Diabetic Retinopathy – Chart Review Codebook



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Diabetic Retinopathy – Chart Review Codebook

VERSION – 05/24/2010

The purpose of this chart review is to locate and document information in the medical record that indicates if an individual does or does not have diabetic retinopathy and/or macular edema. The primary goal of this chart review is not to collect a large amount of data, but to confirm if the individual should be considered a case, control, or if a determination cannot be made.



Important information about dates


For chart abstractions done on this study, the most recent date you should look at in the medical record is ___/___/_____. If a patient has a relevant diagnosis after this date, you should ignore it. Since the patient’s medical status is changing, using a static reference date saves us from having to review charts again to see if anything new has been added.

1. Patient has a confirmed diagnosis of diabetic retinopathy or macular edema


The following diagnoses (including ICD9 codes) are used to specify if a subject has diabetic retinopathy or macular edema. Along with each specific diagnosis that could be used, a separate “Group” has been added, which is how diabetic retionpathy and macular edema are being categorized in this study. You will need to specify the first positive mention of a diagnosis for a particular group. Note that you will need to identify which eye the diagnosis was made for – if it is unspecified anywhere in the record, you should indicate “Unknown”.
The abbreviations used in ophthalmology for the location include:

Initial diagnoses will most commonly be made by a physician in an ophthalmology department, but may be indicated in other clinical notes if a diagnosis was made outside of the institution. It is important that the diagnosis be for diabetic retinopathy or macular edema. Since other non-diabetic types exist, you must ensure the distinction is made in the note.




Group

Diagnoses

ICD9 Codes

Background

Background diabetic retinopathy

Diabetic Retinopathy Nos

Unspecified background retinopathy

Diabetic retinopathy, background




362.01

362.10


Exudative

Exudative retinopathy

Retinal exudates and deposits

Retina Exudates/Deposits

Coats' disease




362.12

362.82


Ischemic

Retinal ischemia

Retinal nerve fiber bundle defects

Retinal Nerv Fiber Defec


362.84

362.85


Macular edema

Diabetic macular edema


362.07

Nonproliferative

Nonproliferative diabetic retinopathy NOS

Mild nonproliferative diabetic retinopathy

Moderate nonproliferative diabetic retinopathy

Mod Nonproliferative Diabetic Retinopathy

Severe nonproliferative diabetic retinopathy

Sev Nonproliferative Diabetic Retinopathy




362.03

362.04


362.05

362.06


Proliferative

Proliferative diabetic retinopathy

Prolif Diab Retinopathy

Diabetic retinopathy, proliferative


362.02

Other

Diabetic retinopathy

Diabetic retinopathy, pre-proliferative





In addition, some procedures are performed for diabetic retinopathy or macular edema. These procedures will be performed by a physician in an ophthalmology department, but may be indicated in other clinical notes if the procedure was performed at another institution. Consent forms for laser treatment may also indicate a procedure took place.


A procedure alone does not indicate a diagnosis of diabetic retinopathy or macular edema, but if one of the procedures below is indicated you may need to look before or after the procedure note to see if a procedure was performed for diabetic retinopathy or macular edema and was just not formally diagnosed within the institution. This could happen if a patient was referred in for the procedure, but receives care elsewhere.


Procedures

CPT Codes

Impltj Intravitreal Drug Dlvr Sys Rmvl Vts

Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous



67027

Vtrc Mchnl Pars Plna

Vtrc Mchnl Pars Plna Focal Endolaser Pc

Vtrc Mchnl Pars Plna Endolaser Panrta Pc

Vitrectomy Pars Plana Remove Preretinal Membrane

Vitrectomy, mechanical, pars plana approach;

Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping

Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation

Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation

Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker)

Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique

Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens


67039

67040


67041

67113


Dstrj Loclzd Les Retina 1+ Sess Crtx Dthrm

Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; cryotherapy, diathermy




67208


2. Patient had a dilated eye exam within the past 2 years


Starting with the most recent, look at all ophthalmology and optometry documentation for the past 2 years prior to the reference date (listed at the top of the code book). If a patient is deceased, look at the past 2 years prior to their date of death. If the patient had an eye exam performed and the documentation indicates that the patient was dilated, mark this as “Yes”. If there is an eye exam but you cannot determine if the patient was dilated or not, the exam does not count.
If it doesn’t explicitly say that the patient’s eyes were dilated, there are other ways that the use of the dilation drops are documented. This includes:

  • Drops

  • M1

  • Neo 2.5

  • M1/Neo 2.5

  • M1/N2.5

  • M/N

  • M/Neo

  • Phenyothine Hydrochlroide 2.5

  • Tropicamide 1%



3. Last eye exam has indications of diabetic retinopathy or macular edema


For the last dilated eye exam found in question 2, look for any indication that the patient had or might have diabetic retinopathy or macular edema.
For initial patients (consults, new patients) and for some established patients, the forms will have a specific area for “Pupils” where the assessment is documented. If the pupils are clear, and there is no indication of diabetic retinopathy or macular edema, there will be a notation of “PERRLA” (pupils equal, round, reactive to light and accomodation) or “- APD” (the “-“ means negative, so also look for a neagative indication such as the terms “neg” or “negative” or “no”). If there is a pupil abnormality, you will see a positive indication of APD (afferent puil defect) documented as “APD” and may have a numeric grade such as “+1 APD” or “2+ APD”.
Note that some forms do not have a designated location for an assessment of the pupils. The nomenclature of PERRLA and APD are still used, but will require you to look at the entire form. Additional abbreviations, acronyms and terms that would indicate possible diabetic retinopathy or macular edema are listed below.
NVD – neovascularization of the disc (creation of new blood vessels)

NVE – neovascularization of the retina elsewhere (outside the disc)

PPDR – pre-proliferative diabetic retinopathy

BDR – background diabetic retinopathy



Edema

Exudate


Rubeosis

4. Additional comments/notes


Please use this area for any additional notes that you might want to make for yourself, or questions that need to be raised for a re-review. This can be filled at any time during the chart review.

5. Review Completed


This is an optional field that you may use to mark this chart review as completed when you feel you have reviewed all of the relevant information in the medical record. This does not need to be filled in if you choose to use some other mechanism (i.e. special folder for completed review forms) to manage the review.


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