Documentation Compliance

Sclerotherapy
by Cheryl Nash
Sclerotherapy: It is just an injection! So why is so much documentation required for this simple service to be covered by the payers? In fact, Ultrasound Guided Sclerotherapy (also known as USG or Echosclerotherapy) is categorized as a surgical service and needs to be documented according to these standards. Typically USG is preceded by a duplex scan, either unilateral, or bilateral, to identify the veins that still need to be treated. This should be reported in the chart as a permanent record of the Ultrasound performed.

In addition to this report, there should also be documentation in an operative report format describing the Sclerotherapy service along with the ultrasonic guidance if performed. Remember, it is imperative to identify the veins treated in both reports and to note the rationale behind the decision for additional treatment. Even if an authorization has been obtained from the payer, they are still likely to request these records after the fact to ensure compliance prior to issuing payment.

Some payers also require the patient to continue to exhibit symptoms, and an additional progress note stating that this is the case, along with the examination results, duplex scan results, impression and plan ordering additional treatment may also be indicated. It seems like a lot of paper to generate, but with a consistent system in place, the reality is not as daunting as it sounds. The revenue and the patient outcome more than justify the means.