Diabetic retinopathy (DR) continues to be the leading cause of preventable blindness globally, with a prevalence of 22.27% for any kind of DR, 6.17% for vision-threatening DR (VTDR), and 4.07% for diabetic macular edema (DME) among patients with diabetes.^1,2 However, most patients with diabetes do not receive annual eye screening per recommended guidelines.^3-5 Telemedicine can overcome this barrier by extending care to rural or hard-to-access areas⁶ and reducing person-to-person contact amidst the coronavirus disease 2019 (COVID-19) pandemic.^7-9 By deploying nonmydriatic cameras in primary care or laboratory settings, remote retinal imaging technologies can broaden eye-care access and reduce costs. The efficacy and value of teleophthalmology has been demonstrated for many ocular conditions¹⁰ including glaucoma,^11,12 retinopathy of prematurity,¹³ and DR.^14,15 Despite the rapid growth and technological advancements in remote eye imaging and artificial intelligence, financial barriers threaten the sustainability of teleophthalmology.

Current Billing Landscape for Remote Retinal Imaging

The Current Procedural Terminology (CPT) system was created by the American Medical Association (AMA) to maintain a consistent and accurate reimbursement model for the services performed by physicians and other health care providers. The Centers for Medicare and Medicaid Services (CMS) adopted the CPT system in the 1980s, and CPT would later be recognized as the national standard coding for health care services.¹⁶ The CPT codes for teleophthalmology were implemented in 2011, and they included 92227 for the detection of retinal disease and 92228 for monitoring active retinal disease. These codes were designed for “store-and-forward” remote imaging, where images are sent electronically to an offsite ophthalmologist for analysis, as opposed to real-time telemedicine encounters. However, these codes do not pay much, with 92227 valued at 0.40 relative value units (RVU) that only includes a technical component, and 92228 valued at 0.97 RVUs that includes both professional and technical fees, which in 2019 totaled about $16 and $37 for the 2 codes, respectively. Many practices resorted to using CPT code 92250 instead, which is valued at 1.43 RVU or roughly $52.00, although this code is designated for fundus photography and not technically specified for teleophthalmology.

We recently analyzed how insurance coverage and payments may have impacted the use of these CPT codes over the past 10 years using a national database of de-identified insurance claims.¹⁷ We compared CPT codes 92227, 92228, and 92250 by non-eyecare providers, and found that teleophthalmology utilization increased nearly threefold over the past decade, from 11,603 encounters in 2011 to 33,392 in 2020, while insurance coverage (whether the claim was paid or denied) actually decreased from 88% to 47% over that period. Nearly 90% of encounters used CPT 92250, as compared to 8.2% for 92227 and 1.8% for 92228. When adjusted for inflation, reimbursement for 92250 was not only much higher, but steadily increased over the 10 years, from $45.15 in 2011 to $64.70 in 2020. By contrast, payments for 92227 and 92228 were much lower and remained stagnant, from $12.38 in 2011 to $14.85 in 2020 for 92227 and from $19.31 in 2011 to $25.10 in 2020 for 92228. Strikingly, we found that insurance denials disproportionately impacted vulnerable populations, including individuals older than age 65, Blacks, and those from lower-income households.¹⁷ We also found that insurance coverage was inconsistent, with code 92227 more likely covered for patients with existing DR than those without, even though the code is designated for asymptomatic screening. Together, the inconsistent insurance coverage and declining payments contribute to a confusing reimbursement landscape for remote retinal imaging, inappropriate incentivization for higher-paying CPT codes, and overall greater financial barrier for adopting teleophthalmology services.

University of California, Davis launched a pilot teleophthalmology program in 2018 for remote DR screening using CPT 92227, and found that the average collections for its payer mix was $19.86 per patient, similar to the national level, with most denials coming from Medicare.¹⁸ However, the cost estimate for operating this teleophthalmology program, including camera cost and personnel time, was close to $41 per patient, suggesting a net loss. The program could only be sustained when taking into account a projected bonus of about $43 per patient from incentive programs such as the Integrated Healthcare Association Pay for Performance or the Medicare Shared Savings Program, as well as downstream revenue from referrals to the Unviersity’s Eye Center, which is applicable for practices that are part of a larger integrated health care system.¹⁸ Importantly, the university’s program increased DR screening rates from 49% to 63%, highlighting the important clinical benefit for patients despite the financial challenges.

New Rules, New Codes

In 2021, CMS edits to the CPT code set included revisions to the language of the existing teleophthalmology codes. Both 92227 and 92228 are now available for remote retinal imaging for either detection or monitoring of retinal disease, with the distinction being the requirement for interpretation by a physician or other qualified health care professional for CPT 92228.¹⁹ A new code, 92229, was added to account for the introduction of automated systems for DR detection using artificial intelligence (AI) technology.²⁰ AI software enables near-instantaneous reporting and higher sensitivity for detecting DR than human physicians or expert graders, although currently FDA-approved algorithms are limited to DR only.^21,22 A recent real-world, large-scale study applying AI in DR demonstrated its ability to increase screening access and decrease cost, without missing sight threatening disease or increasing human workload; in actuality, it decreased workload.²³ Unfortunately, CMS has rejected the recommendations from the AMA’s RVU scale update committee (RUC), and Medicare contractors are setting lower rates for CPT 92229.²⁴ The American Academy of Ophthalmology has objected to these price plans, as dwindling reimbursements will continue to limit widespread adoption of teleophthalmology and reduce eye-care access.

When access to preventive eye care is limited, patients experience worse health outcomes and disease progression, and greater financial strain is imposed on the health care system. Our observations highlight the changes needed to overcome the financial barriers for sustaining teleophthalmology services and expanding eye-care access. Reforming the reimbursement landscape for remote retinal imaging could promote widespread adoption to benefit patients, physicians, and payers.

References

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