Medicare Appreciation Month
by Marcy Riviezzo and AJ Riviezzo
Unless we have completely scarred you off from seeing Medicare patients, January is a good month for treating your Medicare patients. The reason for this is deductibles. Your commercial patients have typically just entered their new deductible cycle for the year. They may be reticent to begin treatment on something that is a bit elective. Medicare members typically have a secondary policy that absorbs their small deductible.
Reach out to your referring PCP's. Let them know that January is your Medicare appreciation month. It is an 'excuse' to re-market to these physicians, their office manager, and their referring coordinator.
Also reach out to your existing patients and database. Send a letter to all of your current and former Medicare patients thanking them for having chosen your practice for receiving their care. In it you can mention it is Medicare Appreciation Month and that you would be happy to meet their friends or neighbors if they have a need for your services. You might offer them a $10 gift card (see above limitations) for any of their referrals as a further thank you.
Finally, there are likely some retirement communities in your area. Find out if they have a physician day or similar program in which you can participate. Spend an hour or two explaining venous disease and answering the communities questions. You can bring a portable ultrasound machine and show how it works by using a volunteer. This type of outreach has proven very successful for a number of practices.
Tuesday, December 14, 2010
Free Screenings
Federal Anti-Kickback Laws
by AJ Riviezzo, MBA
Our last email contained information regarding ZPIC audits. This generated a discussion with Dr. Calcagno regarding potential concerns with performing free screenings on federal health care program patients (Medicare, Medicaid, TriCare, CHAMPUS, VA, CHP or Indian Health Service). It turns out there is some cause for concern. The Office of the Inspector General (OIG) is potentially concerned with free screenings as it may constitute an impermissible kickback to the patient.
The OIG does allow a nominal incentive to be given. The nominal value is typically set at $10.00 per item or $50 total per year per 65 Fed. Reg. 24400, 24410-24411 dated April 26, 2000. A pretty low value which I am sure has not been adjusted for inflation.
Our recommendation is to establish a value for your 'education services' at $10.00. In essence, that is what the free consultation is... education services. You are providing a small bit of information about the underlying issues and current treatment methodologies for their possible condition. As a matter of course, you adjust these services down to zero for all patients.
A thank you to Dr. Calcagno for creating such an interesting discussion.
by AJ Riviezzo, MBA
Our last email contained information regarding ZPIC audits. This generated a discussion with Dr. Calcagno regarding potential concerns with performing free screenings on federal health care program patients (Medicare, Medicaid, TriCare, CHAMPUS, VA, CHP or Indian Health Service). It turns out there is some cause for concern. The Office of the Inspector General (OIG) is potentially concerned with free screenings as it may constitute an impermissible kickback to the patient.
The OIG does allow a nominal incentive to be given. The nominal value is typically set at $10.00 per item or $50 total per year per 65 Fed. Reg. 24400, 24410-24411 dated April 26, 2000. A pretty low value which I am sure has not been adjusted for inflation.
Our recommendation is to establish a value for your 'education services' at $10.00. In essence, that is what the free consultation is... education services. You are providing a small bit of information about the underlying issues and current treatment methodologies for their possible condition. As a matter of course, you adjust these services down to zero for all patients.
A thank you to Dr. Calcagno for creating such an interesting discussion.
Diagnosis Coding
A New Delay Scenario
by Cheryl Nash and AJ Riviezzo
When coding (diagnosis) for a diagnostic ultrasound and new patient visit, we recommend coding with the patient's presenting complaints and symptoms. For example, if the patient has swelling of the legs as well as pain in the legs then you would use the ICD-9 codes for these two elements (729.81 and 729.5 respectively). After you have reviewed the patient's condition and made a medical diagnosis you then begin using a more comprehensive diagnosis like Varicose Veins of Lower Extremities with Other Complications of Edema, Pain and Swelling (454.8).
United Healthcare and payers who use Ingenix as their data source for coding are now beginning to hold any claims with a primary diagnosis of Pain in Limb (729.5). They are automatically generating a letter to the patient as if the patient was in an accident. The patient is supposed to note the accident date and time and return the form. Since there was no accident, many of the patients are disregarding the letter. Throughout this process, your claim remains unpaid. I do remember when automation was supposed to help drive down health care costs...
