Crystal's MCW Coder Hub⚕️CPT Code 92227 - Remote Imaging for Detection of Retinal Disease
📋 Full Code Description
Imaging of retina for detection or monitoring of disease; with remote clinical staff review and report, unilateral or bilateral
This code describes a store-and-forward teleophthalmology service in which non-physician clinical staff capture retinal images at an acquiring site (e.g., primary care office, FQHC, endocrinology clinic), transmit those images electronically to a reading site, and produce a report under physician supervision — without requiring direct physician interpretation. The key distinguishing factor from 92228 is that 92227 is performed and reported by clinical staff only, not a physician or other qualified health care professional (QHCP).
Note
This code is billed once regardless of whether one or both eyes are imaged (unilateral or bilateral).
🏥 Code Placement in the CPT Hierarchy
| Level | Description |
|---|---|
| Section | Medicine |
| Subsection | Ophthalmology |
| Range | 92002-92499 |
| Sub-range | Special Ophthalmological Services: 92225-92260 |
| Code | 92227 |
🌳 Code Tree / Family
Special Ophthalmological Services - Remote Retinal Imaging
│
├── 92227 — Remote imaging; clinical staff review & report only (NO physician interpretation)
│ ↳ Detection or monitoring; unilateral or bilateral
│ ↳ Staff-performed, physician supervision only
│ ↳ Technical component only; no -26 / -TC split
│
├── 92228 — Remote imaging; physician review, interpretation & report
│ ↳ Detection or monitoring; unilateral or bilateral
│ ↳ Requires physician/QHCP interpretation (can split -26 / -TC)
│
└── 92229 — Remote imaging; point-of-care autonomous (AI) analysis & report
↳ FDA-cleared AI algorithm performs analysis autonomously
↳ No human physician interpretation required
↳ Currently limited to diabetic retinopathy detection
📝 History & Revisions
- Implemented: 2011 — original teleophthalmology codes added to CPT
- Revised: 2021 — AMA CPT Editorial Panel expanded scope; both 92227 and 92228 now cover detection OR monitoring of retinal disease (previously 92227 was detection only; 92228 was monitoring only)
- New companion code added: 2021 — 92229 for AI-autonomous analysis
- Current descriptor reflects the 2021 revision in force today
⚙️ Technical Details
| Field | Detail |
|---|---|
| Global Period | XXX (no global period applies) |
| PC/TC Indicator | 5 — Technical Component Only. This means 92227 has no professional component; it cannot be billed with modifier -26 or -TC. The entire payment is technical. |
| wRVU (Work RVU) | 0.00 — There is no physician work component assigned because no physician interpretation is required. Clinical staff perform the service under physician supervision. |
| Total RVU (2025) | ~0.40 |
| 2025 Medicare MPFS Payment | ~$17.14 (national average; geographically adjusted) |
| Assistant Payable | ❌ No — not applicable; this is not a surgical procedure |
| Bilateral Indicator | Code is inherently unilateral or bilateral — bill once regardless of eye count |
| Telehealth Designation | Yes — store-and-forward; classified as a telemedicine service |
| Place of Service | Typically POS 11 (Office), 22 (Outpatient Hospital), 71 (Public Health Clinic), or 50 (FQHC) |
✅ What This Code Includes
- Capture of fundus/retinal images at the acquiring site by clinical staff (not a physician)
- Electronic transmission of images (store-and-forward) to a remote reading site
- Remote clinical staff review of the images
- Generation of a written report under physician supervision
- Coverage of both eyes when bilateral imaging is performed (billed as a single unit)
- Services for patients with Type 1 or Type 2 diabetes for early detection of diabetic retinopathy
- Per Noridian LCD: annual screening for Type 1 DM (>5 years duration) or Type 2 DM (at diagnosis) until retinopathy is detected
❌ What This Code Does NOT Include / Excludes
- Physician or QHCP interpretation — that is 92228 (requires physician to review, interpret, and report)
- AI-autonomous analysis — that is 92229
- Fundus photography — 92250 is a separately billable code for traditional fundus photography but cannot be billed on the same date of service (NCCI edit)
- Real-time interactive telemedicine E/M visits — those are reported with appropriate E/M codes + modifier -95
- Use after retinopathy has already been diagnosed — per Noridian LCD, once retinopathy is detected, 92227 no longer applies because care is no longer screening in nature; transition to 92228 or 92229
- Modifier -26 (Professional Component) — 92227 has a PC/TC indicator of 5 (technical component only); cannot be split
- Modifier -TC (Technical Component) — similarly, cannot be appended; the service is inherently global/technical only
🔢 NCCI / Bundling Edits
The following codes cannot be billed on the same date of service as 92227:
| Bundled Code | Description | Edit Type |
|---|---|---|
| 92228 | Remote imaging w/ physician interpretation | Mutually exclusive |
| 92229 | Remote imaging w/ AI autonomous analysis | Mutually exclusive |
| 92250 | Fundus photography | Column 1 / Column 2 |
⚠️ These are partial NCCI listings. Always verify the full NCCI table for the most current edits.
