Crystal's MCW Coder Hub🧬 CPT Code 92229 - Remote Imaging for Detection or Monitoring of Retinal Disease, Point-of-Care Autonomous AI Analysis
📋 Full Code Description
Imaging of retina for detection or monitoring of disease; with point-of-care autonomous analysis and report, unilateral or bilateral
This code reports the use of a U.S. FDA-cleared autonomous artificial intelligence (AI) system to capture retinal images, automatically analyze those images, and generate an immediate diagnostic report — all at the point of care and entirely without physician interpretation. The AI algorithm independently performs the complete analytical function that in 92228 is performed by a physician or QHCP, and that in 92227 is performed by trained clinical staff.
92229 holds a unique distinction in American medicine: it was the first Category I CPT code ever created for autonomous artificial intelligence in any specialty when it became effective January 1, 2021. It represents a landmark in both health technology policy and reimbursement — the first formal acknowledgment by the AMA and CMS that an AI algorithm, operating without any human clinical interpretation, can be reimbursed as a billable medical diagnostic service.
The term “autonomous” is legally and clinically significant. The AI systems eligible for billing under 92229 must:
- Be FDA-cleared (via De Novo, 510(k), or PMA pathway) for autonomous operation
- Produce a diagnostic result (positive/negative for more-than-mild diabetic retinopathy) without requiring physician review
- Operate at the point of care — results are generated immediately during the clinical encounter, not sent off-site for remote review
- Have the device manufacturer assume liability for the diagnostic output (not the provider)
The code is reported as one unit regardless of laterality — unilateral or bilateral imaging is billed as a single unit.
🤖 Autonomous AI vs. AI-Assisted: A Critical Distinction
| Feature | Autonomous AI (92229) | AI-Assisted (part of physician workflow) |
|---|---|---|
| Physician reviews images | ❌ No | ✅ Yes |
| AI provides final diagnostic output | ✅ Yes | Aids physician decision |
| Liability for diagnosis | AI manufacturer | Physician |
| FDA clearance type | De Novo / SaMD clearance for autonomous diagnosis | Software clearance for physician-decision support |
| Reimbursement vehicle | 92229 | Typically included in existing physician E/M or procedure code |
| CPT code | 92229 | No separate AI-specific code; part of 92228 or E/M |
| Physician required on-site | ❌ No (supervising physician may or may not be present) | ✅ Yes |
📌 Definition of “autonomous” per CMS/AMA (2023 CPT revision): The 2023 CPT codebook reintroduced the explicit term “autonomous” into the 92229 descriptor to distinguish it from AI-augmented physician interpretation. Autonomous = the AI system provides the medical diagnosis without a human clinician in the diagnostic loop.
🔬 How the Technology Works
Integrated Point-of-Care Workflow
PATIENT WITH DIABETES
│
▼
STEP 1: Image Acquisition
- Clinical staff (MA, RN, CNA) positions patient at non-mydriatic retinal camera
- Camera (Topcon NW400, Canon CR-2, Optomed Aurora IQ, or approved model)
captures macula-centered ± disc-centered fundus photographs, both eyes
- No pupil dilation typically required (non-mydriatic systems)
- No physician needs to be present during image capture
│
▼
STEP 2: Autonomous AI Analysis
- Images automatically uploaded to AI system (cloud or on-device)
- FDA-cleared algorithm analyzes for:
• Presence/absence of more-than-mild diabetic retinopathy (mtmDR)
• Presence/absence of vision-threatening diabetic retinopathy (VTDR)
• Image quality assessment (adequate/inadequate)
- Analysis completes in <60 seconds (typically <30 seconds)
│
▼
STEP 3: Point-of-Care Report Generation
- AI system generates IMMEDIATE report with:
• Binary result: "Negative" (no mtmDR) OR "Positive" (mtmDR detected)
• Image quality assessment
• Referral recommendation (routine vs. urgent ophthalmology referral)
- Report delivered to provider/EMR before patient leaves
│
▼
STEP 4: Provider Counseling (E/M separately billable — see below)
- Physician reviews AI report and discusses results with patient
- Physician makes referral decision, documents findings in encounter note
- E/M code may be separately billed with modifier [[-25]] when documented
🏥 Code Placement in the CPT Hierarchy
| Level | Description |
|---|---|
| Section | Medicine |
| Subsection | Ophthalmology |
| Range | 92002-92499 |
| Sub-range | Special Ophthalmological Services: 92225-92260 |
| Code | 92229 |
🌳 Code Tree / Family
