Medicare Compliance & Reimbursement

Find out the codes the MACs are targeting in their TPE reviews.

Cataract surgery claims continue to sit atop auditors’ to-do lists. And because that scrutiny doesn’t seem to be going away any time soon, you may want to review the codes they’re looking at as well as the probe results from recent prepayment claims reviews.

TPE: Over the past year, most of the Medicare Administrative Contractors (MACs) have either completed Targeted Probe and Educate (TPE) probes of cataract removal claims or have added them to their active topic lists. The specific code(s) included in the audit depends on the MAC and can vary, but the following CPT^® codes are ones to know:

• 66821 (Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages))
• 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation)
• 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure))
• 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation)

Currently, this is the status of MAC audits by jurisdiction for cataract removal claims:

• CGS Medicare: The Part B MAC, which operates in jurisdiction 15, is doing prepayment TPE reviews of cataract surgery claims using codes 66821, 66982, and 66984.
• First Coast Service Options: FCSO, jurisdiction N’s Part B MAC, has CPT^® codes 66982-66984 on its TPE active agenda.
• National Government Services: NGS Medicare, the Part B carrier for jurisdictions 6 and K, is specifically focusing its TPE audits on the extracapsular cataract removal code 66984.
• Noridian Healthcare Solutions: Under Part A, Noridian conducted TPE audits for both jurisdictions E and F of cataract claims, posting results in July and August.
• Novitas: The MAC for jurisdictions JH and JL lists active TPE audits under both Part A and B for CPT^® codes 66982-66984.
• Palmetto GBA: Under jurisdiction M, Palmetto added prepayment probe results for CPT^® code 66984 to its website in August. The Part B MAC is also in charge of jurisdiction J and started performing TPE reviews of outpatient claims for 66984 in that area as of Aug. 18.
• WPS Government Health Administrators: According to its webpage, the Part A/B MAC, which operates in jurisdictions J5 and J8, is not auditing cataract surgery codes or claims via the TPE program at this time.

RACs: The Centers for Medicare & Medicaid Services (CMS) added cataract surgery claims to its approved audit issues for Recovery Audit Contractors (RACs) in 2017. According to both Cotiviti and Performant, the RACs continue to investigate cataract surgery claims problems in all regions.

CERT: Last December, CMS published the 2022 Medicare Fee-for-Service Supplemental Improper Payment Data as part of its Comprehensive Error Rate Testing (CERT) program. “Eye procedures” defined as cataract removal/lens insertion claims had an error rate of 8.3 percent and accounted for more than $146 million in improper payments, according to Table D1: Top 20 Service Types with Highest Improper Payments: Part B of the 2022 CERT report.

CMS noted that 100 percent of the issues were due to insufficient documentation. The 2023 CERT report is expected by the end of the year.