Article Date: 7/1/2012

Telemedicine's Role in Diabetic Eye Care
SPONSORED BY ELLEX, INC. AND PRN

Telemedicine's Role in Diabetic Eye Care

Making eye care more accessible to patients and decreasing unnecessary visits

By Paul M. Larson, MMSc, MBA, COMT, COE, CPC, CPMA and Kevin J. Corcoran, COE, CPC, FNAO

The advent of telemedicine heralds a new era in ophthalmology, helping to bridge the gap between physician and patient and offering many benefits for the screening, diagnosis, monitoring and management of eye disease. Advances in computing and telecommunications technology enable ophthalmologists and optometrists to offer a higher standard of care despite geographic distance. Significant cost savings can be realized by using telemedicine instead of annual eye exams.1

TELEMEDICINE AND DIABETES

Diabetic retinopathy is now considered to be one of the leading causes of vision impairment in the developed world. Experts at the National Institutes of Health estimate that by 2020, there will be more than 7.2 million Americans with diabetic retinopathy. Right now, nearly 26 million Americans have diabetes, and there are an additional 79 million Americans who are pre-diabetic.2 The estimated 20,000 ophthalmologists and 30,000 optometrists in practice aren't nearly enough to screen and treat the aging “Baby Boomer” population, much less the growing population of younger diabetics.

At present, “…fewer patients with diabetes are referred by their primary care physicians for ophthalmic care than would be expected according to guidelines by the American Diabetes Association and the American Academy of Ophthalmology,”3 which suggests that more diabetic patients should be sent for annual eye exams by their GPs. The demand for eye care will increase when that occurs. Furthermore, as demand for eye care grows and the supply of eyecare practitioners fails to keep pace, greater efficiencies will be needed. Because screening exams are associated with only a modest reimbursement, eyecare practitioners should see telemedicine as a viable alternative due to the speed of the interaction and time saved in the office. As a triage tool, telemedicine offers a way to quickly and inexpensively segregate diabetics without retinopathy from those with retinopathy who need additional evaluation and treatment.4 Telemedicine also provides for more coordination of care between specialists who are managing a single patient. A current lack of cooperation and coordination is a weakness in our current system according to Donald Berwick, MD, former Administrator of the Centers for Medicare and Medicaid Services (CMS).5

The standard of care for diabetic patients is an annual fundus exam by a qualified eyecare provider.6,7 With early detection and treatment of diabetic eye disease, vision loss can be mitigated.8 Unfortunately, only 30% to 60% of individuals with eye disease receive a yearly eye exam.9,10 Telemedicine has the potential to increase the number of patients being screened for eye disease; it has been shown to provide cost-effectiveness and total savings in terms of public health spending.11 The National Quality Forum has endorsed eye screening for diabetic retinal disease (NQF 0055) using fundus photography in which results are read by a qualified reading center.12 It's already common in the Veterans' Administration to use remote imaging when an eyecare provider is not immediately available.13 Clinical trials commonly use image-reading centers, and other organizations have used remote imaging as a way to expand the number of patients screened.4

Telemedicine isn't just for eye care, either — Healthcare IT News predicts that the world market for telehealth will expand at a compound annual growth rate of 55% or more in the next 5 years.14

CPT CODING

Two new CPT codes, 92227 and 92228, for remote imaging were introduced in 2011. In CPT Changes: An Insider's View 2011, published by the AMA,15 the rationale for establishing these new telemedicine codes was to “…meet the needs of diabetic retinopathy screening programs which provide remote imaging and data submission to a centralized reading center.” This ignited an interest among eyecare providers, particularly in areas where diabetic screening is most needed.



An Ellex drs image of a healthy retina (A) and a patient with diabetes (B).

Very little guidance has been published on these codes and how they should be used.16 Some speculate that only primary care providers should use these codes, while others consider believe they can be used by primary care and eyecare providers. To further confound matters, the longstanding fundus photography code, 92250, may also apply in some settings and under some circumstances. The relevant CPT codes are described as:

92227 — 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

92228 — Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral

92250 — Fundus photography with interpretation and report

These codes are mutually exclusive from one another — choose only one of the three to denote a service. For the remote imaging codes, CPT instructs, “Do not report [92227, 92228] in conjunction with 92002-92014, 92133, 92134, 92250 … or with the evaluation and management of the single system organ system, the eye, 99201-99350.”

