Raising in-office diabetic retinal screening from 50% to 80% in CPP practices can add around 60% more revenue from imaging plus incentives while closing key quality gaps for NC Medicaid, Aledade ACO, and Medicare Advantage lives.Â
Why Retinal Eye Exams Matter
In many CPP practices, only about half of patients with diabetes complete a diabetic retinal exam each year, leaving both care gaps and revenue on the table. By deploying in-office teleretinal imaging, you can move more exams out of distant specialists’ offices and into your own chronic care and AWV workflows.
For rural and hard-to-reach patients, this means fewer missed referrals, earlier detection of retinopathy, and better alignment with HEDIS/Star and ACO quality measures. For practices, it means a predictable stream of imaging revenue plus upside from closed care gaps.
The Financial UpsideÂ
Using a simple 100-patient diabetic panel, we have modeled three screening rates: 50%, 60%, and 80%. The practice must use teleretinal imaging codes 92227 (clinical staff review) and 92228 (physician/QHP review), plus CPT II codes 2022F/2023F to document retinopathy status.
At 50% screening (50 exams), total annual revenue (fee-for-service imaging plus incentive payments per closed gap) is about 3,175 dollars; at 80% screening (80 exams), it rises to roughly 5,080 dollars, with average revenue per completed exam holding around 63.50 dollars. This assumes most exams are billed as 92228 at an average allowed amount of 30 dollars, a smaller fraction as 92227 at 15 dollars, and an average 50 dollars per closed diabetic eye-exam gap in certain Medicaid and MA incentive programs, with about 70% of completed exams closing a documented gap.
Core Coding Framework
The document lays out a consistent coding strategy across NC Medicaid, Aledade ACO (Medicare FFS-centric), and Medicare Advantage in North Carolina. The emphasis is on using teleretinal codes correctly, layering CPT II codes to secure quality credit, and respecting payers’ frequency limits.
Key CPT and CPT II Codes
Use the following core codes for in-office diabetic retinal screening with teleretinal imaging.
| Code | Description (high-level) | Typical use in CPP practices |
|---|---|---|
| 92228 | Remote retinal imaging with physician/QHP interpretation | Default teleretinal imaging when an ophthalmologist/optometrist or other QHP reads the images. |
| 92227 | Remote retinal imaging with clinical staff interpretation | Reserved for staff-only interpretation workflows. |
| 2022F | Diabetic retinopathy present (CPT II) | Add diabetic retinal exams when retinopathy is documented. |
| 2023F | Diabetic retinopathy not present (CPT II) | Add when the exam confirms no retinopathy, for HEDIS/Star closure. |
These CPT II codes pay 0 dollars but are critical for capturing diabetic eye-exam performance and can secure the measure for up to two years when used consistently.
NC Medicaid and Medicaid MCOs
NC Medicaid policy generally limits fundus/retinal studies for diabetic retinopathy detection to about one exam per 365 days, with coverage tied to medical necessity. Medicaid telehealth policy supports teleretinal imaging when general telehealth criteria are met, which allows a rural PCP workflow if the underlying ophthalmology policy is satisfied.
For NC Medicaid patients, practices should default to 92228 when an ophthalmologist/optometrist or other QHP interprets the images and reserve 92227 for strictly staff-only reads. Visits should document the diabetes diagnosis, purpose of the exam (screening/monitoring for diabetic retinopathy), medical necessity, and that the exam is being used to detect or monitor diabetic retinopathy.
Aledade ACO and Medicare FFS
Aledade’s focus is improving quality and total cost of care for Medicare FFS and some MA/Medicaid lives rather than maximizing imaging revenue alone. Diabetic eye-exam completion is a standard ACO quality metric, typically aligned to HEDIS EED.
Medicare Part B covers one diabetic eye exam annually for beneficiaries with diabetes, generally with 80% of the approved amount paid after the deductible and supplemental coverage often picking up the rest. For these patients, practices bill 92228 for teleretinal imaging with specialist interpretation, add 2022F or 2023F to capture presence or absence of retinopathy, and ensure documentation covers diabetes diagnosis, exam purpose, interpreter, findings, and laterality.
Medicare Advantage in North Carolina
Many MA plans in NC recognize diabetic retinal exams performed in primary care when interpreted by an ophthalmologist or optometrist, though coverage and allowed amounts vary by plan. These plans often run care-gap incentive programs that pay around 50 dollars per closed diabetic eye-exam gap, tied to combinations of 92227/92228/92250 and CPT II codes 2022F/2023F.
For MA diabetics, the core play is to bill 92228 when using teleretinal imaging with specialist interpretation, append 2022F or 2023F for HEDIS/EED, and confirm that the interpreting clinician and device meet plan criteria. Practices should also ask MA provider reps whether these code combinations close diabetic eye-exam gaps and whether incentives are paid to PCPs, ACOs, or specialists.
Practical Steps for CPP Practices
For CPP practices, the essentials include standardizing base CPT selection, CPT II usage, exam frequency, documentation, and payer-specific checks.
Key operational steps for CPP practices include:
- Standardize 92228 as the default teleretinal code when images are read by an ophthalmologist/optometrist or QHP; reserve 92227 for staff-only reads
- Add 2022F/2023F to all diabetic retinal exams (Medicaid, ACO/Medicare FFS, MA) to ensure HEDIS/Star closure and ACO reporting.
- Limit exams to one per patient per year per payer policy unless specific medical necessity justifies more frequent imaging, and document this clearly.
- Build a simple grid by payer (NC Medicaid MCOs, major MA plans, Aledade) noting whether they pay 92227/92228 in primary care, their telehealth stance, frequency limits, and any prior auth requirements.
- By embedding teleretinal imaging in chronic care, AWVs, and gap-closure visits, CPP practices can systematically raise screening rates, improve quality performance, and capture both line-item and incentive revenue.
If you are a CPP practice that wants to launch or tighten up in-office diabetic retinal screening—whether you need help picking the right codes, building payer grids, or designing workflows—please contact us so we can review your specific panels, payers, and incentives and help you implement a high-value teleretinal program.