CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Retinal telescreening (digital retinal imaging) for detection of diabetic retinopathy - Coverage and coding

This policy governs coverage and coding for retinal telescreening using digital imaging (including AI interpretation) for detection of diabetic retinopathy for BCBSRI members, with distinctions for Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRetinal telescreening (digital retinal imaging) for detection of diabetic retinopathy - Coverage and coding

Policy CodePolicy N/A

Change TypeMinor update / review

Effective DateMar 1, 2023

Next Review DateN/A

Key ActionPrimary care providers must include one of the specified Category II codes (2022F variants) on screening claims to ensure reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

92227-29CPT codes referenced

IDx-DR, EyeArtFDA-cleared AI examples

Category IIPCP requirement

95% vs 44%Screening uptake (RCT)

Coverage Criteria

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Medicare Advantage coverage

Medicare Advantage Plans

Medicare Advantage screening coverage: Retinal telescreening with digital imaging and manual grading by a primary care provider (PCP), optometrist, or ophthalmologist may be considered medically necessary for detection of diabetic retinopathy or for monitoring and management of disease in individuals diagnosed with diabetic retinopathy.

BCBSRI follows CMS guidelines for Medicare Advantage; Medicare Advantage policies may differ from Commercial products.

Commercial coverage and limits

Commercial Products

Commercial screening coverage: Digital retinal imaging with manual grading by a primary care provider (PCP), optometrist, or ophthalmologist may be considered medically necessary as a screening technique for detection of diabetic retinopathy.

Retinal telescreening is not medically necessary for other indications, including monitoring and management of individuals diagnosed with diabetic retinopathy due to insufficient evidence.

Covered CPT codes for screening: CPT codes 92228 (remote physician interpretation/report) and 92229 (point-of-care automated analysis) are covered when used as a screening technique for detection only of diabetic retinopathy when filed by a PCP, optometrist, or ophthalmologist.

See coding section for code descriptions and use constraints.

Automated interpretation (AI) coverage

Automated image interpretation

AI-based screening coverage: Digital retinal imaging with image interpretation by FDA-cleared automated/artificial intelligence software (examples cited include IDx-DR and EyeArt) may be considered medically necessary for screening for diabetic retinopathy.

Performance varies by software version, camera, dilation, and population; each marketed software should be evaluated for the specified camera/dilation and validated performance.

Coverage and billing criteria for retinal imaging screening

Covered when used for screening detection of diabetic retinopathy and billed according to provider type requirements:

General coverage: CPT codes 92228 and 92229 are covered when used as a screening technique for detection only of diabetic retinopathy when filed by a primary care provider (PCP), optometrist, or ophthalmologist (92228 for remote interpretation/report; 92229 for point-of-care automated analysis).

Supports screening only per policy.

PCP billing requirement: Primary care providers MUST include one of the Category II codes (2022F variants) on screening claims; additional CPT code(s) will not be reimbursed if this is not included.

For optometrists or ophthalmologists use of Category II codes is optional and will not impact claims processing.

Modifier guidance: It is incorrect to file CPT codes 92227 or 92228 with modifier TC or 26 because these codes include both technical and interpretation/report components.

Do not append modifier TC or 26 to 92227 or 92228.

Retinal telescreening using digital retinal imaging is covered for screening to detect diabetic retinopathy when performed as described for Commercial Products. However, for Commercial Products this policy specifies that retinal telescreening is not medically necessary for indications other than screening, including the monitoring and management of patients already diagnosed with diabetic retinopathy because the evidence is insufficient to demonstrate benefit.

Billing must reflect that CPT codes 92227 and 92228 include both the technical and interpretation/report components; therefore, it is incorrect to append modifier TC or 26 to these codes. Providers should not submit these codes with TC or 26 modifiers because those combinations do not align with the code definitions and the policy guidance.

For Commercial Products, the policy explicitly states that the use of retinal telescreening for monitoring and management of individuals with diagnosed diabetic retinopathy is not medically necessary. The rationale is that current evidence is insufficient to show that telescreening improves health outcomes for disease management beyond its role in screening.

Coding and Billing

Covered CPT Codes (general/institutional)CPTCovered

92227

Imaging of retina for detection or monitoring of disease; with remote clinical staff review and report; unilateral or bilateral

Covered CPT Codes (remote physician interpretation)CPTCovered

92228

Imaging of retina for detection or monitoring of disease; with remote physician or other qualified health care professional interpretation and report; unilateral or bilateral

Covered CPT Codes (autonomous/AI analysis)CPTCovered

92229

Imaging of retina for detection or monitoring of disease; point-of-care autonomous (automated) analysis and report; unilateral or bilateral

Category II codes (recommended/required for PCPs)Modifier

2022F

Category II code: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM) / without evidence of retinopathy (DM)

Covered/Required Billing Codes and Category IICPTCovered

92227	Imaging of retina for detection or monitoring of disease; with remote clinical staff review and report; unilateral or bilateral
92228	Imaging of retina for detection or monitoring of disease; with remote physician or other qualified health care professional interpretation and report; unilateral or bilateral
92229	Imaging of retina for detection or monitoring of disease; point-of-care automated analysis and report unilateral or bilateral
2022F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM) / without evidence of retinopathy (DM)

Provider Actions and Billing Rules

Note

Prior Authorization

Not applicable

Denial Risk

Commercial Product Limitation

Retinal telescreening with digital imaging and manual grading of images performed by a primary care provider (PCP), optometrist or ophthalmologist may be considered medically necessary as a screening technique for the detection of diabetic retinopathy. Retinal telescreening is considered not medically necessary for all other indications, including the monitoring and management of disease in individuals diagnosed with diabetic retinopathy.

