Ophthalmology Under the Microscope: RAC, TPE, and Exam Code Frequency

Get ready for a fast-moving, expert-level discussion on the compliance pressures facing ophthalmology practices right now. In this episode, our consultants break down what the government reopening means for held claims, the latest RAC audit topics targeting providers, how TPE reviews are evolving, and the rules behind how often comprehensive versus intermediate eye codes can be billed. Packed with practical guidance and red-flag insights, this episode is a must-listen for any practice focused on staying compliant, reducing denials, and protecting revenue.

Contact us by calling (800) 399-6565 or visiting CorcoranCCG.

Transcript

Welcome to Ophthalmology Reimbursed, the podcast that discusses all things coding, reimbursement, auditing, and education for the ophthalmic community. 

Welcome back to the podcast, everyone. My name is Mary Pat Johnson.

I'm here with my colleague. And I'm Rebecca Greenlaw. We wanted to share a few things with you.

I know we're so focused on getting ready for 2026 that you might overlook a few of the things that are pertinent as we wind down 2025. So I wanted to share a few things that have come through our email and phone line, just to kind of keep everyone on track. So first off, Rebecca, a couple of questions for you about this whole government shutdown. 

Luckily, that's behind us. I know that I'm getting a lot of questions about what this means when the government is reopening. I know a few of them, unfortunately, did have some claims being held.

What are you seeing in terms of Medicare's response to the end of that government shutdown? Yeah, so now that the government has reopened, we're seeing that MACs are clearing their backlogs and they're doing it pretty fast. The claims that were pending due to staffing gaps or suspended review activity are moving again. But the flip side of this is that auditors are also catching up.

So practices may start receiving more ADRs that they weren't getting during the shutdown. Oh, that's a good point. It didn't even occur to me that the auditors would be some of those employees that were not working during that time.

So I'm making two practices probably need to start rechecking some of these claims rather than presuming Medicare is going to process. Do you have a process for following up on pending or suspended claims to make sure nothing falls through the cracks? Yeah, it's a good practice to reconcile accounts receivable, make note of anything over 90 to 120 days, and they should get a detailed review. A lot of claims from the shutdown period can be resurrected, but they may require some proactive follow-up.

That's good to know. Yeah, people forget, you know, policy flexibilities that were in place during the emergency period may no longer apply. So the claim submission date we probably need to pay attention to.

Even a claim that was compliant when it was submitted may have gotten kind of caught up in this delay. So probably a good idea for them to keep track of all that. I'm going to step into the next question.

This one came through my phone just as recently as yesterday. What about the RAC program? You mentioned that the auditors are back to work and the requests for ADRs are coming through, but are they expanding on any of the topics that they had been looking on? What stands out to you in terms of where this is going? Yes, so there's a number of new automated and complex review targets. Most of them are not ophthalmology specific, but they do impact practices billing high-volume evaluation and management, diagnostic imaging, or global services.

So it'd be good to watch those modifiers relating to global services. Yeah, that's a good point, too. Even if those services aren't specifically on the ophthalmology specialty list, there's a lot that happens in medicine that kind of, I don't want to say eases into, but covers ophthalmology as well.

E&M codes, not specifically for our use, but certainly we use a lot of them. And then the modifiers affect ophthalmology as well. Yeah, those codes, those high utilization codes, they always attract attention.

So practices should tighten up their internal audits, verify documentation completeness for codes that they use most, such as comprehensive eye exams, intermediate exams, post-op visits for those who need to report, injections, and diagnostic imaging. Yeah, good point. This is a good time to reinforce all of that.

And the importance on modifiers, I think, can't be overstated. So RAC reviews aside, I also had a couple of experiences in the last few months with TPE audits. And we are seeing more TPE audits coming through, particularly E&M codes, as you just mentioned, cataract surgery, and modifier 25.

I think some practices underestimate how serious these can become. I think because they're not a RAC review, some people don't take them as seriously as they should. Right, because the TPE is framed as educational, but you can end up in round two or three quickly if your documentation isn't tight. 

And after round three, MACs can escalate and possibly refer you to RAC or UPIC. Right, right. So the key is responding quickly.

And they have to get better. From round one to round two, they have to show some kind of meaningful improvement. And the earlier, the better.

I did have a very favorable experience with a TPE audit recently. Retina provider in the Midwest got on the phone for the educational session after round one. I think the fact that his tone was so smooth and so calming and so cooperative, I think that set the stage for the reviewer's response.