🏷️ Applicable Modifiers
| Modifier | Name | Application to 92227 |
|---|---|---|
| -95 | Synchronous Telemedicine | May be appended when service is delivered via telehealth technology |
| -LT | Left Side | When imaging is performed on left eye only |
| -RT | Right Side | When imaging is performed on right eye only |
| -59 | Distinct Procedural Service | When a distinct service is performed on the same day as another procedure |
| -76 | Repeat Procedure, Same Physician | If imaging must be repeated same day (e.g., poor image quality) |
| -GQ | Via Asynchronous Telecommunications | Used in federal telemedicine programs for store-and-forward services |
| -GT | Via Interactive Audio & Video | Rarely applicable since 92227 is store-and-forward, not real-time |
❌ Do NOT append -26 or -TC — PC/TC indicator is 5 (technical only; no split permitted per CMS).
🏥 MS-DRG Applicability
CPT 92227 is an outpatient/professional service and does not directly map to an MS-DRG.
However, the ICD-10-CM diagnosis codes associated with 92227 do group to MS-DRGs when used in the inpatient setting. The most common associated diagnosis codes group to:
| MS-DRG | Description | MCC/CC |
|---|---|---|
| 637 | Diabetes w/ MCC | w/ MCC |
| 638 | Diabetes w/ CC | w/ CC |
| 639 | Diabetes w/o CC/MCC | w/o CC/MCC |
For inpatient encounters where diabetic retinopathy is documented as a secondary complication (e.g., E11.319), it may serve as a CC (complication/comorbidity) and influence DRG grouping.
🩺 Associated ICD-10-CM Diagnosis Codes
💡 Tip: 92227 is a screening/detection code. Code the underlying diabetes type first, then any identified retinal findings. If no retinopathy is found, use the “without complications” or Z-code approach.
Primary Indications for Billing 92227
Diabetes Without Retinopathy (Screening Encounter)
| ICD-10-CM Code | Description | HCC | Notes |
|---|---|---|---|
| E11.9 | Type 2 DM without complications | HCC 39 (v28) / HCC 19 (v24) | Most common dx for screening |
| E10.9 | Type 1 DM without complications | HCC 39 (v28) / HCC 19 (v24) | Type 1 screening |
| E13.9 | Other specified DM without complications | HCC 39 (v28) | Secondary/drug-induced DM |
| Z13.5 | Encounter for screening for eye/ear disorders | None | Adjunct screening code; may be used as secondary |
| Z79.4 | Long-term (current) use of insulin | None | Secondary code when applicable |
Diabetes With Retinopathy — Type 2 (Nonproliferative)
| ICD-10-CM Code | Description | HCC |
|---|---|---|
| E11.311 | Type 2 DM, unspecified DR, with macular edema | HCC 38 (v28) / HCC 18 (v24) |
| E11.319 | Type 2 DM, unspecified DR, without macular edema | HCC 38 (v28) / HCC 18 (v24) |
| E11.3211 | Type 2 DM, mild NPDR, with macular edema, right eye | HCC 38 (v28) |
| E11.3212 | Type 2 DM, mild NPDR, with macular edema, left eye | HCC 38 (v28) |
| E11.3213 | Type 2 DM, mild NPDR, with macular edema, bilateral | HCC 38 (v28) |
| E11.3291 | Type 2 DM, mild NPDR, without macular edema, right eye | HCC 38 (v28) |
| E11.3292 | Type 2 DM, mild NPDR, without macular edema, left eye | HCC 38 (v28) |
| E11.3293 | Type 2 DM, mild NPDR, without macular edema, bilateral | HCC 38 (v28) |
| E11.3311 | Type 2 DM, moderate NPDR, with macular edema, right | HCC 38 (v28) |
| E11.3312 | Type 2 DM, moderate NPDR, with macular edema, left | HCC 38 (v28) |
| E11.3313 | Type 2 DM, moderate NPDR, with macular edema, bilateral | HCC 38 (v28) |
| E11.3391 | Type 2 DM, moderate NPDR, without macular edema, right | HCC 38 (v28) |
| E11.3392 | Type 2 DM, moderate NPDR, without macular edema, left | HCC 38 (v28) |
| E11.3393 | Type 2 DM, moderate NPDR, without macular edema, bilateral | HCC 38 (v28) |
| E11.3411 | Type 2 DM, severe NPDR, with macular edema, right | HCC 38 (v28) |
| E11.3412 | Type 2 DM, severe NPDR, with macular edema, left | HCC 38 (v28) |
| E11.3413 | Type 2 DM, severe NPDR, with macular edema, bilateral | HCC 38 (v28) |
| E11.3491 | Type 2 DM, severe NPDR, without macular edema, right | HCC 38 (v28) |
| E11.3492 | Type 2 DM, severe NPDR, without macular edema, left | HCC 38 (v28) |
| E11.3493 | Type 2 DM, severe NPDR, without macular edema, bilateral | HCC 38 (v28) |
