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Billing and Reimbursement for Autonomous Diabetic Eye Exam

Diabetic retinopathy (DR), a diabetes complication, is the leading cause of vision loss in working-age adults in the US. Payers incentivize providers to screen for early signs of the diseases. Since 2022, a dedicated CPT code was created to allow primary care providers to perform diabetic eye exams using FDA-cleared AI technology, instead of referring patients to an eye specialist. Guidelines According to the CDC, and as indicated by the CMS, patients with diabetes are recommended to undergo an annual fully dilated eye exam to screen for DR. While traditional exams were performed by ophthalmologists, requiring annual referrals and dilation, evidence has shown that traditional screening is inaccessible to more than 50% of patients, resulting in increasing demand for point-of-care screening. Point-of-care screening enables patients to be screened by healthcare professionals and receive an instant diagnosis using artificial intelligence (AI), a procedure that takes less than two minutes to complete and rarely requires dilation. With point-of-care screening, patients can complete their annual exam at their primary care provider (PCP), relieving them of the hassle and costs associated with traditional screening processes, and resulting in increased adherence to recommended screening protocols. AEYE Diagnostic Screening (AEYE-DS) With the use of AI, for the first time ever, primary care physicians are able to perform a procedure that traditionally required referral to eye specialists. AEYE-DS’s FDA-cleared solution is uniquely designed for primary care, providing vision-saving screening for patients while enabling doctors to receive direct reimbursement and qualify for various payer incentives. Using an easy-to-operate retinal camera, any primary care staff obtains one image from each eye and uploads the images to AEYE-DS for diagnosis. A diagnostic result is provided instantly. Reporting Codes Diabetic Eye Exams performed in primary care using AI technology are reimbursable using dedicated CPT code 92229 and reportable using CPT Category II codes:

Reimbursable by Primary Care Providers CPT code 92229 was created for primary care providers and covers retinal imaging for detection or monitoring of DR, point-of-care automated analysis, and report. Improves HEDIS scores and Star-ratings Diabetic Eye Exams performed in primary care can be reported using CPT Category II codes and credited in various HEDIS measurements. Point of care screening payment programs Screening for diabetic retinopathy addresses MIPS measure 117 and may qualify PCPs for additional payer incentives

Reimbursement As of January 2021, a new dedicated CPT code, 92229 was introduced specifically for retinal screenings where the analysis is performed by artificial intelligence (AI) software. This is the first ever CPT code that allows AI software to provide a medical diagnosis that replaces humans. The national average reimbursement by CMS for CPT 92229 is around $50. Point-of-care Screening Incentive Programs CMS and private payers created various incentive programs to promote the early detection of diabetic retinopathy in patients with diabetes. Merit-based Incentive Payment System (MIPS)- Quality Measure 117 The Merit-based Incentive Payment System (MIPS) is an incentive program for eligible clinicians that measures the performance of recommended procedures. Clinicians may receive payment bonuses, penalties or no adjustments, based on their performance. MIPS Measure 117 measures the percentage of adult patients with diabetes who complete their annual diabetic eye exam. Diabetic Eye Exams performed using AEYE-DS directly address measure 117. Quality measures HEDIS Comprehensive Diabetes Care Preventative screenings, including DR screening, are an important component in HEDIS measures and Star Ratings, which publically grade insurers based on their performance. HEDIS comprehensive diabetes care consists of 6 components, one of which is an annual diabetic eye exam for the detection of diabetic retinopathy. Due to the low patient adherence when patients are referred for diabetes eye exams, it is one of the more difficult quality measures to attain. Therefore performing the eye exams in primary care can dramatically increase the adherence to the annual screening regimen. . Schedule a demo to learn how AEYE-DS could improve your practice’s diabetes care programs and easily introduce new revenue streams


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