Another Reason to Refer to You
by AJ Riviezzo
One 'campaign' that has been successful for a few of our clients is to provide same-day service on referrals for DVT scans. In many areas, the PCP has limited options for sending their patient out for an ultrasound on a suspected DVT. If you have a full time (or near enough) sonographer, you can offer out to the PCP community that you can provide this service.
There are a couple keys to really making this work. First, you need to be able to work that patient into your sonographer's schedule within a few hours. Second, you need to ensure a telephone call is placed back to the PCP confirming or denying the presence of a DVT. Third, you need to follow up the telephone call with a very good report to the PCP.
There are multiple benefits for having a program like this. For the PCP, this allows them to ensure their patient is seen in a rapid and friendly way rather than going to an urgent/emergent facility. It also allows the PCP to begin a treatment program perhaps more quickly than their current available options. For the practice, you are now being referred to for two different reasons... one of which, DVT, is very clearly understood by the PCP community. It does generate some revenue to offset the cost of your ultrasound technician. It is also not uncommon that what is a suspected DVT is frequently painful varicose veins. This program also allows a new reason for reaching back out to the PCP community . Overall, one of those rare win-win scenarios for everyone... including the patient.
Tuesday, November 29, 2011
Quick Marketing Thoughts
For Your Consideration
by Marcy Riviezzo
Health Fairs: For whatever reason, there tends to be a number of health fairs after the first of the year in most areas. Some practices have done very well at health fairs and some... not so well. If you do attend one, do not forget to market not only to the attendees of the fair but also to all of the other vendors. Frequently they can become a referral source or help lead you to a referral source.
Medicare: After the New Year, many commercial patients are going to be a bit more reticent to receive treatment for an elective procedure due to their deductible amounts starting over with the new year. Medicare patients have a very low deductible which is frequently covered by their secondary policy. One potential marketing outreach is to hold an educational seminar at a retirement community. Most of these seniors are still very active and concerned about their health. They also are very prone to attend any sort of meeting at their complex that has a physician giving a class. One tip: Bring an US machine (if you have one that is portable) and have one of the residents scanned for everyone to watch. Show and tell still works if you are eight or eighty!
Marketing Materials: With the new year fast coming upon us, you may want to take a little bit of the down time to review your marketing materials. All too often we just reproduce the same materials... frequently with the same results. Are the materials up to date with address, telephone, hours of operation and other pertinent details? Have you added other services such as Botox that should be listed? Try to really read all of your documents as if this is the first time you have seen them.
Internet Updates: Another consideration is updating your Social Living exposure. There are a number of programs like Facebook, Yahoo, and Yelp. You should also review your website to see if it is looking current. Is the material fresh or also a bit out of date. So many patients are now reviewing websites and social media that you need to ensure this is being refreshed regularly.
by Marcy Riviezzo
Health Fairs: For whatever reason, there tends to be a number of health fairs after the first of the year in most areas. Some practices have done very well at health fairs and some... not so well. If you do attend one, do not forget to market not only to the attendees of the fair but also to all of the other vendors. Frequently they can become a referral source or help lead you to a referral source.
Medicare: After the New Year, many commercial patients are going to be a bit more reticent to receive treatment for an elective procedure due to their deductible amounts starting over with the new year. Medicare patients have a very low deductible which is frequently covered by their secondary policy. One potential marketing outreach is to hold an educational seminar at a retirement community. Most of these seniors are still very active and concerned about their health. They also are very prone to attend any sort of meeting at their complex that has a physician giving a class. One tip: Bring an US machine (if you have one that is portable) and have one of the residents scanned for everyone to watch. Show and tell still works if you are eight or eighty!
Marketing Materials: With the new year fast coming upon us, you may want to take a little bit of the down time to review your marketing materials. All too often we just reproduce the same materials... frequently with the same results. Are the materials up to date with address, telephone, hours of operation and other pertinent details? Have you added other services such as Botox that should be listed? Try to really read all of your documents as if this is the first time you have seen them.
Internet Updates: Another consideration is updating your Social Living exposure. There are a number of programs like Facebook, Yahoo, and Yelp. You should also review your website to see if it is looking current. Is the material fresh or also a bit out of date. So many patients are now reviewing websites and social media that you need to ensure this is being refreshed regularly.
Sclerotherapy Billing
Sclero... One More Time
by AJ Riviezzo
My apologies to our regular readers but I received quite a number of questions regarding Medically Necessary Ultrasound Guided Sclerotherapy. Below is our answers to two very frequent questions posed at the this year's ACP Annual Congress:
Is Medically Necessary Sclerotherapy Paid for by Insurance Plans?
Medicare and almost all commercial insurance plans do pay for medically necessary sclerotherapy (MNS). There are a few keys to being reimbursed. First, you need to ensure the service is medically necessary based upon that payers medical criteria. Second, you typically need to authorize the service with the commercial plan in the same way you would authorize the ablation. Third, you need to ensure you have an operative note for the procedure as well as some notes showing why the patient requires this service.
How do You Bill for Medically Necessary Sclerotherapy?
Each payer is a bit different and there is even some difference in Medicare administrators. That being noted, our typical set of codes for MNS is a 93971 - single leg doppler US as you are usually re-scanning the leg before doing any injection, 76942 for the US guidance, and a 36471 if multiple veins are injected or a 36470 if only one vein is being injected. Even if the 76942 US guidance is rejected or excluded per the policy, we recommend still billing it as you are performing the service.
by AJ Riviezzo
My apologies to our regular readers but I received quite a number of questions regarding Medically Necessary Ultrasound Guided Sclerotherapy. Below is our answers to two very frequent questions posed at the this year's ACP Annual Congress:
Is Medically Necessary Sclerotherapy Paid for by Insurance Plans?
Medicare and almost all commercial insurance plans do pay for medically necessary sclerotherapy (MNS). There are a few keys to being reimbursed. First, you need to ensure the service is medically necessary based upon that payers medical criteria. Second, you typically need to authorize the service with the commercial plan in the same way you would authorize the ablation. Third, you need to ensure you have an operative note for the procedure as well as some notes showing why the patient requires this service.
How do You Bill for Medically Necessary Sclerotherapy?
Each payer is a bit different and there is even some difference in Medicare administrators. That being noted, our typical set of codes for MNS is a 93971 - single leg doppler US as you are usually re-scanning the leg before doing any injection, 76942 for the US guidance, and a 36471 if multiple veins are injected or a 36470 if only one vein is being injected. Even if the 76942 US guidance is rejected or excluded per the policy, we recommend still billing it as you are performing the service.
Tuesday, October 25, 2011
CAQH and the Physician
Something Else to Worry About
by Marcy Riviezzo
What is CAQH and why does this impact me and my practice?
