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Diabetic Retinopathy Screening and Fundus Photography Notification

Health Partners Plans (HPP) would like to inform you of upcoming changes to our HPP Policy Bulletin Library. Effective January 1, 2022, HPP will be implementing a new claim payment policy: RB.023.A Diabetic Retinopathy Screening and Fundus Photography.

HPP considers Digital Diabetic Retinopathy Screening (92227) and Fundus Photography (92550) eligible for reimbursement consideration one time per calendar year when the following criteria are met:

  • The test can be performed by a Primary Care Provider (PCP), Optometrist or Ophthalmologist.
    • Results must be interpreted and billed by an Optometrist or Ophthalmologist.
    • PCPs must establish an agreement or contractual arrangement with an eye care professional (Optometrist or Ophthalmologist) in order to bill for the service.
  • The test is being utilized as screening technique for the detection of Diabetic Retinopathy or for monitoring and management of disease in individuals diagnosed with Diabetic Retinopathy.
  • The device used has been approved by the Food and Drug Administration (FDA).

Additional information:

  1. Prior authorization is not required for participating providers for Digital Diabetic Retinopathy Screening and Fundus Photography.
    NOTE: Although Digital Retina Eye Screening and Fundus Photography are covered and do not require a prior authorization, HPP may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity.
  2. PCPs should report code 92250 with Modifier TC for retinal imaging.
  3. A specialist should report code 92250 with Modifier 26 for the interpretation and report of the films.
  4. Accepted place of service codes include: (11), (19), (22), (49), (50).
  5. Cost sharing for the member will not apply.

As a reminder, HPP’s medical policy bulletins define medical necessity criteria and coverage positions on topics such as medical services, procedures, DME, therapies, etc., while our claim payment policy bulletins provide reimbursement rules and billing guidelines necessary to ensure timely and appropriate payment.

We maintain a policy bulletin library on at HPPlans.com/PolicyBulletins.