Demystifying Reimbursement for Diabetic Retinopathy Exams for Primary Care Physicians

On November 1, 2018, the Centers for Medicare and Medicaid (CMS) issued final rules for updating the 2019 Medicare Physician Fee Schedule to implement recent telehealth-related legislative reforms. Together, these rules represent a substantial expansion of Medicare reimbursement for services provided via telehealth. However, for ocular telehealth, particularly as it applies to Diabetic Retinopathy Exams (DRE), the situation remains somewhat misunderstood.

One of the frequent questions we get asked pertains to reimbursement for telemedicine-based Diabetic Retinopathy Exams (DRE). This involve a scenario where a patient receives a retinal exam in their primary care physician’s office with fundus images being interpreted by a qualified eye care professional (e.g. ophthalmologist or optometrist) at a remote site using a store and forward method. What are the CPT codes for this procedure and how much they pay?

Let’s take a look at the situation as it exists now in the United States. There are 3 procedure codes that are applicable to DRE testing:

At the moment, there is no national coverage determination for diabetic retinopathy screening. However, there is a bi-partisan congressional bill currently under committee review (H.R. 6639) to establish a national minimum payment amount for CPT code 92250. This will go a long way to rectify the situation. As it stands, here are some general guidelines insofar as payer coverage for DREs is concerned:

• Commercial Plans & Medicare Advantage: Many commercial and Medicare Advantage health plans reimburse for DREs and many provide favorable coverage for CPT 92250.
• Medicare: CPT 92227 and 92228 are the only two applicable codes. Some Medicare Authorized Contractors (MACs) have issued Local Coverage Determinations that provide indications and limitations for coverage regarding fundus photography.
• Medicaid: Medicaid may cover DREs when medically necessary. Coverage varies according to each Medicaid program. Consult with your contracted payers, state Medicare/Medicaid agencies and local MAC for their specific coverage policies.
• Private Payers: DREs may be covered when medically necessary. Coverage varies according to each plan.

As coverage varies, we encourage providers to consult with their contracted payers, state Medicare/Medicaid agencies and local MAC for their specific coverage policies.

As anyone can see, the reimbursement range for 92227 and 92228 does not always provide a compelling case in favor of establishing a DRE program in a primary care setting. Keep in mind that practices must consider the proportion of their commercial to Medicare/Medicaid panel size. A practice with a 60%/40% spit between commercial and Medicare/Medicaid patients would get mixed reimbursement rates for 92250 (for commercial) and 92227/92228 for (Medicare/Medicaid).

Understanding the DRE ROI Model

However, looking solely at the DRE reimbursement misses the big picture when it comes to diabetic retinopathy screening in primary care. Retina Labs has developed a 3-pronged DRE ROI model as follows:

HEDIS Improvement

For all patients with diabetes, retinal exams are now included in the Medicare Advantage STARS and Medicare quality ratings programs. Traditionally, these patients were referred by the primary care provider to eye care specialists for a fully dilated eye exam. Evidence shows that many do not follow through with this exam.

CMS can impose financial and contractual penalties on health plans that score poorly on HEDIS measures and Star Ratings. Preventative screenings are a key component of payer quality improvement strategies. Increasingly, commercial and Medicare Advantage payers are offering financial incentives to PCPs for compliance gap closure including Diabetic Retinopathy Exams.

By offering diabetic patients a convenient retinal exam as part of their routine visit, PCPs can take control of their diabetes quality measures and unlock lucrative payer-based financial incentives. For example, United Healthcare’s PATH quality improvement program has paid out over $150M to 1,900 PCPs for closing gaps on DREs, cancer or colorectal cancer screening. That works out to $77,000 per PCP.

Risk Adjustment

An additional layer of incentive for DRE involves risk-adjustment. For providers, ACOs and health systems involved in risk-based contracts, identifying ocular disorders can represent significant increases in per member capitation payments. Clinical evidence shows that upwards of 35% of screened patients are diagnosed with some form of ocular disorder which would otherwise be missed. This includes detection of diabetic retinopathy, glaucoma, age-related macular degeneration, cataracts and surface diseases.

Bottom line: When evaluating the feasibility of a DRE program in a primary care setting, practices must consider all revenue sources, not just reimbursement fees for the actual procedure.