Teleophthalmology Using Remote Retinal Imaging During the COVID-19 Pandemic

INSURANCE REIMBURSEMENTS FOR TELEOPHTHALMOLOGY

The proportion of claims paid for remote imaging increased only temporarily from 47.6% in January to 56.7% in April, but declined back to 45.9% by December 2020. The transient increase was more pronounced for the more specific telehealth codes 92227/92228, which increased from 57.2% in January to 83.1% in April, but decreased to 53.5% in December, similar to the payment proportion (SD) of 56.5% (18.9%) averaged across 2017 to 2019 (Fig. 1C). Insurance coverage using fundus photography code 92250 by non-eye care providers also showed a slight increase from 46.8% in January to 54.4% in April before returning to 45.3% in December, even lower than the prepandemic payment proportion (SD) of 63.4% (2.9%) averaged across 2017 to 2019 (Fig. 1D).

Discussion

The COVID-19 pandemic in 2020 highlighted the importance of expanding telemedicine to improve eye care access. Although remote retinal imaging provides the advantage of minimizing in-person visits with eye care providers, we found that utilization of these services declined in March and April, corresponding to the initial period of the COVID-19 lockdown and AAO’s recommendation to cease nonessential eye care at the time.

Interestingly, adoption of other teleophthalmology services such as virtual or video visits was also disproportionately lower among ophthalmologists than other surgical subspecialties during the pandemic at one academic institution.²⁹ Although use of teleretinal imaging gradually returned after the initial lockdown period, the utilization rates did not exceed prepandemic levels, indicating no clearly sustained overall increase in utilizing teleophthalmology technologies even as lockdown restrictions were eased.

Despite broadened guidelines for telehealth reimbursements from the CMS during the COVID-19 public health emergency, insurance coverage for remote retinal imaging increased only temporarily in March and April, and largely returned to prepandemic levels by end of the year. CMS expanded telehealth payments for Medicare enrollees under Section 1135 of the Social Security Act from March 1, 2020, which had not yet expired by the end of 2020. Surprisingly, although 92227 and 92228 are telehealth codes in the CPT book, these codes were not included in CMS’s list of telehealth services. Nonetheless, the transient increase in claims paid was mostly observed when teleophthalmology screening codes such as 92227 and 92228 were used, while coverage for the nonspecific 92250 billing code for fundus photography by non-eye care providers did not exhibit a significant change during this period.

Ironically, our previous study found that most denied claims from 2011 to 2019 were from Medicare Advantage enrollees rather than commercial enrollees.²⁴ Such inconsistent insurance coverage for teleophthalmology services, even during the expanded flexibilities for other telemedicine services afforded by the ongoing COVID-19 pandemic, demonstrates the economic challenges of utilizing remote retinal imaging to enhance eye care access.

Our study focused on remote retinal imaging, and does not address the broader use of teleophthalmology services such as virtual or video visits or e-consultations. In fact, a recent study that focused on a single payer in Michigan demonstrated increases in both asynchronous retinal imaging and synchronous video visits, possibly reflecting the differential use of telemedicine for preventative eye screening versus acute management of eye diseases.³⁰ Because CPT codes 92227 and 92228 are designated for asynchronous remote eye imaging only, we did not capture synchronous telehealth visits that may have increased during the COVID-19 lockdown.

Also, the CMS updated definitions for these CPT codes in 2021 and added new codes for retinal imaging with automated point-of-care using artificial intelligence, and so, we did not evaluate longer term changes beyond 2020.³¹ Furthermore, using the fundus photography code 92250 by non-eye care providers may exclude ophthalmologists billing for remote image interpretations, and inappropriately include general providers who perform fundus photography without store-and-forwarding to eye care specialists for interpretation.

The COVID-19 pandemic underscored the need to expand telehealth services, but did not appear to confer any sustained improvements in the utilization or insurance coverage of teleophthalmology by remote imaging in the U.S. health care market. Use of teleretinal imaging decreased briefly during the initial lockdown in March 2020, with a concomitant increase in insurance coverage. Despite continued expansion of Medicare coverage of telemedicine during the COVID-19 public health emergency announced by CMS, our analysis of national claims data showed that insurance reimbursement rates dwindled back to prepandemic levels by the end of 2020. We encourage policy makers and health care advocates to strengthen efforts to promote teleophthalmology screening and access to eye care.

Authors’ Contributions

G.Y. and S.A. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: G.Y.

Acquisition, analysis, or interpretation of data: S.C.L., S.A., and G.Y.

Drafting of the article: S.C.L. and G.Y.

Critical revision of the article for important intellectual content: S.C.L., M.K.L., S.A., P.E.-N., and G.Y.

Statistical analysis: S.A.

Study supervision: G.Y.

Disclosure Statement

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Yiu reports grants and personal fees from Alimera, Allergan, Carl Zeiss Meditec, Clearside Biomedical, Genentech, Gyroscope Therapeutics, Intergalactic Therapeutics, Iridex, NGM Biopharmaceutical, Regeneron, Topcon, and Verily, all outside of the submitted work. No other disclosures were reported.

Funding Information

This work is supported by the UC Davis Eye Center. Glenn Yiu is supported by NIH R01 EY032238, NIH R21 EY031108, the BrightFocus Foundation, and the Macula Society. This project was also supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1 TR001860. Dr. Monica K. Lieng was supported by training funds from the J. William Kohl Summer Scholarship for Medical Students. The funding organizations did not play any role in the design or conduct of this retrospective study; the collection, management, analysis, or interpretation of data; or the preparation, review, approval, and submission decision of the article. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.