The best way to describe CAQH comes directly quoted from their website:
"The Council for Affordable Quality Healthcare (CAQH) is a council of 25 of America's largest Health plans and insurers and three of the principal health plan associations working together to help improve the healthcare experience for consumers and physicians. CAQH member health plans have more than 110 million Americans and 600,000 providers in the networks."
It is the standard credentialing source for over two hundred healthcare plans. It maintains the UPD (Universal Provider Data Source). All information you provide to the Universal Data Source is maintained through encrypted technology.
If you are contracted personally or perhaps with a hospital or group, chances are someone in your administrative staff has created a profile for you on CAQH/UPD.
Here's WHY it matters:
ALL major insurance health plans access your profile regularly to keep your contracts and credentialing or recredentialing updated with information such as a copy of your current medical license, DEA License and Malpractice Insurance, just to mention a few requirements for you to practice medicine. The encrypted technology allows CAQH to streamline your data storage and manage it for distribution to all health plans and networks for easier contract applications and renewals. It is important that all physicians and mid level practitioners keep a current profile of their data for easy access.
Every six months CAQH emails a request prompting you to review and submit any new updates or renewals of information. Many of your contracts renew at the beginning of the new year and will want to access CAQH regarding your profile, so now is a great time to be proactive and contact or call CAQH to ensure you are current!
Annual updates to your profile include renewal of your Medical License, DEA license, malpractice insurance, BLS or ACLS, TB skin test, your current practice location and any hospital affiliations.
If you do not have a CAQH ID number and profile, I encourage you find someone to help you to create your CAQH/UPD as it can be frustrating and time consuming to complete it on your own. It is basically a process of gathering your professional profile but is usually an extra task that does not fall into a priority list of our day-to-day activities -- so often times this just doesn't get done. Once you get behind, it takes much longer to catch up.
If you have any questions regarding CAQH please do not hesitate to contact me directly to chat about helpful hints to keep CAQH on your priority list! I can be reached directly at 719.232.5566.
by Marcy Riviezzo
What is CAQH and why does this impact me and my practice?
The best way to describe CAQH comes directly quoted from their website:
"The Council for Affordable Quality Healthcare (CAQH) is a council of 25 of America's largest Health plans and insurers and three of the principal health plan associations working together to help improve the healthcare experience for consumers and physicians. CAQH member health plans have more than 110 million Americans and 600,000 providers in the networks."
It is the standard credentialing source for over two hundred healthcare plans. It maintains the UPD (Universal Provider Data Source). All information you provide to the Universal Data Source is maintained through encrypted technology.
If you are contracted personally or perhaps with a hospital or group, chances are someone in your administrative staff has created a profile for you on CAQH/UPD.
Here's WHY it matters:
ALL major insurance health plans access your profile regularly to keep your contracts and credentialing or recredentialing updated with information such as a copy of your current medical license, DEA License and Malpractice Insurance, just to mention a few requirements for you to practice medicine. The encrypted technology allows CAQH to streamline your data storage and manage it for distribution to all health plans and networks for easier contract applications and renewals. It is important that all physicians and mid level practitioners keep a current profile of their data for easy access.
Every six months CAQH emails a request prompting you to review and submit any new updates or renewals of information. Many of your contracts renew at the beginning of the new year and will want to access CAQH regarding your profile, so now is a great time to be proactive and contact or call CAQH to ensure you are current!
Annual updates to your profile include renewal of your Medical License, DEA license, malpractice insurance, BLS or ACLS, TB skin test, your current practice location and any hospital affiliations.
If you do not have a CAQH ID number and profile, I encourage you find someone to help you to create your CAQH/UPD as it can be frustrating and time consuming to complete it on your own. It is basically a process of gathering your professional profile but is usually an extra task that does not fall into a priority list of our day-to-day activities -- so often times this just doesn't get done. Once you get behind, it takes much longer to catch up.
If you have any questions regarding CAQH please do not hesitate to contact me directly to chat about helpful hints to keep CAQH on your priority list! I can be reached directly at 719.232.5566.
Quick Hits
Some Info for You
by AJ Riviezzo
E-Prescribe: The deadline for submitting a request for exemption from the E-prescribe program is November 1st. One way to be exempt is for the practice to be below a 10% threshold of specific codes. Most of these codes are essentially Evaluation and Management codes. Almost all phlebology practices should meet this exemption as the primary payments by Medicare are for surgery and ultrasound services. You need to file a letter with CMS to ensure you are exempt from any possible Medicare penalties.
Ultrasound Report Addition: On your ultrasound reports, we recommend adding a line to the body of the report that states: The permanent ultrasound recording is on file. This will help ensure you meet all legal requirements in your documentation.
Change in Code Use: Code 76942, ultrasound guidance, is receiving another short jab. Medicare and some other payers are now only allowing one 76942 to be billed per day. This means that if you are performing bilateral US guided sclerotherapy injections, you will not only be cut by 50% on the second sclero injection code you can also be cut back by the full amount for the US guidance as well. For Medicare patients we recommend against billing the second guidance code even to receive a denial. Our supposition is that fewer denials may hopefully mean fewer audit reasons.
by AJ Riviezzo
E-Prescribe: The deadline for submitting a request for exemption from the E-prescribe program is November 1st. One way to be exempt is for the practice to be below a 10% threshold of specific codes. Most of these codes are essentially Evaluation and Management codes. Almost all phlebology practices should meet this exemption as the primary payments by Medicare are for surgery and ultrasound services. You need to file a letter with CMS to ensure you are exempt from any possible Medicare penalties.
Ultrasound Report Addition: On your ultrasound reports, we recommend adding a line to the body of the report that states: The permanent ultrasound recording is on file. This will help ensure you meet all legal requirements in your documentation.
Change in Code Use: Code 76942, ultrasound guidance, is receiving another short jab. Medicare and some other payers are now only allowing one 76942 to be billed per day. This means that if you are performing bilateral US guided sclerotherapy injections, you will not only be cut by 50% on the second sclero injection code you can also be cut back by the full amount for the US guidance as well. For Medicare patients we recommend against billing the second guidance code even to receive a denial. Our supposition is that fewer denials may hopefully mean fewer audit reasons.
Administrative Law Judge
Follow Up Information on ZPIC Audit
by AJ Riviezzo
American Physician recently supported a practice that was involved in a ZPIC audit (essentially like a RAC audit except this was prospective and not retrospective). Eight of our ablation claims were denied at the first and second level appeal stages. This left using an Administrative Law Judge (ALJ) as our next recourse.
