Conservative Treatment Changes

Documenting Stockings
by Cheryl Nash and AJ Riviezzo
In the past the patient report regarding the wearing of compression stockings was sufficient. Unfortunately, a passing 'nod' is no longer sufficient by a growing list of payers. With the Phlebology requirements becoming more and more payer specific, a trend has been emerging that may change the way you document conservative treatment.

In the past if a patient stated that they had worn compression stockings and tried other forms of conservative treatment, (leg elevation, exercise, NSAIDS, etc.) this information alone was sufficient to support medical necessity. The trend in the clinical guidelines now state that the medical record includes physician office notes indicate failure of medically supervised conservative management, including but not limited to compression stocking therapy for . (Excerpt from Cigna Medical Coverage Policy #0234).

The terms about this type of requirement vary. It is sometimes called medical management, supervised trial, or ordered by the treating physician. It all translates to the same end result. You must place the patient in compression hose and follow the patient's conservative therapy for the (typically) 90 days.

Obviously this causes some issues in scheduling timelines for treatment, but after the initial stall with these payers, this should even out. When doing a supervised trial, the patient should be brought back into the office at intervals to assess the success or failure of the conservative treatment and at the end of the trial. If appropriate, a new diagnostic US to clearly show that the symptoms and disease has not changed would be indicated. (Please check your payer policy to ensure that there are no limitations on this service as well.)

You may also want to consider selling the compression hose in your office. While some payers do not cover the stockings, others do. By selling, and then submitting the claim to their insurance plan, you have another record that the patient did indeed have the hose with them when leaving your office.

While this has language has been around for a while, it was mainly confined to isolated local payers. With this addition to Cigna's policy, as well to various Medicare guidelines and several of the Blues plans, it has now "made the big time".

As always, we at American Physician cannot stress enough; check your payer's policies often to ensure you are meeting their guidelines!

Blues Audit to Recoup $72,000

A Cautionary Tale
by AJ Riviezzo
A provider was audited by the Blues in their home state. They reviewed twenty charts. Not very many overall. Based on these twenty charts the determined that the level of coding for new patient and current patient office visits was not supported by the documentation. The Blues determined that instead of a 3 level code, they would only allow a 1 or 2 level code.

A dollar difference was determined and then applied to ALL of the office visit codes for the past three years. While an office visit may not be a large dollar item, and while the difference between the 2 level and the 3 level codes is not large either; when multiplied by a large number of office visits for three years... the dollar figure does indeed become large.

Given the various Medicare audits and the increasing reality of commercial audits, it is critical to ensure your charts match your coding.

Please have someone external review your charting. It is difficult to 'proof' your own work with an objective eye. In the above example the physician was spending a good bit of time with each patient. As such, this good doctor fully believe that this would justify the code levels selected. An internal audit would have supported that conclusion. Unfortunately an external audit conducted by personnel who do not already 'know' how much time is being spent will derive a different determination.

The above information is not designed to drum up business for my company. Please just use someone with good coding training that is external to your system to perform a bill-to-chart audit.

CIGNA Changes

More Fun by a Payer
by AJ Riviezzo
Our friends at CIGNA are now placing a limitation of services on their policies (those that even have ablations allowed in the first place). They will only authorize two vein treatments per year. There is an exception as you may call to re-authorize if there is a compelling need.

For example, Ms. Smith needs both GSV's and SSV's treated. You decide to authorize and treat the two GSV's. Now, at the one month follow-up visit, Ms. Smith's SSV's show no improvement and she still complains of pain, swelling and night-cramps. You may be able to get this treatment authorized but it will require another request and likely further documentation. Dependent on how the guidelines are being interpreted, you may have to hold a peer-to-peer conversation with the CIGNA Medical Director.

CIGNA has also recently announced in one of their online newsletters that the focus for audits this year is... Evaluation and Management coding. In keeping with our article above, please ensure your documentation is bullet proof. Everyone appears to have focused on this area this year. Not because of the high dollars but because of the ease in which they can find fault. Even if you are using an EMR, there can still be some nuances that are missed. Please have your work proofed.

Insurance Plan Riders

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.

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.

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.

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.

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.

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.

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.