Crystal's MCW Coder Hub⚕️CPT Code 92228 - Remote Imaging for Detection or Monitoring of Retinal Disease, Physician Interpretation
📋 Full Code Description
Imaging of retina for detection or monitoring of disease; with remote physician or other qualified health care professional interpretation and report, unilateral or bilateral
This code describes a store-and-forward teleophthalmology service in which retinal images are captured at one location (the acquiring site) and transmitted electronically to a remote site where a physician or other qualified health care professional (QHCP) — typically an ophthalmologist or optometrist — personally reviews, interprets, and produces a formal written report with findings and recommendations.
The defining distinction between 92228 and its sibling code 92227 is the level of the reviewer: 92228 requires physician or QHCP review and interpretation; 92227 requires only clinical staff review under physician supervision. This distinction has direct implications for who can bill the code, how it is split, and what payment is received.
92228 is applicable for both detection (initial identification of disease in a patient who may not yet be known to have retinal pathology) and monitoring (ongoing surveillance of an established condition, such as known diabetic retinopathy or macular degeneration). This dual scope was formally codified with the 2021 CPT revision to 92228.
The code is billed as one unit regardless of laterality — whether one or both eyes are imaged and interpreted, 92228 is reported once. It is an inherently unilateral or bilateral code.
🔬 Clinical Context: What Makes This Code Tick
| Feature | Detail |
|---|---|
| Service model | Store-and-forward teleophthalmology; images captured, stored, then forwarded — NOT real-time videoconferencing |
| Image acquisition | Non-mydriatic (or mydriatic) fundus camera; typically at a primary care office, FQHC, endocrinology clinic, rural health clinic, or diabetes management center |
| Reviewer | Physician (MD/DO, ophthalmologist or optometrist) or other QHCP — must personally review, interpret, and sign the report |
| Report requirements | Formal written report documenting findings, severity staging of retinopathy, presence/absence of macular edema, and follow-up/treatment recommendations |
| Laterality | Unilateral or bilateral — billed once regardless |
| When used vs. 92227 | 92227 is for screening (no retinopathy yet found); once retinopathy is detected, 92228 is the appropriate code per Noridian/MAC guidance |
| When used vs. 92229 | 92229 uses autonomous AI for analysis with no physician interpretation; 92228 requires human physician interpretation |
| Primary disease targeted | Diabetic retinopathy (most common), but may be used for any retinal disease requiring remote monitoring |
🏥 Code Placement in the CPT Hierarchy
| Level | Description |
|---|---|
| Section | Medicine |
| Subsection | Ophthalmology |
| Range | 92002-92499 |
| Sub-range | Special Ophthalmological Services: 92225-92260 |
| Code | 92228 |
🌳 Code Tree / Family
Special Ophthalmological Services - Remote Retinal Imaging
│
├── 92227 — Remote imaging; clinical staff review & report ONLY
│ ↳ NO physician interpretation required
│ ↳ PC/TC indicator: 5 (technical component only — no split)
│ ↳ Total RVU: ~0.40 | wRVU: 0.00
│ ↳ Used for SCREENING (no retinopathy yet detected)
│ ↳ 2025 Medicare payment: ~$17.14 (global)
│
├── 92228 — Remote imaging; PHYSICIAN or QHCP interpretation and report ← THIS CODE
│ ↳ Physician must personally review, interpret, and report
│ ↳ PC/TC indicator: 2 (can split with -26 and -TC)
│ ↳ Total RVU: ~0.89 | wRVU: ~0.50 (professional component)
│ ↳ Used for DETECTION or MONITORING (includes established retinopathy)
│ ↳ 2025 Medicare payment: ~$28.79 (global) | ~$15-16 (-26) | ~$13 (-TC)
│
└── 92229 — Remote imaging; point-of-care autonomous AI analysis and report
↳ FDA-cleared AI algorithm; no physician interpretation
↳ Currently limited to diabetic retinopathy detection
↳ 2025 Medicare payment: ~$43.67
📌 Non-standard hierarchy note: Per CPT Assistant (Vol. 31, Issue 6), the 92227-92229 family does not follow the typical CPT indented hierarchy. Each code is entirely distinct based on the entity performing the review, not an add-on or variant of the prior code. Each stands independently.