A comparison of the three CPT codes reveals some nuances that should be considered for claims submission (Table 1). Since 92227 doesn't take into account physician interpretation (i.e., no relative value unit (RVU) assigned for a technical and professional component), and isn't used for previously identified retinopathy, it's not a suitable choice when an ophthalmologist or optometrist is an essential part of the telemedicine protocol. Conversely, code 92228 does contemplate an ophthalmologist's or optometrist's involvement, does require an interpretation, and is only used for monitoring and management of patients with previously identified retinopathy (not just diabetes); it would be a suitable choice for a telemedicine program except for screening. As currently defined, only 92250 accurately describes telemedicine screening by an eyecare practitioner, physician interpretation and written report.

Table 1. Comparison of Codes for Fundus Photography
CPT CodeRemote UseInterpretation RequiredHistory of Diabetic Eye Disease2012 RVUTC/26Supervision Level
92227YesNoNo0.36NoGeneral(1)
92228YesYesYes1.01YesGeneral
92250Yes or NoYesYes or No2.25YesGeneral
(1) 92227 is described in CPT as “under physician supervision” although a level of supervision is not stipulated by CMS. In our view, “general supervision” is appropriate.

The RVUs assigned by CMS to 92227 and 92228 are substantially lower than for 92250. It is likely that payers would prefer the new codes for this reason.

All of these codes require general supervision, meaning the procedure is furnished under the physician's overall direction and control, but the physician's presence isn't required during the performance of the procedure.

OTHER CONSIDERATIONS

Claims for reimbursement are further affected by other considerations.

► Who owns the camera?
► Where is the camera physically located?
► Who employs the assistants or technicians taking the photographs?

Which party may bill for taking the images is a function of who owns the fundus camera and supervises the medical assistant or technician. The place of service (i.e., clinic, hospital) and its geographic location determine the applicable payment rate. Note that we do not assume that the camera and the reading center are subject to the same geographic practice cost indices (GPCI). Which party may bill for the interpretation of the fundus images is a matter of authorship. In other words, the physician who analyzes the image and makes a diagnosis bills for his or her work. Each party bills only for the services he or she delivers. Before any billing takes place, proper credentialing is required for each provider and location. There may also be important legal considerations that impact telemedicine arrangements.

COVERAGE BY MEDICARE AND OTHER PAYERS

Under the Medicare law, coverage exists for services performed “... for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” as set forth in the Social Security Act §1862(a)(1)(A). Screening for a disease that might or might not be present doesn't meet this requirement, and unless specifically covered elsewhere in the Act (e.g., glaucoma screening), is not a Medicare benefit. While other third-party payers often have coverage rules that are similar to those of Medicare, they don't have to be the same.

Ellex drs: The Retinal Camera Designed for Telemedicine
Advances in retinal screening technology, such as the new Ellex drs™ retinal fundus camera, combined with the advent of smartphone and tablet PC technology and “cloudbased” patient referral software, have dramatically enhanced the process of retinal disease management. Physicians are able to remotely access and review patient data and images, allowing for more timely diagnoses and enhanced patient referral flow.
The drs is the perfect system for telemedicine applications — allowing the retina specialist to effortlessly network high-resolution images received remotely from a referring practitioner to an external monitor, tablet PC or smartphone with a high level of confidence, speed and consistency through HIPAA-compliant, cloud-based, third-party software. In particular, the drs offers exceptional image accessibility and ease of use: it automatically syncs to your EMR and any staff member can operate the system with confidence, consistency and minimal training.



Featuring fully robotic alignment and automated image acquisition, the drs auto-senses the patient, selfaligns to the target eye, focuses the retina, adjusts the flash level and captures the image. Quick and easy to use, the image-capture process takes less than 30 seconds per eye. The drs also offers touchscreen-based operation: simply enter the patient name and birth date; push start and the drs does the rest.
The drs is the essential retinal fundus camera for efficient, effective telemedicine applications — and allows you to expand your retinal-screening program. To learn more, or take part in an in-office demonstration, contact us at 800-824-7444.

