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Confusion and Documentation Tips
by Cheryl Nash
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There has been some confusion in the phelebology community regarding conservative treatment guidelines and compression stockings. Questions such as how long, what constitutes proof, does the provider have to initiate the treatment or can he take the patient’s word for it, and how recently should this have been completed?
These are all good questions, and unfortunately there is no real easy answer. All payers have slightly differing requirements, and reading and understanding their policies is the first step.
Here at American Physician, we have noticed an increase in the documentation levels required for conservative measures. For example, most payers now include language stating that conservative treatment includes compression stockings as well as other treatments such as elevating the legs, exercise, NSAIDS, etc. Most of the charts I review do not mention anything other than compression stockings. Some payers are viewing this as non-compliance, and it is an easy fix to add these measures to your documentation. The other issue I frequently see is that these are indeed addressed on the patient intake form, but not in the History of Present Illness (HPI). This inconsistency in charting can also cause denials, as well as compliance issues in an audit.
The second issue we are coming across more frequently is that the payer is no longer taking the patient’s word regarding conservative therapy. Language in the chart stating that “the patient has worn compression stockings for many years” is no longer being accepted. “Prove it” seems to be the general theme. Some payers are requiring the conservative treatment to be within a recent timeframe, such as the last 12 months, and that it be performed either by the patient’s PCP, with records to show proof, or by you, the treating physician. Quite a few are asking for a copy of the prescription for the compression hose, and for follow-up visits documenting the failure of the treatment prior to interventional surgery being performed.
An example is from Cigna’s policy number 0234: failure of medically supervised conservative treatment, including but not limited to compression stocking therapy for three consecutive months.
The most important wording here being “medically supervised”. If you have no recent records of a conservative management program from a previous physician you will need to start the 3 month window yourself.
Another example is from the Medicare contractor Novitas’ Local Coverage Determination (LCD):
For Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) Classification Class 2-3 veins, failure to control symptoms with a documented three- to six-month trial of conservative therapy ordered by the treating physician including graduated, elasticized compression stockings (with proper instruction on their use), mild exercise, periodic leg elevation and weight reduction, as appropriate. Compression stockings are defined as graduated elasticized compression stockings. Use of non-graduated compression garments such as support pantyhose does not fulfill this requirement. Lack of patient compliance with compression stockings does not support the need for intervention without documentation of other failed conservative treatments as well. Conservative treatment should include adequate instruction on weight reduction, daily exercise (e.g., a walking plan) and leg elevation. Failure is defined by presence of severe and persistent edema or severe and persistent pain interfering with activities of daily living as defined above despite conservative therapy as outlined above. Failure of conservative therapy must be documented in medical records by a follow-up visit after an appropriate period of time (e.g., three months) and must be noted in the history and physical examination findings.
As you can see, they are very thorough in the language used to define the documentation required in the chart. There is no room in a policy such as this for the provider not to begin the conservative treatment themselves. And, trust me, if Medicare does an audit, they will be looking for this.
These are just two examples among the multiple insurances we work with daily, and more and more payers are adding language such as this to their policies. In reality, though starting an effective conservative management program may cause some delays in scheduling, after the initial implementation window, things should smooth out be back to “business as usual”. The benefits of a program that is airtight is that it will stop denials from happening and increase consistent revenues for the practice, not to mention protection against a future audit!
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