Medicare through the various administrators across the United States is apparently taking a stronger look at claims. In the past, the Medicare intermediaries (MACs) rarely requested records in order to process a claim. The requests for records were normally from the third party companies performing a RAC or ZPIC audit. We have seen a marked uptick in documentation requests from the MACs in several areas. The requests have focused on three areas so far.Diagnostic Ultrasounds. Some of the MACs are requesting documentation to support why a full bilateral diagnostic ultrasound is being performed further into the course of treatment. The documentation needs to clearly reflect why a complete bilateral diagnostic ultrasound was performed and reflect that level of service was performed as well. Many practices still code a bilateral ultrasound using the 93970 code. Unfortunately this can be incorrect unless you are truly doing a full diagnostic workup and there is medical justification for doing so. If you are really performing a follow up ultrasound, even if bilateral, the code that should be used is 93971.
Ablations. We have also seen an increase in records requests (and then denials) for ablations. The reasons for the denials is because the surgery report did not contain: A. The name of the specific vein being treated. B. The diameter(s) of the vein being treated. C. Exact location of the access point. Basically Medicare, as are the commercial payers, is cracking down on rather vague, cookie-cutter documentation be it from an EMR or a manually produced report.
New Patient Visits. The final area that has had some requests for medical records is the new patient visit. Even a moderately coded 99203 has been met with a records request – and subsequently was denied for not meeting that level of code. There are multiple factors that go into the various levels which we’ve addressed before. ALL of the factors much reach the 3 level or the code level is not met. If you like a copy of our primer on billing new patient visits, please shoot me an email. We will send you a copy of that older article.
Our concern is that a few records requests from Medicare can turn into even more records requests. Failure in meeting the various charting requirements could then trigger a full blown RAC or ZPIC audit. Something no one wants!
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