# Presentation: 155414

## ICD-9-CM Coordination and Maintenance Committee MeetingOctober 8th, 2004

- Matthew J. Sheetz, MD, PhD

- Promoting Clear Identification of Diabetic Retinopathy

## Overview

- Clinical Manifestations and Diagnosis of Diabetic Retinopathy and Diabetic Macular Edema
- Disease Epidemiology
- Inadequacy of Current Diagnostic Codes
- Proposed Modifications and Clarification
- Discussion

## Diabetic Retinopathy (DR)

- Diabetic Retinopathy is a disorder of the retinal vasculature that eventually develops to some degree in nearly all diabetic patients1
- Third most common cause of blindness in the US and leading cause of blindness in individuals 20-74 years of age2
- Significant impairment of quality of life1
- Significant resources are spent to treat patients with DR
- Estimated $422M in total direct health care expenditures3
- Treatment includes:
- Control of diabetes-associated metabolic abnormalities (e.g. hyperglycemia; hyperlipidemia; hypertension)
- Laser photocoagulation and vitrectomy

- 1. American Academy of Ophthalmology. *Preferred Practice Pattern: Diabetic Retinopathy*., 2003
- 2. National Society to Prevent Blindness: *Vision Problems in the US*. New York, Prevent Blindness America, 1980
- 3. American Diabetes Association. Economic Cost of Diabetes in US in 2002*. Diabetes Care* 26:917-932, 2003

## AAO Disease Severity Scale	 	  Dilated Opthalmoscopy Findings 
No Apparent Retinopathy			   No Abnormalities

Mild Non-Proliferative Diabetic Retinopathy	   Microaneurysms only
Moderate Non-Proliferative Diabetic Retinopathy       More than just microaneurysms, but 
					                    less than severe NPDR

Severe Non-Proliferative Diabetic Retinopathy 	    Any of the following:
						     - More than 20 intraretinal hemorrhages
						       in each of four quadrants
						     - Definite beading in two or more quadrants
                       				     - Prominent intraretinal mircovascular 
						       anomalies in one or more quadrants
						    And no signs of proliferative retinopathy

Proliferative Diabetic Retinopathy		   One or both of the following:
						    - Neovascularization
						    - Vitreous/preretinal hemorrhage

- No Apparent Retinopathy			   No Abnormalities
- Mild Non-Proliferative Diabetic Retinopathy	   Microaneurysms only
- Moderate Non-Proliferative Diabetic Retinopathy       More than just microaneurysms, but
- 					                    less than severe NPDR
- Severe Non-Proliferative Diabetic Retinopathy 	    Any of the following:
- 						     - More than 20 intraretinal hemorrhages
- 						       in each of four quadrants
- 						     - Definite beading in two or more quadrants
-                        				     - Prominent intraretinal mircovascular
- 						       anomalies in one or more quadrants
- 						    And no signs of proliferative retinopathy
- Proliferative Diabetic Retinopathy		   One or both of the following:
- 						    - Neovascularization
- 						    - Vitreous/preretinal hemorrhage

- Natural History – Diabetic Retinopathy

- American Academy of Ophthalmology. *Preferred Practice Pattern: Diabetic Retinopathy*., 2003

## Diabetic Macular Edema (DME)

- Defined as retinal thickening or hard exudates in posterior pole resulting from increased vascular permiability1
- Frequent manifestation of diabetic retinopathy. Diabetic Macular Edema can occur in both the non-proliferative and proliferative stages of diabetic retinopathy
- Clinically significant macular edema (CSDME) may result in DR patients losing vision2
- DME within 500 μm of the center of the retina, or within 1500 μm and one disc area or larger in size
- Generally the threshold at which laser photocoagulation is applied

- 1. American Academy of Ophthalmology. *Preferred Practice Pattern: Diabetic Retinopathy*., 2003
- 2. Ciulla TA et al: Diabetic Retinopathy and Macular Edema. *Diabetes Care.* 26:2653-64. 2003

## Epidemiology

**Sight-Threatening DR is defined as proliferative DR or severe nonproliferative DR or macular edema**

**4.1 MM**

**0.8 MM**

**Source:  Kempen et al, Arch Ophthalmol 2004; 122:552-563**

## Inadequacy of Existing Codes

- Background Diabetic Retinopathy (362.01)
- Older term that does not represent current AAO/NEI language
- Does not allow for clear understanding of disease progression
- Includes Macular Edema: not allowing for a clear understanding of the Non-Proliferative Diabetic Retinopathy patients at risk for vision loss

## Maintain 362.01 Background diabetic retinopathy
Remove Diabetic macular edema & diabetic retinal edema from 362.01
Maintain 362.02 Proliferative diabetic retinopathy
Create four unique codes to describe the different stages of Diabetic Retinopathy 
362.03 Mild non-proliferative diabetic retinopathy
362.04 Moderate non-proliferative diabetic retinopathy
362.05 Severe non-proliferative diabetic retinopathy
362.06 Diabetic macular edema (code first for retinopathy)
		   Diabetic retinal edema

- Remove Diabetic macular edema & diabetic retinal edema from 362.01
- Maintain 362.02 *Proliferative diabetic retinopathy*
- Create four unique codes to describe the different stages of Diabetic Retinopathy
- 362.03 *Mild non-proliferative diabetic retinopathy*
- 362.04 *Moderate non-proliferative diabetic retinopathy*
- 362.05 *Severe non-proliferative diabetic retinopathy*
- 362.06 *Diabetic macular edema (code first for retinopathy)*
*	**	**   *Diabetic retinal edema

- Modification to Diabetic Retinopathy Codes

## Conclusion

- DR and DME are frequent, progressive complications of diabetes associated with significant morbidity and costs
- Current ICD-9-CM codes do not allow for categorization of the different stages of DR resulting in the loss of valuable information on the epidemiology and costs of the disease
- Modification of current codes will better represent the clinical presentation of DR and DME
- 362.01*Background diabetic retinopathy*
- 362.02 *Proliferative diabetic retinopathy*
- 362.03 *Mild non-proliferative diabetic retinopathy*
- 362.04 *Moderate non-proliferative diabetic retinopathy*
- 362.05 *Severe non-proliferative diabetic retinopathy*
- 362.06 *Diabetic macular edema (code first for retinopathy)*
*	**	**   **	*Diabetic retinal edema