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.
Friday, June 24, 2011
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
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