telehealth programs used the 92250 (Fundus Photography with interpretation and report) Current Procedural Terminology (CPT) code. Billing is usually divided into technical or image capture and professional or interpretation components. Some programs used CPT 92499 (Unlisted Ophthalmic Service or Procedure), which requires negotiated use with the Þscal intermediary or carrier. The Center of Medicare and Medicaid Services (CMS) approved two new codes speciÞc for remote retinal imaging in the fall of 2010. CPT codes 92227 and 92228 became effective January 1, 2011. See Appendix I for additional information.

Grants

Grants have been used to establish telemedicine programs for deÞned circumstances and duration. Although an important method for proof of concept, grants are usually not viable for sustained clinical operation. DR telehealth programs should have business plans that ensure revenue for sustainability, usually through reimbursement for services via Medicare, Medicaid, or private insurance carriers.

Federal Programs

There are several large telemedicine programs that reside within federal agencies and are funded by recurring federal appropriations. Examples include the Indian Health Service and the Veterans Health Administration.

Other Financial Factors

Non-revenue-producing beneÞts of a DR telehealth program may include cost savings and improved operational efÞciencies over traditional care delivery; however, beneÞts may not be realized by the entity creating them. For example, patients and third-party payers may realize Þnancial savings produced by a DR telehealth program operated by a physician, while physicians funding the program realize no savings. Under current

reimbursement policy, DR telehealth may be a better business model in closed systems, such as managed care, where costs and return on investment are realized by the same entity. Government pay-for-performance incentive programs may change the relationship between program funding and reimbursement in the future. Appendix I contains information on logistic efÞciencies, disease prevention, and resource utilization.

Equipment Cost

With the decreasing cost of computing and telecommunications, a retinal camera may be the largest capital investment for a DR telehealth program. Imaging costs depends on many factors. Devices range from $3,500 to over $65,000 including fundus camera, camera back, lenses, computer, software, and network hardware. Costs can be amortized over several years. Specialty imaging devices are in development with the potential to reduce cost further.

Summary

Ocular telemedicine and telehealth have the potential to decrease vision loss from DR. Planning, execution, and follow-up are key factors for success. Telemedicine is complex, requiring the services of expert teams working collaboratively to provide care matching the quality of conventional clinical settings. Improving access and outcomes, however, makes telemedicine a valuable tool for our diabetic patients. Programs that focus on patient needs, consider available resources, deÞne clear goals, promote informed expectations, appropriately train personnel, and adhere to regulatory and statutory requirements have the highest chance of achieving success.

Glossary

DICOM – Digital Imaging and Communication in Medicine An international standard for distributing, storing, and viewing medical images.