With the advent of new treatment options being approved by the FDA, practices are finding their documentation under more scrutiny than previously experienced. This has caused some unforeseen and sometimes surprising results.
When sending claims for an unlisted procedure code for a service that has no defined guidelines, some internal protocols should be implemented. Knowing the basic rules of when to assign an unlisted code is a good place to start.
In brief: When billing for a service or procedure, you must select the CPT or HCPCS code that accurately identifies what was performed; a close approximation is not allowed. If no such code exists, then an appropriate unlisted code should be used. An unlisted code should not be used when a valid code is available. It is the provider’s responsibility to ensure all information needed to process an unlisted code is included with the CMS 1500 form or the Electronic Media Claim. The information needs to be included in box 19 or the electronic equivalent. This must include a concise description of the service performed. Attachments may be submitted. Follow the individual payers’ guidelines for submission of additional information.
A good process to follow can be outlined in a few steps.
First, be sure that the documentation meets all guidelines for medical necessity. Regardless of the modality used for treatment, all interventional services follow some basic guidelines to meet medical necessity.
Next, be sure that the procedure being submitted is very clearly explained in the operative report. A letter describing why the service is indicated instead of more traditional treatments is helpful, along with a comparison to other treatments that are similar in scope of practice to aid the reviewer in understanding and ultimately pricing and payment of the service.
For varicose vein procedures a complete package will include a copy of the patient’s H&P showing the patient’s signs and symptoms, how these affect the patient’s daily activities (ADL’s), what conservative measures were attempted, what was diagnosed, and what treatments were ordered. Also include a copy of the diagnostic ultrasound report showing reflux in the affected veins, any progress notes detailing the failure of conservative management, other conventional treatments tried such as prior EVLA or RF, the operative report for the unlisted service provided, a letter of medical necessity from the provider as mentioned above, the approval from the FDA, any supply invoices to aid with pricing, and any other supporting documentation that may be relevant.
This seems like a lot of information, but is absolutely necessary to speed processing for claims using these codes. TMI (Too Much Information) is the rule here, and the more information you provide the better educated the payer will be. Take an extremely critical eye to your records and ask yourself a few questions. Will someone that has never seen records for this treatment previously understand what we have done? Will it meet all medical necessity requirements for surgical intervention? What are we missing? Remember that the medical reviewer at the insurance will be going over every page with a fine toothed comb and any discrepancies will be noted immediately.
The insurance carrier is not in the business of forgiving bad charting, and if it is bad enough, it could raise flags for an audit, so an internal review is advised!
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