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September 15, 2022

Targeted Probe and Education Program to Focus on Cataract Removal Claims

The CGS Targeted Probe and Education (TPE) program will begin review of claims associated with outpatient cataract removal services. Guidance for cataract removal services provision and documentation may be found in the CGS’ Local Coverage Determination (LCD) L33954External Website located in the Part B Medical Policies section of the CGS website.

All cataract removal services must meet all requirements regarding medical reasonableness and necessity as outlined in the applicable statute, regulations, and manual provisions.

Outpatient cataract removal services must be: [1] incident to a physician's service, and [2] reasonable and necessary for the diagnosis or treatment of the patient's condition (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1). This means the services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient's condition. In all cases, the appropriate documentation must be kept on file and, upon request. The cataract removal service must meet all program coverage criteria for payment to be made.

We expect the documentation submitted to include a copy of the following legible and signed documentation from each patient's medical record:

  1. Beneficiary name
  2. Date of service on all documentation
  3. Relevant history
  4. Patient informed consent
  5. Documentation of the pe-operative evaluation to include comprehensive eye exam
  6. Results of pertinent tests/ procedures
  7. Signed and dated office visit record, or attestation if unsigned
  8. Signed and dated Operative note or attestation if unsigned including devices or techniques utilized
  9. Expanded therapeutic procedures credentials for optometrist in Kentucky
  10. Any other supporting documentation
  11. Advance Beneficiary Notice-if applicable
  12. Appropriate signatures
    • Signature and credentials of person performing the service
    • Amendments/corrections/delayed entries are properly identified
    • Amendments/corrections/delayed entries are initialed and dated by author within 30 days of the billed service

For additional documentation requirements, please reference:

CPT codes under review will include:

  • 66821- Discussion of secondary membranous cataract (Opacified posterior lens capsule/and or anterior Hyaloid) Laser Surgery
  • 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 routing cataract surgery
  • 66984- Extracapsular Cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique

For more information on Targeted Probe and Education, please see the following links:

Consider using the myCGS Portal for claim review status and submission of documentation. For more information, please access myCGS


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