⚙️ Technical Details
| Field | Detail |
|---|---|
| Global Period | XXX — No global period applies (no pre-op/post-op bundling) |
| PC/TC Indicator | 2 — Both a professional component (physician interpretation) and a technical component (image acquisition equipment/staff) exist; the code can and commonly is split with modifier -26 (professional) and -TC (technical) |
| wRVU (Work RVU) | ~0.50 (reflects the professional component; verify via CMS MPFS Addendum B) |
| Total RVU (2025) | ~0.89 |
| 2025 Medicare MPFS Global Payment | ~$28.79 (national average; geographic adjustment applies) |
| 2025 Medicare MPFS - - 26 (Professional) | ~16.60 (national average; billed by interpreting ophthalmologist/QHCP) |
| 2025 Medicare MPFS - -TC (Technical) | ~13.78 (national average; billed by acquiring/equipment site) |
| Assistant Payable | ❌ No — not applicable; this is not a surgical procedure |
| Bilateral Indicator | Inherently unilateral or bilateral — bill one unit only, regardless of eye(s) imaged |
| Telehealth Designation | ✅ Yes — store-and-forward telemedicine service |
| Place of Service | POS 11 (Office), POS 22 (Outpatient Hospital), POS 71 (Public Health Clinic), POS 50 (FQHC), POS 72 (Rural Health Clinic) |
| MUE | 1 unit per date of service |
| Conversion Factor (2025) | $32.35 |
💡 PC/TC Split Billing — The Core Complexity of 92228
Unlike 92227 (which cannot be split), 92228 carries a PC/TC indicator of 2, meaning the professional and technical components can be billed separately when performed by different entities. This is the most common real-world billing scenario for 92228 in teleretinal programs.
How the Split Works
ACQUIRING SITE (e.g., primary care office, FQHC, diabetes clinic)
└── Owns/operates the fundus camera and employs the staff who image the patient
└── Bills: 92228 -TC — Technical Component
└── Payment: ~$12.88-$13.78 (2025 national average)
READING SITE (e.g., ophthalmology practice, retina specialist group)
└── Physician reviews images remotely, interprets, and generates formal report
└── Bills: 92228 -26 — Professional Component
└── Payment: ~$15.01-$16.60 (2025 national average)
When One Entity Does Both (Global Billing)
SINGLE PRACTICE (e.g., ophthalmology group with its own fundus camera)
└── Owns the equipment AND employs the interpreting physician
└── Bills: 92228 (no modifier — global billing)
└── Payment: ~$28.79 (2025 national average)
⚠️ Critical rule:
✅ What This Code Includes
- Image acquisition by trained clinical staff at the acquiring site (part of the practice expense/technical component)
- Electronic transmission (store-and-forward) of retinal images from acquiring site to reading site
- Personal physician or QHCP review of transmitted retinal images
- Physician interpretation — formal clinical analysis of findings including:
- Presence or absence of diabetic retinopathy
- Retinopathy severity staging (no DR, mild NPDR, moderate NPDR, severe NPDR, PDR)
- Presence or absence of clinically significant macular edema (CSME)
- Other retinal pathology identified incidentally
- Formal written report documenting all findings with recommended follow-up, treatment, or referral plan
- Coverage for one or both eyes (unilateral or bilateral — billed as one unit)
- Monitoring of known established retinal disease (not limited to screening)
- Services for patients with Type 1 or Type 2 diabetes, or any other retinal disease indication
❌ What This Code Does NOT Include / Excludes
- Clinical staff-only review without physician interpretation — that is 92227
- AI autonomous analysis without physician interpretation — that is 92229
- Direct real-time ophthalmoscopy (in-person dilated fundus exam) — not a telehealth service
- Fundus photography 92250 — traditional, in-person fundus photography with interpretation; NCCI edit prevents same-day billing with 92228
- OCT of the retina 92134 — may provide complementary information but is a distinct service; NCCI edit prevents same-day billing with 92228
- OCT of the optic nerve head 92133 — similarly an NCCI edit with 92228
- E/M visit charges — an E/M service may be separately billable if a separately identifiable, medically necessary E/M service is performed and documented on the same date; append modifier -25 to the E/M code (not -59 to 92228)
- Laboratory interpretation of any specimens — pathology/lab billed separately by the lab
- Modifier -50 (Bilateral) — never append; the code is inherently bilateral and Medicare prices it as such; appending -50 will cause claim denial or overpayment recovery
- Modifier -26 or -TC when global billing — only one method (global or split) per encounter per entity
🔢 NCCI / Bundling Edits
The following codes have NCCI edits with 92228 and cannot be billed on the same date of service from the same provider:
| Code | Description | Edit Type |
|---|---|---|
| 92227 | Remote imaging, staff review only | Mutually exclusive — distinct approaches to same service |
| 92229 | Remote imaging, autonomous AI analysis | Mutually exclusive |
| 92250 | Fundus photography with interpretation | Column 1/Column 2 edit — 92250 bundles with 92228 |
| 92133 | OCT posterior segment (optic nerve head) | NCCI edit with 92228 |
| 92134 | OCT posterior segment (retina) | NCCI edit with 92228 |
| 99211 | Office visit, established patient, minimal | NCCI edit — cannot be billed same day as 92228 |
Caution
⚠️ Always verify the current CMS NCCI Procedure-to-Procedure (PTP) edit table. NCCI edits are updated quarterly.
