AUDITS ON THE INCREASE

Two practices, with whom we consult, have recently had Medicare audits.  Two very different results.  The first practice was one with whom we had worked over the past two years doing chart audits and updates to their templates, documentation and coding.  They were in a pre-payment audit and were not paid for three months.  At the end of the three months all claims were released for payment except for any SSV’s performed on a different day than the GSV’s.   The Noridian Medical Director took it upon himself to declare these should have been performed on the same day and changed the coding to a 36476 on each of these SSV claims.

 

Needless to say, the claims payment department was unable to pay a 36476 as a stand-alone procedure and denied these claims.  The denial was appealed using the proper 36475.  The Medical Director again stepped in and wanted an unlisted code to be used.  We are assisting in the appeal of the decision.  Unfortunately legal support will likely be needed as there is zero justification in the policy for the Noridian Medical Director’s ‘opinion’.  We are confident of winning the appeals in the long run.

 

The second practice was in the audit process when we were contacted.  Again, it was a pre-payment audit.  Thirty-nine ablations were reviewed.  They approved three for payment.  The issues noted by Novitas were in two categories.  For claims using RF, code 36475, the primary denial reason was no documentation of a conservative therapy management program.  The practice had, unfortunately, been accepting and noting the patient’s report of having worn compression stockings.  This was deemed insufficient.

 

For claims using code 37241, all four claims were denied.  The report from the auditor stated “…that varicose vein ablations of the lower extremities should never be billed using procedure code 37241 based on the very description of the code.”  Unfortunately, the practice was then subject to a retrospective audit and is being asked to repay all claims with a 37241 CPT code.  The amount is in excess of $100,000.00.  We are working with the practice to mitigate some of this damage.

 

It is increasingly important to ensure you are meeting the guidelines as written.  To assist everyone, we have posted on our website a Medicare guideline checklist for each of the Medicare administrators.  This is free and can be found at:  www.apfsbilling.com.

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