In 2024, cataract surgery was a primary focus of the Targeted Probe and Educate (TPE) program, a trend expected to continue into 2025. Several Medicare administrative contractors (MACs) have cataract surgery on their active worklists this year to ensure compliance with Medicare billing and documentation requirements. This heightened scrutiny seems to stem from the high volume of cataract surgeries performed — the Centers for Medicare & Medicaid Services (CMS) reimbursed approximately 1.6 million procedures in 2022.¹

This Q&A outlines the TPE process, focusing on how practices can avoid common documentation pitfalls and pass the first-round review.

Q. What is the Targeted Probe and Educate (TPE) program?

A. The TPE program is a CMS initiative to reduce claim denials and appeals. It offers direct, one-on-one education to help providers improve their documentation and billing practices. The program specifically targets services or procedures with high error rates or improper payments, as identified by MACs.

Q. How does the TPE process begin?

A. The process starts when a MAC sends a notification letter to a provider or facility selected for review. The letter details the reason for selection and includes an additional documentation request (ADR) for the claims under review. Typically, 20 to 40 claims are assessed, which can occur pre- or post-payment. If issues are found, up to two additional rounds of reviews may be required, with a 45-day period between each round for improvements.

Q. Can we ask for an extension? How does that work?

A. Yes. The ADR letter typically outlines the process for requesting an extension, which involves contacting the MAC that issued the ADR. It may be beneficial for practices to request an extension immediately upon receiving their ADR letter to ensure adequate time to compile all the necessary documentation to submit.

Q. What are common reasons for denials in cataract TPE reviews?

A. According to MACs,^2,3,4,5 the most frequent reasons for denials are:

1. 1. Lack of Medical Necessity: The documentation submitted does not support the medical necessity listed in the coverage determination requirements.
      
      
   2. Insufficient Documentation:
      
      
      • No response to ADR, or documentation was not submitted on time.
        
        
      • Documentation submitted was for the incorrect eye.
        
        
      • The documentation submitted was for the wrong date of service.
        
        
   3. Billing Errors: Denials can result from incorrect billing codes or mismatched procedure and diagnosis codes.

Q. What are the key documentation requirements for cataract surgery?

A. TPE reviewers focus on whether cataract surgery meets medical necessity criteria outlined by each MAC’s local coverage determination (LCD) and local coverage article (LCA). Common key documentation requirements include:

• • • Evidence of a specific, compromised activity of daily living (ADL)
      
      
    • Confirmation that cataracts are the primary cause of visual impairment
      
      
    • Best-corrected visual acuity (BCVA) results from a manifest refraction
      
      
    • A statement that a change in glasses or contact lenses would not adequately improve the patient’s visual function

Q. What are some challenges in documenting ADLs for cataract surgery?

A. Common challenges include ensuring specific issues (such as difficulties with driving or reading) are documented, as well as maintaining consistency between the chief complaint (CC) and the patient’s ADL questionnaire. Inconsistencies, such as a CC stating “no vision issues” while the questionnaire highlights several compromised ADLs, can weaken documentation and lead to a possible denial.

Q. How should practices document ADLs for second-eye surgery?

A. The key element to document for second-eye cataract surgery is the subjective ADL component. This can be captured through a new questionnaire or by noting a chief complaint during a postoperative visit that shows ongoing ADL issues in the non-surgical eye.

Q. What is a BCVA challenge that some practices may not consider?

A. Some practices rely on optometrists to document BCVA during prior visits. If this refraction is recent and reliable, the surgeon may reference the optometrist’s findings instead of repeating the test. When submitting ADR responses, include both the optometrist’s and surgeon’s notes, ensuring the BCVA is clearly referenced by the surgeon when the decision for surgery is made.

Q. Is a glare test necessary for cataract surgery documentation?

A. Some MACs require a glare test to help meet the medical necessity criteria, while others mandate it only if the patient complains of glare. If a glare test is performed, ensure the documentation reflects that it was performed over the BCVA.

Q. Is it necessary to state that a change in glasses won’t improve the patient’s vision?

A. Absolutely. Many MACs’ LCDs and LCAs require documentation that clearly states: “visual impairment and function are not correctable by glasses or other non-surgical measures.”⁶ Failing to include this statement when the decision for surgery is made may result in a denial. Based on recent client feedback from auditor education, Noridian is specifically looking for this documentation in their TPE reviews.

Q. What is the key takeaway from the cataract TPE process?

A. The TPE audit ensures compliance with Medicare regulations. Precise and thorough documentation is critical for passing the first round. If your practice receives a negative result, request the education component to identify necessary improvements or discuss potential documentation oversight from the auditor that could reverse a denial.  OM

References 

1. CMS Data Physician/Supplier Procedure Summary. Accessed Oct. 28, 2024. https://data.cms.gov/summary-statistics-on-use-and-payments/physiciansupplier-procedure-summary/data.

2. First Coast Service Options, Inc. Targeted Probe and Educate (TPE) Round Results–surgical services: cataract extraction (CPT 66982-66984). https://medicare.fcso.com/Medical_review/0502051.asp. Accessed Oct. 28, 2024.

3. Novitas Solutions Targeted Probe and Educate (TPE) round results: Cataract extraction services (CPT 6698-66984). https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00261705. Accessed Oct. 28, 2024.

4. Palmetto GBA Pre-Payment Review Results for Extracapsular Cataract Removal with Insertion for April to June 2024. https://palmettogba.com/palmetto/jjb.nsf/DIDC/VJ0XD3URK9~Medical%20Review~Targeted%20Probe%20and%20Educate. Accessed Oct. 28, 2024.

5. Noridian Healthcare Solutions Targeted Probe and Educate Medical Record Review Results for CPT 66984. https://med.noridianmedicare.com/web/jfb/cert-review/mr/review-results/66984. Accessed Oct. 28, 2024.

6. First Coast Service Options, Inc. Local Coverage Determination L38926 Cataract Extraction (including Complex Cataract Surgery).  https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=38926&ver=23. Accessed Oct. 28, 2024.

Brittney Irwin, COT, CPC-A, CEP, is a consultant within the billing, coding and compliance division of VMG Health. In her role, she provides ongoing billing and coding support to ensure ophthalmic regulatory compliance. Previously, she spent more than 10 years working in ophthalmology, most recently as the clinical director of a multi-specialty group.