Medicare Reimbursement for Ophthalmic Telemedicine (Ellex)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR OPHTHALMIC TELEMEDICINE
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Q What is telemedicine?
A Telemedicine is the remote diagnosis and treatment of patients by means of telecommunication technology. In eye care, digital fundus photography lends itself to telemedicine because the camera can be placed in a primary care physician’s (PCP) office and be operated by the PCP’s staff. Then, the images are transmitted to an ophthalmologist or optometrist for interpretation. Patients benefit from access to specialists who are not otherwise available locally.
Q Are there CPT codes for ophthalmic telemedicine?
A Yes. In 2011, two codes were added:
92227 Remote imaging for detection of retinal disease (e.g., 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 (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral
Q Who uses these codes?
A There are several different providers who might use these codes, including PCPs, an imaging center, an ophthalmologist, or an optometrist.
Which party bills for taking the images is a function of who owns the fundus camera and supervises the medical assistant. Which party bills for interpretation of the images is a simple matter of authorship.
Q What is the difference between these codes?
A These codes are distinguished by two key points:
1) The interpretation
2) The presence of retinal disease
CPT 92227 does not require a formal interpretation, while 92228 does. 92227 describes a screening service which might or might not identify retinal disease, while CPT 92228 entails an assessment of existing retinal disease. Consequently, 92228 is a greater service than 92227 in scope and value.
Q Does Medicare cover these services?
A Medicare covers 92228 because this service is performed “… for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” as set forth in the Social Security Act §1862(a)(1)(A). A retinal disease justifies coverage.
Screening services are considered to be non-covered in the absence of a statutory provision to the contrary (e.g., glaucoma screening). Several Medicare Administrative Contractors (MACs) have published local coverage determinations (LCDs) on this topic, check your MAC’s website for further details.
Q Are there any coding bundles or other limitations?
A These codes are mutually exclusive with one another – choose one or the other, but not both, for a patient encounter.
In addition, CPT specifically states, for both codes, “Do not report [92227, 92228] in conjunction with 92002-92014, 92133, 92134, 92250,… or with the evaluation and management of the single system organ system, the eye, 99201-99350”.
Q Must a physician be present while these tests are being performed?
A No. CPT 92228 requires only general supervision. General supervision means that the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.
In CPT, 92227 is described as “under physician supervision” although a level of supervision is not stipulated. In our view, “general supervision” is likewise appropriate.
Q What is the reimbursement for these codes?
A In the first quarter of 2015, the Medicare Physician Fee Schedule allows $14.66 for 92227. There is no technical / professional fee breakdown since the code does not require an interpretation.
The allowed amount for 92228 is $35.75; of this total, $13.94 is assigned to the technical component and $21.81 to the professional component. As always, these amounts are adjusted in each area by local wage indices.
Bill for these services on a per patient basis rather than per eye, because the descriptor says “unilateral or bilateral”. Payment is the same whether one or both eyes are imaged.
Provided Courtesy of Ellex (800) 824-7444
Last updated January 26, 2015
The reader is strongly encouraged to review federal and state laws, regulations and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on all matters pertaining to reimbursement. The reader is also reminded that this information, including references and hyperlinks, can and does change over time, and may be incorrect at any time following publication.
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