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And remember to save images for documentation purposes.

From detecting conditions such as retinopathy in diabetic patients, detached retinas and macular degeneration in older patients, or corneal abrasions and cataracts in the general patient population, eye care has always occupied a small yet significant area of practice for primary care providers. And now, with technological advances making retinal imaging affordable in the primary care setting, chances are you鈥檒l be dealing with retinal imaging codes more and more in the future.

That鈥檚 why coders have a lot of questions about the services, especially now that CPT^庐 has added a new retinal imaging code and revised two existing ones. So, we set out to find the answers, and here鈥檚 what we鈥檝e discovered.

What Is the New Code, and How Have the Old Codes Changed?

CPT^庐 2021 introduced a brand new retinal imaging code 鈥� 92229 (Imaging of retina for detection or monitoring of disease; point-of-care automated analysis and report, unilateral or bilateral) 鈥� and revised two existing codes. Per Appendix B of CPT^庐 2021, the codes are revised in the following ways, with the old, deleted language in strikethrough, and the new language underlined:

• 92227 (Remote imaging Imaging of retina for detection or monitoring of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral; with remote clinical staff review and report, unilateral or bilateral)
• 92228 (Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with remote physician review or other qualified health care profes颅sional interpretation and report, unilateral or bilateral)

Why the Changes?

There are two driving forces behind the code addition and revisions.

The codes further clarify the purpose of the remote services and who is performing them: The original language for 92227 stated that you would report the code when the service was used for detection purposes, while you could use 92228 for both monitoring and management purposes. This has now changed, and by designating 92227 as the parent of both codes, CPT^庐 has now made it clearer that each code may be use for detection or monitoring of a condition.

Additionally, 鈥渢he descriptor language changes for 92227 and 92228 specify the type of healthcare professional performing the remote services, which was a major reason for the revisions according to the January 2021 CPT^庐 Assistant,鈥� says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Specifically, the previous 92227 descriptor showed it was intended for detection purposes with the analysis done 鈥渦nder physician supervision鈥� (i.e. by clinical staff). Meanwhile, 92228 was intended for monitoring and management of an active retinal condition, with physician or other qualified healthcare professional (QHP) analysis and report.

These descriptors created problems when a coder wanted to assign a code for detection done with remote physician/QHP interpretation or report or monitoring done with remote clinical staff review and report. But now, the revisions tell you to use 92227 if clinical staff perform the remote review and report, or 92228 if a physician/QHP performs them.

The codes further clarify the location of the service: 鈥淎ccording to the CPT^庐 Assistant article, new code 92229 is reported when computer software is used to test for retinal diseases, such as diabetic retinopathy, using a point-of-care automated analysis, which interprets the fundus photography to provide an immediate report with findings that are frequently performed in the primary care office. This report may include management recommendations at the point of care,鈥� says Moore.

The revisions to 92227 and 92228, however, remove the ambiguity that previously existed over the word 鈥渞emote.鈥� The new versions of the codes now make it clear that the imaging is not conducted remotely, but rather the interpretation/review and report occur remotely.

Documentation Remains the Same

Despite all the changes to the retinal image codes, one thing hasn鈥檛 changed: you will still need to retain any images generated by the services.

鈥淔undus photography involves the use of a retinal camera to document abnormalities of the retina and disease processes affecting the eye in order to follow the progress of such diseases,鈥� said Gail O鈥橪eary of NGS Medicare, a Medicare Administrative Contractor (MAC), during NGS鈥檚 鈥淰ision Services鈥� webinar.

As 鈥渢he test must be used in the medical decision making [MDM] of the patient, a copy of the fundus photographs must be retained in the patient鈥檚 medical records,鈥� O鈥橪eary continued. In addition, retinal imaging claims must include a written interpretation and report in the patient鈥檚 electronic medical record (EMR) along with information about whether one or both of the pupils were dilated and which dilation drug was used in the process.

Coding alert: The retinal imaging codes鈥� descriptors say 鈥渦nilateral or bilateral.鈥� From a CPT^庐 perspective, that means modifier 50 (Bilateral procedure) should not be appended to the code when the services are performed bilaterally (see CPT^庐 Assistant, October 2012). In fact, Medicare considers them inherently bilateral and prices them as such, and other payers may do the same. So, if your provider performs a service unilaterally, 鈥測ou could be subject to a fee reduction,鈥� O鈥橪eary cautioned.