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!

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.

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.