January 14, 2022
Diabetic Retinopathy Screening and Fundus Photography
Health Partners Plans (HPP) wants to inform providers of a change to our HPP Policy Bulletin Library. Effective 1/1/2022, HPP implemented a new claim payment policy: RB.023.A Diabetic Retinopathy Screening and Fundus Photography.
HPP considers Digital Diabetic Retinopathy Screening (92227) and Fundus Photography (92250) 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.
- PCP’s must establish an agreement 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).
- Prior authorization is not required for participating providers for digital diabetic retinopathy screening and fundus photography.
NOTE: Although digital retinal 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.
- PCP’s should report code 92250 with the TC modifier for retinal imaging.
- A specialist should report code 92250 with the 26 modifier for the interpretation and report of the films.
- Specialists must report the following Category II codes 2022F, 2023F, 2024F, 2025F, 2026F, 2033F.
NOTE:CPT II codes for diabetes retinal eye exams can be billed by any provider type.
- Accepted place of service codes includes: (11), (19), (22), (49), (50).
- 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 the policy bulletin library at HPPlans.com/PolicyBulletins.