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.
Tuesday, January 25, 2011
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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