| Follow Up Information on ZPIC Audit
by AJ Riviezzo |
| American Physician recently supported a practice that was involved in a ZPIC audit (essentially like a RAC audit except this was prospective and not retrospective). Eight of our ablation claims were denied at the first and second level appeal stages. This left using an Administrative Law Judge (ALJ) as our next recourse.
I have a more detailed article in the next Vein Therapy News but the findings in brief were:
Your documentation has to be viewed not as if another physician can understand and follow it but as if an attorney can understand it. Any, and I do mean any, variation in what is on one form to another was stringently questioned. For example, if your CEAP classification mentions swelling of the legs and your History and Physical does not specifically mention swelling of the legs, that is a problem.
It also became clear that any patient information that was not specifically noted as reviewed by the physician was discounted. Further, patient statements regarding previous attempts at conservative therapy (and thereby meeting the Medicare guidelines) were also discounted. We did argue that this was an unfair burden on both the patient and on the practice. It is normally standard to accept the patient’s word when reviewing previous treatment, history, or compliance with something like conservative therapy management. That argument fell completely flat.
With the budget issues facing the Medicare program and recommendations that ‘changes’ be made to save money without impacting the actual entitlement, I can only assume that audits to find inappropriate or fraudulent treatment will be expanded. The primary weapon at your disposal for combating these audits is your well documented medical record. |
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