I have a more detailed article in the next Vein Therapy News but the findings in brief were:
Your documentation has to be viewed not as if another physician can understand and follow it but as if an attorney can understand it. Any, and I do mean any, variation in what is on one form to another was stringently questioned. For example, if your CEAP classification mentions swelling of the legs and your History and Physical does not specifically mention swelling of the legs, that is a problem.
It also became clear that any patient information that was not specifically noted as reviewed by the physician was discounted. Further, patient statements regarding previous attempts at conservative therapy (and thereby meeting the Medicare guidelines) were also discounted. We did argue that this was an unfair burden on both the patient and on the practice. It is normally standard to accept the patient's word when reviewing previous treatment, history, or compliance with something like conservative therapy management. That argument fell completely flat.
With the budget issues facing the Medicare program and recommendations that 'changes' be made to save money without impacting the actual entitlement, I can only assume that audits to find inappropriate or fraudulent treatment will be expanded. The primary weapon at your disposal for combating these audits is your well documented medical record.
by AJ Riviezzo
American Physician recently supported a practice that was involved in a ZPIC audit (essentially like a RAC audit except this was prospective and not retrospective). Eight of our ablation claims were denied at the first and second level appeal stages. This left using an Administrative Law Judge (ALJ) as our next recourse.
I have a more detailed article in the next Vein Therapy News but the findings in brief were:
Your documentation has to be viewed not as if another physician can understand and follow it but as if an attorney can understand it. Any, and I do mean any, variation in what is on one form to another was stringently questioned. For example, if your CEAP classification mentions swelling of the legs and your History and Physical does not specifically mention swelling of the legs, that is a problem.
It also became clear that any patient information that was not specifically noted as reviewed by the physician was discounted. Further, patient statements regarding previous attempts at conservative therapy (and thereby meeting the Medicare guidelines) were also discounted. We did argue that this was an unfair burden on both the patient and on the practice. It is normally standard to accept the patient's word when reviewing previous treatment, history, or compliance with something like conservative therapy management. That argument fell completely flat.
With the budget issues facing the Medicare program and recommendations that 'changes' be made to save money without impacting the actual entitlement, I can only assume that audits to find inappropriate or fraudulent treatment will be expanded. The primary weapon at your disposal for combating these audits is your well documented medical record.
Monday, August 22, 2011
Moving your Practice Forward
Free (or Close Enough) Support
by AJ Riviezzo
Phlebology is an interesting niche as it is becoming one of the few types of practice where there is a solo physician owner. This creates some unique opportunities and challenges as most of the physicians that start a phlebology practice have worked for a larger group, a group within the hospital system, or the hospital system itself. Being a good physician is only half the battle. The other half of the battle then begs the question: How do you gain the necessary information to be a successful business?
Trial and error is one very painful way of course. And, sad to say, it will indeed be part of your experience. Reviewing other practices that have been successful is another way to gain a bit of information (using someone else's trial and error). This has limited results as your market, your patient base, your referral network and even your payers may be different.
I recommend a multi-faceted approach. The first facet is to use your vendors. You as the physician/owner will be spending a fair amount of money on equipment, supplies and services. Many of the vendors for these services have a plethora of information, marketing materials, and other support available. For example, CoolTouch has a hotline to answer any billing questions along with a lot of materials both on line and in print. VNUS has an extensive collection of marketing materials available on line along with some recommendations for marketing efforts. Juzo, who has an excellent line of compression stockings, has marketing materials that are great for Lunch and Learns. My own small company provides a variety of support efforts to our physicians as well. All of this is free for the asking. In short, talk with your vendors and see what they can bring to the table for you besides an invoice.
The second facet is to develop a Board of Directors. As a physician/owner you are not likely well versed in banking, marketing, public relations, human resources and a number of other areas that are important to developing and maintaining a strong business. One way to have these types of people support you is to have them on a Board. You likely have friends or friends of friends with some of the skill sets. A retired banker, a semi-retired CPA, a stay at home mom who used to be the Director of Marketing for a company would all make excellent Board members. They have the time to attend a quarterly meeting. They have the energy to think about your needs. You can usually have these folks be part of your team for not much more than a small meeting stipend and a catered meal. The key here is to actually use these folks as a sounding board and do your best to actually implement some of their ideas (if no real authority they will quickly fade away).
The third facet is to reach out to your local Chamber of Commerce. The CoC's usually have programs and support geared specifically for small businesses. They have a network of relationships already built. They can recommend tried and true services available in your community. The cost to join the Chamber is usually very minimal but the offerings they have to help enhance your success is usually vast.
There are likely a number of other low cost to no cost options as well. The key is to find a bit of time out of your normal operations and focus on the practice as a business. While this can be neither easy nor comfortable it is important to do every so often.
by AJ Riviezzo
Phlebology is an interesting niche as it is becoming one of the few types of practice where there is a solo physician owner. This creates some unique opportunities and challenges as most of the physicians that start a phlebology practice have worked for a larger group, a group within the hospital system, or the hospital system itself. Being a good physician is only half the battle. The other half of the battle then begs the question: How do you gain the necessary information to be a successful business?
Trial and error is one very painful way of course. And, sad to say, it will indeed be part of your experience. Reviewing other practices that have been successful is another way to gain a bit of information (using someone else's trial and error). This has limited results as your market, your patient base, your referral network and even your payers may be different.
I recommend a multi-faceted approach. The first facet is to use your vendors. You as the physician/owner will be spending a fair amount of money on equipment, supplies and services. Many of the vendors for these services have a plethora of information, marketing materials, and other support available. For example, CoolTouch has a hotline to answer any billing questions along with a lot of materials both on line and in print. VNUS has an extensive collection of marketing materials available on line along with some recommendations for marketing efforts. Juzo, who has an excellent line of compression stockings, has marketing materials that are great for Lunch and Learns. My own small company provides a variety of support efforts to our physicians as well. All of this is free for the asking. In short, talk with your vendors and see what they can bring to the table for you besides an invoice.
The second facet is to develop a Board of Directors. As a physician/owner you are not likely well versed in banking, marketing, public relations, human resources and a number of other areas that are important to developing and maintaining a strong business. One way to have these types of people support you is to have them on a Board. You likely have friends or friends of friends with some of the skill sets. A retired banker, a semi-retired CPA, a stay at home mom who used to be the Director of Marketing for a company would all make excellent Board members. They have the time to attend a quarterly meeting. They have the energy to think about your needs. You can usually have these folks be part of your team for not much more than a small meeting stipend and a catered meal. The key here is to actually use these folks as a sounding board and do your best to actually implement some of their ideas (if no real authority they will quickly fade away).