Special Ophthalmological Services - Remote Retinal Imaging
│
├── [[92227]] — Remote imaging; clinical STAFF review & report only
│ ↳ Staff-performed, physician supervision only
│ ↳ PC/TC indicator: 5 (technical/practice expense only)
│ ↳ wRVU: 0.00 | Total RVU: ~0.40
│ ↳ 2025 Medicare: ~$17.14 (global)
│ ↳ Cannot split -26 / -TC
│ ↳ Used for SCREENING (pre-retinopathy detection)
│
├── [[92228]] — Remote imaging; PHYSICIAN or QHCP interpretation and report
│ ↳ Physician must personally interpret
│ ↳ PC/TC indicator: 2 (can split -26 / -TC)
│ ↳ wRVU: ~0.50 | Total RVU: ~0.89
│ ↳ 2025 Medicare: ~$28.79 (global)
│ ↳ Used for DETECTION or MONITORING (including established disease)
│
└── [[92229]] — Point-of-care AUTONOMOUS AI analysis and report ← THIS CODE
↳ FDA-cleared autonomous AI algorithm; NO human physician interpretation
↳ PC/TC indicator: 5 (practice expense only; no physician work; no split)
↳ wRVU: 0.00 | Total RVU: ~1.35
↳ 2025 Medicare: ~$43.00-$47.00 (global)
↳ Most highly reimbursed of the 92227-92229 family
↳ Point-of-care (not store-and-forward to remote site)
↳ First CPT code for autonomous AI in any specialty
↳ MIPS Measure 117 qualifying; HEDIS qualifying
📌 Non-standard hierarchy note (CPT Assistant, Vol. 31, Issue 1 & Issue 6): The 92227-92229 code family does not follow the typical CPT indented hierarchy. Each code is fully independent and is distinguished solely by the entity performing the review/analysis — staff, physician, or AI. Each code stands alone with no hierarchical parent-child relationship.
⚙️ Technical Details
| Field | Detail |
|---|---|
| Global Period | XXX — No global period; no pre-op/post-op bundle |
| PC/TC Indicator | 5 — Practice expense (technical) only. No physician work component. Cannot be billed with modifier -26 or -TC. The service is valued entirely as a practice/technical expense. |
| wRVU (Work RVU) | 0.00 — No physician work is assigned because no physician interpretation is required. The AI performs the diagnostic function. |
| Total RVU (2025 est.) | ~1.35 — Entirely composed of practice expense and malpractice RVUs; zero work RVU |
| CMS RVU Crosswalk | CMS finalized the 92229 RVU value via direct crosswalk to 92325 (Modification of contact lens) in the CY2022 PFS Final Rule — a crosswalk justified by comparable clinical labor and equipment use |
| 2025 Medicare MPFS Payment | ~47.00 national average (geographically adjusted); rates vary by MAC locality |
| 2022 CY Inaugural National Rate | ~$45.69 (Eyenuk reported at CY2022 finalization) |
| 2023 Base Rate (non-geographic) | ~$40.28 (Retina Specialist data) |
| Commercial payer rates | Highly variable; median Anthem CA/NY negotiated rate reported at $127.81 in 2021 |
| Assistant Payable | ❌ Not applicable — not a surgical procedure |
| Bilateral Indicator | Inherently unilateral or bilateral — bill one unit only |
| Telehealth Designation | ✅ Point-of-care (in-office); some payers distinguish this from store-and-forward |
| MUE | 1 unit per date of service |
| Place of Service | POS 11 (Office), POS 22 (Outpatient Hospital), POS 71 (Public Health Clinic), POS 50 (FQHC), POS 72 (Rural Health Clinic) |
| Who bills | Primary care physician, endocrinologist, internist, or any qualifying provider who owns the AI device and performs the service at their facility; ophthalmologist offices may also bill |
| Liability | The AI manufacturer assumes diagnostic liability for the automated output; the provider assumes liability for the decision to use the system and any subsequent clinical action |
🔬 FDA-Cleared Autonomous AI Systems Eligible for 92229 Billing
⚠️ Only FDA-cleared autonomous AI systems may be billed under 92229. Using non-cleared software or physician-supervised AI decision-support tools under 92229 is a compliance violation. Below are the three commercially available FDA-cleared systems as of 2026:
1. LumineticsCore™ (Digital Diagnostics; formerly IDx-DR)
| Feature | Detail |
|---|---|
| Developer | Digital Diagnostics (Coralville, Iowa) |
| FDA Clearance | De Novo clearance — April 11, 2018 (first FDA-cleared autonomous AI diagnostic in any specialty) |
| Compatible cameras | Topcon NW400 |
| Detection target | More-than-mild diabetic retinopathy (mtmDR) in adults ≥22 years with diabetes, not previously diagnosed with DR |
| Output | Positive (mtmDR present, refer to eye care specialist) or Negative (no mtmDR, rescreen in 12 months) |
| Images per eye | 2 (macula-centered + disc-centered) per eye |
| Dilation required | No (non-mydriatic) |
| Validation | Pivotal trial at 10 U.S. clinical sites; sensitivity 87.2%, specificity 90.7% vs. ophthalmologist gold standard |