🏷️ Applicable Modifiers
| Modifier | Name | Application to 92228 |
|---|---|---|
| -26 | Professional Component | Most clinically significant modifier for 92228 — appended when the interpreting physician bills only their professional interpretation and report, and a separate entity owns the equipment/technical side. Billed by the ophthalmologist/optometrist/QHCP at the reading site. |
| -TC | Technical Component | Appended when the acquiring site (e.g., PCP office, FQHC) bills only for the equipment and staff used to capture and transmit the images. Billed by the entity that owns the fundus camera. |
| -GQ | Via Asynchronous Telecommunications | Used in federal telehealth programs (Indian Health Service, federal programs) for store-and-forward services. Indicates the service was furnished via asynchronous telehealth technology. |
| -GT | Via Interactive Audio and Video | Rarely applicable to 92228 since this is a store-and-forward code, not a real-time interactive telehealth service; do not routinely apply unless specific real-time component applies. |
| -95 | Synchronous Telemedicine Service | Applicable only if the telehealth platform used qualifies as synchronous; not standard for store-and-forward 92228 |
| -LT | Left Side | When imaging and interpretation apply to the left eye only |
| -RT | Right Side | When imaging and interpretation apply to the right eye only |
| -59 | Distinct Procedural Service | May be appropriate in unusual circumstances where 92228 is performed as a genuinely distinct service from another same-day service; document clearly. Note: a same-day E/M should have -25 on the E/M code, not -59 on 92228. |
| -25 | Significant, Separately Identifiable E/M | Applied to the E/M code (NOT to 92228) when a medically necessary, separately documented E/M service is performed on the same date as 92228 |
| -76 | Repeat Procedure, Same Physician | If imaging must be repeated same day (e.g., image quality failure on first attempt) |
| -77 | Repeat Procedure, Different Physician | If a different physician repeats the imaging interpretation on the same day |
❌ Do NOT append -50 (Bilateral) — the code is inherently unilateral or bilateral; applying -50 will result in claim denial or audit.
🏥 MS-DRG Applicability
CPT 92228 is an outpatient/professional service and does not directly map to an MS-DRG.
92228 is virtually always performed and billed in the outpatient or office setting (or as a telehealth service) and will not be a principal procedure driving inpatient DRG assignment. However, the ICD-10-CM diagnosis codes associated with 92228 — primarily diabetic retinopathy codes — do carry significant DRG and HCC implications when present as secondary diagnoses in an inpatient encounter.
Most commonly associated diagnoses in the inpatient setting group to:
| MS-DRG | Description | Notes |
|---|---|---|
| 637 | Diabetes w/ MCC | When diabetes with retinopathy (HCC 38) is a secondary complication |
| 638 | Diabetes w/ CC | E11.319 (unspecified DR without ME) qualifies as CC |
| 639 | Diabetes w/o CC/MCC | Diabetes without significant retinal complication |
For facility/inpatient coders: diabetic retinopathy codes (E11.3x1, E11.3x9, E10.3x1, etc.) commonly function as CC (complication/comorbidity) diagnoses and influence DRG assignment when present as secondary diagnoses.
🩺 Associated ICD-10-CM Diagnosis Codes
💡 Coding tip: 92228 is used for both detection and monitoring. When retinopathy is already established (per Noridian and other MAC guidance), this is the appropriate code — not 92227. Code the most specific retinopathy stage, laterality, and macular edema status that is documented in the physician interpretation report.
