by AJ Riviezzo
During the past quarter, we have been privileged to review a number of charts. There are some common basic themes we continue to see when performing these audits. You may want to take a few minutes and compare the below against your own documentation.
NEW PATIENT EXAMINATIONS –
Coding levels for new patient (and established patient) examinations is based on time spent with the patient and, if performed the day of the examination, the amount of time completing the documentation. The time spent on one or both elements need to be noted in the chart. Attached is a guide Click for Guide Here for determining time spent versus code level.
Conservative treatment continues to be an issue as well. Please remember you cannot take the patient’s word for having worn compression stockings. Further, conservative therapy is typically more than just the order for compression. It typically includes leg elevation, avoidance of prolonged standing or sitting, use of NSAIDs and weight loss if appropriate. Our recommendation is to review your Medicare Local Coverage Determination and craft your note to reflect what the Medicare requirement is for your area.
Lack of or lack of specificity of disease impacting the patient’s Activities of Daily Living (ADL’s). Many payers are wanting to see specific information such as the patient states she has difficulty completing household chores due to the pain in her legs. The easiest way to obtain specific information is to ensure the patient intake form has an open-ended question like: My varicose veins prevent me from ______________. Your team will likely need to assist the patient in completing the sentence. That should be carried into your new patient examination.
Finally, your new patient examination should have the order for the Diagnostic Ultrasound (Dx. US) as part of the plan.
DIAGNOSTIC ULTRASOUND –
There must be an interpretive report that notes the findings of the technical report. The interpretive report must be a separate document. Simply signing the technicians report is insufficient.
Other elements to include in the interpretive report are the equipment used, the position of the patient (standing and supine), response to compression and other maneuvers, actual reflux time (not just greater than half a second), deep system patency, and that the images are retained on file.
ABLATION REPORTS –
In the header of the report, you should note the vein being treated, which leg and the size of the vein. This helps eliminate any confusion for a reviewer when documentation is requested. You should also document specifically where the vein is accessed. The ‘best possible access site’ is woefully unspecific.
Be sure your ablation reports are vein specific. It is disconcerting to read about a short saphenous vein in which the catheter is advanced to 3 cm below the sapheno-femoral junction. You should also include the description and amount of any drugs given prior to or during the procedure, this includes the type of tumescent used.
Varithena Ablations – While we feel like we have beat this horse to death a few times, we still regularly see a misuse of the Varithena codes. ONLY treated truncal veins including the short saphenous vein can use the 36465 or 36466 codes. If you treat anything other than a truncal vein, the code is the sclerotherapy codes of 36470 or 36471. If using the 36466 multiple vein code, both veins must be truncal veins.
SCLEROTHERAPY REPORTS –
When documenting your sclerotherapy, be sure to include some specificity of location of the treatment. A somewhat general area like posterior distal thigh would suffice. You should also note how many cc’s of whichever agent was used in the report as well. If the procedure is done under ultrasound guidance, just be sure to note that in the report. It is also required to note that images are saved and on file. You can the bill for the 76942 guidance. You may not get paid as some plans consider it inclusive to the sclerotherapy, but it is not incorrect to submit the claim. If not paid, then write off the charge.