What is Retinal Screening?

Retinal screening are retinal fundus image(s) acquired by a retinal imaging device, that are used as baseline documentation of a healthy eye or to screen for potential disease(s). These images are reviewed by a Doctor of Optometry for the detection of diseases that manifest in the posterior segment of the eye.

• Retinal screening is a separate service from a patient’s WellVision Exam^®.
• Retinal screening is not required by medical necessity.
• Retinal screening can be incorporated as part of a patient’s overall wellness care to check for disease(s) that may otherwise go undetected.
• Patients should be informed prior to services performed of any out-of-pocket cost.
• Patients have the right to decline retinal screening services.
• Retinal screening only pertains to routine, retinal fundus imaging. Scanning laser procedure such as optical coherence tomography (OCT), Heidelberg Retinal Tomography (HRT), and GDx are excluded.

Please use your best clinical judgment to determine if this service is appropriate for your patient.

VSP offers different coverage options related to retinal screening. The table below provides a summary of the services.

Retinal screening and fundus photography are two separate services that share the same CPT code, 92250.

•  Bill CPT code 92250 with modifier 52 to report retinal screening. Modifier 52 signifies that the service is reduced. This provides a means of reporting a reduced service without disturbing the identification of the basic service.
• Bill CPT code 92250 (without modifier 52) to report fundus photography with interpretation and report.

For a summary of how to bill retinal screening to VSP please download this one-page billing guide.

Routine retinal screening is offered as standard coverage on VSP Signature Plan^®, VSP Choice Plan^® , VSP Advantage and Enhanced Advantage Plan^® as a value-added feature to complement the WellVision Exam^® benefit.

Eligibility

Retinal screening is an enhancement to a patient’s WellVision Exam; therefore, patients are typically eligible every 12 months. However, there are no restrictions to the number of procedures performed each year.

Charging the Patient

Charge the patient $39 or your U&C fee (whichever is lower) for each routine retinal screening.

Submitting Claims and Reimbursement

For the value-added feature, you do not need to submit a claim. This charge is considered a private transaction between you and the patient. Be sure to check for retinal screening coverage before your patient pays out-of-pocket. Bill the WellVision Exam and any materials as you normally would.

Covered in full or with a set copay, routine retinal screening is offered to VSP clients for purchase as an optional benefit enhancement to the WellVision Exam under VSP Signature Plan^®, VSP Choice Plan^®, VSP Advantage Plan^®, and Enhanced Advantage Plans.

Eligibility

Please refer to the Patient Record Report for eligibility. Retinal screening is an enhancement to a WellVision Exam; therefore, patients are typically eligible every 12 months.

Charging the Patient

Please refer to the Patient Record Report for coverage amount and/or applicable copays.

Submitting Claims

Covered routine retinal screening must be billed with a patient’s WellVision Exam.

When submitting claims for routine retinal screening, use CPT code 92250 with modifier 52.

Reimbursement

For eligible routine retinal screening covered benefit claims, you’ll be reimbursed up to $39 or your U&C fees (whichever is lower) less any applicable patient copay.

If retinal screening reveals disease(s) or abnormalities, the image(s) can be billed as fundus photography with interpretation and report with appropriate documentation requirements.

Eligibility^*

Please refer to the Patient Record Report for Essential Medical Eye Care eligibility and coverage.

Charging the Patient

When a patient has Essential Medical Eye Care and a valid medical diagnosis, there is no copay and the fundus photography service is covered-in full.

Submitting Claims

Fundus photography with interpretation and report can be billed on the same day as the WellVision Exam for eligible patients. This service is covered under VSP’s supplemental medical eye care plans and must be billed with Essential Medical Eye Care authorization.

When submitting claims for fundus photography, use CPT code 92250 and a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed. No Modifier is required.

Detailed information about payable diagnosis codes and documentation requirements are available in the Essential Medical Eye Care Provider Reference Manual sections.

Reimbursement

For eligible claims, you’ll be reimbursed 80% of your U&C fee, up to the Essential Medical Eye Care maximum allowables.

Covered-in-full retinal screening (use CPT code 92250 and modifier 52) is available to patients who have diabetes but don’t show signs of diabetic eye disease.

For full coverage details, please refer to the Essential Medical Eye Care or Diabetic Eyecare Plus Program Manual.

If pathology is identified, the image(s) can be billed as fundus photography with interpretation and report with appropriate documentation requirements. Documentation should include, but is not limited to, relevant medical history, physical examination, findings and/or diagnosis, and treatment plan recommendations.

Fundus photography with interpretation and report is covered under VSP’s supplemental medical eye care plans and can be billed with an Essential Medical Eye Care or Diabetic Eyecare Plus authorization.

Detailed information about payable diagnosis codes is listed in the Essential Medical Eye Care and Diabetic Eyecare Plus Program Provider Reference Manual sections.