🧬 Diabetic Retinopathy — Type 2 (Most Common)
Without Macular Edema
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E11.319 | T2DM, unspecified DR, without macular edema | HCC 38 (v28) | CC |
| E11.3293 | T2DM, mild NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E11.3291 | T2DM, mild NPDR, without ME, right eye | HCC 38 (v28) | CC |
| E11.3292 | T2DM, mild NPDR, without ME, left eye | HCC 38 (v28) | CC |
| E11.3393 | T2DM, moderate NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E11.3391 | T2DM, moderate NPDR, without ME, right eye | HCC 38 (v28) | CC |
| E11.3392 | T2DM, moderate NPDR, without ME, left eye | HCC 38 (v28) | CC |
| E11.3493 | T2DM, severe NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E11.3491 | T2DM, severe NPDR, without ME, right eye | HCC 38 (v28) | CC |
| E11.3492 | T2DM, severe NPDR, without ME, left eye | HCC 38 (v28) | CC |
| E11.3593 | T2DM, PDR, without ME, bilateral | HCC 38 (v28) | CC |
| E11.3591 | T2DM, PDR, without ME, right eye | HCC 38 (v28) | CC |
| E11.3592 | T2DM, PDR, without ME, left eye | HCC 38 (v28) | CC |
With Macular Edema
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E11.311 | T2DM, unspecified DR, with macular edema | HCC 38 (v28) | CC |
| E11.3213 | T2DM, mild NPDR, with ME, bilateral | HCC 38 (v28) | CC |
| E11.3211 | T2DM, mild NPDR, with ME, right eye | HCC 38 (v28) | CC |
| E11.3212 | T2DM, mild NPDR, with ME, left eye | HCC 38 (v28) | CC |
| E11.3313 | T2DM, moderate NPDR, with ME, bilateral | HCC 38 (v28) | CC |
| E11.3311 | T2DM, moderate NPDR, with ME, right eye | HCC 38 (v28) | CC |
| E11.3312 | T2DM, moderate NPDR, with ME, left eye | HCC 38 (v28) | CC |
| E11.3413 | T2DM, severe NPDR, with ME, bilateral | HCC 38 (v28) | CC |
| E11.3411 | T2DM, severe NPDR, with ME, right eye | HCC 38 (v28) | CC |
| E11.3412 | T2DM, severe NPDR, with ME, left eye | HCC 38 (v28) | CC |
| E11.3513 | T2DM, PDR, with ME, bilateral | HCC 38 (v28) | CC |
| E11.3511 | T2DM, PDR, with ME, right eye | HCC 38 (v28) | CC |
| E11.3512 | T2DM, PDR, with ME, left eye | HCC 38 (v28) | CC |
High-Risk PDR Variants
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E11.3523 | T2DM, PDR with traction retinal detachment, bilateral | HCC 38 (v28) | CC |
| E11.3531 | T2DM, PDR with combined traction and rhegmatogenous detachment, right | HCC 38 (v28) | CC |
| E11.3541 | T2DM, PDR, stable, right eye | HCC 38 (v28) | CC |
| E11.3543 | T2DM, PDR, stable, bilateral | HCC 38 (v28) | CC |
🧬 Diabetic Retinopathy — Type 1
💡 Type 1 DM retinopathy codes follow the same laterality/staging/macular edema structure as Type 2. Substitute E10 for E11 for all equivalent codes. Selected examples:
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E10.311 | T1DM, unspecified DR, with macular edema | HCC 38 (v28) | CC |
| E10.319 | T1DM, unspecified DR, without macular edema | HCC 38 (v28) | CC |
| E10.3293 | T1DM, mild NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E10.3393 | T1DM, moderate NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E10.3493 | T1DM, severe NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E10.3513 | T1DM, PDR, with ME, bilateral | HCC 38 (v28) | CC |
| E10.3593 | T1DM, PDR, without ME, bilateral | HCC 38 (v28) | CC |
🩸 Other Diabetes — Secondary/Drug-Induced/Specified
| ICD-10-CM | Description | HCC | Notes |
|---|---|---|---|
| E13.311 | Other specified DM, unspecified DR, with ME | HCC 38 (v28) | Drug-induced, secondary, other DM |
