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Medical Policy Retinal Telescreening for Diabetic Retinopathy Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 065 BCBSA Reference Number: 9.03.13 Related Policies Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions, #401 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Screening for retinopathy in diabetics performed by ophthalmologists or optometrists using conventional fundus photography OR digital retinal imaging technology may be considered MEDICALLY NECESSARY when all of the following criteria are met: The individual does not have prior known diabetic retinopathy; and The imaging technique covers a total retinal area which includes the Diabetic Retinopathy Study seven-standard fields (DRS7); and Use does not exceed one study, utilizing either method, per member, per provider, per year. Screening for retinopathy in diabetics ordered by non-eye care professionals using digital retinal imaging technology may be considered MEDICALLY NECESSARY when all of the following criteria are met: The individual does not have prior known diabetic retinopathy; and The imaging technique covers a total retinal area which includes the Diabetic Retinopathy Study seven-standard fields (DRS7); and Use does not exceed one study per member per provider per year. Note: Digital retinal imaging can be performed through either a dilated or undilated pupil. Retinal telescreening is INVESTIGATIONAL for all other indications, including the monitoring and management of disease in individuals diagnosed with diabetic retinopathy. Medicare HMO BlueSM and Medicare PPO BlueSM Members Local Coverage Determination (LCD): Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (L25466) 1 http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=25466&ContrId=292&ver=58&ContrVer=1&Date=02%2f26%2f2014&DocID=L25466 &bc=iAAAAAgAAAAAAA%3d%3d& Prior Authorization Information Commercial Members: Managed Care (HMO and POS) Prior Authorization is NOT required. Commercial Members: PPO, and Indemnity Prior Authorization is NOT required. Medicare Members: HMO BlueSM Prior Authorization is NOT required. Medicare Members: PPO BlueSM Prior Authorization is NOT required. CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes: 92227 92228 92250 Code Description Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral Fundus photography with interpretation and report ICD-9 Diagnosis Codes ICD-9-CM diagnosis codes: 250.50 250.51 250.52 250.53 362.01 362.02 362.03 362.04 362.05 362.06 362.07 Code Description Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled Background diabetic retinopathy Proliferative diabetic retinopathy Nonproliferative diabetic retinopathy NOS Mild nonproliferative diabetic retinopathy Moderate nonproliferative diabetic retinopathy Severe nonproliferative diabetic retinopathy Diabetic macular edema 2 ICD-10-CM Diagnosis Codes ICD-10-CM diagnosis codes: E08.311 E08.319 E08.321 E08.329 E08.331 E08.339 E08.341 E08.349 E09.311 E09.319 E09.321 E09.329 E09.331 E09.339 E09.341 E09.349 E08.351 E08.359 E09.351 E09.359 E10.311 E10.319 E10.321 E10.329 E10.331 E10.339 Code Description Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema 3 E10.341 E10.349 E10.351 E10.359 E10.36 E10.39 E11.311 E11.319 E11.321 E11.329 E11.331 E11.339 E11.341 E11.349 E11.351 E11.359 E11.39 E11.65 E13.311 E13.319 E13.321 E13.329 E13.331 E13.339 E13.341 E13.349 E13.351 E13.359 E13.36 E13.39 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema Type 1 diabetes mellitus with diabetic cataract Type 1 diabetes mellitus with other diabetic ophthalmic complication Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema Type 2 diabetes mellitus with other diabetic ophthalmic complication Type 2 diabetes mellitus with hyperglycemia Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema Other specified diabetes mellitus with diabetic cataract Other specified diabetes mellitus with other diabetic ophthalmic complication Description Diabetic retinopathy is the leading cause of blindness among adults aged 20–74 years in the United States. The major risk factors for developing diabetic retinopathy are duration of diabetes and severity of hyperglycemia. After 20 years of disease, almost all patients with type 1 and greater than 60% of patients 4 with type 2 diabetes will have some degree of retinopathy. Other important risk factors include hypertension and elevated serum lipid levels. Diabetic retinopathy progresses, at varying rates, from asymptomatic, mild nonproliferative abnormalities to proliferative diabetic retinopathy (PDR), with new blood vessel growth on the retina and posterior surface of the vitreous. The 2 most serious complications for vision are diabetic macular edema and PDR. Although proliferative disease is the main blinding complication of diabetic retinopathy, macular edema is more frequent and is the leading cause of moderate vision loss in people with diabetes. The value of screening is well-established, since diabetic retinopathy has few visual or ocular symptoms until vision loss develops. With early detection, diabetic retinopathy can be treated with modalities that can decrease the risk of severe vision loss. Diabetic retinopathy telescreening is a diagnostic test, which uses a digital fundus camera and the internet to transmit digital images of the retina to another location for evaluation by trained readers. Screening can be performed in the medical doctor’s office rather than having to make an additional appointment. Results are sent back to the medical doctor’s office with recommendations for follow-up with an eye specialist if necessary. Examples of digital camera and transmission systems for diabetic retinopathy telescreening include the Diabetic Retinopathy Digital Disease Detection and Tracking System from Inoveon Corp., DigiScope® from EyeTel Corp., and the Fundus AutoImagerä from Visual Pathways Inc. All retinal telescreening for diabetic retinopathy are considered investigational regardless of the commercial name, the manufacturer or FDA approval status except when used for the medically necessary indications that are consistent with the policy statement. Summary A number of studies have reported on the agreement regarding the presence and stage of retinopathy based on ophthalmoscopy versus photography or standard film versus digital imaging. The studies generally found a high level of agreement between retinal examination and imaging. Several studies suggested that retinal imaging through a dilated pupil was equivalent or superior to ophthalmic examination regarding the detection of diabetic retinal changes. Although evidence indicates that digital imaging without mydriasis leads to an increase in the proportion of ungradable photographs, practice guidelines and clinical input supports the use of both dilated and undilated retinal telescreening. At this time, it is unclear whether nonspecialist photographers would evaluate undilated photographs at the point-of-care and, if needed, repeat photography with dilation. Overall, the published medical literature is adequate to conclude that digital imaging systems are safe and effective alternatives to the gold standard of dilated indirect ophthalmoscopy coupled with biomicroscopy or stereoscopic fundus photography. Additional advantages of digital imaging systems include short examination time and the ability to perform the test in the primary care physician setting. Automated scoring also has the potential to improve screening in the primary care setting, and several automated scoring systems are being evaluated. Although the sensitivity of these systems to rule out disease appears to be high, the moderate specificity indicates there are a substantial number of false positive results, implying that positive results would need to be confirmed by referral to and examination by appropriate specialists. Policy History Date 6/2014 1/2014 11/20114/2012 2/2012 2/2010 Action Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. New references added from BCBSA National medical policy. Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements. Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 5 2/2009 9/2008 1/2014 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. New policy, effective 9/2008, describing covered and non-covered indications. New references added from BCBSA National medical policy. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. Garg S, Davis RM. Diabetic retinopathy screening update. Clinical Diabetes; 27(4) 140-5 Available online at: http://clinical.diabetesjournals.org/content/27/4/140.full. Last accessed September, 2013. 2. American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care. 2010; 33 Suppl 1:S11-61 2010. Available online at: http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html. Last accessed September, 2013. 3. Early Treatment Diabetic Retinopathy Study Research Group. 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