The third facet is to reach out to your local Chamber of Commerce. The CoC's usually have programs and support geared specifically for small businesses. They have a network of relationships already built. They can recommend tried and true services available in your community. The cost to join the Chamber is usually very minimal but the offerings they have to help enhance your success is usually vast.
There are likely a number of other low cost to no cost options as well. The key is to find a bit of time out of your normal operations and focus on the practice as a business. While this can be neither easy nor comfortable it is important to do every so often.
Documentation Compliance
Sclerotherapy
by Cheryl Nash
Sclerotherapy: It is just an injection! So why is so much documentation required for this simple service to be covered by the payers? In fact, Ultrasound Guided Sclerotherapy (also known as USG or Echosclerotherapy) is categorized as a surgical service and needs to be documented according to these standards. Typically USG is preceded by a duplex scan, either unilateral, or bilateral, to identify the veins that still need to be treated. This should be reported in the chart as a permanent record of the Ultrasound performed.
In addition to this report, there should also be documentation in an operative report format describing the Sclerotherapy service along with the ultrasonic guidance if performed. Remember, it is imperative to identify the veins treated in both reports and to note the rationale behind the decision for additional treatment. Even if an authorization has been obtained from the payer, they are still likely to request these records after the fact to ensure compliance prior to issuing payment.
Some payers also require the patient to continue to exhibit symptoms, and an additional progress note stating that this is the case, along with the examination results, duplex scan results, impression and plan ordering additional treatment may also be indicated. It seems like a lot of paper to generate, but with a consistent system in place, the reality is not as daunting as it sounds. The revenue and the patient outcome more than justify the means.
by Cheryl Nash
Sclerotherapy: It is just an injection! So why is so much documentation required for this simple service to be covered by the payers? In fact, Ultrasound Guided Sclerotherapy (also known as USG or Echosclerotherapy) is categorized as a surgical service and needs to be documented according to these standards. Typically USG is preceded by a duplex scan, either unilateral, or bilateral, to identify the veins that still need to be treated. This should be reported in the chart as a permanent record of the Ultrasound performed.
In addition to this report, there should also be documentation in an operative report format describing the Sclerotherapy service along with the ultrasonic guidance if performed. Remember, it is imperative to identify the veins treated in both reports and to note the rationale behind the decision for additional treatment. Even if an authorization has been obtained from the payer, they are still likely to request these records after the fact to ensure compliance prior to issuing payment.
Some payers also require the patient to continue to exhibit symptoms, and an additional progress note stating that this is the case, along with the examination results, duplex scan results, impression and plan ordering additional treatment may also be indicated. It seems like a lot of paper to generate, but with a consistent system in place, the reality is not as daunting as it sounds. The revenue and the patient outcome more than justify the means.
Medical Policy Alert
Humana Moves Towards AEtna's Policy
by Cheryl Nash
Some of you may have noticed the new changes to the language in Humana's coverage policy. Along the lines of last year's changes to Aetna's guidelines , Humana has also added a notation in their guidelines stating:
Initially, one treatment session of RFA, TIPP or, EVLT™, per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session.
Interestingly enough, we agree that 'staging' the GSV into more than one session is rarely if ever indicated. The above statement though is being used to state treatment of both the great and short saphenous vein should be treated in the same setting. They want the claim to be billed as a 36475/36478 for the GSV and 36476/36479 for the SSV. While this is of concern, they did allow a small amount of room for leeway in the statement:
Repeat sessions of RFA, TIPP, EVLT™ or stripping/division/ligation may be requested and are subject to medical necessity review. Repeat sessions may be medically necessary for persons with persistent or recurrent junctional reflux.
We have had some varying results on recent authorizations, and like Aetna, it appears to be subject to the medical director's discretion on how stringently this is being enforced. Also of interest is that Humana excluded the treatment of perforators, tributaries, and accessory veins with either RF or EVLT, stating that these services are considered experimental and investigational. We will be following up on this development as we receive more feedback from the insurance company and our clients.
by Cheryl Nash
Some of you may have noticed the new changes to the language in Humana's coverage policy. Along the lines of last year's changes to Aetna's guidelines , Humana has also added a notation in their guidelines stating:
Initially, one treatment session of RFA, TIPP or, EVLT™, per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session.
Interestingly enough, we agree that 'staging' the GSV into more than one session is rarely if ever indicated. The above statement though is being used to state treatment of both the great and short saphenous vein should be treated in the same setting. They want the claim to be billed as a 36475/36478 for the GSV and 36476/36479 for the SSV. While this is of concern, they did allow a small amount of room for leeway in the statement:
Repeat sessions of RFA, TIPP, EVLT™ or stripping/division/ligation may be requested and are subject to medical necessity review. Repeat sessions may be medically necessary for persons with persistent or recurrent junctional reflux.
We have had some varying results on recent authorizations, and like Aetna, it appears to be subject to the medical director's discretion on how stringently this is being enforced. Also of interest is that Humana excluded the treatment of perforators, tributaries, and accessory veins with either RF or EVLT, stating that these services are considered experimental and investigational. We will be following up on this development as we receive more feedback from the insurance company and our clients.
Friday, June 24, 2011
E-Perscribing Requirements
Out Clause for Phlebology
by AJ Riviezzo
One of the new(er) concerns we have been fielding of late is the Medicare decision on E-prescribing. Medicare is turning it from a small bonus to a penalty if you are not in compliance. While the 1% reduction for next year isn't large, it will increase each subsequent year.
On to the good news though. The Federal Register, Vo. 76, No. 105 dated June 1, 2011, page 31550 states:
"...the 2012 eRx payment adjustment does not apply to an individual eligible profession or group practice if less than 10 percent of an eligible professional's or groups practice's estimated total allowed charges for the Jan 1, 2011 through June 30, 2011 reporting period are comprised of services that appear in the denominator of the 2011 eRx measurer."
In summary, if your services for certain codes are less than 10% of what Medicare pays you for all of your Medicare reimbursed services, the E-Prescribe requirements do not apply. There are multiple codes but the primary ones for a phlebology practice are the 99201-99205 new patient exams and 99211-99215 office visit exams. Please contact me if you would like a copy of all of the codes (877.611.1322).
We reviewed three different phlebology practices to see if they came close to the 10% mark. Out of the three, the highest percentage was 4% with the other two less than half of that. Essentially, unless your practice was only seeing new patients and not providing US services or treatment, you likely fall well under the 10 percent mark as well. You may want to double check this assumption but I feel pretty confident that this rule will not apply to phlebology practices as it is currently written.
by AJ Riviezzo
One of the new(er) concerns we have been fielding of late is the Medicare decision on E-prescribing. Medicare is turning it from a small bonus to a penalty if you are not in compliance. While the 1% reduction for next year isn't large, it will increase each subsequent year.
