by AJ Riviezzo
Over the past years quite a number of practices have added phlebology to their existing operations. The increase in RAC audits have pointed out some documentation difficulties that these practices are experiencing including an inability to survive an audit without recoupment of monies. I would like to outline a few items to consider if you happen to perform varicose vein procedures in an existing cardiology, dermatology, OB/GYN or other practice.
Separate Report: One difficulty that I have seen even in my own chart audits performed for folks tied up in a RAC audit is the need for a separate History and Physical. While this may not be a new patient examination, a comprehensive existing patient examination should be conducted and focused solely on their varicose vein diagnosis. The primary reasons for a separate report are ensuring the authorization coordinator is clear on what the care plan is moving forward, ease for the authorization clerk at the payer to review and understand what is being requested, ensuring a reviewer for a pre-payment check or a medical review can understand the documentation, and finally to enable an auditor in their review by having clear and specific reporting.
History and Physical: While we have covered the History and Physical (H&P) before, here is a reminder of what needs to be in the H&P at a minimum.
– History of Present Illness – The chief complaint noted needs to match the subsequent documentation. I have seen a chief complaint of swelling of the lower legs with no further mention of swelling.
– Activities of Daily Living (ADL’s) – The ADL information is one of the top targets for review by the RAC audits I have seen. The disease impact on the patient’s ADL’s needs to be patient specific and not a generic ‘patient notes disease impacts her ability to perform some activities of her daily living’. How is it impacting? What specific activities are being impacted? The ADL impact needs to conform to the payer policy requirements as some payers have loose and some have very restrictive ADL language. My recommendation is to have a line on your intake form that says something like: My varicose vein disease keeps me from doing_______________ which the patient can complete.
– Some other documentation elements to ensure are in your H&P are:
o Review of Systems, Cardiovascular – Pedal pulse examination and quick note as to what the findings mean.
o Integumentary – Should match the History of Present Illness and later Exam/Assessment information.
o Examination – I frequently see ‘normal’ when there should be documentation of skin changes, bulging varicosities, swelling or edema, etc.
– Plan – The first element of the plan should be the order for the diagnostic ultrasound. You also need to ensure you have a good Conservative Therapy order if the payer requires conservative therapy. Typical elements for the order include:
o Duration of Therapy (ranging from two weeks to three months dependent upon the payer’s requirements
o Use of 20/30 compression stockings
o Leg elevation
o Weight loss recommendation if appropriate
o Use of NSAID’s
o Avoidance of prolonged sitting or standing
o You cannot take the ‘patient’s word’ that they have done the above. This is the fastest way to fail a RAC audit.
o Be sure to document any results (or non-results) at the end of the conservative therapy program.
– Treatment Plan – I recommend developing the treatment plan (at least via documentation) at the end of conservative therapy. I have seen some overly zealous auditors note that the development of a treatment plan before conservative therapy has been performed indicates the physician expects conservative therapy to fail. I know it is unlikely to succeed. You do as well. On we go with the insurance games.
The primary tool to effectively communicate why the patient needs treatment is the H&P. If it is hard to read, has too many abbreviations, is cluttered with other care elements or does not meet necessary requirements like the ADL segment then it is possible for all subsequent care to be denied or recouped. Not at all the end result you want for your time, energy, effort and expense of treatment.
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