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.
Tuesday, November 29, 2011
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
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