Cost Analysis of Teleophthalmology Screening for Diabetic Retinopathy Using Teleophthalmology Billing Codes

Abstract

BACKGROUND AND OBJECTIVE: To evaluate the financial sustainability of teleophthalmology screening for diabetic retinopathy (DR) using telehealth billing codes. PATIENTS AND METHODS: The authors performed an Institutional Review Board-approved retrospective review of medical records, billing data, and quality metrics at the University of California Davis Health System from patients screened for DR through an internal medicine-based telemedicine program using CPT codes 92227 or 92228. RESULTS: A total of 290 patients received teleophthalmology screening over a 12-month period, resulting in an increase in the DR screening rate from 49% to 63% ( P < .0001). The average payment per patient was $19.86, with an estimated cost of $41.02 per patient. The projected per-patient incentive bonus was $43.06 with a downstream referral revenue of $39.38 per patient. One hundred seventy-eight clinic visits were eliminated, providing an estimated cost savings of $42.53 per patient. CONCLUSION: Sustainable teleophthalmology screening may be achieved by billing telehealth codes but only with health care incentive bonuses, patient referrals, and by accounting for the projected cost-savings of eliminating office visits. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:S26–S34.]

Trends in Remote Retinal Imaging Utilization and Payments in the United States

“…Our study showed a major decline in proportion of claims paid for remote retinal imaging over the decade, especially for CPT 92227 which decreased from 86.5% in 2011 to 51.9% in 2020, similar to findings from our tele-retinal screening program in California that used the same billing code. 6 Yet, this decline is occurring at a time of rapid expansion in using remote imaging to screen diabetics without eye diseases. In fact, claims for these patients were more often denied compared to those with eye diseases, even for 92227 which is designated for screening patients without retinopathy.…”

Cost-effectiveness of the anti-vascular endothelial growth factor intravitreal injection and panretinal photocoagulation for patients with proliferative diabetic retinopathy in South Korea

“…Another difference is that the ICER in our study is lower than the one in Hutton's. One reason could be that our low ICER may be due to the lower medical costs of South Korea than those found in the US [23][24][25][26]. Hutton indicated that if the price of ranibizumab (which has the greatest effect on ICER) fell from $1,916 to $900, ranibizumab would become more cost-saving than the combined treatment of PRP and ranibizumab in patients with DME.…”

Teleophthalmology provides earlier eye care access for patients with newly-diagnosed diabetes

“…However, the expansion of teleophthalmology programs has been hindered by inconsistencies in insurance coverage and reimbursements. At a large integrated health system in Northern California, Ellis et al found that 55% of charges for remote DR screening using telehealth codes were denied by non-capitated insurance plans, and 40% were denied by private insurers [ 14 ]. Despite the rapid increase in teleophthalmology utilization across the U.S., insurance coverage has declined according to national insurance claims data, with disproportionate impact on vulnerable populations such as older, Black, and lower-income patients [ 15 ].…”