| EMR integration | Epic integration available |
| Liability | Digital Diagnostics assumes liability for diagnostic output |
2. EyeArt® (Eyenuk, Inc.)
| Feature | Detail |
|---|---|
| Developer | Eyenuk, Inc. (Los Angeles, California) |
| FDA Clearance | De Novo clearance — August 2020; subsequently expanded scope |
| Compatible cameras | Canon CR-2 AF, Canon CR-2 Plus AF, Topcon NW400 (multi-camera platform) |
| Detection target | More-than-mild DR and vision-threatening DR (VTDR); both tiers of severity |
| Distinction | Only FDA-cleared system detecting both mtmDR and VTDR at the time of clearance; multi-manufacturer camera compatibility |
| Output | Tiered result: no DR / mild DR / moderate DR or worse (refer) |
| Dilation required | No (non-mydriatic) |
| Validation | Multi-site validation; sensitivity 95.5%, specificity 56.1% for VTDR detection |
3. AEYE-DS (AEYE Health)
| Feature | Detail |
|---|---|
| Developer | AEYE Health |
| FDA Clearance | 510(k) clearance — November 2022 |
| Compatible cameras | Topcon NW400; Optomed Aurora IQ AEYE (handheld; portable camera option) |
| Detection target | More-than-mild diabetic retinopathy (mtmDR) |
| Distinction | Offers portable/handheld camera option (Optomed Aurora IQ) for bedside or mobile clinic use |
| Output | Positive/Negative for mtmDR |
| Peer-reviewed validation | Limited published peer-reviewed data at time of clearance compared to LumineticsCore/EyeArt |
📌 As the autonomous AI retinal imaging space evolves, additional systems may receive FDA clearance. Always verify FDA clearance status before billing 92229 with any new system.
✅ What This Code Includes
- Preparation of the patient for retinal image acquisition by clinical staff (positioning, patient instruction)
- Bilateral or unilateral non-mydriatic fundus photography using an FDA-cleared AI-compatible camera
- Automatic image quality assessment by the AI system
- Autonomous AI algorithm analysis of retinal images for detection or monitoring of retinal disease (primarily diabetic retinopathy at this time)
- Generation of an immediate point-of-care diagnostic report with findings and referral recommendations
- Delivery of the report to the provider/EMR at the point of care
- Coverage for one or both eyes (unilateral or bilateral — billed as one unit)
- Technical/practice expense components: clinical staff labor, equipment depreciation, AI software use per-patient fee (though CMS characterizes the per-patient AI software fee as an indirect practice expense)
❌ What This Code Does NOT Include / Excludes
- Physician interpretation — no physician interpretation is performed or required; if a physician personally interprets the images, use 92228 instead
- Remote/store-and-forward service — 92229 is a point-of-care code; the AI delivers results immediately on-site; it is not the same workflow as 92227 or 92228 where images are transmitted to a remote reading site
- Staff-only review — 92227 is for clinical staff remote review; 92229 is for AI autonomous analysis
- Non-FDA-cleared AI systems — only FDA-cleared autonomous AI systems may be billed under 92229; non-cleared software does not qualify
- AI-assisted physician review — if the AI helps a physician make their interpretation but the physician is still the one interpreting, this is not 92229; it would fall under the physician’s existing E/M or 92228
- Fundus photography with physician interpretation (92250) — in-person, same-session photography with a physician reviewing the images in real-time is 92250, not 92229
- Physician E/M service for discussing results — the physician’s time discussing the AI report results and counseling the patient may be separately billable with an E/M code + modifier -25; this counseling work is not included in 92229
- Retinal diseases other than diabetic retinopathy — currently, all three FDA-cleared systems are limited to DR detection; AMD, glaucoma, and other retinal diseases are not yet autonomous-AI billed under 92229 (though future FDA clearances may expand this)
- Modifier -26 or -TC — 92229 carries PC/TC indicator 5 (practice expense only; no physician work); these modifiers cannot be applied; applying them will result in claim denial
- Modifier -50 (Bilateral) — the code is inherently bilateral; applying -50 is incorrect and will generate an overpayment or denial
📌 E/M Billing Alongside 92229 — A Critical and Frequently Misunderstood Rule
Per CPT Assistant (Vol. 31, Issue 6, 2021) and subsequent AAPC guidance, a physician may separately bill an E/M code on the same date as 92229 to report the physician’s work of:
- Reviewing the AI-generated report with the patient
- Counseling the patient about the findings and implications
- Making clinical decisions about referral, follow-up, or treatment changes based on the AI result
- Documenting these discussions in the medical record
Correct billing:
Incorrect billing:
92229 -59 + 99213 (the -59 belongs on neither code; the -25 goes on the E/M)
⚠️ The E/M must be separately identifiable and documented from the 92229 service itself. A note that says only “AI retinal scan performed, results reviewed, no DR detected” is insufficient to support a separate E/M. The note must document medical decision-making, history, exam components, or time-based criteria independent of the AI scan.