Diabetes With Retinopathy — Type 2 (Proliferative)
| ICD-10-CM Code | Description | HCC |
|---|---|---|
| E11.3511 | Type 2 DM, PDR, with macular edema, right eye | HCC 38 (v28) |
| E11.3512 | Type 2 DM, PDR, with macular edema, left eye | HCC 38 (v28) |
| E11.3513 | Type 2 DM, PDR, with macular edema, bilateral | HCC 38 (v28) |
| E11.3591 | Type 2 DM, PDR, without macular edema, right eye | HCC 38 (v28) |
| E11.3592 | Type 2 DM, PDR, without macular edema, left eye | HCC 38 (v28) |
| E11.3593 | Type 2 DM, PDR, without macular edema, bilateral | HCC 38 (v28) |
Diabetes With Retinopathy — Type 1 (Selected)
| ICD-10-CM Code | Description | HCC |
|---|---|---|
| E10.311 | Type 1 DM, unspecified DR, with macular edema | HCC 38 (v28) |
| E10.319 | Type 1 DM, unspecified DR, without macular edema | HCC 38 (v28) |
| E10.3491 | Type 1 DM, severe NPDR, without macular edema, right | HCC 38 (v28) |
| E10.3591 | Type 1 DM, PDR, without macular edema, right eye | HCC 38 (v28) |
💡 Type 1 codes follow the same laterality/staging structure as Type 2 — replace E11 with E10.
🎯 HCC (Hierarchical Condition Category) Notes
⚕️ HCC categories apply to ICD-10-CM diagnosis codes only — not CPT codes.
CMS-HCC Model v28 (Effective 2024+)
| HCC | Category Description | Relevant Codes | RAF Score (approx.) |
|---|---|---|---|
| HCC 37 | Diabetes with Acute Complications | E11.00, E11.01, E10.10, etc. | ~0.302 |
| HCC 38 | Diabetes with Chronic Complications | E10.3xx, E11.3xx (retinopathy codes), E11.4xx, E11.5xx, E11.6xx | ~0.302 |
| HCC 39 | Diabetes without Complication | E10.9, E11.9, E13.9 | ~0.105 |
- HCC 38 captures significant risk-adjustable value for all diabetic retinopathy codes (NPDR and PDR, with or without macular edema)
- These codes hierarchy downward: HCC 37 > HCC 38 > HCC 39 (only the highest HCC in the hierarchy is scored per patient)
- Documentation tip: Specificity matters enormously. Coding E11.319 (unspecified DR) vs. E11.3293 (mild NPDR bilateral, without ME) both map to HCC 38 in v28 — but specificity supports better clinical documentation, audit defense, and quality metrics
- Macular edema documentation should also prompt evaluation for separate coding of H35.81 (Macular cyst, hole, or pseudohole) or DME-specific codes depending on clinical context
💡 Who Can Bill 92227?
| Scenario | Billable? | Notes |
|---|---|---|
| Primary care practice (PCP) owns the equipment and staff performs/reviews | ✅ Yes | PCP bills 92227; pays ophthalmologist via separate contract arrangement |
| Ophthalmologist’s practice provides both equipment and reads | ✅ Yes | Bills 92227 globally |
| PCP captures, ophthalmologist reads remotely | ✅ Yes | Either party bills the global service; contract defines who collects |
| Ophthalmologist performs real-time interpretation | ❌ No | Use 92228 instead (requires physician interpretation) |
| AI software provides automated report | ❌ No | Use 92229 instead |
| Retinopathy already detected — ongoing monitoring | ❌ No | 92227 is for detection/screening; transition to 92228 per Noridian LCD |
🧾 Coding Examples
Example 1 — Straightforward Screening, No Retinopathy Found
A 58-year-old patient with Type 2 DM (diagnosed 3 years ago, no known retinopathy) presents to a primary care clinic for annual diabetic retinopathy screening. A medical assistant uses a non-mydriatic fundus camera to capture bilateral retinal images. Images are transmitted electronically to a remote reading site where a trained ophthalmic technician reviews them under ophthalmologist supervision and documents “no diabetic retinopathy detected.”
CPT: 92227 ICD-10-CM: E11.9 (primary), Z13.5 (secondary screening encounter) Modifier: None required; bilateral service billed as 1 unit
Example 2 — Screening Reveals Mild NPDR, Bilateral
A 44-year-old patient with Type 2 DM on insulin presents for annual tele-retinal screening. Staff capture bilateral images at a federally qualified health center. Remote review identifies bilateral mild nonproliferative diabetic retinopathy without macular edema. Report is generated and signed off by supervising ophthalmologist.