| E13.319 | Other specified DM, unspecified DR, without ME | HCC 38 (v28) | |
| E13.3493 | Other specified DM, severe NPDR, without ME, bilateral | HCC 38 (v28) | |
| E13.3593 | Other specified DM, PDR, without ME, bilateral | HCC 38 (v28) |
👁️ Non-Diabetic Retinal Disease (Additional Indications for 92228)
| ICD-10-CM | Description | HCC | Notes |
|---|---|---|---|
| H35.30 | Unspecified macular degeneration | None | AMD monitoring |
| H35.31x | Nonexudative AMD, unspecified eye | None | Dry AMD |
| H35.3111 | Nonexudative AMD, right eye, unspecified stage | None | |
| H35.3112 | Nonexudative AMD, left eye, unspecified stage | None | |
| H35.313 | Nonexudative AMD, bilateral, unspecified stage | None | |
| H35.3210 | Exudative AMD, right eye | None | Wet AMD — active monitoring critical |
| H35.3220 | Exudative AMD, left eye | None | |
| H35.323 | Exudative AMD, bilateral | None | |
| H35.00 | Unspecified background retinopathy | None | Non-diabetic retinopathy |
| H35.051 | Hypertensive retinopathy, right eye | None | HTN-related monitoring |
| H35.052 | Hypertensive retinopathy, left eye | None | |
| H35.053 | Hypertensive retinopathy, bilateral | None | |
| H35.061 | Retinal vasculitis, right eye | None | |
| H35.062 | Retinal vasculitis, left eye | None | |
| H35.63 | Retinal vasculitis, bilateral | None | |
| H35.81 | Macular cyst, hole, or pseudohole, right eye | None | |
| H35.82 | Macular cyst, hole, or pseudohole, left eye | None | |
| H30.10 | Disseminated chorioretinal inflammation, unspecified | None | |
| H30.90 | Unspecified chorioretinal inflammation, unspecified eye | None | |
| H33.051 | Total retinal detachment, right eye | None | If monitoring post-treatment |
| H33.052 | Total retinal detachment, left eye | None |
🏥 Diabetes Without Retinopathy (When Used in a Detection Context)
Per Noridian LCD guidance, 92228 is the appropriate code once retinopathy is found. For initial screening (no retinopathy yet), use 92227. However, in some interpretations, 92228 may be used in detection contexts when a physician interprets regardless of retinopathy status.
| ICD-10-CM | Description | HCC | Notes |
|---|---|---|---|
| E11.9 | T2DM without complications | HCC 39 (v28) | Detection visit when physician interprets |
| E10.9 | T1DM without complications | HCC 39 (v28) | Detection visit when physician interprets |
| Z79.4 | Long-term use of insulin | None | Secondary code; always add when applicable |
| Z79.84 | Long-term (current) use of oral hypoglycemic drugs | None | Secondary code; add when applicable |
🎯 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 | Description | Relevant Codes for 92228 | Approx. RAF Score |
|---|---|---|---|
| HCC 37 | Diabetes with Acute Complications | Diabetic ketoacidosis, hyperosmolarity codes | ~0.302 |
| HCC 38 | Diabetes with Chronic Complications | All diabetic retinopathy codes (E10.3xx, E11.3xx, E13.3xx) — the primary HCC category for 92228 encounters | ~0.302 |
| HCC 39 | Diabetes without Complication | E10.9, E11.9, E13.9 | ~0.105 |
Hierarchy Rule
The CMS-HCC v28 model applies a hierarchy among these three categories for diabetes:
HCC 37 > HCC 38 > HCC 39
If a patient has codes mapping to HCC 38 and HCC 39 in the same measurement year, only HCC 38 is scored (the more specific, higher-weighted category). diabetic retinopathy codes (E11.3xx, E10.3xx) all map to HCC 38 and will suppress HCC 39 for that patient.