On to the good news though. The Federal Register, Vo. 76, No. 105 dated June 1, 2011, page 31550 states:
"...the 2012 eRx payment adjustment does not apply to an individual eligible profession or group practice if less than 10 percent of an eligible professional's or groups practice's estimated total allowed charges for the Jan 1, 2011 through June 30, 2011 reporting period are comprised of services that appear in the denominator of the 2011 eRx measurer."
In summary, if your services for certain codes are less than 10% of what Medicare pays you for all of your Medicare reimbursed services, the E-Prescribe requirements do not apply. There are multiple codes but the primary ones for a phlebology practice are the 99201-99205 new patient exams and 99211-99215 office visit exams. Please contact me if you would like a copy of all of the codes (877.611.1322).
We reviewed three different phlebology practices to see if they came close to the 10% mark. Out of the three, the highest percentage was 4% with the other two less than half of that. Essentially, unless your practice was only seeing new patients and not providing US services or treatment, you likely fall well under the 10 percent mark as well. You may want to double check this assumption but I feel pretty confident that this rule will not apply to phlebology practices as it is currently written.
Local Coverage Determinations
Matching Tit for Tat
by AJ Riviezzo
The requirements by the various payers continue to evolve and shift. Some, like United Healthcare, have become slightly more user friendly as they finally recognized that wearing stockings for three months does absolutely nothing for a patients venous disease. Others, like the Medicare intermediary Trailblazer, have changed their guidelines and are now starting to enforce the need to place the patient in stockings and track them for three to six months.
All of these changes are necessitating changes at the practice level.
First, it is imperative that the guidelines for each payer are reviewed regularly to identify any changes. Second, these changes must be clearly understood by the physician, the medical team, and the authorization coordinator. These are the two 'easy' changes.
Third, and becoming increasingly more important, is that the documentation needs to be tailored to a certain extent to meet the payer's guidelines. For example, Trailblazer and some commercial payers require the patient to be placed in compression hose and monitored by the physician. There must be an initial review of the patient, and order placing them in stockings, a review of any relief or continued symptoms at the 45 day mark, and a similar review at the 90 day mark. All of this needs to be captured in your summary of the patient's condition as to why you are now recommending an ablation to be performed. Other payers may want you to wait 90 days before performing a phlebectomy. Again, your documentation needs to match the expectations that the patient is re-reviewed and a phlebectomy is ordered based on that follow up visit.
Unfortunately, the old adage that "if you didn't document it, you didn't do it" is becoming the rule even before you are authorized to treat the patient.
by AJ Riviezzo
The requirements by the various payers continue to evolve and shift. Some, like United Healthcare, have become slightly more user friendly as they finally recognized that wearing stockings for three months does absolutely nothing for a patients venous disease. Others, like the Medicare intermediary Trailblazer, have changed their guidelines and are now starting to enforce the need to place the patient in stockings and track them for three to six months.
All of these changes are necessitating changes at the practice level.
First, it is imperative that the guidelines for each payer are reviewed regularly to identify any changes. Second, these changes must be clearly understood by the physician, the medical team, and the authorization coordinator. These are the two 'easy' changes.
Third, and becoming increasingly more important, is that the documentation needs to be tailored to a certain extent to meet the payer's guidelines. For example, Trailblazer and some commercial payers require the patient to be placed in compression hose and monitored by the physician. There must be an initial review of the patient, and order placing them in stockings, a review of any relief or continued symptoms at the 45 day mark, and a similar review at the 90 day mark. All of this needs to be captured in your summary of the patient's condition as to why you are now recommending an ablation to be performed. Other payers may want you to wait 90 days before performing a phlebectomy. Again, your documentation needs to match the expectations that the patient is re-reviewed and a phlebectomy is ordered based on that follow up visit.
Unfortunately, the old adage that "if you didn't document it, you didn't do it" is becoming the rule even before you are authorized to treat the patient.
Audit Alert
More Fun by a Payer
by Cheryl Nash
Humana has started issuing letters requesting medical records for an audit of their Medicare Advantage Plan members. We have received information of from two providers in phlebology practices that have received the same request - in different states. This appears to be a random audit to compare to current medical necessity and correct coding guidelines.
If a request of this nature is received, all records should be pulled and copied, placed in chronological order, and checked for completeness prior to submitting. Submission will need to be timely as there is typically a deadline for compliance.
We recommend doing an internal audit of your Humana Medicare patient's charts to ensure your records are complete. If there is something missing but the information is captured on a different form in the chart, you can provide an addendum to something like the History and Physical. The addendum needs to be clearly dated with the current date and signed. However, the information should be present in the chart already and cannot be created whole cloth into the chart.
Humana's Medicare Advantage plans follow your local LCD policies; these can be found through the following link;http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
by Cheryl Nash
Humana has started issuing letters requesting medical records for an audit of their Medicare Advantage Plan members. We have received information of from two providers in phlebology practices that have received the same request - in different states. This appears to be a random audit to compare to current medical necessity and correct coding guidelines.
If a request of this nature is received, all records should be pulled and copied, placed in chronological order, and checked for completeness prior to submitting. Submission will need to be timely as there is typically a deadline for compliance.
We recommend doing an internal audit of your Humana Medicare patient's charts to ensure your records are complete. If there is something missing but the information is captured on a different form in the chart, you can provide an addendum to something like the History and Physical. The addendum needs to be clearly dated with the current date and signed. However, the information should be present in the chart already and cannot be created whole cloth into the chart.
Humana's Medicare Advantage plans follow your local LCD policies; these can be found through the following link;http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
Tuesday, April 12, 2011
Conservative Treatment Changes
Documenting Stockings
by Cheryl Nash and AJ Riviezzo
In the past the patient report regarding the wearing of compression stockings was sufficient. Unfortunately, a passing 'nod' is no longer sufficient by a growing list of payers. With the Phlebology requirements becoming more and more payer specific, a trend has been emerging that may change the way you document conservative treatment.
In the past if a patient stated that they had worn compression stockings and tried other forms of conservative treatment, (leg elevation, exercise, NSAIDS, etc.) this information alone was sufficient to support medical necessity. The trend in the clinical guidelines now state that the medical record includes physician office notes indicate failure of medically supervised conservative management, including but not limited to compression stocking therapy for. (Excerpt from Cigna Medical Coverage Policy #0234).
The terms about this type of requirement vary. It is sometimes called medical management, supervised trial, or ordered by the treating physician. It all translates to the same end result. You must place the patient in compression hose and follow the patient's conservative therapy for the (typically) 90 days.