🔢 NCCI / Bundling Edits
92229 has the following NCCI relationships (partial list):
| Code | Description | Edit Type |
|---|---|---|
| 92227 | Remote imaging, staff review | Mutually exclusive — same encounter, different methodologies of the same service |
| 92228 | Remote imaging, physician interpretation | Mutually exclusive — cannot bill AI autonomous AND physician interpretation for the same imaging session |
| 92250 | Fundus photography with interpretation | NCCI edit — in-person fundus photography bundles with 92229 |
| 92133 | OCT posterior segment, optic nerve head | NCCI edit |
| 92134 | OCT posterior segment, retina | NCCI edit |
| 99212 | Office/outpatient visit, low, established patient | NCCI edit — cannot bill with 92229 without -25 on the E/M |
⚠️ Always verify the current CMS NCCI PTP edit table. NCCI edits are updated quarterly. The NCCI edit between 92229 and 92228 is absolute — you cannot simultaneously bill AI autonomous analysis AND physician interpretation for the same retinal imaging encounter.
🏷️ Applicable Modifiers
| Modifier | Name | Application to 92229 |
|---|---|---|
| -25 | Significant, Separately Identifiable E/M | Applied to the E/M code (NOT to 92229) when a separately documented, medically necessary E/M service is provided on the same date as 92229 — e.g., physician discusses AI results, counsels patient, adjusts diabetes management |
| -52 | Reduced Services | When the AI analysis is initiated but cannot be completed due to inadequate image quality (poor media clarity, cataracts, small pupils) and a partial service is delivered |
| -59 | Distinct Procedural Service | Rarely applicable to 92229 itself; may occasionally be relevant when a genuinely separate and distinct procedure is performed on the same date — document carefully |
| -GQ | Via Asynchronous Telecommunications | Used in federal telehealth programs (IHS, federal programs) for store-and-forward services; only applicable to 92229 if the payer specifically designates it as a telehealth service in their policy |
| -76 | Repeat Procedure, Same Physician | If the AI imaging must be repeated on the same date due to image failure or technical issue |
| -LT | Left Side | When imaging performed on left eye only |
| -RT | Right Side | When imaging performed on right eye only |
❌ Do NOT append -26 or -TC** — PC/TC indicator is 5 (practice expense only); these modifiers do not apply and will result in denial. ❌ Do NOT append -50 (Bilateral) — inherently bilateral; one unit regardless.
💡 Quality Program Benefits: MIPS, HEDIS, and Star Ratings
92229 is the only imaging code with documented multi-program quality measure qualification as of 2025:
MIPS Measure 117 — Diabetes: Eye Exam
- Measures the percentage of adult patients (18-75) with type 1 or type 2 diabetes who had a retinal or dilated eye exam performed in the measurement year, OR a negative retinal exam in the prior year
- 92229 qualifies as a satisfying exam for Measure 117
- Bonus opportunity: MIPS bonuses for high performers can represent 4%-9% of Medicare Part B revenue
- The positive performance data from 92229 can be submitted directly from the AI system’s EMR integration in many implementations
HEDIS — Comprehensive Diabetes Care (Eye Exam Component)
- HEDIS CDC (Comprehensive Diabetes Care) eye exam component measures annual retinal exam rates
- AI-based retinal exams performed with FDA-cleared 92229 systems count toward HEDIS CDC measure
- Relevant for Medicare Advantage and commercial health plan star ratings
CMS Star Ratings (Medicare Advantage)
- The annual diabetes eye exam is a double-weighted Star Rating measure in many contract years
- Plans with strong 92229 utilization rates — particularly in primary care — can drive measurable improvements in their MA star ratings
- This creates a payer incentive for MA plans to encourage primary care adoption of autonomous AI retinal screening
🏥 MS-DRG Applicability
CPT 92229 is an outpatient/professional service and does not directly map to an MS-DRG.
92229 is virtually always performed in an outpatient, office, FQHC, or primary care setting and will not function as a principal procedure in an inpatient DRG assignment. However, the ICD-10-CM diagnosis codes associated with 92229 — primarily diabetic retinopathy and diabetic complication codes — carry important DRG and HCC implications as secondary diagnoses in inpatient encounters.
The most commonly associated diagnoses group to:
| MS-DRG | Description | Notes |
|---|---|---|
| 637 | Diabetes w/ MCC | When diabetic complications (HCC 38) are present as secondary inpatient diagnoses |
| 638 | Diabetes w/ CC | Diabetic retinopathy codes (E11.3x9 etc.) qualify as CC |
| 639 | Diabetes w/o CC/MCC | Diabetes without significant retinal documentation |
For inpatient facility coders: documenting and coding diabetic retinopathy secondary diagnoses (E11.319, E11.3293, etc.) from the medical record when a patient is admitted for a related condition (e.g., diabetic foot ulcer, DKA, hyperglycemic crisis) will shift the DRG from 639 to 638, which represents a significant reimbursement difference.
