DON’T BE THE NAIL ABOVE THE BOARD

What You Are Doing:  Below are some scenarios of which we have heard over the years.  If any of this holds true for your practice, you may want to consider a change.

All Four/Every Time – How often are you performing an ablation on both GSV’s and both SSV’s?  Always?  Frequently?  If your patient experience falls into this category, your documentation has to be spot on in regards to being symptomatic for that leg and vein.  During the audit process, they are looking for treatment not being medically necessary.  One ‘easy’ way to identify possible non-necessary services is to see the frequency of services being performed per patient.

Bonus Program for Finding Reflux – Do you pay your ultrasonographer a bonus for finding reflux?  Are they under pressure either financially or in any other way to find reflux and large veins?  Should an audit include a discussion with your team members, this scenario can cause a practice to be in dire jeopardy.

Perforators – Are the perforators being closed as an ablation on separate days?  Is there a reason they could not have been closed the same day as the ablation of the GSV or SSV?  If done separately, is there a reason two or more could not have been ablated on the same day?  Is there a reason they were closed as an ablation instead of via US guided sclerotherapy?  Finally, the perforators need to meet the same standards as any other vein and should never be closed prophylactically.

Stacked Procedures – We have heard of a practice that performs two to four procedures in the same day and then bills them as if performed on subsequent days.  This, my friends, is fraud in the first degree.  Billed claims should always reflect the date the services were performed.  You may not like the second surgery reduction and believe it is unfair, however, being questioned while in handcuffs is equally unfair.

When Are You Doing It:  While ‘when’ is not as consequential as some of the scenarios noted above, it still can be a problem worth considering.

Ablations Back-to-Back – If you are performing your ablations on subsequent days, say on Monday, Tuesday, Wednesday, and Thursday, for the same patient; a reviewer or Medical Director can ask why some of these weren’t done on the same day as a second insert or as a bilateral set of procedures.  This is an excellent question that really needs an excellent answer.  The most common practice pattern we see is ablations being scheduled about a week apart.  Do keep in mind that some payers are requesting same leg or bilat procedures to be completed (e.g. bilat GSV ablations) on the same day.  Be aware of the policies and try to work within those guidelines if possible.

Aftercare Program – If you routinely bring patients back for a leg check at six months, one year, and annually thereafter and they are asymptomatic, this can be a problem.  Medicare does not expect services to be performed on a patient who has no symptoms.  Our recommendation is to put the patient on a tickler system and call them at the six month and annual marks.  If the patient, upon telephonic review, notes pain and/or swelling, then you may bring them in for a leg check.  Be sure to use their new symptoms as your diagnosis.

Standing Orders – Some practices have ‘standing orders’ to allow for a diagnostic ultrasound to be performed.  Your Medical Assistant or Receptionist does not have the qualifications to order an ultrasound even if you have given them a checklist.  A qualified professional needs to order the ultrasound after reviewing the patient (e.g. performing a History and Physical examination).  Yes, this makes the process flow less well for the office.  We do understand that.  However, a diagnostic test should be ordered as part of the patient review.

Documentation of Services:  We have written numerous articles on documentation, so we will not reiterate all of that.  However, one item still crops up on a regular basis and falls partly under documentation and partly under the ‘When Are You Doing It’ category.

Conservative Therapy – Everyone’s favorite element to try to skirt.  If the policy states that the patient must have three months of conservative therapy which should include use of compression grade stockings, an exercise plan, leg elevation, and a recommendation for weight loss, these elements MUST be documented in your chart.  If the policy has an exception rule for ulcers or stasis dermatitis then they need to be fully documented.  If there is no exception rule, the conservative therapy management program needs to be completed.  Some ‘practice exceptions’ we routinely see are as follows:

Patient Couldn’t Wear Stockings – Document that you have coached the patient to wear their compression grade stockings.  Continue to document the other elements of the conservative therapy program.  You cannot treat the patient a month after initiating conservative therapy because the patient doesn’t like to wear stockings.  This claim will deny upon a formal review.

Patient States They’ve Worn Stockings – Unless you have medical documentation from another physician ordering the use of compression stockings for their venous disease, you cannot accept the patient’s word.  In addition, most conservative management policies include other elements that still need to be addressed for the time frame they note.

Patient Has an Ulcer – Unless the policy has an exception to conservative management for an ulcer, you must complete the conservative therapy program.

Medicare, Blues, and the other payers are starting to really review their expenses.  One target, unfortunately, is phlebology.  It is critical to provide medically necessary services in a prudent fashion and within their guidelines.  Doing anything else is to be the nail above the board… and the hammer has been painful.