Medicare Carrier Underprices New AI Screening Code, Breaking From Peers

Three more Medicare administrative contractors have priced an innovative new screening technology, one declining the value the Academy recommended for CPT 92229.

The pricing disparity could slow Kentucky and Ohio patients’ access to this new diagnosis and referral tool for diabetic retinopathy. Ophthalmologists in those states also may receive lower reimbursements if they utilize these screenings.

Accepting the Academy’s recommended rate is First Coast Service Options, which covers Florida, Puerto Rico and the U.S. Virgin Islands. It has announced a price of $54.51. Novitas, which covers 11 states, also said it will pay $54.51. WPS Government Health Administrators was the first Medicare contractor to cover the service at that level.

However, Cigna Government Services (CGS) has priced the new screening service at $29.45 for Ohio and $28.42 for Kentucky, even though the latter state has the country’s fifth-highest rate of adults with diabetes. According to the Centers for Disease Control and Prevention’s Diabetes Atlas, 11.8% of Kentucky adults had diabetes in 2016.

CPT 92229 is a new code reimbursing the use of a screening method using artificial intelligence that provides real-time diabetic retinopathy diagnoses in patients with diabetes. This is the first time that providers will have a device that uses AI to diagnose diabetic retinopathy patients.

First Coast and Novitas cover three states with higher diabetes prevalence than Kentucky. Though a higher share of their patients may qualify for the screening, those carriers pay nearly twice as much as Cigna Government Services.

Since the Academy provided its price recommendations, Medicare contractors covering 18 states have now announced their reimbursement rate for CPT code 92229. Earlier this year, WPS priced the code at $55.

The Centers for Medicare & Medicaid Services (CMS) declined to price the code or accept recommendations from the American Medical Association’s Relative Value-Scale Update Committee. The Academy has objected to CMS’ carrier price plan, which is a slower and less certain process, from the start.

We’ll keep you posted on responses to our recommendations from other MACs. If you encounter issues getting reimbursed for CPT 92229, contact healthpolicy@aao.org.

Learn more about AI’s emerging use in ophthalmology during the Academy’s Mid-Year Forum 2021, now a free online two-day event. Don’t miss the April 23 session, Technology, AI and Telehealth, moderated by Emily Y. Chew, MD.