Show Me the Money
Coding tips for teleglaucoma.
As the incidence of glaucoma grows,1 so does the burden on patients and ophthalmologists for long-term monitoring and follow-up.2 The emergence of teleglaucoma—glaucoma care delivered to patients remotely—is a potential solution to the growing health care costs and access issues. Coding for teleglaucoma, therefore, becomes very important as televisits become part of the way ophthalmologists provide glaucoma care to their patients.
AT A GLANCE
• Teleglaucoma can be either synchronous, where there is a direct audio and visual link between patient and physician, or store and forward, where information is gathered at one time point and interpreted at a different time point.
• There are limited Current Procedural Terminology codes for teleglaucoma. Synchronous teleglaucoma has more billable codes than store and forward.
• Teleglaucoma allows practitioners to expand their patient base by reaching patients that they might not otherwise reach because of distance. It improves the patient’s experience while being a more efficient use of a patient’s and aprovider’s time.
Teleglaucoma can be either synchronous, where there is a direct audio and visual link between patient and physician, or store and forward, where information is gathered at one time point and interpreted at a different time point.
In synchronous care, a patient can go to a teleglaucoma station to meet a technician who facilitates the encounter. The technician can position a slit lamp capable of streaming video per the physician’s instructions, and the physician performs an examination by viewing the live video stream. The physician then directly discusses treatment options with the patient.
In store and forward, a patient enters a teleglaucoma station, and a technician performs a variety of tests (eg, visual fields, optical coherence tomography, IOP measurement), stores that information, and forwards it to a remote interpreting physician, who, after review of the clinical information, can make appropriate treatment decisions.
Providers in countries such as Canada, the United Kingdom, and Australia have found that the majority of glaucoma and macular degeneration patients find this type of monitoring acceptable and that they often prefer the convenience of remote follow-up, because it saves them the cost and time to travel to the ophthalmologist.2,3 Furthermore, preliminary data indicate that managing patients remotely is safe and offers high-quality care, although further studies are necessary.2,4-6
CODING FOR TELEMEDICINE
Even though it is clear that teleglaucoma is valuable and benefits patients, there are limited Current Procedural Terminology (CPT) codes for its use. In addition, many payers do not have an allowable, effectively meaning that the physician can bill the correct CPT code yet still not be reimbursed.
In 2011, two store-and-forward telemedicine codes were developed for diabetic teleretinal screening. CPT 92227 is used if the patient is screened and no retinopathy is found. The code is reimbursed at a rate of $14.80. CPT 92228 (remote imaging for monitoring and management of active retinal disease with physician review) cannot be used unless there is disease. The code has both a technical ($13.71) and a professional component ($21.74), for a total reimbursement of $35.45.
There is low utilization of the 92227 and 92228 codes, even for diabetic screening, and they are the most comparable telemedicine codes one could bill for a store-and-forward teleglaucoma program. Because these codes are for diabetes, however, payers might not accept 92228 for glaucoma, a nondiabetic eye condition.
There are more billable codes for a synchronous teleglaucoma program. Modifier 95 (synchronous telemedicine where services are rendered from a real-time interactive audio and video telecommunications system) can be appended to Evaluation and Management codes of 99201-99205, 99212-99215, and 99307-99310 (nursing facility care). The most important caveat for the use of this modifier is that the physician has to perform the examination through the video connection (eg, the technician holds up a 90.00 D lens to the slit lamp and brings the nerve into view, and the physician sees the nerve). This type of synchronous setup is more costly, requires more equipment and skill to execute, and takes the physician more time than a store-and-forward method, but reimbursement is at a similar rate for the corresponding Evaluation and Management codes listed earlier.
RETURN ON INVESTMENT
Few codes exist to adequately reimburse physicians for using ophthalmologic telemedicine, including teleglaucoma. Because teleglaucoma provides such immense value to the physician and the patient, however, it may be worth implementing even if it may not immediately provide a financial return on investment.
Teleglaucoma allows practitioners to expand their patient base by reaching patients that they might not otherwise reach because of distance. In addition, teleglaucoma allows ophthalmologists to manage more diseased patients and eases the burden of travel for those patients to their appointments. Teleglaucoma thereby improves the patient’s experience while being a more efficient use of the patient’s and the provider’s time. An effect of better follow-up and compliance might ultimately also improve visual outcomes.
1. Thomas SM, Jeyaraman MM, Hodge WG, et al. The effectiveness of teleglaucoma versus in-patient examination for glaucoma screening: a systematic review and meta-analysis. PLoS One. 2014;9(12):e113779.
2. Strouthidis NG, Chandrasekharan G, Diamond JP, Murdoch IE. Teleglaucoma: ready to go? Br J Ophthalmol. 2014;98(12):1605-1611.
3. Dai M, Xu J, Lin J, et al. Willingness to use mobile health in glaucoma patients [published online ahread of print April 18, 2017]. Telemed J E Health. doi:10.1089/tmj.2016.0254.
4. Sreelatha OK, Ramesh SV. Teleophthalmology: improving patient outcomes? Clin Ophthalmol. 2016;10:285-295.
5. Kassam F, Sogbesan E, Boucher S, et al. Collaborative care and teleglaucoma: a novel approach to delivering glaucoma services in Northern Alberta, Canada. Clin Exp Optom. 2013;96(6):577-580.
6. Kiage D, Kherani IN, Gichuhi S, et al. The Muranga Teleophthalmology Study: comparison of virtual (teleglaucoma) with in-person clinical assessment to diagnose glaucoma. Middle East Afr J Ophthalmol. 2013;20(2):150-157.
April Maa, MD
• associate professor, Emory School of Medicine, Atlanta
• director of technology-based eye care services and comprehensive ophthalmology, Atlanta VA Medical Center
• (404) 321-6111; email@example.com
• financial interest: none acknowledged