🩺 Associated ICD-10-CM Diagnosis Codes
💡 Critical coding note: 92229 is currently FDA-cleared and clinically deployed exclusively for diabetic retinopathy screening/monitoring. All three FDA-cleared systems (LumineticsCore, EyeArt, AEYE-DS) are indicated for patients with known diabetes who are screened for the presence or absence of diabetic retinopathy. The ICD-10-CM code should reflect the most specific diabetic status and retinopathy finding documented at the time of the encounter.
🩸 Diabetes Without Identified Retinopathy (Pre-Detection Screening)
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E11.9 | Type 2 DM without complications | HCC 39 (v28) | None |
| E10.9 | Type 1 DM without complications | HCC 39 (v28) | None |
| E13.9 | Other specified DM without complications | HCC 39 (v28) | None |
| Z79.4 | Long-term use of insulin | None | None — secondary code; add when applicable |
| Z79.84 | Long-term use of oral hypoglycemic drugs | None | None — secondary code; add when applicable |
| Z13.5 | Encounter for screening for eye/ear disorders | None | None — may be used as secondary screening encounter code |
🧬 Type 2 Diabetic Retinopathy — Nonproliferative (Most Common 92229 Encounters)
Unspecified Severity
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E11.311 | T2DM, unspecified DR, with macular edema | HCC 38 (v28) | CC |
| E11.319 | T2DM, unspecified DR, without macular edema | HCC 38 (v28) | CC |
Mild NPDR
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| 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 |
| E11.3213 | T2DM, mild NPDR, with 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 |
| E11.3293 | T2DM, mild NPDR, without ME, bilateral | HCC 38 (v28) | CC |
Moderate NPDR
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| 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 |
| E11.3313 | T2DM, moderate NPDR, with 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 |
| E11.3393 | T2DM, moderate NPDR, without ME, bilateral | HCC 38 (v28) | CC |
Severe NPDR
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| 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 |
| E11.3413 | T2DM, severe NPDR, with 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 |
| E11.3493 | T2DM, severe NPDR, without ME, bilateral | HCC 38 (v28) | CC |
🧬 Type 2 Diabetic Retinopathy — Proliferative (PDR)
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E11.3511 | T2DM, PDR, with ME, right eye | HCC 38 (v28) | CC |
| E11.3512 | T2DM, PDR, with ME, left eye | HCC 38 (v28) | CC |
| E11.3513 | T2DM, PDR, with 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 |
| E11.3593 | T2DM, PDR, without ME, bilateral | HCC 38 (v28) | CC |
| E11.3541 | T2DM, PDR, stable, right eye | HCC 38 (v28) | CC |
| E11.3542 | T2DM, PDR, stable, left eye | HCC 38 (v28) | CC |
| E11.3543 | T2DM, PDR, stable, bilateral | HCC 38 (v28) | CC |
| E11.3521 | T2DM, PDR with traction retinal detachment involving macula, right | HCC 38 (v28) | CC |
| E11.3522 | T2DM, PDR with traction retinal detachment involving macula, left | HCC 38 (v28) | CC |
| E11.3523 | T2DM, PDR with traction retinal detachment involving macula, bilateral | HCC 38 (v28) | CC |
🧬 Type 1 Diabetic Retinopathy (Selected)
Type 1 DR codes follow the same laterality/staging/macular edema structure as Type 2. Substitute E10 for E11 for all equivalent codes.
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E10.311 | T1DM, unspecified DR, with ME | HCC 38 (v28) | CC |
| E10.319 | T1DM, unspecified DR, without ME | 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 Specified Diabetes (Drug-Induced, Secondary)
| ICD-10-CM | Description | HCC | CC/MCC |
|---|---|---|---|
| E13.311 | Other specified DM, unspecified DR, with ME | HCC 38 (v28) | CC |
| E13.319 | Other specified DM, unspecified DR, without ME | HCC 38 (v28) | CC |
| E13.3293 | Other specified DM, mild NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E13.3393 | Other specified DM, moderate NPDR, without ME, bilateral | HCC 38 (v28) | CC |
| E13.3493 | Other specified DM, severe NPDR, without ME, bilateral | HCC 38 (v28) | CC |
⚠️ Negative AI Result — How to Code “No Retinopathy Found”
When the AI system returns a negative result (no more-than-mild DR detected):
| ICD-10-CM | Description | HCC | Notes |
|---|---|---|---|
| E11.9 | T2DM without complications | HCC 39 (v28) | Primary DX when no DR found |
| E10.9 | T1DM without complications | HCC 39 (v28) | Primary DX when no DR found |
| Z13.5 | Screening encounter for eye disorders | None | May be added as secondary |
| Z79.4 | Long-term insulin use | None | Add when applicable as secondary |
| Z79.84 | Long-term oral hypoglycemic use | None | Add when applicable as secondary |
⚠️ Do NOT code a retinopathy ICD-10-CM code (e.g., E11.319) when the AI result is negative for retinopathy. The AI report states only “negative for more-than-mild DR” — it does not establish or rule out mild DR specifically. If the physician has NOT personally reviewed the images, only the AI result (positive/negative) and the underlying diabetes diagnosis code should be used.
