In working claims for our billing clients, conducting audits as part of our consulting services, and in assisting practices going through a Medicare or commercial audit, we have noted a few trends that the payers focus on. Below are some of the key and consistent elements we see in failing an audit.
- Conservative Therapy – Many payers have conservative therapy guidelines which need to be met. Some practices try to avoid this step through two mechanisms: Taking the patient’s word regarding use of compression stockings or noting the patient has a high CEAP score.
Taking the patient’s self-report that they have worn compression stockings is not going to survive an audit. Conservative therapy typically consists of multiple elements including but not limited to recommendations for use of NSAIDs, weight loss, leg elevation, and calf-pumping exercises. Further, most of the payer language notes this should be clinically directed program and not something the patient sort of did on their own.
If the patient has a high CEAP score, some policies allow for conservative therapy to be waived. The key here is some. Not all policies allow for a waiver due to a high CEAP score. Be sure the documentation is sufficiently robust in describing the patient’s condition.
- Over-coding – There are usually three ways in which a practice may be over-coding. The first is rather consistent use of 99205 for a new patient examination. We understand that there is a good bit of time spent with a new varicose vein patient. Unfortunately time is only one of five criteria that must be met. Other elements include medical complexity, the examination, patient history and the review of systems.
The second example of over-coding is use of 99214 and 99215 existing patient office visits. Most follow-up office visits tend to be rather quick and not overly complicated. The coding should reflect the work being performed.
The third way in which phlebology practices may be over-coding is to use a 93970 full diagnostic study code when a bilateral post-procedural study is being performed. The 93970 code is a hip-to-heel/deep and superficial vein study. The payers expected this to be completed once for that course of treatment. A better code would be 76970 post-procedure US or 93971 for a limited diagnostic US.
As always, we caution to use correct coding in all circumstances. Doctors who were using an embolization code instead of a general venous surgery code are now having to repays hundreds of thousands of dollars.
- Impact on the Patient’s ADL’s – Many of the auditors are not well-versed in varicose vein disease and treatment. As such, they tend to use elements of their policy that are easy for a lay person to understand. One of these is documentation of the disease impact on the patient’s activities of daily living. Having a note that states, “Patient’s ADL’s are impacted by their venous disease,” typically will not pass muster. More often the payer is looking for a descriptive sentence or two on how the disease is impacting that patient’s life.
- US Report Deficiencies – After the History and Physical, the initial diagnostic US report provides the clinical indicators as to why the patient needs treatment. We have seen claims that are denied or recouped due to incomplete or insufficient US reports. One example is having discrepancies between the technician’s report and the report by the physician (wrong leg, different vein sizes noted). Another concern is not really having a physician report but merely one quick hand-written line and a signature on the technician’s report. It is critical to have a good physician’s report and one that matches your technician’s findings.
- Chief Complaint – The care rendered to the patient needs to match the patient’s chief complaint. If the patient comes in for pain and swelling in the right leg only, there is technically no reason to perform a diagnostic US on the left leg. We have seen claims be denied or recouped if the left leg is subsequently treated even though the patient had met the vein diameter and reflux criteria. The patient did not note symptoms requiring treatment of that leg.
- Post-Ablation Services – If a phlebectomy or sclerotherapy is being performed, the criteria for these procedures is similar to the criteria for the ablation. The patient must have symptoms from these untreated veins and they must be impacting the patient’s quality of life. Simply treating these veins because you want to ensure all possible issues are resolved is insufficient. Having an authorization for these services is no guarantee either.
The payers are alarmed at their rising costs in varicose vein treatment. They are attempting to identify physicians and practices that are not treating the individual patient’s medical needs. Poor or inadequate documentation will provide the payer with all of the ammunition they need to deny or recoup claims on an audit.
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