We are, therefore, recommending a primary diagnosis (should the patient have these symptoms) of venous insufficiency (459.81) with pain in limb being your secondary or tertiary diagnosis. This will help ensure your claim is paid in a timely fashion without the delays associated with an accident investigation.
by Cheryl Nash and AJ Riviezzo
When coding (diagnosis) for a diagnostic ultrasound and new patient visit, we recommend coding with the patient's presenting complaints and symptoms. For example, if the patient has swelling of the legs as well as pain in the legs then you would use the ICD-9 codes for these two elements (729.81 and 729.5 respectively). After you have reviewed the patient's condition and made a medical diagnosis you then begin using a more comprehensive diagnosis like Varicose Veins of Lower Extremities with Other Complications of Edema, Pain and Swelling (454.8).
United Healthcare and payers who use Ingenix as their data source for coding are now beginning to hold any claims with a primary diagnosis of Pain in Limb (729.5). They are automatically generating a letter to the patient as if the patient was in an accident. The patient is supposed to note the accident date and time and return the form. Since there was no accident, many of the patients are disregarding the letter. Throughout this process, your claim remains unpaid. I do remember when automation was supposed to help drive down health care costs...
We are, therefore, recommending a primary diagnosis (should the patient have these symptoms) of venous insufficiency (459.81) with pain in limb being your secondary or tertiary diagnosis. This will help ensure your claim is paid in a timely fashion without the delays associated with an accident investigation.
Tuesday, November 16, 2010
Review the Payer Guidelines
Knowledge is Essential
by Cheryl Nash and AJ Riviezo
Most commercial insurances and Medicare have clinical guidelines they review one to two times per year. It is essential that you are operating under the most current guidelines. As the United example shows, the changes can be dramatic and result in denials.
One way to ensure you are reviewing your top payers on a regular basis is to see if they have a 'Next Review Date' listed on the current guidelines. You can place a note on your calendar to go to that payer's guidelines and see if there is a new publication of the guideline or if the date has been changed. Key elements to review are changes in documentation requirements, changes in medical necessity requirements, and changes in conservative therapy. Be sure to read the fine print. Sometimes the changes are in the addendums or are a few words hiding in the middle of what appears to be an unchanged paragraph.
by Cheryl Nash and AJ Riviezo
Most commercial insurances and Medicare have clinical guidelines they review one to two times per year. It is essential that you are operating under the most current guidelines. As the United example shows, the changes can be dramatic and result in denials.
One way to ensure you are reviewing your top payers on a regular basis is to see if they have a 'Next Review Date' listed on the current guidelines. You can place a note on your calendar to go to that payer's guidelines and see if there is a new publication of the guideline or if the date has been changed. Key elements to review are changes in documentation requirements, changes in medical necessity requirements, and changes in conservative therapy. Be sure to read the fine print. Sometimes the changes are in the addendums or are a few words hiding in the middle of what appears to be an unchanged paragraph.
ZPIC Audits
Is Phlebology Being Targeted?
by AJ Riviezzo, MBA
The new Zone Program Integrity Audits (ZPIC), which have been in the making for several years, have really begun to be conducted over the past three months. The goal of these audits is to detect fraud and abuse in Medicare claims. These audits are being done by sub-contractors on behalf of the Medicare Administrative Contractors (MAC). It also appears that these several sub-contractors are paid only on the 'found' dollars. This lends serious concerns regarding their processes and the neutrality of the review.
Further, the rules (like those surrounding the RAC audits) were never formalized by Congress. This is allowing the ZPIC sub-contractors to devise their own rules and regulations regarding the process. These rules are certainly not provider friendly to date. It has also created a significant variance between Zones on how these audits are being conducted. In one area it appears they are being treated much like the RAC audits with thirty charts being reviewed on a retrospective review. In another area, ALL claims are being reviewed with payments being denied prospectively, with virtually no feedback as to the reason why save the standard Medicare denial codes.
Attempts to gain further information have, to date, been difficult. One phlebology provider has basically been told that it is not the ZPIC contractor's responsibility to 'educate' the provider, and yet they are still holding essentially all payments prospectively. Thankfully this provider has a relatively small percentage of Medicare patients as part of their payer mix. For a provider with a large Medicare mix, this is tantamount to a forced closure.