Why HCC Documentation Matters for 92228 Encounters
- Every 92228 encounter at which retinopathy findings are documented and coded represents an opportunity to capture or confirm HCC 38 for risk-adjustment purposes
- For Medicare Advantage and ACO risk-adjustment, HCC 38 codes must be documented and coded at least once per measurement year to be credited
- The physician’s interpretation report is the source document — it must clearly state the retinopathy type, severity, laterality, and macular edema status to support specific code assignment
- Unspecified codes (E11.319) still map to HCC 38 but reduce audit defensibility and quality metrics performance; specificity (e.g., E11.3293) is always preferred
- Never downcode to E11.9 when retinopathy is documented — this maps only to HCC 39 and represents a significant missed risk-adjustment opportunity
💡 Who Bills What in 92228 Scenarios?
| Entity | What They Do | What They Bill | Payment |
|---|---|---|---|
| Ophthalmology group (owns both camera + reads) | Acquires images AND interprets them | 92228 global (no modifier) | ~$28.79 |
| Ophthalmologist at reading site (does not own camera) | Reviews and interprets images only | 92228 -26 | ~16.60 |
| PCP office (owns camera, sends to ophthalmologist for reading) | Acquires and transmits images only | 92228 -TC | ~13.78 |
| FQHC (owns camera, sends images remotely) | Acquires and transmits images | 92228 -TC or global FQHC billing | Payer-specific |
| PA/NP interpreting (QHCP) under physician supervision | Reviews and interprets as QHCP | 92228 -26 | ~16.60 (at QHCP rate) |
| AI system only | Automated analysis | Neither 92228 nor 92227 — use 92229 | ~$43.67 |
⚠️ Contracting note:
📋 Documentation Requirements for the Physician Interpretation Report
Per Noridian LCD and CMS guidance, the interpreting physician’s report must include:
- Patient demographics — name, DOB, date of service
- Clinical indication — documented reason for imaging (e.g., “T2DM, known moderate NPDR bilateral, annual monitoring”)
- Image quality assessment — adequate vs. inadequate; if inadequate, reason and disposition
- Laterality — which eye(s) were imaged and interpreted
- Findings — itemized retinal findings for each eye, including:
- Retinopathy stage (no DR / mild NPDR / moderate NPDR / severe NPDR / PDR)
- Presence or absence of clinically significant macular edema (CSME)
- Disc findings (neovascularization of the disc — NVD)
- Vitreous findings (vitreous hemorrhage, traction)
- Peripheral findings (if visible)
- Other incidental pathology (drusen, epiretinal membrane, etc.)
- Impression — synthesized clinical interpretation (e.g., “Bilateral moderate NPDR without macular edema; stable compared to prior”)
- Recommendations — specific follow-up plan (e.g., “Annual monitoring,” “Refer for anti-VEGF evaluation,” “Urgent referral for vitreoretinal consultation”)
- Physician signature — with credentials; the interpreting provider must sign and date the report
- HIPAA-compliant transmission — documentation that image transmission complied with HIPAA privacy requirements
⚠️ Audit risk:
A report that only states “no retinopathy” or “stable findings” without specifying stage, laterality, and ME status is insufficient for both billing defensibility and accurate ICD-10-CM code assignment.
🧾 Coding Examples
Example 1 — First Detection of Diabetic Retinopathy, Bilateral, With Physician Read
A 57-year-old male with Type 2 diabetes presents to his PCP’s office for his annual visit. The PCP’s medical assistant captures bilateral non-mydriatic fundus images using the office’s fundus camera. Images are transmitted electronically to a contracted ophthalmology reading service. The ophthalmologist reviews the images, documents bilateral moderate NPDR without macular edema, and issues a formal report recommending annual follow-up.
If PCP’s office bills: 92228 -TC If ophthalmologist’s reading service bills: 92228 -26 ICD-10-CM: E11.3393 (T2DM, moderate NPDR, bilateral, without ME), Z79.84 (oral hypoglycemic use) Note: Now that retinopathy has been detected, 92227 is no longer appropriate for future monitoring encounters — 92228 is used going forward per Noridian/MAC guidance.
Example 2 — Known PDR Monitoring, Single Ophthalmology Group Performing Both Services
A 64-year-old female with T2DM and known bilateral PDR (stable, treated) presents to her ophthalmology group’s satellite clinic in a rural area. A technician captures bilateral fundus images. The interpreting ophthalmologist at the main office remotely reviews and documents stable bilateral PDR without macular edema and recommends continued quarterly monitoring.
CPT: 92228 (global — single entity owns equipment AND provides interpretation) ICD-10-CM: E11.3543 (T2DM, PDR, stable, bilateral), Z79.4 (long-term insulin) Modifier: None (global billing) Payment: ~$28.79
Example 3 — Type 1 Diabetes, Severe NPDR, Unilateral Finding
A 32-year-old male with T1DM (diagnosed age 8). Annual store-and-forward retinal monitoring. Left eye shows severe NPDR without macular edema. Right eye is moderate NPDR without macular edema. The ophthalmologist interprets and reports both eyes, noting the severity asymmetry and recommending referral to a vitreoretinal specialist for the left eye.
