewed; without evidence of retinopathy (M1221)

OR

Performance Met: 7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (2024F)

OR

Performance Met: 7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (2025F)

OR

Performance Met: Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy (2026F)

OR

Performance Met: Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy (2033F)

OR

Performance Met: Low risk for retinopathy (no evidence of retinopathy in the prior year) (3072F)

OR

Performance Met: Retinal exam finding with evidence of retinopathy in left, right or both eyes with severity level documented (M1429)

OR

Performance Met: Retinal exam finding without evidence of retinopathy in both eyes with severity level documented (in measurement year or in the prior year) (M1430)

OR

Performance Not Met: Dilated eye exam was not performed, reason not otherwise specified (2022F or 2024F or 2026F with 8P)

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 (American Diabetes Association [ADA], 2024). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (Centers for Disease Control [CDC], 2025a). 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 (CDC, 2025b).

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 (Parker et al., 2022). Diabetes is the leading cause of new cases of blindness among adults aged 18–64 years (CDC, 2025c). Diabeticretinopathy 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 (CDC, 2025c).

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. (Level of Evidence: B)