Is phlebology being targeted? The author cannot state that it is. However, two phlebology practices are already in review that we know about. Given the small number of providers in review by these ZPIC contractors and given the even smaller percentage of all providers that perform ablations, it does give one serious pause for concern.
So what is a practice to do proactively? First, we recommend that you re-read your Local Coverage Determinations (LCD) regarding phlebology services for your area. Make sure your patients are meeting the medical necessity requirements outlined in the LCD.
Second, the LCD may also have documentation requirements that are specifically required on each chart or operative note. Please review your documentation against these requirements. You may also want to have an external agency conduct a chart-to-bill, bill-to-chart audit. Yes, you can do these on your own but it is a bit like proof-reading your own work. An outside eye will not overlook 'assumed' elements.
What are the next steps should your practice be contacted by ZPIC? The request from ZPIC will be for copies of your charts. We recommend sending, as quickly as possible, the copies requested. Typically they are requesting for a specific date of service. We recommend sending all of the documentation necessary for that specific date (e.g. Diagnostic Ultrasound, History and Physical, Operative Note, any other documentation). If they request records for multiple dates of service, send the same type of packet for each date of service. Do not assume they will copy the Diagnostic Ultrasound and attach it to each date of service. They will not do so. We also suggest that you immediately contact an attorney in your area with some ZPIC or at least RAC audit experience.
Now to the vaguely good news. Once ZPIC has denied your claims (recent experience shows a denial rate of over 95%), you can then appeal these denials through the Medicare system. Medicare has five levels of appeal that can be attempted. These are:
1. Redetermination. This goes through MAC and is basically to keep the claims open for additional appeal processes. On the average 50% of claim denials are overturned at this stage.
2. Reconsideration. These appeals go through a completely different department, usually a Physician panel, for review. These reviewers do not work for Medicare or the ZPIC contractor, and are not paid by the denial. (this is a completely independent review team).
3. Administrative Law Judge Hearing. Established for any outstanding claims over $130.00. This stage allows for a teleconference with a legal entity to discuss the medical necessity of the services, and functions like a peer-to-peer review. There is a high level of success at this stage of appeals.
4. Medicare Appeal Council Review. This is an independent team of professionals tasked with reviewing the decision made by the ALJ panel. Any contested issues found in the ALJ hearing will be reviewed here.
5. District Court. Established for any claims over $1260.00. You may request a review in district court.
The encouraging news is that at the 3rd level of appeal, if a physician's services may not have exactly met criteria set forth by the MAC, the claims may still be considered for payment if the physician is able to state, in a concrete fashion, as to why the services were necessary and prudent.
In short, these ZPIC audits are looking to be both unpleasant and expensive with few guidelines that are required to be followed. It appears the assumption is that fraud has been committed unless proven otherwise. Review your documentation, medical necessity assumptions, and the Local Coverage Determinations soon.
by AJ Riviezzo, MBA
The new Zone Program Integrity Audits (ZPIC), which have been in the making for several years, have really begun to be conducted over the past three months. The goal of these audits is to detect fraud and abuse in Medicare claims. These audits are being done by sub-contractors on behalf of the Medicare Administrative Contractors (MAC). It also appears that these several sub-contractors are paid only on the 'found' dollars. This lends serious concerns regarding their processes and the neutrality of the review.
Further, the rules (like those surrounding the RAC audits) were never formalized by Congress. This is allowing the ZPIC sub-contractors to devise their own rules and regulations regarding the process. These rules are certainly not provider friendly to date. It has also created a significant variance between Zones on how these audits are being conducted. In one area it appears they are being treated much like the RAC audits with thirty charts being reviewed on a retrospective review. In another area, ALL claims are being reviewed with payments being denied prospectively, with virtually no feedback as to the reason why save the standard Medicare denial codes.
Attempts to gain further information have, to date, been difficult. One phlebology provider has basically been told that it is not the ZPIC contractor's responsibility to 'educate' the provider, and yet they are still holding essentially all payments prospectively. Thankfully this provider has a relatively small percentage of Medicare patients as part of their payer mix. For a provider with a large Medicare mix, this is tantamount to a forced closure.
Is phlebology being targeted? The author cannot state that it is. However, two phlebology practices are already in review that we know about. Given the small number of providers in review by these ZPIC contractors and given the even smaller percentage of all providers that perform ablations, it does give one serious pause for concern.