CPT: 92228 -26 (ophthalmologist’s professional component) ICD-10-CM: E10.3491 (T1DM, severe NPDR, without ME, right eye — wait, right = 1, left = 2; the more severe side is the left eye here: E10.3492 T1DM, severe NPDR, without ME, left eye), E10.3391 (T1DM, moderate NPDR, without ME, right eye), Z79.4 Note: Report both laterality-specific codes when staging differs between eyes; most specific code for the worse eye typically listed first.
Example 4 — 92228 Same Day as an E/M Visit (Correct Modifier Placement)
A 71-year-old female with T2DM presents for a diabetic follow-up visit (E/M) at her endocrinologist’s office. After the E/M, the endocrinologist’s MA captures retinal images which are sent to the contracted ophthalmology reading service, which issues a same-day interpretation report documenting moderate NPDR with macular edema bilaterally.
CPT (ophthalmologist): 92228 -26 CPT (endocrinologist’s office for E/M): 99214 -25 + 92228 -TC ICD-10-CM: E11.3313 (T2DM, moderate NPDR, with ME, bilateral), Z79.84 Modifier note: -25 goes on the E/M code 99214, not on 92228. Adding -59 to 92228 in place of -25 on the E/M is a common and incorrect error.
Example 5 — Inadequate Image Quality, Exam Incomplete
A 68-year-old male with T2DM and dense cataracts bilaterally. Fundus images are captured but image quality is inadequate for interpretation bilaterally due to media opacity. The ophthalmologist reviews the images, documents inability to adequately assess the retina, and recommends an in-person dilated fundus examination.
CPT: 92228 -52 (reduced services — interpretation attempted but could not be completed due to image quality failure) ICD-10-CM: E11.9 (T2DM — retinopathy status undetermined due to inadequate image), H26.9 (cataract, unspecified — documented cause of image degradation) Note: The interpretation report should clearly document image quality failure and reason. Some payers may not reimburse 92228 -52 for inadequate images; verify MAC policy.
Example 6 — AMD Monitoring (Non-Diabetic)
A 78-year-old female with known bilateral exudative (wet) AMD is being remotely monitored by a retina specialist. Her PCP’s office captures fundus images monthly; images are forwarded to the retina specialist who interprets and documents status of neovascular membranes and edema response to prior anti-VEGF therapy.
CPT: 92228 -26 (retina specialist, professional component) CPT: 92228 -TC (PCP’s office, technical component) ICD-10-CM: H35.323 (exudative AMD, bilateral) Note: 92228 is not limited to diabetic retinopathy — it applies to any retinal disease requiring remote monitoring with physician interpretation.
Example 7 — 92228 vs. 92250: The Key Distinction
A patient with known diabetic retinopathy has fundus photographs taken and interpreted in person at an ophthalmology office during a face-to-face exam.
Correct code: 92250 (Fundus photography with interpretation and report — in-person, not remote) NOT 92228 — 92228 requires the store-and-forward model where images are captured at one site and interpreted remotely at a different site. In-person same-session photography and interpretation = 92250.
⚠️ This is one of the most frequently confused distinctions in ophthalmic coding. The telehealth/remote nature of 92228 is the defining clinical and billing feature. If the physician is physically present at the time of image acquisition and interprets the same day on-site, 92250 applies.