And she, too, was very cooperative, extremely helpful, could not have been more cordial. You know, I think we build up in our head what these phone calls are going to be like or what the auditor's attitude might be. And maybe the provider then gets a bit defensive.

This could not have gone more smoothly. And I'm very confident that at round two, based on the conversation and the instruction given, the physician's likely to pass with flying colors. So these can work out very well if you kind of follow their instructions and then go into it with a very open-minded attitude.

It is supposed to be educational. And don't get defensive quite yet. We can save that for later if necessary.

But if you go in with the right attitude, hopefully these will end up smoothly. But with ophthalmology in mind, remember, too, that the target codes are sometimes inconsistent with documentation. And oftentimes, that's really all they're looking for is improved documentation.

Yeah, that was a great example and a great reminder that, you know, if you're selected, pull some internal audit samples. Do it quickly. Find the error patterns and educate your clinicians.

The providers need to understand what elements CMS expects for the codes that they use most. And going into a TPE if you're selected with a great attitude, I think, can help make all the difference in the world. Right.

Sometimes easier said than done, especially if you feel a bit challenged. You know, we need to have control of our emotions in those situations. Let's talk about one more thing, if you don't mind.

You mentioned comprehensive eye exams. That question I get repeatedly, even outside a chart review, when physicians challenge how frequently is that billable. And I am seeing denials coming from non-Medicare payers for the use of that code more frequent than expected. 

Yeah, I think that's what I was going to say. It just seems to create a lot of confusion. Technically, Medicare doesn't publish a hard frequency limit.

A lot of carriers expect them to be used. You know, once every six to 12 months, unless something significant changes clinically. Yeah, I think that makes perfect sense.

When you look at the exam elements that are required at the comprehensive eye exam level, you'd have to clinically ask yourself, is it medically necessary to repeat all of those required elements in very short succession? So things like confrontation visual fields on an otherwise healthy patient. Why would you need to do that three or four times a year? And in the unique situation where a physician did feel clinically it was appropriate, I think they could probably defend a more frequent use of the code. But for most of these doctors, I think they do some of those elements just as part of their comprehensive to say they did it all.

But clinically, it may or may not be contributing to their diagnosing. Right. And you have to take efficiency in the clinic into consideration too.

Is it necessary to be hitting all of these elements when it may not be clinically appropriate? Right. And I still see, even with E&M codes, because the template in EMR is set up to capture a certain number of elements, I still see practices that document all of those on essentially every patient, whether again, it's contributing to the care or not. I think it's just a force of habit and the familiarity with the template in their EMR.

Right. Typically, the intermediate exam can be billed a little bit more frequently than comprehensive, but I don't see any specific guideline or limit on that one either. No.

And I don't see any frequency guideline on intermediate. Intermediate, I think, would be most appropriate if a patient returns within a few months for the same problem. Yeah.

The intermediate code kind of doubles up with some of those E&M levels as well. So physicians at that level returning kind of follow-up, stable follow-up, maybe even a follow-up where the condition's not stable, progressing just a bit, they can determine or they can select between those modest level E&M codes and the appropriate eye code or intermediate eye code if they needed. Right.

Right. So, you know, a safe rule would be comprehensive when there's a full evaluation of the visual system with decision-making shift. Intermediate for follow-ups, condition management, and targeted assignments.

Yeah, exactly. I think that makes perfect sense. And as a reminder, I know we've talked about this before, but practices that track their utilization, they can see the ratio of comprehensive eye exams to intermediate or comprehensive eye exams to similar level E&M codes and compare them themselves or compare their practice utilization with the known benchmarks that Medicare provides.

It'll not only help them identify red flags for codes that perhaps they're doing more frequently than would be expected, but they might identify some areas of opportunity. It's not uncommon that we see in a utilization analysis that doctors really undercode their service. They stick with all those modest level E&Ms, never going to the higher level, and avoiding eye codes altogether. 

So, you might introduce or you might identify some areas where more accurate coding actually could lead to additional revenue. Final thoughts? Just that there's some heavy topics here that we've covered. We are available for questions. 

Should you need to reach out, 800-399-6565. Call us anytime. You can also reach us through our website.

We do have the What's New 2026 coming up, so make sure you get registered for that. There's going to be a lot of good information delivered there. 

Thanks for listening to Ophthalmology Reimbursed. Brought to you by Corcoran Consulting Group, the experts in coding, reimbursement, auditing, and education for the ophthalmic community. To learn more about how we can support your practice, visit corcoranccg.com. Be sure to follow and leave a review wherever you listen to podcasts. Until next time, thanks for listening to Ophthalmology Reimbursed.