Obviously this causes some issues in scheduling timelines for treatment, but after the initial stall with these payers, this should even out. When doing a supervised trial, the patient should be brought back into the office at intervals to assess the success or failure of the conservative treatment and at the end of the trial. If appropriate, a new diagnostic US to clearly show that the symptoms and disease has not changed would be indicated. (Please check your payer policy to ensure that there are no limitations on this service as well.)
You may also want to consider selling the compression hose in your office. While some payers do not cover the stockings, others do. By selling, and then submitting the claim to their insurance plan, you have another record that the patient did indeed have the hose with them when leaving your office.
While this has language has been around for a while, it was mainly confined to isolated local payers. With this addition to Cigna's policy, as well to various Medicare guidelines and several of the Blues plans, it has now "made the big time".
As always, we at American Physician cannot stress enough; check your payer's policies often to ensure you are meeting their guidelines!
by Cheryl Nash and AJ Riviezzo
In the past the patient report regarding the wearing of compression stockings was sufficient. Unfortunately, a passing 'nod' is no longer sufficient by a growing list of payers. With the Phlebology requirements becoming more and more payer specific, a trend has been emerging that may change the way you document conservative treatment.
In the past if a patient stated that they had worn compression stockings and tried other forms of conservative treatment, (leg elevation, exercise, NSAIDS, etc.) this information alone was sufficient to support medical necessity. The trend in the clinical guidelines now state that the medical record includes physician office notes indicate failure of medically supervised conservative management, including but not limited to compression stocking therapy for
The terms about this type of requirement vary. It is sometimes called medical management, supervised trial, or ordered by the treating physician. It all translates to the same end result. You must place the patient in compression hose and follow the patient's conservative therapy for the (typically) 90 days.
Obviously this causes some issues in scheduling timelines for treatment, but after the initial stall with these payers, this should even out. When doing a supervised trial, the patient should be brought back into the office at intervals to assess the success or failure of the conservative treatment and at the end of the trial. If appropriate, a new diagnostic US to clearly show that the symptoms and disease has not changed would be indicated. (Please check your payer policy to ensure that there are no limitations on this service as well.)
You may also want to consider selling the compression hose in your office. While some payers do not cover the stockings, others do. By selling, and then submitting the claim to their insurance plan, you have another record that the patient did indeed have the hose with them when leaving your office.
While this has language has been around for a while, it was mainly confined to isolated local payers. With this addition to Cigna's policy, as well to various Medicare guidelines and several of the Blues plans, it has now "made the big time".
As always, we at American Physician cannot stress enough; check your payer's policies often to ensure you are meeting their guidelines!
Blues Audit to Recoup $72,000
A Cautionary Tale
by AJ Riviezzo
A provider was audited by the Blues in their home state. They reviewed twenty charts. Not very many overall. Based on these twenty charts the determined that the level of coding for new patient and current patient office visits was not supported by the documentation. The Blues determined that instead of a 3 level code, they would only allow a 1 or 2 level code.
A dollar difference was determined and then applied to ALL of the office visit codes for the past three years. While an office visit may not be a large dollar item, and while the difference between the 2 level and the 3 level codes is not large either; when multiplied by a large number of office visits for three years... the dollar figure does indeed become large.
Given the various Medicare audits and the increasing reality of commercial audits, it is critical to ensure your charts match your coding.
Please have someone external review your charting. It is difficult to 'proof' your own work with an objective eye. In the above example the physician was spending a good bit of time with each patient. As such, this good doctor fully believe that this would justify the code levels selected. An internal audit would have supported that conclusion. Unfortunately an external audit conducted by personnel who do not already 'know' how much time is being spent will derive a different determination.
The above information is not designed to drum up business for my company. Please just use someone with good coding training that is external to your system to perform a bill-to-chart audit.
by AJ Riviezzo
A provider was audited by the Blues in their home state. They reviewed twenty charts. Not very many overall. Based on these twenty charts the determined that the level of coding for new patient and current patient office visits was not supported by the documentation. The Blues determined that instead of a 3 level code, they would only allow a 1 or 2 level code.
A dollar difference was determined and then applied to ALL of the office visit codes for the past three years. While an office visit may not be a large dollar item, and while the difference between the 2 level and the 3 level codes is not large either; when multiplied by a large number of office visits for three years... the dollar figure does indeed become large.
Given the various Medicare audits and the increasing reality of commercial audits, it is critical to ensure your charts match your coding.
Please have someone external review your charting. It is difficult to 'proof' your own work with an objective eye. In the above example the physician was spending a good bit of time with each patient. As such, this good doctor fully believe that this would justify the code levels selected. An internal audit would have supported that conclusion. Unfortunately an external audit conducted by personnel who do not already 'know' how much time is being spent will derive a different determination.
The above information is not designed to drum up business for my company. Please just use someone with good coding training that is external to your system to perform a bill-to-chart audit.
CIGNA Changes
More Fun by a Payer
by AJ Riviezzo
Our friends at CIGNA are now placing a limitation of services on their policies (those that even have ablations allowed in the first place). They will only authorize two vein treatments per year. There is an exception as you may call to re-authorize if there is a compelling need.
For example, Ms. Smith needs both GSV's and SSV's treated. You decide to authorize and treat the two GSV's. Now, at the one month follow-up visit, Ms. Smith's SSV's show no improvement and she still complains of pain, swelling and night-cramps. You may be able to get this treatment authorized but it will require another request and likely further documentation. Dependent on how the guidelines are being interpreted, you may have to hold a peer-to-peer conversation with the CIGNA Medical Director.
CIGNA has also recently announced in one of their online newsletters that the focus for audits this year is... Evaluation and Management coding. In keeping with our article above, please ensure your documentation is bullet proof. Everyone appears to have focused on this area this year. Not because of the high dollars but because of the ease in which they can find fault. Even if you are using an EMR, there can still be some nuances that are missed. Please have your work proofed.
by AJ Riviezzo
Our friends at CIGNA are now placing a limitation of services on their policies (those that even have ablations allowed in the first place). They will only authorize two vein treatments per year. There is an exception as you may call to re-authorize if there is a compelling need.
For example, Ms. Smith needs both GSV's and SSV's treated. You decide to authorize and treat the two GSV's. Now, at the one month follow-up visit, Ms. Smith's SSV's show no improvement and she still complains of pain, swelling and night-cramps. You may be able to get this treatment authorized but it will require another request and likely further documentation. Dependent on how the guidelines are being interpreted, you may have to hold a peer-to-peer conversation with the CIGNA Medical Director.
CIGNA has also recently announced in one of their online newsletters that the focus for audits this year is... Evaluation and Management coding. In keeping with our article above, please ensure your documentation is bullet proof. Everyone appears to have focused on this area this year. Not because of the high dollars but because of the ease in which they can find fault. Even if you are using an EMR, there can still be some nuances that are missed. Please have your work proofed.
