Sneaky Exclusions
by AJ Riviezzo and Cheryl Nash
We have seen a growing use of 'riders' for self funded plans. To help keep premium costs low, these self funded plans have carved a number of niches or riders out of the normal plan. We have seen a growing number of these riders being focused on varicose vein treatments. In short with these riders, the patient has no coverage or may have very different benefits.
The difficulty is that the administering plan's front line people are unaware of these riders and frequently give incorrect benefit information. While you can sometimes use a complaint about incorrect information to eventually get paid, it is, at best, a gamble that takes up to a year to pay off.
If you are working with payers that typically administer self funded plans who may have a rider (CIGNA, Multiplan, some Blues plans), you may want to verify a little bit more. Ask the clerk if this is a 3rd party administered plan and if there are any exclusions. You may want to go ahead and have the claim reviewed by the pre-determination folks for that payer to ensure payment. We realize these extra steps take time and effort, but it is much better than giving care away unintentionally.
Wednesday, February 23, 2011
AETNA Clinical Bulletin
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation 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. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation 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. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation 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. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna's Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation 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. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.
After discussing this with an assistant to the Medical Director's office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.
It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual's interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.
Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.
American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.
Authorizations
Grab a Bunch
by AJ Riviezzo
When obtaining the authorization for the ablation, we also recommend obtaining the authorization for any additional services you routinely provide. Let us presuppose in your practice you average one phlebectomy for every two ablations and one to two medically necessary sclero procedures for every ablation. When obtaining the authorization for the ablation, we would recommend going forward and obtaining the all of the necessary authorization for the phlebectomy and the sclerotherapy as well.
Using the above assumptions, for two ablations we would also ask for two phlebectomies and four sclerotherapy authorizations; for four ablations, you would request four phlebectomies and eight sclerotherapy authorizations. It is usually much easier to obtain the authorizations for the attendant services up front than after you have initiated treatment.
One thing to remember is that authorizations are typically time sensitive. The authorization for some of these attendant services could expire before you are able to use them. If so, you can typically ask for the authorization termination date to be extended. If not, you can also just request a new authorization. As they have previously authorized the service, it tends to be very easy to obtain a new authorization.
If you never use an authorization, no problem. If you do not have an authorization and need one, big problem.
by AJ Riviezzo
When obtaining the authorization for the ablation, we also recommend obtaining the authorization for any additional services you routinely provide. Let us presuppose in your practice you average one phlebectomy for every two ablations and one to two medically necessary sclero procedures for every ablation. When obtaining the authorization for the ablation, we would recommend going forward and obtaining the all of the necessary authorization for the phlebectomy and the sclerotherapy as well.
Using the above assumptions, for two ablations we would also ask for two phlebectomies and four sclerotherapy authorizations; for four ablations, you would request four phlebectomies and eight sclerotherapy authorizations. It is usually much easier to obtain the authorizations for the attendant services up front than after you have initiated treatment.
One thing to remember is that authorizations are typically time sensitive. The authorization for some of these attendant services could expire before you are able to use them. If so, you can typically ask for the authorization termination date to be extended. If not, you can also just request a new authorization. As they have previously authorized the service, it tends to be very easy to obtain a new authorization.
If you never use an authorization, no problem. If you do not have an authorization and need one, big problem.
Tuesday, January 25, 2011
Coding Clarification
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.
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.
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.
Tuesday, December 14, 2010
January Marketing Tip
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.
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.
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.
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