🎯 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 92229 | Approx. RAF |
|---|---|---|---|
| HCC 37 | Diabetes with Acute Complications | DKA, hyperosmolarity codes | ~0.302 |
| HCC 38 | Diabetes with Chronic Complications | All diabetic retinopathy codes (E10.3xx, E11.3xx, E13.3xx) | ~0.302 |
| HCC 39 | Diabetes without Complication | E10.9, E11.9, E13.9 | ~0.105 |
HCC Hierarchy in v28
HCC 37 > HCC 38 > HCC 39
Only the highest-tier HCC is scored per patient. All diabetic retinopathy codes (NPDR, PDR, with/without ME) map to HCC 38, suppressing HCC 39.
The HCC Capture Opportunity Unique to 92229
92229 is most commonly deployed in primary care settings (endocrinology, internal medicine, family medicine, federally qualified health centers) — settings where the annual diabetes visit is occurring but ophthalmology retinopathy codes may historically have been missed on claims.
Every 92229 encounter that results in a positive AI finding creates a HCC 38 capture opportunity that would otherwise be missed until the patient saw an ophthalmologist (which, for many underserved patients, may not happen for years). This makes the code significant not just for reimbursement but for Medicare Advantage risk score accuracy and population health management.
Documentation protocol for HCC accuracy:
- When the AI result is positive for mtmDR → the physician should document the finding in the encounter note and code the most specific DR ICD-10-CM code available (at minimum E11.319 or E10.319, but ideally with severity specificity once confirmed by ophthalmology)
- When the AI result is negative → code E11.9 or E10.9; do not assign retinopathy codes
- Z79.4 and Z79.84 should be consistently captured as secondary codes where applicable — these support accurate chronic disease coding and care gap closure
- After a positive AI result leads to ophthalmology follow-up, the ophthalmologist’s confirmed staging should be used for all subsequent coding specificity (e.g., E11.3293 confirmed by retinal specialist)
🧾 Coding Examples
Example 1 — Negative AI Result, Annual Diabetes Screening (Most Common Use Case)
A 55-year-old female with T2DM (on metformin) presents to her PCP for an annual wellness visit. The MA uses the clinic’s LumineticsCore system (Topcon NW400 camera) to capture bilateral non-mydriatic fundus images. The AI system analyzes the images and returns a negative result: “No more than mild diabetic retinopathy detected. Recommend rescreening in 12 months.” The physician reviews the AI report with the patient, counsels her on the importance of annual screening and glycemic control, and documents this discussion.
CPT - AI scan: 92229 CPT - Physician counseling E/M: 99213 -25 (or higher level if documentation supports) ICD-10-CM: E11.9, Z79.84 MIPS/HEDIS: Qualifies for Measure 117 and HEDIS CDC eye exam component
Example 2 — Positive AI Result, Referral to Ophthalmology
A 68-year-old male with T2DM on insulin presents to a federally qualified health center. Bilateral retinal images captured with EyeArt system (Canon CR-2 AF). AI result: positive — “More than mild diabetic retinopathy detected. Ophthalmology referral recommended.” The physician discusses the result with the patient, emphasizes urgency of ophthalmology referral, and updates the problem list to reflect diabetic retinopathy.
CPT - AI scan: 92229 CPT - E/M: 99214 -25 (elevated level given new finding, complex management decision) ICD-10-CM: E11.319 (T2DM, unspecified DR, without ME — code reflects AI positive result; specific staging to be confirmed by ophthalmologist), Z79.4 Note: Use E11.319 (or E11.311 if ME is suspected) when the AI is positive but ophthalmology staging has not yet been performed. Update to specific NPDR/PDR code after ophthalmology confirms the finding.
Example 3 — Image Quality Failure (Reduced Service)
A 74-year-old male with T2DM, bilateral dense nuclear cataracts, and small pupils presents for annual AI retinal screening using AEYE-DS. The AI system returns: “Image quality inadequate for analysis — right eye and left eye.” No diagnostic result can be generated.
CPT: 92229 -52 (reduced services — imaging attempted but AI cannot analyze due to image quality failure) ICD-10-CM: E11.9, H26.9 (cataract, unspecified — documented cause of inadequate image quality) Note: Some payers do not reimburse 92229 -52 for image quality failure; verify MAC/payer policy. The physician note should document the failure and subsequent recommendation for in-person dilated fundus exam.