Wednesday, February 23, 2011
Insurance Plan Riders
Sneaky Exclusions
by AJ Riviezzo and Cheryl Nash
We have seen a growing use of 'riders' for self funded plans. To help keep premium costs low, these self funded plans have carved a number of niches or riders out of the normal plan. We have seen a growing number of these riders being focused on varicose vein treatments. In short with these riders, the patient has no coverage or may have very different benefits.
The difficulty is that the administering plan's front line people are unaware of these riders and frequently give incorrect benefit information. While you can sometimes use a complaint about incorrect information to eventually get paid, it is, at best, a gamble that takes up to a year to pay off.
If you are working with payers that typically administer self funded plans who may have a rider (CIGNA, Multiplan, some Blues plans), you may want to verify a little bit more. Ask the clerk if this is a 3rd party administered plan and if there are any exclusions. You may want to go ahead and have the claim reviewed by the pre-determination folks for that payer to ensure payment. We realize these extra steps take time and effort, but it is much better than giving care away unintentionally.
by AJ Riviezzo and Cheryl Nash
We have seen a growing use of 'riders' for self funded plans. To help keep premium costs low, these self funded plans have carved a number of niches or riders out of the normal plan. We have seen a growing number of these riders being focused on varicose vein treatments. In short with these riders, the patient has no coverage or may have very different benefits.
The difficulty is that the administering plan's front line people are unaware of these riders and frequently give incorrect benefit information. While you can sometimes use a complaint about incorrect information to eventually get paid, it is, at best, a gamble that takes up to a year to pay off.
If you are working with payers that typically administer self funded plans who may have a rider (CIGNA, Multiplan, some Blues plans), you may want to verify a little bit more. Ask the clerk if this is a 3rd party administered plan and if there are any exclusions. You may want to go ahead and have the claim reviewed by the pre-determination folks for that payer to ensure payment. We realize these extra steps take time and effort, but it is much better than giving care away unintentionally.
AETNA Clinical Bulletin
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Authorizations
Grab a Bunch
by AJ Riviezzo
When obtaining the authorization for the ablation, we also recommend obtaining the authorization for any additional services you routinely provide. Let us presuppose in your practice you average one phlebectomy for every two ablations and one to two medically necessary sclero procedures for every ablation. When obtaining the authorization for the ablation, we would recommend going forward and obtaining the all of the necessary authorization for the phlebectomy and the sclerotherapy as well.
Using the above assumptions, for two ablations we would also ask for two phlebectomies and four sclerotherapy authorizations; for four ablations, you would request four phlebectomies and eight sclerotherapy authorizations. It is usually much easier to obtain the authorizations for the attendant services up front than after you have initiated treatment.
One thing to remember is that authorizations are typically time sensitive. The authorization for some of these attendant services could expire before you are able to use them. If so, you can typically ask for the authorization termination date to be extended. If not, you can also just request a new authorization. As they have previously authorized the service, it tends to be very easy to obtain a new authorization.
If you never use an authorization, no problem. If you do not have an authorization and need one, big problem.
by AJ Riviezzo
When obtaining the authorization for the ablation, we also recommend obtaining the authorization for any additional services you routinely provide. Let us presuppose in your practice you average one phlebectomy for every two ablations and one to two medically necessary sclero procedures for every ablation. When obtaining the authorization for the ablation, we would recommend going forward and obtaining the all of the necessary authorization for the phlebectomy and the sclerotherapy as well.
Using the above assumptions, for two ablations we would also ask for two phlebectomies and four sclerotherapy authorizations; for four ablations, you would request four phlebectomies and eight sclerotherapy authorizations. It is usually much easier to obtain the authorizations for the attendant services up front than after you have initiated treatment.
One thing to remember is that authorizations are typically time sensitive. The authorization for some of these attendant services could expire before you are able to use them. If so, you can typically ask for the authorization termination date to be extended. If not, you can also just request a new authorization. As they have previously authorized the service, it tends to be very easy to obtain a new authorization.
If you never use an authorization, no problem. If you do not have an authorization and need one, big problem.
Tuesday, January 25, 2011
Coding Clarification
Stabs 1 - 9
by Cheryl Nash and AJ Riviezzo
In the past, there have been some variances in the code used for noting less than ten stabs performed during a phlebectomy. The new guidelines have clearly defined using the 37799 code. You must note the number of stabs actually performed in block 19 of the CMS-1500 billing form or electronic version of the same.
Reimbursement may be interesting as this is generic code without hard-wired pricing tied to the code (one reason you have to note the number of stabs). As with the sclerotherapy injections noted above, this is a surgical procedure and it requires a procedure note stating where, how and why the phlebectomy was performed.
by Cheryl Nash and AJ Riviezzo
In the past, there have been some variances in the code used for noting less than ten stabs performed during a phlebectomy. The new guidelines have clearly defined using the 37799 code. You must note the number of stabs actually performed in block 19 of the CMS-1500 billing form or electronic version of the same.
Reimbursement may be interesting as this is generic code without hard-wired pricing tied to the code (one reason you have to note the number of stabs). As with the sclerotherapy injections noted above, this is a surgical procedure and it requires a procedure note stating where, how and why the phlebectomy was performed.
The History and Physical
Your Presentation of the Patient to the Payer
by AJ Riviezzo, MBA
We have been noting, for several years now, the importance of documentation to ensure your practice can survive an audit. We now have a real life customer that has been on the receiving end of a ZPIC audit. The key issue upon which the audit rested was indeed the History and Physical documentation.
While this practice had been performing a more than sufficient examination of their patients, the data was primarily contained in a patient completed form and a physician completed form with minimal narrative elements. It was this lack of narrative report that deemed the documentation as insufficient to support the recommended course of treatment. In essence, while the data was obtained it was not verbalized in a way that Medicare's audit team would accept as appropriate.
Whether or not you are writing your own History and Physicals or using an EMR such as StreamlineMD or Sonosoft, there are some essential components that must be included in your report. Medicare has detailed three key components. These are:
1. History - The history must contain a Chief Complaint, a history of the present illness, a review of systems (ROS) and a past family and social history (PFSH). The extent of the above, which is obtained and documented, is dependent upon clinical judgment and the nature of the presenting problem. In other words, the documentation needs to clearly support why you are treating the patient.
The patient self-report elements (ROS and PFSH) need to be incorporated into your History and Physical by reference which both acknowledges the report was reviewed and considered regarding the patient's potential course of treatment.
