Coding Teleretinal Screening

May 18, 2018 | Optometry HQ Announcements

The coding council received a question regarding the capturing of retinal scanning workload for the tech when the retinal images are being interpreted by a remote provider (store and forward/telehealth).  According to CPT coding rules, the scan is not coded separately for the remote imaging; it is bundled into the teleretinal codes.

The response below is the correct coding:

CPT ®Assistant, July, 2016, Volume 26, Issue 7, Page 9
Medicine: Ophthalmology

Question: What is the appropriate code(s) to report automated diabetic retinopathy screening using retinal image analysis, which is described as: “For each patient encounter (or visit), multiple images per eye (different fields and/or external images) are acquired. The screening system automatically detects/localizes the lesions from the input color retinal fundus images, assesses the severity of diabetic retinopathy and presence of surrogate markers for clinically significant macular edema, and recommends if the patient needs to be referred to a specialist.” Is it appropriate to report this procedure with code 92250, Fundus photography with interpretation and report, in addition to code 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?

Answer: No, it is not appropriate to report code 92250 in addition to code 92227. Only code 92227 should be reported for this procedure.

CPT Coding would be:
–  Patient Site – 92250 with the TC (Technical Component) modifier
–  92227 – remote imaging for detection of retinal disease with the TC modifier
–  Provider Site – 92228 – remote imaging for monitoring and management of active retinal disease
– Teleretinal Screening Exams – if images are unreadable:
–  Assign ICD-10 code Z13.9
–  Assign CPT Code 99499