CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Retinopathy telescreening policy

Defines medical necessity and coverage distinctions for retinal telescreening (digital retinal imaging) with manual or automated interpretation for detection, monitoring, and management of diabetic retinopathy for BlueCHiP for Medicare and Commercial products, including coding and billing guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRetinopathy telescreening policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionPrimary care providers MUST include one of the Category II codes (2022F or 2023F) on claims; claims filed without one of these additional CPT codes will not be reimbursed.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Distinct coverage stances (Medicare vs Commercial)

3CPT codes referenced

2Required Category II codes

Coverage Summary

Defines medical necessity and coverage distinctions for retinal telescreening (digital retinal imaging) with manual or automated interpretation for detection, monitoring, and management of diabetic retinopathy for BlueCHiP for Medicare and Commercial products. Coverage stance is mixed: some uses are considered medically necessary while others are not. Target population: diabetic individuals. Effective date: 01/01/2021; Last review: 10/14/2020. Distinctions exist between BlueCHiP for Medicare and Commercial products with differing allowances and limitations.

Policy metadata

Effective Date2021-01-01

Last Review2020-10-14

Policy StatusCURRENT

Coverage StanceMixed — Medicare and Commercial distinctions (BlueCHiP for Medicare: manual grading covered; Commercial: screening covered, monitoring not medically necessary; automated interpretation not covered/not medically necessary)

Scope SummaryDefines medical necessity and coverage distinctions for retinal telescreening (digital retinal imaging) with manual or automated interpretation for detection, monitoring, and management of diabetic retinopathy, including coding and billing guidance.

Medical-Necessity Criteria

BlueCHiP for Medicare - Manual Grading by PCP/Optometrist/Ophthalmologist

Considered medically necessary when performed by PCP, optometrist, or ophthalmologist:

Retinal telescreening with digital imaging and manual grading of images performed by a primary care provider (PCP), optometrist or ophthalmologist

May be used as a screening technique for detection of diabetic retinopathy or for monitoring and management of disease in individuals diagnosed with diabetic retinopathy

Commercial Products - Manual Grading by PCP/Optometrist/Ophthalmologist

Considered medically necessary for screening only:

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 detection of diabetic retinopathy

Retinal telescreening for monitoring and management of disease in individuals diagnosed with diabetic retinopathy

Not medically necessary for Commercial products because evidence is insufficient to determine effects on health outcomes

Automated Image Interpretation (BlueCHiP for Medicare and Commercial)

Coverage stance for automated interpretation:

Digital retinal imaging with automated image interpretation

Considered not covered for BlueCHiP for Medicare products and not medically necessary for Commercial products due to insufficient evidence

Fundus Photography Performed by Non-Eye Specialists

Provision of fundus photography by providers other than ophthalmologists or optometrists as a screening test to facilitate referral to a specialist

Contrary to requirements in 42 CFR 410.32 and not covered/reimbursable

Ordering/performance of fundus photography by eye specialists without a face-to-face encounter

Similarly not covered or reimbursable

Coding

Covered and separately reimbursed (BlueCHiP for Medicare)CPTCovered

92227	Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral
92228	Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report; unilateral or bilateral

Covered (Commercial)CPTCovered

92227

Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral

Not medically necessary / Not covered (Commercial)CPTNot Covered

92228

Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report; unilateral or bilateral

Incorrect / Not to be used for these servicesCPTNot Covered

92250	Fundus Photography with physician review, interpretation and report; unilateral or bilateral
92229	Dilated retinal eye exam with automated analysis and report, unilateral or bilateral (new code effective 1/1/2021) - stated as incorrect to file for these services

Required Category II codes for PCP claims (must include one)CPT

2022F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM)
2023F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)

Provider Actions & Billing Guidance

Documentation Required

Include Category II code on PCP claims

Primary care providers MUST include one of the Category II codes on claims; claims filed without one of these additional CPT codes will not be reimbursed.

Affected codes: 2022F, 2023F
Claims filed without one of these Category II codes will not be reimbursed

Billing Rule

Do not append TC or 26 modifiers

It is incorrect coding to file 92227 and 92228 with modifier TC or 26 because the codes include technical and interpretation/report components.

Affected codes: 92227, 92228
Do not append TC or 26 modifiers to these codes

Billing Rule

Do not bill with specified CPT codes

Services should not be billed using CPT codes 92250 or 92229 for these telescreening services; these are incorrect coding for these services.

Affected codes: 92250, 92229
These codes are incorrect to file for retinopathy telescreening services

Denial Risk

Claims without Category II code denied for PCPs

Claims filed by PCPs for 92227/92228 without one of the Category II codes will not be reimbursed.

Affected codes: 92227, 92228, 2022F, 2023F
Denial consequence: Claims filed without an included Category II code will not be reimbursed

Background & Evidence

Retinal telescreening uses digital fundus cameras to acquire retinal images that may be transmitted to remote readers for interpretation and reporting and is an alternative to conventional dilated fundus examination for diabetic individuals. It can increase screening uptake by enabling acquisition and transmission in primary care settings. Automated interpretation systems have reported high sensitivity with moderate specificity and variability across systems, whereas manual grading by trained readers has shown high concordance with standard retinal examination methods.

Key evidence

RCT uptake findingOne randomized controlled trial demonstrated higher uptake of screening with a telescreening strategy.

ConcordanceMultiple studies report high agreement between retinal examination and imaging (high concordance between standard examination/film and digital imaging).

Automated interpretation accuracyStudies report high sensitivity with moderate specificity and variability across systems; evidence insufficient to determine effects on health outcomes.

Retinal telescreening: Digital retinal imaging with transmission of images to remote readers for interpretation and reporting.

Name	Number	Effective Date
Intraocular Photography	80.6	1979