So what is a practice to do proactively? First, we recommend that you re-read your Local Coverage Determinations (LCD) regarding phlebology services for your area. Make sure your patients are meeting the medical necessity requirements outlined in the LCD.
Second, the LCD may also have documentation requirements that are specifically required on each chart or operative note. Please review your documentation against these requirements. You may also want to have an external agency conduct a chart-to-bill, bill-to-chart audit. Yes, you can do these on your own but it is a bit like proof-reading your own work. An outside eye will not overlook 'assumed' elements.
What are the next steps should your practice be contacted by ZPIC? The request from ZPIC will be for copies of your charts. We recommend sending, as quickly as possible, the copies requested. Typically they are requesting for a specific date of service. We recommend sending all of the documentation necessary for that specific date (e.g. Diagnostic Ultrasound, History and Physical, Operative Note, any other documentation). If they request records for multiple dates of service, send the same type of packet for each date of service. Do not assume they will copy the Diagnostic Ultrasound and attach it to each date of service. They will not do so. We also suggest that you immediately contact an attorney in your area with some ZPIC or at least RAC audit experience.
Now to the vaguely good news. Once ZPIC has denied your claims (recent experience shows a denial rate of over 95%), you can then appeal these denials through the Medicare system. Medicare has five levels of appeal that can be attempted. These are:
1. Redetermination. This goes through MAC and is basically to keep the claims open for additional appeal processes. On the average 50% of claim denials are overturned at this stage.
2. Reconsideration. These appeals go through a completely different department, usually a Physician panel, for review. These reviewers do not work for Medicare or the ZPIC contractor, and are not paid by the denial. (this is a completely independent review team).
3. Administrative Law Judge Hearing. Established for any outstanding claims over $130.00. This stage allows for a teleconference with a legal entity to discuss the medical necessity of the services, and functions like a peer-to-peer review. There is a high level of success at this stage of appeals.
4. Medicare Appeal Council Review. This is an independent team of professionals tasked with reviewing the decision made by the ALJ panel. Any contested issues found in the ALJ hearing will be reviewed here.
5. District Court. Established for any claims over $1260.00. You may request a review in district court.
The encouraging news is that at the 3rd level of appeal, if a physician's services may not have exactly met criteria set forth by the MAC, the claims may still be considered for payment if the physician is able to state, in a concrete fashion, as to why the services were necessary and prudent.
In short, these ZPIC audits are looking to be both unpleasant and expensive with few guidelines that are required to be followed. It appears the assumption is that fraud has been committed unless proven otherwise. Review your documentation, medical necessity assumptions, and the Local Coverage Determinations soon.
United Health Care Update
Positive Change for Once
by Cheryl Nash and AJ Riviezzo
United Health Care, effective October 25th, 2010, has again revised their medical policy guidelines for ablations. The submission of color photographic prints is no longer required. Also, the submission of US prints is no longer required. It appears their system could not handle the massive amount of data they were receiving thus forcing a change.
The best news coming out of the new policies is that compression stockings are no longer required as a part of conservative treatment. A completed questionnaire addressing the degree and severity of pain still must be submitted for authorization. This questionnaire can be found at: https://www.unitedhealthcareonline.com
The bad news is that diameter sizes have not changed... it is still 5.5mm for GSV, 5mm for SSV. Only one measurement is required. If bleeding or ulceration is present vein sizes of a lower diameter will be accepted.
Perforator size for treatment has dropped to 3.5mm. Additionally, the notes must document the presence of venous stasis ulceration for laser or RF ablation of the perforator.
There are some other requirements so please read the policy for some of the various nuances.
by Cheryl Nash and AJ Riviezzo
United Health Care, effective October 25th, 2010, has again revised their medical policy guidelines for ablations. The submission of color photographic prints is no longer required. Also, the submission of US prints is no longer required. It appears their system could not handle the massive amount of data they were receiving thus forcing a change.
The best news coming out of the new policies is that compression stockings are no longer required as a part of conservative treatment. A completed questionnaire addressing the degree and severity of pain still must be submitted for authorization. This questionnaire can be found at: https://www.unitedhealthcareonline.com
The bad news is that diameter sizes have not changed... it is still 5.5mm for GSV, 5mm for SSV. Only one measurement is required. If bleeding or ulceration is present vein sizes of a lower diameter will be accepted.