Example 4 — 92229 Same Day as Annual Wellness Visit (AWV)
A 62-year-old female with T2DM presents for her Medicare Annual Wellness Visit (AWV, G0439). The care team performs bilateral AI retinal screening with LumineticsCore during the same visit. AI result is negative.
CPT: G0439 (AWV, subsequent visit) + 92229 ICD-10-CM: E11.9, Z00.00 (encounter for general adult medical examination, no abnormal findings — primary for AWV), Z79.84 Note: 92229 and AWV codes (G0438, G0439) may be billed together on the same date without a -25 modifier since the AWV is preventive and not an E/M service. The -25 modifier scenario applies when a problem-oriented E/M (99xxx series) is billed on the same day as 92229.
Example 5 — Type 1 DM Pediatric-Aged Adult Patient
A 22-year-old female with T1DM (diagnosed at age 6; 16-year history) presents for AI retinal screening at her endocrinologist’s office. Per ADA guidelines, annual screening begins at diagnosis for T1DM patients or at puberty onset with 5+ years of disease. AI result: positive — more than mild DR detected.
CPT: 92229 + 99213 -25 (E/M for result counseling and referral planning) ICD-10-CM: E10.319 (T1DM, unspecified DR, without ME — pending ophthalmology staging), Z79.4 Note: LumineticsCore is indicated for patients ≥22 years. Verify the specific AI system’s age indication before billing 92229 for patients approaching this lower age threshold.
Example 6 — FQHC Setting, Underserved Patient Population
A rural FQHC deploys EyeArt to screen all diabetic patients during primary care visits, targeting a patient population with historically low ophthalmology follow-up rates. A 48-year-old male migrant farmworker with poorly controlled T2DM is screened. AI result: positive for mtmDR. First known detection of retinopathy in this patient, who has no established ophthalmologist.
CPT: 92229 + E/M with -25 ICD-10-CM: E11.319, Z59.0 (homelessness — if applicable), Z79.84 Place of Service: POS 50 (Federally Qualified Health Center) MIPS: Qualifies for Measure 117 Health equity note: This is the primary intended use case articulated in the CMS final rule and ADA guidelines — extending access to DR screening for underserved, rurally-located, and otherwise ophthalmology-limited populations
Example 7 — Monitoring Previously Detected DR With AI (Ongoing)
A 60-year-old female with known bilateral mild NPDR (previously confirmed by ophthalmologist) returns to her PCP for a monitoring AI scan between ophthalmology appointments. AI result: positive — consistent with known DR. No escalation detected.
CPT: 92229 (monitoring use; 92229 descriptor covers both detection and monitoring) ICD-10-CM: E11.3293 (T2DM, mild NPDR, without ME, bilateral — prior confirmed staging from ophthalmologist), Z79.4 Note: Unlike 92227 (which per Noridian LCD applies to screening before DR is detected), 92229 can be used for both detection and monitoring per the CPT descriptor. Verify individual MAC/payer LCD for monitoring coverage frequency limitations.
🔄 Full Comparison: 92227 vs. 92228 vs. 92229
| Feature | 92227 | 92228 | 92229 |
|---|---|---|---|
| Reviewer entity | Clinical staff | Physician / QHCP | Autonomous AI algorithm |
| Physician interpretation | ❌ No | ✅ Yes | ❌ No |
| Point-of-care result | ❌ No (store-and-forward) | ❌ No (store-and-forward) | ✅ Yes (immediate) |
| FDA clearance required | ❌ No | ❌ No | ✅ Yes (mandatory) |
| PC/TC indicator | 5 (tech only) | 2 (can split) | 5 (PE only) |
| wRVU | 0.00 | ~0.50 | 0.00 |
| Total RVU (est.) | ~0.40 | ~0.89 | ~1.35 |
| 2025 Medicare rate | ~$17.14 | ~$28.79 | ~47 |
| Can split -26 / -TC | ❌ No | ✅ Yes | ❌ No |
| After retinopathy found | ❌ Transition away | ✅ Appropriate | ✅ Appropriate |
| E/M separately billable | ✅ With -25 on E/M | ✅ With -25 on E/M | ✅ With -25 on E/M (CPT Assistant confirmed) |
| MIPS Measure 117 | ✅ Yes | ✅ Yes | ✅ Yes |
| HEDIS qualifying | ✅ Yes | ✅ Yes | ✅ Yes |
| Payer adoption | Widespread | Widespread | Growing; some MAC variation |
| Highest paid of family | ❌ No | ❌ No | ✅ Yes |
⚠️ Common Coding Pitfalls
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Billing 92229 with a non-FDA-cleared AI system — This is the most serious compliance risk associated with 92229. The AI system must have explicit FDA clearance for autonomous diabetic retinopathy detection. Using a physician-decision-support AI tool, a non-cleared algorithm, or a research-use-only system and billing 92229 constitutes healthcare fraud.
