Surgical Services Targeted Probe and Educate Review Results - JF Part A
Surgical Services Targeted Probe and Educate Review Results
The Jurisdiction F, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review on a variety of surgical services.The findings of the claims reviewed from October 1, 2025 through December 31, 2025 are as follows:
Review Results
- 182 claims were reviewed with 9.36% error rate
Top Trending Errors
- Documentation to support medical necessity
Educational Resources
- Local Coverage Determination (LCD): Total Knee Arthroplasty (L36575)
- Local Coverage Determination (LCD): Total Hip Arthroplasty (L34163)
- Local Coverage Determination (LCD): Cataract Surgery in Adults (L34203)
- Documentation Requirements
- IOM, Pub 100-08, MPIM Chapter 3
Education
Local Coverage Determinations
A Local Coverage Determination (LCD) is a useful tool for providers determining whether specific medical items or services may be covered. It is important that providers code claims correctly based on the medical documentation upon initial submission for Medicare coverage. Providers must check for applicable LCDs for services rendered and the documentation must support the medical necessity of the services as defined by the LCD.
Documentation Requirements for Cataract Surgery
Per Local Coverage Determination (LCD) L34203 required documentation to support medical necessity must include:
- Statement indicating specific symptomatic visual functional impairment resulting in inability to perform activates of daily living satisfactorily. Activities of daily living include but are not limited to, reading, watching television, and driving.
- Best corrected visual acuity test at distance showing inability to correct the patient's visual function with changes to glasses or contact lenses.
- Degree of lens opacity correlating impairment of best corrected visual acuity with cataract as primary cause of visual compromise.
- Cataract is believed to be significantly contributing to impairment when other ocular diseases are present.
- Statement that the patient wishes to have surgical correction and that risks, benefits and alternatives were explained.
- Appropriate preoperative ophthalmologic evaluation, which includes a comprehensive ophthalmologic examination.
- Any specialized ophthalmologic studies are completed for medically necessary reasons unique to that patient.
For additional information, reference Cataract Surgery in Adults LCD L34203.
Medical Necessity of Total Knee Arthroplasty
Under Title XVIII of the Social Security Act, §1862 (a)(1)(A), documentation must support services are reasonable and necessary.
To support medical necessity of a total knee arthroplasty there are specific criteria that must be supported per the Total Knee Arthroplasty LCD L36575.
Documentation must support:
- Advanced joint disease demonstrated by radiographic supported evidence of:
- Subchondral cysts
- Subchondral sclerosis
- Periarticular osteophytes
- Joint subluxation
- Joint space narrowing
- Avascular necrosis
- Bone on bone; and
- Pain or functional disability; and
- Conservative measures trialed and failed, if appropriate
Examples of conservative measures may include: anti-inflammatories or analgesics, flexibility and muscle strengthening exercises, physical therapy, assistive device use, weight reduction, or therapeutic injections.
Refer to the Total Knee Arthroplasty LCD L36575 for documentation requirements and coverage and limitations. The billing and coding article, Total Knee Arthroplasty A57685, details documentation requirements and approved ICD-10-CM codes.
Medical Necessity of Total Hip Arthroplasty
Under Title XVIII of the Social Security Act, §1862 (a)(1)(A), documentation must support services are reasonable and necessary.
To support medical necessity of a total hip arthroplasty there are specific criteria that must be support per the Total Hip Arthroplasty LCD L34163.
Documentation must support:
- Advanced joint disease demonstrated by radiographic supported evidence of:
- Subchondral cysts
- Subchondral sclerosis
- Periarticular osteophytes
- Joint subluxation
- Severe Joint space narrowing
- Avascular necrosis; and
- Pain or functional disability; and
- Conservative measures trialed and failed, if appropriate
Examples of conservative measures may include: anti-inflammatories or analgesics, flexibility and muscle strengthening exercises, physical therapy, assistive device use, weight reduction, or therapeutic injections.
Refer to the Total Hip Arthroplasty LCD L34163 for documentation requirements and coverage and limitations. The billing and coding article, Total Hip Arthroplasty A57683, details documentation requirements and approved ICD-10-CM codes.