Perforator size for treatment has dropped to 3.5mm. Additionally, the notes must document the presence of venous stasis ulceration for laser or RF ablation of the perforator.
There are some other requirements so please read the policy for some of the various nuances.
Friday, October 22, 2010
PAD Requirements
A Growing Trend
by Cheryl Nash and AJ Riviezo
Some payers are requiring a rule out of peripheral artery disease to be contained in the history and physical prior to granting an authorization. One way to add this element is through a pedal pulse examination. Another is to have your RVT (or you as the case may be) perform an ultrasound peripheral arterial examination. The codes for these studies are 93925 bilaterally and 93926 for a single leg examination. The relevant diagnosis code is 459.81 - venous insufficiency.
One concern to consider is the amount of time each patient will be spending prior to any real treatment if you couple an ultrasound arterial examination with a venous examination and the history and physical. Some patients may not be willing to spend that much time being 'worked up'. Discussing the reasons for the amount of time and what each elements helps determine will assist in alleviating this concern.
by Cheryl Nash and AJ Riviezo
Some payers are requiring a rule out of peripheral artery disease to be contained in the history and physical prior to granting an authorization. One way to add this element is through a pedal pulse examination. Another is to have your RVT (or you as the case may be) perform an ultrasound peripheral arterial examination. The codes for these studies are 93925 bilaterally and 93926 for a single leg examination. The relevant diagnosis code is 459.81 - venous insufficiency.
One concern to consider is the amount of time each patient will be spending prior to any real treatment if you couple an ultrasound arterial examination with a venous examination and the history and physical. Some patients may not be willing to spend that much time being 'worked up'. Discussing the reasons for the amount of time and what each elements helps determine will assist in alleviating this concern.
Marketing Thought...
Lunch and Learn with Bariatric Surgeons
by AJ Riviezzo, MBA
When establishing your referral base of physicians, one specialty niche to consider targeting is bariatric surgeons. Patients who receive lap band and other bariatric surgeries frequently have venous insufficiency surface as an issue. Their weight issues were masking the signs and symptoms until they have lost a sufficient amount of weight. A course of stockings to meet conservative therapy guidelines may be required as many of these patients have likely not been wearing compression stockings.
There are some bariatric surgeons who also dabble in phlebology so please ensure you are not marketing to a competitor.
by AJ Riviezzo, MBA
When establishing your referral base of physicians, one specialty niche to consider targeting is bariatric surgeons. Patients who receive lap band and other bariatric surgeries frequently have venous insufficiency surface as an issue. Their weight issues were masking the signs and symptoms until they have lost a sufficient amount of weight. A course of stockings to meet conservative therapy guidelines may be required as many of these patients have likely not been wearing compression stockings.
There are some bariatric surgeons who also dabble in phlebology so please ensure you are not marketing to a competitor.
Quick Information Regarding Ablation of Other Elements
Quick Information Regarding Ablation of Other Elements
by AJ Riviezo, MBA
We are frequently asked if one can perform an RF or laser ablation for a tributary, anterior accessory or perforator - and receive payment for the work.
The answer is, like most everything regarding insurance, perhaps.
First, the vein to be ablated must meet the minimum guidelines that are in place by the payer for the saphenous veins. For example, they may require the vein to be at least 3mm in diameter, showing evidence of reflux, and the patient has to have met conservative treatment guidelines.
Second, please note that many payers believe this procedure should be performed concurrently with an ablation of the saphenous vein. The codes for a second insertion/ablation are 36476 and 36479 for RF or laser. You should have a progress note stating why the patient needs this ablation versus alternative treatment, and why you are recommending this to be a staged procedure.
Next, should you determine that there is a need to stage the procedure and not perform it during the ablation of the saphenous vein, we recommend reviewing the patient insurance carrier's guidelines regarding ablations. Some, like Anthem Blue Cross/Blue Shield, are very clear that they will not authorize the service. Their guidelines note usage of sclerotherapy to resolve these issues after an ablation of the saphenous vein. You will not have to review these guidelines every time but we do recommend reviewing them at least quarterly to check for any changes. Some payers, like Blues of Illinois, changes their guidelines at least once per year.
