Summary & Overview
HCPCS M1430: Retinal Exam, No Retinopathy in Both Eyes with Severity Documented
HCPCS Level II code M1430 denotes a documented retinal exam finding of no evidence of retinopathy in both eyes with the severity level recorded within the measurement year or the prior year. As a documentation-focused HCPCS Level II code, it captures clinical status important for chronic disease management, quality measurement, and payer reporting. Nationally, such codes support tracking of diabetic eye disease outcomes, adherence to screening practices, and risk stratification for population health programs.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for the code, typical sites of service, and what to expect in administrative use. The publication summarizes common benchmarks and reporting uses for documentation codes like M1430, highlights relevant policy and coding considerations affecting national reporting efforts, and explains how this code fits into broader retinal screening and quality measurement workflows.
Where specific payer or modifier data is not provided, the text notes that data are not available in the input. The focus is on clinical meaning, service setting implications, and the code's role in documentation and quality reporting rather than reimbursement specifics.
Billing Code Overview
HCPCS Level II code M1430 represents a retinal exam finding of no evidence of retinopathy in both eyes with a documented severity level (documented in the measurement year or the prior year). This denotes a clinical assessment outcome indicating the absence of diabetic retinopathy while capturing the documented severity level for both eyes.
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Service type: Eye/retinal examination assessment
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Typical site of service: Ophthalmology or optometry outpatient settings, including clinic visits and eye care specialty practices
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient with type 2 diabetes presents to an ophthalmology clinic for an annual diabetic eye exam. The clinician performs a dilated retinal examination in each eye and documents no findings of diabetic retinopathy, recording the severity level (for example, “no retinopathy” or “level 0”) in the electronic health record during the measurement year. Visual acuity and intraocular pressure are measured, and a slit-lamp with dilated fundus exam is performed. The exam is performed in an outpatient ophthalmology clinic or a multispecialty ambulatory surgical center. Documentation includes laterality (both eyes), the absence of microaneurysms, hemorrhages, exudates, or neovascularization, the severity level, and the date of exam to support reporting of M1430 for quality reporting programs or supplemental HCPCS Level II reporting.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day | Use when a distinct E/M visit is performed in addition to the retinal exam |
26 | Professional component |