Diabetic Eye Exam Prescription / Report
Everyone with Diabetes should get a Comprehensive Eye Exam at least once a year to prevent potential
vision loss. Based on our records, you are due for a Diabetic Eye exam. Please present this form to your
eye specialist and request the completed report be returned to your PCP via fax.
Section to be completed by Primary Care Physician (PCP):
Physician Address:
Phone:
Fax:
Patient Name:
Date of Birth:
Address:
Day Phone:
Eye Care Professional: Please complete this portion of the form and return to the primary care
professional via fax.
Name of Eye Care Practice/Facility:
Phone:
Address:
Fax:
Date of exam:
Patient received a dilated fundus examination with the following results:
□ Normal Diabetic Eye Exam
□ No diabetic retinopathy was detected
□ Nonproliferative retinopathy was detected, which requires monitoring.
No treatment is indicated at this time
□ Retinopathy requiring further testing and/or treatment was detected. See comments below.
Comments / Recommendations:
Choose the appropriate procedure(s) and diagnostic code(s) by circling the service performed:
Ophthalmology/Optometry
Service Codes
E/M Codes
CPT Category II codes
HCPCs Codes
ICD9 Procedure Codes
Johncode
Eye Exam9/0St
diagnosis
67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108,
67110, 67112, 67113, 67121, 67141, 67145, 67208. 67210, 67218, 67220,
67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225,
92226, 92230, 92235, 92240, 92250, 92260
99203-99205, 99213-99215, 99242-99245
2022F, 2024F, 2026F, 3072F
S0620, S0621,S0625, S3000
14.1-14.5, 14.9, 95.02-95.04, 95.11, 95.12, 95.16
V72.0, 249.5, 250.xx, 648.0x
USt John
Patient is to return for re-evaluation in
months. Appointment Date:
Print Name of Eye Care Professional
Signature:
Date: