And you are asking yourself, why should I care about Blues of Illinois since I do not live in Illinois. Unfortunately, United Airlines employees have Blues of Illinois, along with a few other large employer groups, who may come to see you. Also the Blues of Illinois guidelines have been adopted by Blues of Oklahoma, Blues of Texas, and Blues of New Mexico.
Doppler Study Requirements for Ablation: As of 5/15/09, Blues of Illinois does not require any conservative therapy prior to an ablation but preauthorization is typically required (if not performed in conjuction with any other surgical procedures). However, your doppler ultrasound examination must document “…condition of the deep and superficial systems of the extremity including saphenofemoral junction, saphenopopliteal junction, greater saphenous vein, lesser saphenous vein, and perforator veins as well as the precise location and extent of the varicosities to be treated. This study must document an outward flow lasting more than 500 milliseconds in either the saphenous veins or the perforating veins.”
Follow Up Procedures: If you perform any other surgical intervention such as sclerotherapy or stab phlebectomy on this patient, there must be an observation period of at least four months with at least one follow up visit documented by the provider to show there are still areas needing treatment. You must re-preauthorize these services before treatment.
Phlebectomy/Sclerotherapy during an Ablation: The doppler study noted above must meet the same requirements. Conservative treatment must be followed for a period of four months prior to any ablation coupled with additional procedures. During the conservative therapy time period, the patient must try compression stockings, elevation of limbs, walking, weight loss, and when possible, NSAIDS. All of these conservative treatment elements must be included in your progress notes. The patient must have the initial examination and one follow up visit towards the end of the four month time span noting no improvement.
Documentation: You will be required to send your findings, notes and treatment plan for pre-authorization. You will also have to submit the treatment notes and other documentation after billing for your services. Unfortunately, the records will now be going to your local Blues and then be forwarded to Blues of Illinois. This process has significant issues. Blues of Illinois will not typically allow you to send records directly. One way to get around this is to have your patient call and see if the medical records are on file. If not, the patient can be given by Blues a fax number for sending the records. You can then submit the records on the patient’s behalf. Remember, the insurance is the patient’s insurance and you should not hesitate to involve them once the claim starts to go a bit ‘sideways’.
Exceptions to the Four Month Period of Conservative Treatment:
1. Only one four month period of conservative treatment is required prior to initiating surgical treatment even if using multiple modalities on the same patient.
2. The four month requirement is waived if the clinical findings are skin changes ascribed to venous disease, skin changes in conjunction with healed ulceration, and any active ulceration.
AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts
719.233.0099 www.apfsbilling.com
Great Patient Outcomes Deserve Great FinancialIncomes
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