Summary & Overview
CPT 3072F: No Evidence of Retinopathy / Low Risk of Retinopathy
CPT code 3072F documents that a prior eye examination within the past 12 months found no evidence of diabetic retinopathy or that the patient is at low risk for retinopathy. Nationally, this performance-measure code supports surveillance of patients with diabetes or other conditions that risk retinal disease, enabling payers and providers to track absence of disease and appropriate intervals for follow-up. Key payers commonly referenced for coverage and reporting include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find a concise explanation of the code’s clinical meaning and expected service setting, plus an overview of how the code is used in quality measurement and claims reporting. The publication summarizes benchmarks and common reporting practices where available, outlines relevant policy considerations for payers and providers, and places the code in clinical context for ophthalmology and optometry services. Data not available in the input will be noted where necessary.
Billing Code Overview
CPT code 3072F indicates that the provider documents no evidence of diabetic retinopathy or low risk of retinopathy when a prior eye examination within the previous 12 months shows this result. The code applies when a clinician confirms absence of retinopathy based on clinical evaluation; an automated result is not required.
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Service type: Ophthalmologic surveillance / diabetic eye exam follow-up
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Typical site of service: Outpatient ophthalmology or optometry clinic, including retinal screening visits
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with diabetes mellitus undergoing routine ophthalmic surveillance for diabetic retinopathy. The patient presents to an ophthalmology or optometry clinic for an annual eye exam focused on retinal evaluation. Prior records document a dilated fundus examination or retinal imaging within the past 12 months showing either no diabetic retinopathy or only features indicating low risk of retinopathy progression. The clinician performs a focused retinal assessment during the visit, which may include slit-lamp biomicroscopy with a fundus lens, indirect ophthalmoscopy, and review of prior imaging reports. If the current examination corroborates the absence of retinopathy or confirms low risk compared with the prior exam within 12 months, the provider documents that there is no evidence of retinopathy or that risk remains low and reports 3072F to indicate this finding for quality reporting purposes. Typical sites of service include outpatient ophthalmology clinics, optometry offices, and ambulatory care centers. Common patient workflow steps: review prior exam/imaging, patient interview and visual acuity check, dilation if indicated, retinal exam, documentation referencing the prior 12-month examination, and coding of 3072F when criteria are met.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when a separate E/M visit is performed in addition to the retinal exam where 3072F is reported and documentation supports a distinct E/M service |
26 | Professional component | Use when only the professional component of a diagnostic service is billed by the interpreting clinician |
59 | Distinct procedural service | Use when two separate procedures are performed on the same day and documentation supports separate services (use cautiously with specific guidance for ophthalmic services) |
G0 | Temporary exclusion from MIPS reporting for COVID-19 clinical activity | Use when applicable per current reporting rules (not for clinical necessity) — payer-specific applicability required |
TC | Technical component | Use when the facility or technical provider bills for the technical component of a diagnostic service separate from the interpreting clinician |
52 | Reduced services | Use when a service is partially reduced or not completed as documented |
-RT | Right side | Ophthalmology laterality modifier (when required by payer for laterality reporting) |
-LT | Left side | Ophthalmology laterality modifier (when required by payer for laterality reporting) |
GA | Waiver of liability statement on file (patient refusal of ABN) | Use when advance notice/waiver applies per payer rules |
GQ | Institutional telehealth modifier (as applicable) | Use when service is provided via an approved asynchronous telehealth modality qualifying under payer rules |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207W00000X | Ophthalmology | Most common specialty performing comprehensive retinal assessment and reporting 3072F |
163W00000X | Optometry | Optometrists often perform routine diabetic retinal exams and document absence of retinopathy |
207K00000X | Retina Specialist | Vitreoretinal specialists confirm absence or progression of diabetic retinopathy in complex cases |
207Q00000X | Ophthalmic Plastic and Reconstructive Surgery | Rarely involved; included when ocular surface or adnexal evaluation accompanies retinal exam |
261QM0800X | Diabetes Educator/Endocrinology (Clinical) | Endocrinologists or diabetes care teams may document ophthalmic screening status in coordinated care settings |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
E11.319 | Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema | Common diagnosis indicating diabetic patient surveillance; absence of retinopathy on exam supports 3072F |
E10.319 | Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema | Type 1 diabetic patients require regular retinal exams; prior negative exam within 12 months supports 3072F |
Z13.89 | Encounter for screening for other diseases and disorders | Used when visits are coded as diabetes-related screening exams; documentation of no retinopathy can be reported with 3072F |
H35.031 | Nonproliferative diabetic retinopathy, right eye | If prior exam documented minimal nonproliferative changes classified as low risk, current confirmation of low risk may qualify for 3072F |
H35.032 | Nonproliferative diabetic retinopathy, left eye | Same relevance as for the right eye when laterality is specified |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
92002 | Ophthalmological services; new patient, intermediate or initial comprehensive eye service, typically without dilation | May be performed as the initial E/M component when a new patient presents for diabetic eye evaluation prior to retinal exam and documentation of 3072F |
92004 | Ophthalmological services; new patient, comprehensive, with dilation | Used when a comprehensive dilated eye exam is performed for a new patient and retinal status is assessed for reporting 3072F |
92012 | Ophthalmological services; established patient, intermediate, without dilation | May be used for established patients receiving problem-focused or intermediate eye care when retinal assessment documents no retinopathy |
92014 | Ophthalmological services; established patient, comprehensive, with dilation | Commonly used for annual dilated diabetic eye exams where 3072F is reported if no retinopathy is present |
92250 | Fundus photography with interpretation and report | Performed when photographic documentation is obtained; comparison to prior imaging supports reporting 3072F |
92134 | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral (OCT) | OCT may be used to document retinal status; comparison to prior studies within 12 months may support 3072F reporting |