By David Dyer, MD, FACS
PRN: Making the business of referrals easier for specialists and PCPs
The Physician Referral Network (PRN) is a HIPAA-compliant, cloud-based diagnostic referral network, which allows doctors to manage patients more efficiently and cost-effectively.
Currently, 40% of diabetic patients in the United States don't undergo an annual eye exam. They may see their primary doctors, but they don't follow up with an eye doctor. This is a national health issue because it's extremely important that all diabetic patients receive routine eye care and screening.
Studies show that if you offer diabetic patients the chance to have photographs taken in the internist's office, nearly 100% will do so. If you give them the chance to see a general ophthalmologist and optometrist in the next year, only 60% of patients will follow up.9,10 So, there's a huge benefit to capturing the patient while he's in the office. Additionally, it's more efficient for the retina specialist to screen patients with photos rather than bringing all diabetic patients into the office.
The primary purpose of PRN is to take clinical photographs from a primary care office, send them to a retina specialist and have him provide a recommendation for treatment. Often, the patient won't have to see a specialist right away if treatment isn't necessary. Patients can continue to follow up with their primary care physician or optometrist until a retina specialist is needed. This saves the patient a second trip to the doctor, which also saves money. With PRN, patients essentially get two visits out of one.
HOW PRN WORKS
We believe that Ellex has the best camera for taking diagnostic images because it's fully automated. The combination of our software and the Ellex drs camera makes telemedicine a very simple process for the primary care office. PRN software links to the drs camera automatically upon download of our software. Upon acquisition, the drs images are automatically downloaded to the PRN software. Once this is done, the GP office can send clinical images to a predetermined specialist or reading center.
The software on the specialist's side has a series of dropdown boxes, so images can be read quickly. Patient demographics and insurance information are also sent along with the image.



As a retina specialist, I can read a routine diabetic image in about a minute. From the time I open up the software on the computer, make a determination and send it back to the primary care physician, it literally takes about 60 seconds.
The software is free and can be downloaded from our website. We verify that the potential user is a licensed doctor; then they can start to use PRN. Our fee is linked to transferring data. The average transaction fee is $5.59 each way. This varies slightly depending on how much data is being pushed through. This fee covers updates, as well. In addition, we store these images on a secure database for 7 years.
PRN will provide a current list of ophthalmologists, optometrists and primary care practitioners in your area who are using PRN. We contact that doctor's office and provide them with your contact information. You can specify any single doctor or all doctors in that practice if you wish. If you have a doctor you use out of state, we can help with that as long as your state allows for interstate transfers.
Using a cloud-based system, we can update the software onto the cloud and it can be downloaded directly and immediately into the user's system. Doctor lists can be updated this way as well. The software can run on PC operating systems or Macintosh computers using Windows parallel.
The specialist is able to work with the referring doctor through the network, thereby decreasing the need for routine screening and follow up visits at a specialist's office. Patients are only sent to the specialist for testing and procedures not performed at the referring doctor's office, so more retina appointments are available for patients who require specialized treatments.
Learn more about PRN referral at http://prnreferral.com.

Several Medicare Administrative Contractors (MACs) have published local coverage determinations (LCDs) for 92227, which preclude Medicare coverage.17 Code 92228 is a different story; disease is already present; coverage is likely but not assured.18 Check your MAC's website for specific instructions.

In cases where coverage is unlikely or expressly denied,19 use a financial waiver such as an Advance Beneficiary Notice prior to taking the images.

HIPAA

HIPAA security is a significant consideration to avoid the inadvertent disclosure of protected health information (PHI). Be sure that a HIPAA-compliant system of image safeguard and transmission is in place for both the transmitting and receiving systems.

LEGAL CONSIDERATIONS

Since telemedicine provides a triage mechanism for sorting patients who need further evaluation and treatment for diabetic retinopathy, it may be an important source of referrals for ophthalmologists and optometrists from PCPs for services that probably will be covered and paid for by Medicare or other third-party payers. As such, eyecare specialists must be careful to avoid providing PCPs with anything of value that could be construed as a means of soliciting a referral. The Medicare Antikickback Statute20 makes it a crime to offer remuneration in return for referrals. Similar state laws complement this federal law. To avoid this legal jeopardy, a number of safe harbors exist to insulate individuals and entities from prosecution under the Antikickback Statute for conduct, which would otherwise violate the Antikickback Statute. For physicians in Texas, the Medical Board has issued guidance21 on the use of telemedicine as it relates to licensure for its members. Check your state's laws, regulations and guidelines for specific instructions.

THE PROS OF TELEMEDICINE

Telemedicine provides a reliable, cost-effective means of screening diabetic patients for retinopathy, which can lead to blindness. Since the number of diabetics in the United States is growing fast, but the supply of eye-care practitioners is not, healthcare resources are strained and becoming more so. Certainly, not every diabetic now receives the standard of care, an annual eye exam, but that situation will likely worsen unless alternative healthcare delivery systems are employed to address it. With new, easy-to-use, non-mydriatic cameras, nurses and medical assistants without any ophthalmic training can learn to take excellent fundus photographs. These images can be transmitted to a reading center where they can be expertly assessed.
This new methodology has already been adopted in a number of high profile institutions and also is part of the HEDIS standards for comprehensive diabetic care. Payers are slowly coming on board since CPT was amended in 2011 with two codes uniquely defined for this purpose: 92227 and 92228. Ophthalmologists and optometrists will likely find increasing use for telemedicine in the future, and not just for diabetes.

