Have You Read Yours?
by Cheryl Nash
We are well into 2012 and the insurance companies are releasing their Medical Necessity guidelines for Varicose Veins. Some changes are minor, or nonexistent, and some changes are major, and will completely alter the way you need to document the rationale for treating your patients.
There are a number of changes that seem to be a theme. One change that is becoming increasingly common is conservative treatment needing to be documented by the treating physician. Most payers are no longer accepting the patient’s word on wearing compression stockings as sufficient. They are also requiring more than hose, and want these items to be ordered by you, the treating physician. These items include elevating the legs, walking frequently and compression hose for a limited amount of time. During this trial the patient may need to be seen to assess their progress (or lack thereof) and ultimately track them until the trial timeframe is expired. These visits are billable with an established patient visit code 99212 or 99213. At the end of the trial, it may also be appropriate to order another duplex scan to assess the patient clinical condition prior to initiating an authorization. This is also a billable service with cpt code 93970 or 93971, depending on the legs to be treated.
Another trend is the requirement to document the impact of the patient’s condition to their activities of daily living citing specific examples. As always, good documentation of the diameter of the veins, location of reflux, and venous filling index in the US reports is critical. Some payers are again requiring photographs and will ask for them upon review of your claims. Other payers are requiring that the patient be treated in only two sessions or that sclerotherapy being performed at the same time as an ablation is going to be considered inclusive.
Each payer is different, and the requirements can be drastically different. Please note that an authorization does not guarantee payment (as stated in every phone call to the insurance company) and all claims are subject to medical review after services have been provided. Know your payers requirements, and as these guidelines are also subject to review and revision without notifying you, the provider, we recommend re-checking these on a frequent basis to ensure compliance.
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