Medicine: Ophthalmology (Q&A) (July 2016)

July 2016 page 9a Medicine: Ophthalmology Question: What is the appropriate code(s) to report automated diabetic retinopathy screening using retinal image analysis, which is described as: "For each patient encounter (or visit), multiple images per eye (different fields and/or external images) are acquired. The screening system automatically detects/localizes the lesions from the input color retinal fundus images, assesses the severity of diabetic retinopathy and presence of surrogate markers for clinically significant macular edema, and recommends if the patient needs to be referred to a specialist." Is it appropriate to report this procedure with code 92250, Fundus photography with...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article presents a coding question-and-answer from ophthalmology focused on automated diabetic retinopathy screening using retinal image analysis. It explains the reporting context for imaging-based retinal disease detection and discusses how the service is categorized within CPT guidance. The piece is relevant to ophthalmology practices, coders, and billing staff who handle retinal screening and diagnostic imaging claims.

Why This Topic Matters

Retinal screening services can overlap in appearance with other ophthalmic imaging procedures, so accurate CPT reporting is important for compliant claim submission and consistent documentation review. This article helps readers understand the general reporting framework for an automated screening service in the diabetes/retina setting.

Article Sections

  1. July 2016 page 9a

    Introductory publication information for the ophthalmology Q&A item and its placement within the July 2016 CPT Assistant issue.

  2. Medicine: Ophthalmology

    A coding question-and-answer discussing automated diabetic retinopathy screening, retinal imaging, and how the service is reported in CPT guidance.

What You Will Learn

  • The article’s focus within ophthalmology coding guidance
  • The general subject of automated retinal image analysis for diabetic retinopathy screening
  • How a CPT Q&A format addresses reporting questions for imaging-based ophthalmic services
  • Why retinal screening services may require careful code selection

Who Should Read This

  • Ophthalmologists
  • Ophthalmology coders
  • Medical billers
  • Practice managers
  • Compliance staff

Codes Discussed


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