The special requirements of telemedicine in ophthalmology, particularly for high quality fundus images, have inspired technological innovations. Two new technologies that work seamlessly together are the PRN Referral cloud-based telemedicine software and the Ellex drs automated nonmydriatic fundus camera. RP

Paul M. Larson, MMSc, MBA, COMT, COE, CPC, CPMA is an Associate Consultant, for the Corcoran Consulting Group. Kevin J. Corcoran, COE, CPC, FNAO is President of the Corcoran Consulting Group. You can reach Corcoran Consulting Group at 800-399-6565 or WWW.CorcoranCCG.com.

References
1. Rein, DB, et al. The Cost-Effectiveness of Three Screening Alternatives for People with Diabetes with No or Early Diabetic Retinopathy, Health Services Research, Vol 46, Issue 5, p. 1534-1561, October 2011.
2. National Institutes of Health. National Diabetes Statistics, 2011.www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed June 7, 2012.
3. American Academy of Ophthalmology. Preferred Practice Pattern. Diabetic retinopathy. Sept 2008. http://one.aao.org/CE/PracticeGuidelines. Accessed June 7, 2012.
4. Joslin Diabetes Center. Annual Eye Exam. http://www.joslin.org/info/annual _eye_exam.html. Accessed June 7, 2012.
5. Berwick DM and Hackbarth AD. Eliminating waste in US health care. JAMA. Special communication. 307(14):1513-1516.
6. Williams GA, Scott IU, et. al. Single-field fundus photography for diabetic retinopathy screening: a report by the American Academy of Ophthalmology. Ophthalmology. 111(5):1055-1062. (2004).
7. American Academy of Ophthalmology. Preferred Practice Pattern, Comprehensive adult medical eye evaluation. Oct 2010. http://one.aao.org/CE/PracticeGuidelines. Accessed June 7, 2012.
8. National Eye Institute. Press Release, 03/09/1993. Five year follow up data released [Early Treatment Diabetic Retinopathy Study]. http://www.nei.nih.gov/news/pressreleases/030993.asp. Accessed June 7, 2012.
9. Varma R, Mohanty SA, Deneen J, Wu J, Azen SP; LALES Group. Los Angeles Latino Eye Study Group. Burden and predictors of undetected eye disease in Mexican-Americans: the Los Angeles Latino Eye Study. Med Care 2008;46:497-506.
10. Lee PP, Feldman ZW, Ostermann J, et al. Longitudinal rates of annual eye examinations of persons with diabetes and chronic eye diseases. Ophthalmology 2003;110:1952-1959.
11. Javitt JC, Aiello LP. Cost-effectiveness of detecting and treating diabetic retinopathy. Ann Intern Med. 1996;124:164-169.
12. National Quality Forum, Comprehensive Diabetes Care, p 13, HEDIS 2009 Volume 2 Technical Update, October 1, 2008.
13. VHA Office of Telehealth. http://www.telehealth.va.gov. Accessed June 7, 2012.
14. Inmedica predicts shake-up in the telehealth market. Press Release, October 8, 2010.
15. CPT Changes: An Insider's View 2011, American Medical Association.
16. Asbell RL, Resolving the coding dilemmas related to remote imaging. Retinal Physician. October 2011.
17. Posterior Segment Imaging (Extended Ophthalmology and Fundus Photography) – Supplemental Instructions Article. A44439, rev. eff. 10/17/2011.
18. Blue Cross Blue Shield of Delaware, Policy 2.01.M-72, Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy, January 2012.
19. Aetna Clinical Policy Bulletin: Diabetic Retinopathy Telescreening Systems, No. 0563, March 2012. http://www.aetna.com/cpb/medical/data/500_599/0563.html. Accessed June 7, 2012.
20. Office of Inspector General, Federal Anti-Kickback Law and Regulatory Safe Harbors, Fact Sheet, November 1999. http://oig.hhs.gov/fraud/docs/safeharborregulations/safefs.htm. Accessed June 7, 2012.
22. Texas Medical Board. TMB Telemedicine FAQs. http://www.tmb.state.tx.us/professionals/physicians/licensed/telemedicineFAQs.php. Accessed June 7, 2012.


Retinal Physician, Issue: July 2012, page(s): 3 - 7