🔄 Comparison: 92227 vs. 92228 vs. 92229 vs. 92250
| Feature | 92227 | 92228 | 92229 | 92250 |
|---|---|---|---|---|
| Who interprets | Clinical staff only | Physician / QHCP | Autonomous AI | Physician (in person) |
| Telehealth/remote | ✅ Yes | ✅ Yes | ✅ Yes | ❌ No (in-person) |
| Store-and-forward | ✅ Yes | ✅ Yes | ✅ Yes | ❌ No |
| PC/TC split allowed | ❌ No (indicator 5) | ✅ Yes (indicator 2) | Varies | ✅ Yes (indicator 2) |
| wRVU | 0.00 | ~0.50 | Varies | ~0.50 |
| Total RVU (2025) | ~0.40 | ~0.89 | ~1.35 | ~1.10 |
| 2025 Medicare payment | ~$17.14 | ~$28.79 | ~$43.67 | ~$35.58 |
| Retinopathy required | ❌ No (screening) | ❌ No (detection or monitoring) | ❌ No (DR detection only) | ❌ No |
| After retinopathy found | ❌ Transition away | ✅ Appropriate | ✅ If AI-eligible | ✅ In-person |
| Bilateral indicator | Inherent | Inherent | Inherent | Inherent |
| NCCI edit w/ each other | ✅ Yes | ✅ Yes | ✅ Yes | ✅ Yes |
⚠️ Common Coding Pitfalls
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Billing 92228 globally when two separate entities are involved — If the acquiring site (e.g., PCP’s office) and the reading site (ophthalmologist) are different entities, each must bill their respective component (-TC and -26); billing globally from one entity when the other entity also bills is a Medicare fraud risk.
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Appending -50 for bilateral imaging — 92228 is inherently unilateral or bilateral; Medicare and most payers price it accordingly. Appending -50 will result in improper duplicate payment or audit.
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Appending -59 to 92228 instead of -25 on the E/M — When a same-day E/M is billed, the -25 modifier belongs on the E/M code to indicate it is a significant, separately identifiable service. Adding -59 to 92228 for this purpose is incorrect.
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Using 92228 when only staff reviewed the images — If no physician reviewed and interpreted the images, 92227 is the appropriate code, not 92228. Billing 92228 without documented physician interpretation is a compliance risk.
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Using 92250 for remote/store-and-forward imaging — 92250 (fundus photography) is for in-person, same-session photography and interpretation. If the acquisition and interpretation occur in separate locations/sessions, 92228 is correct. Billing 92250 for teleretinal programs is a frequently cited audit finding.
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Billing 92228 same day as 92250, 92133, or 92134 — NCCI edits exist between 92228 and these codes. Same-day billing without appropriate modifier support will result in denial.
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Using unspecified laterality codes when bilateral findings differ — When the right and left eyes have different retinopathy stages (e.g., severe NPDR right, moderate NPDR left), both laterality-specific codes should be reported. Using a bilateral code or unspecified code reduces specificity and misses the clinical picture.
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Continuing to use 92227 after retinopathy is detected — Per Noridian LCD and MAC guidance, 92227 is for detection/screening only. Once diabetic retinopathy is found, future monitoring should be coded with 92228 or 92229.
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Not capturing HCC 38 annually — For Medicare Advantage and ACO patients, diabetic retinopathy codes (E11.3xx, E10.3xx) must be documented and submitted each measurement year to maintain HCC 38 risk-adjustment credit. The 92228 interpretation report is a critical vehicle for annual HCC capture.
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Inadequate interpretation reports — A report simply stating “no change” or “stable retinopathy” without specifying type, stage, laterality, and macular edema status is insufficient to support specific ICD-10-CM coding and will not withstand a payer audit.
📚 References
^[1] CMS Noridian LCD Article A58914 - Billing and Coding: Remote Imaging of the Retina to Screen for Retinal Diseases ^[2] American Academy of Ophthalmology - Telehealth Retinal Codes Resource; Practice Management (2024) ^[3] Retinal Physician - Reimbursement for Teleophthalmology for Remote Diabetic Eye Screening (Jan/Feb 2022) ^[4] AAPC My Ophthalmology Coding Alert - Decode Ophthalmoscopy Reporting Confusion; Procedure Coding (Apr 2023) ^[5] AAPC My Ophthalmology Coding Alert - Report 92228 for Retinal Imaging with Remote I&R; Reader Questions (Aug 2023) ^[6] Optos/Corcoran Consulting Group - Ophthalmic Imaging CPT Codes and Payment Data 2025 ^[7] Hillrom/Baxter RetinaVue - CPT Coding Resource for Fundus Imaging and Teleretinal Programs (2023) ^[8] CMS Medicare Physician Fee Schedule 2025 (MPFS) - Addendum B, National RVU and Payment Files ^[9] PMC/JAMA Ophthalmology - Teleophthalmology Using Remote Retinal Imaging During COVID-19 Pandemic (PMC9918349, Feb 2023) ^[10] CMS-HCC Model v28 - Risk Adjustment Factor Documentation, CMS Office of the Actuary (2024)