Eligibility for Annual Screening

Members registered for diabetes (ICD-10 codes E10.9 or E11.9) are eligible for an annual eye screening, covered by the scheme benefits. This means that the cost will not be deducted from the member’s savings account.

If there is any uncertainty about the member’s registration, the only alternative is to call in—which is not ideal. Instead, please ask the member to confirm their registration using the member app. The app will display their registration details, including any listed chronic conditions, which the member can show as confirmation.

Important Billing Information

To ensure that the screening is reimbursed from the scheme benefits and not from savings, healthcare providers must use the designated billing codes. If routine eye examination codes (e.g., 11001, 11624, 11801) are used instead, the claim will be processed from the member’s savings, as these codes are not linked to the scheme’s chronic benefit.

Reimbursable Procedure Codes

The following procedure codes are eligible for reimbursement under scheme benefits for registered diabetes patients:

General Practitioners (GPs) with a Fundus Camera:

• 3027 – Fundus photography
• 116AI – AI report generation

Optometrists:

• 116DR1 – Fundus photography
• 116AI – AI report generation
• 116DR2 – Secondary examination if retinopathy is detected

Ophthalmologists:

• 0190 – Consultation
• 3014 – Tonometry
• 3009 – Basic capital equipment used in own rooms
• 3003/3004/3027 – Fundus examination
• 116AI – AI referral report generation using an approved Discovery AI system (only applicable if 3027 is billed)

Please note:

 116DR1 and 3027 may not be billed together.

116AI can only be billed with either 116DR1 or 3027

There are three possible outcomes for a report:

1. Referable – The AI has confidently detected signs of diabetic retinopathy (DR). This report is ready for secondary grading and can be submitted to Discovery for reimbursement.
2. Non-Referable – The AI is confident that no signs of DR are present. Secondary grading is not required, and the report can be submitted to Discovery for reimbursement.
3. Ungradable – The AI was unable to confidently grade the image, often due to poor image quality.
• If the poor image quality is due to operator error (e.g., blurry or incorrectly taken image), Discovery may not reimburse.
• However, if the poor quality is due to a clinical reason such as a cataract, the report may still be eligible for reimbursement.

How do you determine if the image is of sufficient quality?
A good quality image will have a clearly visible nerve fibre layer and no shadows or artifacts, such as those caused by blinking.

If the image is of good quality but the report is still marked as ungradable, it can still be submitted. In such cases, the AI errs on the side of caution and recommends referral—this would still be reimbursable by Discovery.