Per CMS guidelines, "The Chief Complaint is a precise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter. Documentation requires that the medical record should clearly reflect the Chief Complaint." Under the Chief Complaint you should list the history of the present illness (HPI). Again per CMS guidelines, "The HPI is a chronological description of the development of a patient's present illness from the first sign or symptom or the previous encounter to the present. It contains the following elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms." For phlebology, you should describe four or more of these elements so as to include conservative therapy attempts.
It is this section in which most physician's documentation appears to fall short. We strongly recommend performing at least a self audit of this section of your H and P.
2. Examination - A standard examination should be performed including vital signs, general appearance, cardiovascular system, skin, and each extremity at a minimum. If the body area or organ system is normal, a notation indicating negative or normal is sufficient. However, if the organ system or body area is abnormal or symptomatic you must describe your findings in sufficient detail. For the phlebology practice you need to ensure robust documentation of any findings that pertain to the CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system for venous disease.
3. Medical Decision Making - For each encounter, an assessment, clinical impression or diagnosis should be documented. This may be stated or implied in documented decisions regarding the patient's care management plan or needed further evaluation. If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the office visit, the type of service should be documented. For a phlebology practice, this means the diagnostic ultrasound needs to be noted as ordered and why. The results of any diagnostic tests should be documented in the H and P as well.
If you are performing the diagnostic ultrasound prior to performing the H and P, the decision for ordering the diagnostic test and the results should be clearly documented.
When you are noting the plan of care, the documentation must also contain a mention of any risk of significant complications, morbidity or mortality. A reference to ulcerations or DVT's would be appropriate in this section along with any patient specific risks.
A practice needs to ensure these elements are met in their documentation. While this is time consuming and not terribly exciting, it is much better to spend that little extra effort now then when facing an audit. We again recommend you perform a self-audit or have someone external review your documentation to ensure compliance.
by AJ Riviezzo, MBA
We have been noting, for several years now, the importance of documentation to ensure your practice can survive an audit. We now have a real life customer that has been on the receiving end of a ZPIC audit. The key issue upon which the audit rested was indeed the History and Physical documentation.
While this practice had been performing a more than sufficient examination of their patients, the data was primarily contained in a patient completed form and a physician completed form with minimal narrative elements. It was this lack of narrative report that deemed the documentation as insufficient to support the recommended course of treatment. In essence, while the data was obtained it was not verbalized in a way that Medicare's audit team would accept as appropriate.
Whether or not you are writing your own History and Physicals or using an EMR such as StreamlineMD or Sonosoft, there are some essential components that must be included in your report. Medicare has detailed three key components. These are:
1. History - The history must contain a Chief Complaint, a history of the present illness, a review of systems (ROS) and a past family and social history (PFSH). The extent of the above, which is obtained and documented, is dependent upon clinical judgment and the nature of the presenting problem. In other words, the documentation needs to clearly support why you are treating the patient.
The patient self-report elements (ROS and PFSH) need to be incorporated into your History and Physical by reference which both acknowledges the report was reviewed and considered regarding the patient's potential course of treatment.
Per CMS guidelines, "The Chief Complaint is a precise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter. Documentation requires that the medical record should clearly reflect the Chief Complaint." Under the Chief Complaint you should list the history of the present illness (HPI). Again per CMS guidelines, "The HPI is a chronological description of the development of a patient's present illness from the first sign or symptom or the previous encounter to the present. It contains the following elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms." For phlebology, you should describe four or more of these elements so as to include conservative therapy attempts.
It is this section in which most physician's documentation appears to fall short. We strongly recommend performing at least a self audit of this section of your H and P.
2. Examination - A standard examination should be performed including vital signs, general appearance, cardiovascular system, skin, and each extremity at a minimum. If the body area or organ system is normal, a notation indicating negative or normal is sufficient. However, if the organ system or body area is abnormal or symptomatic you must describe your findings in sufficient detail. For the phlebology practice you need to ensure robust documentation of any findings that pertain to the CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system for venous disease.
3. Medical Decision Making - For each encounter, an assessment, clinical impression or diagnosis should be documented. This may be stated or implied in documented decisions regarding the patient's care management plan or needed further evaluation. If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the office visit, the type of service should be documented. For a phlebology practice, this means the diagnostic ultrasound needs to be noted as ordered and why. The results of any diagnostic tests should be documented in the H and P as well.
If you are performing the diagnostic ultrasound prior to performing the H and P, the decision for ordering the diagnostic test and the results should be clearly documented.
When you are noting the plan of care, the documentation must also contain a mention of any risk of significant complications, morbidity or mortality. A reference to ulcerations or DVT's would be appropriate in this section along with any patient specific risks.
A practice needs to ensure these elements are met in their documentation. While this is time consuming and not terribly exciting, it is much better to spend that little extra effort now then when facing an audit. We again recommend you perform a self-audit or have someone external review your documentation to ensure compliance.
Sclerotherapy Injections
One Lump or Two?
by Cheryl Nash and AJ Riviezzo
Many practices are in the habit of automatically using the CPT code 36471 - sclerotherapy injection. We would caution selecting the correct code based on the number of veins injected. Code 36471 is used for injection into two or more veins. If only one vein is being injected, regardless of the number of injections, you should use CPT code 36470 - sclerotherapy injection, single vein. Reimbursement is, of course, a bit less than the 36471, sclerotherapy injection, multiple veins (by about $30).
You can still perform bilateral injections even if one injection is into multiple veins and one is into only one vein. Coding would be 36471 (RT or LT) and 36470 (RT or LT). Do not forget to bill for your diagnostic ultrasound prior to the procedure when you re-map the leg (93970 or 93971) and for the utrasound needle guidance if performed (76942 RT or LT).
Finally, Medicare and the commercial payers treat this as a surgical procedure. There should be a procedure report for your non-cosmetic sclerotherapy injections stating where, how, and why the injection was performed.
by Cheryl Nash and AJ Riviezzo
Many practices are in the habit of automatically using the CPT code 36471 - sclerotherapy injection. We would caution selecting the correct code based on the number of veins injected. Code 36471 is used for injection into two or more veins. If only one vein is being injected, regardless of the number of injections, you should use CPT code 36470 - sclerotherapy injection, single vein. Reimbursement is, of course, a bit less than the 36471, sclerotherapy injection, multiple veins (by about $30).
You can still perform bilateral injections even if one injection is into multiple veins and one is into only one vein. Coding would be 36471 (RT or LT) and 36470 (RT or LT). Do not forget to bill for your diagnostic ultrasound prior to the procedure when you re-map the leg (93970 or 93971) and for the utrasound needle guidance if performed (76942 RT or LT).
Finally, Medicare and the commercial payers treat this as a surgical procedure. There should be a procedure report for your non-cosmetic sclerotherapy injections stating where, how, and why the injection was performed.
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