Commercial products: retinal telescreening is considered not medically necessary for indications other than screening

Billing Rule

CPT Code Screening Use

The following CPT codes are covered when used as a screening technique for the detection only of diabetic retinopathy when filed by a primary care provider (PCP), optometrist or ophthalmologist: 92228 (with remote interpretation and report) and 92229 (point-of-care automated analysis and report).

Covered screening CPT codes: 92228, 92229

Documentation Required

Category II Code Documentation Requirement

PCPs MUST include one of the specified Category II codes when filing for dilated retinal eye exams with interpretation; failure to include the required Category II code may result in non-reimbursement. For optometrists or ophthalmologists, use of Category II codes is optional and will not impact claims processing.

PCP required Category II codes: 2022F (Dilated retinal eye exam with interpretation documented and reviewed; with evidence of retinopathy) and the corresponding code for without evidence of retinopathy — PCPs must include the appropriate Category II code on the claim
Optometrists/ophthalmologists: Category II codes optional

Billing Rule

Billing Component Guidance

Do not file CPT codes 92227 or 92228 with modifier TC or modifier 26; these codes include both the technical component and the interpretation/report components. Filing with TC or 26 is incorrect and may lead to denied or miscoded claims.

Do not append modifier TC or 26 to CPT codes 92227 or 92228

Denial Risk

Claims Documentation and Denial Risk

When submitting claims for screening retinal imaging filed by a PCP, ensure the claim includes the appropriate CPT screening code (92228 or 92229 as applicable) and, for PCPs, the required Category II code documenting the dilated retinal exam with interpretation. Missing required Category II documentation for PCP-filed claims may result in denial or non-reimbursement.

Required elements on PCP claims: screening CPT (92228 or 92229) + appropriate Category II code documenting dilated retinal exam with interpretation
Failure to include required Category II code may lead to non-reimbursement

Definitions

Digital fundus photography — key values

DefinitionDigital fundus photography: photographic capture of the retina (mydriatic or non‑mydriatic) using digital cameras as an alternative to film; enables easier acquisition, transmission, storage, and remote evaluation by trained readers.

Common methodsIncludes mydriatic standard field stereoscopic color fundus photography and non‑mydriatic digital retinal photographs.

Primary advantageFacilitates image transmission and storage for remote interpretation and integration into primary care screening workflows.

Use-caseUsed to obtain retinal images for screening detection of diabetic retinopathy and for evaluation by expert readers or remote graders.

Automated (AI) image interpretation — examples

DefinitionAutomated (AI) image interpretation: software systems that analyze digital retinal images to automatically detect more‑than‑mild diabetic retinopathy; several systems have received FDA marketing clearance.

FDA‑cleared examplesIDx‑DR (de novo clearance, indicated to detect more‑than‑mild diabetic retinopathy) and EyeArt (510(k) clearance; indicated with specified cameras).

Implementation notePerformance varies by software version, camera, and dilation status; each marketed algorithm must be evaluated with the specified camera and population.

Primary benefitIncreases screening rates by providing automated annual screening at routine diabetes visits, enabling earlier detection and referral for treatable disease.

Point-of-care automated analysis (92229) — definition

DefinitionPoint‑of‑care automated analysis (CPT 92229): imaging of the retina performed with on‑site automated (autonomous) analysis and an associated report submitted at the point of care, unilateral or bilateral.

CodingReported with CPT code 92229 when used as a screening technique for detection of diabetic retinopathy.

Use-caseIntended for screening detection of diabetic retinopathy in primary care, optometry, or ophthalmology settings when automated analysis is performed on site.

Telemedicine interpretation (92228) — definition

DefinitionTelemedicine interpretation (CPT 92228): imaging of the retina with remote physician or other qualified health care professional interpretation and report (unilateral or bilateral).

Coding guidanceCPT 92228 is covered when used as a screening technique for detection only of diabetic retinopathy and should be filed without modifier TC or 26 (codes include technical and interpretation/report components).

Provider filingCovered when filed by a primary care provider, optometrist, or ophthalmologist for screening claims; primary care providers must include the required Category II code on screening claims per policy requirements.

OpenPayer

Retinal telescreening (digital retinal imaging) for detection of diabetic retinopathy - Coverage and coding

Coverage Criteria

Coding and Billing

Provider Actions and Billing Rules

Definitions

Background and Evidence