CPT: 92227 × 1 unit ICD-10-CM: E11.3293, Z79.4 Note: Even though retinopathy was found, the encounter began as a screening visit and the findings were discovered at this encounter. Per payer policy, once retinopathy is established, future visits should use 92228 or direct ophthalmology referral. Some LCDs (e.g., Noridian) indicate 92227 no longer applies after retinopathy is detected.
Example 3 — Type 1 Diabetes, >5 Years Duration, Annual Screen
A 29-year-old with Type 1 DM (diagnosed age 14, 15-year history) presents for annual mandated diabetic retinopathy screening at an endocrinology clinic equipped with teleophthalmology hardware. Staff perform bilateral image acquisition; images forwarded to ophthalmology reading center. No retinopathy found.
CPT: 92227 × 1 unit ICD-10-CM: E10.9, Z79.4 Modifier: Consider -GQ if billing under federal store-and-forward telehealth program
Example 4 — Same Day as Dilated Fundus Exam (NCCI Conflict)
Patient is seen at an ophthalmology clinic for a comprehensive dilated fundus exam (92250) performed by a technician, same day as tele-retinal screening via 92227.
⚠️ NCCI Edit Conflict — 92250 and 92227 cannot be billed on the same date of service. Only one should be reported. If a complete dilated fundus exam was performed, bill 92250 (higher-value service with physician interpretation); 92227 is not appropriate.
Example 5 — Primary Care + Contracted Ophthalmology Reading Site
A rural FQHC owns a fundus camera. Staff acquire images and send to an ophthalmology group with which they have a reading contract. The ophthalmology group’s staff reviews images (not the physician) and generates the report under ophthalmologist supervision.
Acquiring site (FQHC): May bill 92227 globally and reimburse the reading site via contract Reading site (ophthalmology): Does not bill separately if the global is billed by the acquiring site under contract ⚠️ Note: Both parties may not separately bill Medicare for the same encounter. A written contract specifying revenue division is required.
🔄 Comparison: 92227 vs. 92228 vs. 92229
| Feature | 92227 | 92228 | 92229 |
|---|---|---|---|
| Who performs review | Clinical staff only | Physician / QHCP | Autonomous AI algorithm |
| Physician interpretation required | ❌ No | ✅ Yes | ❌ No |
| PC/TC split allowed | ❌ No | ✅ Yes (-26/-TC) | Varies |
| wRVU | 0.00 | Higher (professional component) | Varies |
| 2025 Medicare Payment | ~$17.14 | ~$28.79 | ~$43.67 |
| Purpose | Detection or monitoring | Detection or monitoring | Detection only (AI-approved DR) |
| After retinopathy detected | ❌ Transition away | ✅ Appropriate | ✅ Appropriate (if AI-eligible) |
⚠️ Common Coding Pitfalls
- Billing 92227 after retinopathy is already diagnosed — Noridian and other MACs have stated 92227 is for screening/detection only. Once retinopathy is established, transition to 92228 or direct ophthalmology care.
- Appending -26 or -TC — 92227 has a PC/TC indicator of 5 (technical only, no split). Neither modifier applies; doing so will result in claim denial.
- Billing both 92227 and 92250 on the same day — NCCI edit. Only one remote imaging/fundus code per encounter.
- Billing 92227 twice for bilateral — Code is inherently bilateral; bill one unit regardless of eyes imaged.
- Using E11.9 without laterality when retinopathy is found — If retinopathy is identified, the more specific laterality codes (E11.3293 etc.) must be used.
- Missing insulin use code — Z79.4 should be added as a secondary code whenever the patient is on long-term insulin; this has HCC implications and supports risk adjustment accuracy.
- Confusing 92227 with 92228 — The distinction is who reviews: staff only = 92227; physician interprets = 92228.
📚 References
^[1] CMS Noridian LCD Article A58384 - Billing and Coding: Remote Imaging of the Retina to Screen for Retinal Diseases ^[2] American Academy of Ophthalmology - Telehealth Retinal Codes, AAO Practice Management ^[3] Corcoran Consulting Group - Ophthalmic Imaging CPT Codes and Payment Data 2025 ^[4] Retinal Physician - Reimbursement for Teleophthalmology for Remote Diabetic Eye Screening (Jan/Feb 2022) ^[5] PMC / JAMA Ophthalmology - Trends in Remote Retinal Imaging Utilization and Payments in the US (PMC8958947) ^[6] Hillrom/Baxter - CPT Coding Resource for Fundus Imaging and Teleretinal Programs ^[7] CMS Medicare Physician Fee Schedule 2025 (MPFS) - National Payment Rates