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Appending -26 or -TC to 92229 — 92229 carries PC/TC indicator 5 (practice expense only; zero physician work). These modifiers are inapplicable and will result in claim denial. This is distinct from 92228, which does allow splitting.
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Billing 92228 when autonomous AI was used — If a physician then personally reviews the same images, this creates a compliance conflict. If the AI autonomously generated the report (no physician review), 92229 applies. If the physician reviews and interprets, 92228 applies. These are mutually exclusive for the same imaging session.
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Missing the -25 modifier on the E/M — When a physician separately counsels the patient about AI results and bills an E/M, the -25 belongs on the E/M code, not on 92229. Omitting -25 will result in the E/M being denied or bundled.
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Appending -50 for bilateral imaging — The code is inherently unilateral or bilateral; one unit is billed regardless of eyes imaged. Applying -50 generates an overpayment or denial.
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Coding a retinopathy ICD-10-CM code after a negative AI result — A negative AI result does not diagnose, rule out, or stage DR. When the AI is negative, code the underlying diabetes (E11.9, E10.9) only. Do not assign DR codes (E11.319 etc.) based on a negative AI result.
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Not capturing HCC 38 after a positive AI result — When the AI is positive and the physician documents this in the encounter note, the most appropriate retinopathy code (at minimum E11.319 or E10.319) should be assigned. Defaulting to E11.9 after a positive AI result is an HCC capture miss that undersells the patient’s risk profile.
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Failing to verify MAC coverage and frequency limitations — Not all MACs and payers have adopted uniform 92229 coverage policies. Some MACs limit billing to once per year; some require specific documentation of the AI system used; some have LCD restrictions that differ between 92227 and 92229. Always verify your specific payer’s LCD/NCD and policy for 92229.
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Using 92229 for non-DR retinal disease — Currently, all FDA-cleared systems are indicated for diabetic retinopathy only. Using 92229 with a non-DR diagnosis (e.g., AMD, glaucoma) when no FDA-cleared AI for those conditions exists is not appropriate billing at this time.
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Confusing the point-of-care model with store-and-forward — 92229 is a point-of-care code: results are generated immediately at the patient’s location. 92227 and 92228 are store-and-forward: images are transmitted to a remote site for review. This workflow distinction matters for billing accuracy, payer audit defensibility, and EMR documentation.
📚 References
^[1] AMA CPT Codebook 2025 — Medicine, Ophthalmology, Special Ophthalmological Services (92227-92229) ^[2] CPT Assistant Vol. 31, Issue 1 (Jan 2021) and Issue 6 (Jun 2021) — Remote Retinal Imaging Code Guidance ^[3] CMS CY2022 Medicare Physician Fee Schedule Final Rule — Federal Register Document pp. 106-114; Finalization of CPT 92229 national payment rate via crosswalk to CPT 92325 ^[4] Retinal Physician — AI for DR Screening: Where Are We in 2025? (Feb 2025); 2023 base reimbursement rates for 92227/92228/92229 ^[5] Abramoff MD et al. — Pivotal Trial of an Autonomous AI-Based Diagnostic System for Detection of Diabetic Retinopathy in Primary Care Offices. npj Digital Medicine 2018;1:39 ^[6] AAO Practice Management — Medicare Carrier Underprices New AI Screening Code, Breaking from Peers (Mar 2021) ^[7] PMC / Frontiers in Ophthalmology — Clinical Implementation of Autonomous AI Systems for Diabetic Eye Exams (PMC10788651, Jan 2024) ^[8] Ophthalmology Science — Autonomous AI in DR Testing: Lessons Learned on Successful Health System Adoption (Sep 2025) ^[9] AAPC My Ophthalmology Coding Alert — Decode Ophthalmoscopy Reporting Confusion (Apr 2023) ^[10] Retinal Physician — Reimbursement for Teleophthalmology for Remote Diabetic Eye Screening (Jan/Feb 2022) ^[11] CMS Medicare Physician Fee Schedule 2025 (MPFS) — Addendum B, National RVU and Payment Files ^[12] CMS-HCC Model v28 Risk Adjustment Factor Documentation, CMS Office of the Actuary (2024) ^[13] Digital Diagnostics (LumineticsCore) — FDA De Novo Decision Summary, April 2018; Billing and Reimbursement Guide 2024 ^[14] Eyenuk (EyeArt) — CY2022 CMS PFS Final Rule Announcement; EyeArt FDA Clearance Summary (August 2020) ^[15] Nature npj Digital Medicine — Reimbursement in the Age of Generalist Radiology Artificial Intelligence (Dec 2024)