If you have an authorization (if required), the CPT code used for these ablations is the same as for a saphenous ablation - 36475 for RF ablation and 36478 for laser ablation. Documentation of the procedure is essentially the same save for noting as to why this is a staged procedure.
by AJ Riviezo, MBA
We are frequently asked if one can perform an RF or laser ablation for a tributary, anterior accessory or perforator - and receive payment for the work.
The answer is, like most everything regarding insurance, perhaps.
First, the vein to be ablated must meet the minimum guidelines that are in place by the payer for the saphenous veins. For example, they may require the vein to be at least 3mm in diameter, showing evidence of reflux, and the patient has to have met conservative treatment guidelines.
Second, please note that many payers believe this procedure should be performed concurrently with an ablation of the saphenous vein. The codes for a second insertion/ablation are 36476 and 36479 for RF or laser. You should have a progress note stating why the patient needs this ablation versus alternative treatment, and why you are recommending this to be a staged procedure.
Next, should you determine that there is a need to stage the procedure and not perform it during the ablation of the saphenous vein, we recommend reviewing the patient insurance carrier's guidelines regarding ablations. Some, like Anthem Blue Cross/Blue Shield, are very clear that they will not authorize the service. Their guidelines note usage of sclerotherapy to resolve these issues after an ablation of the saphenous vein. You will not have to review these guidelines every time but we do recommend reviewing them at least quarterly to check for any changes. Some payers, like Blues of Illinois, changes their guidelines at least once per year.
If you have an authorization (if required), the CPT code used for these ablations is the same as for a saphenous ablation - 36475 for RF ablation and 36478 for laser ablation. Documentation of the procedure is essentially the same save for noting as to why this is a staged procedure.
Monday, August 30, 2010
United Healthcare Authorization Process Update
More Requirements by UHC
by Cheryl Nash and AJ Riviezo
Over the past few weeks we have obtained further clarification from Dr. Jeff Mason, Senior Medical Director for United Healthcare (UHC). One of the key questions needing clarification was "pictures of what exactly?". UHC, per Dr. Mason, would like to receive the following from the diagnostic duplex ultrasound:
1) Images (black and white, or color) that show the anatomy and size of the vein at sections relevant to the case. These images can be submitted in hard-copy prints, or, preferably, in a digital file. We do not need a record of the entire exam --- several "snapshots' are enough.
2) We need speed and direction of blood flow information, either from a color doppler print(the colors represent direction and speed of flow) or locations (denoted by cursors) where flow readings were taken.
3) We need a report of the exam including results of the above size of vein and degree and timing of reflux, that is signed, hard copy or electronically, by a physician.
UHC has also already modified their policy regarding the surface skin photos. They now want a ruler showing size next to the problem area(s) as well as the patient name. One group is taping the patient name as a flag on the ruler. Another group has the patient stand in front of a white board and the patient name is written on the white board.
If you or your team have questions regarding any of the new UHC processes, do feel free to call us. We are happy to try and explain the processes as we understand them. No charge. We are all in this boat together! Please ask for Cheryl at 719.955.9128 ext. 203.
by Cheryl Nash and AJ Riviezo
Over the past few weeks we have obtained further clarification from Dr. Jeff Mason, Senior Medical Director for United Healthcare (UHC). One of the key questions needing clarification was "pictures of what exactly?". UHC, per Dr. Mason, would like to receive the following from the diagnostic duplex ultrasound:
1) Images (black and white, or color) that show the anatomy and size of the vein at sections relevant to the case. These images can be submitted in hard-copy prints, or, preferably, in a digital file. We do not need a record of the entire exam --- several "snapshots' are enough.
2) We need speed and direction of blood flow information, either from a color doppler print(the colors represent direction and speed of flow) or locations (denoted by cursors) where flow readings were taken.
3) We need a report of the exam including results of the above size of vein and degree and timing of reflux, that is signed, hard copy or electronically, by a physician.
UHC has also already modified their policy regarding the surface skin photos. They now want a ruler showing size next to the problem area(s) as well as the patient name. One group is taping the patient name as a flag on the ruler. Another group has the patient stand in front of a white board and the patient name is written on the white board.
If you or your team have questions regarding any of the new UHC processes, do feel free to call us. We are happy to try and explain the processes as we understand them. No charge. We are all in this boat together! Please ask for Cheryl at 719.955.9128 ext. 203.
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