by AJ Riviezzo
After a bit of peace and quiet from Medicare audits, the processes seem to be ramping up again. This is particularly true for anyone in the WPS and NGS Medicare Administrative Center regions. Of note in this most recent Medicare audit are the first few reviews of Varithena claims and what they appear to be looking for. They also took a much more critical eye towards post-procedure ultrasounds.
Varithena Results – The practice had many Varithena, CPT 36465, claims denied due to: “no assessment of the beneficiary documented on this date of service to support that the beneficiary continued to be symptomatic following procedures performed on” previous dates. What the auditor was seeking is confirmation of the medical necessity for performing a Varithena ablation on the distal portion of the Great Saphenous Vein.
We have recommended in the past, and now strongly recommend, that a new assessment of the patient be performed prior to moving forward with Varithena post thermal ablations. The new assessment should include a mini-history and physical noting patient complaints, pain, swelling, continued disease impact on activities of daily living and results of a limited diagnostic ultrasound. Between what this Medicare audit is noting along with the changes to the CIGNA and the upcoming Anthem policy, a re-assessment is going to be required.
Post Operative Ultrasounds, 93971 – These have been pretty standard for many practices to help ensure the patient doesn’t have an EHIT or DVT and to ensure closure. However, the Medicare auditor was very firm in the need for the patient to be symptomatic. They noted “nor was there any documentation that the beneficiary was experiencing any pain, redness, swelling, or increased skin temperature to either lower extremity to support the need for the duplex ultrasound testing.”
The Clinical Research Studies in the Journal of Vascular Surgery: Venous and Lymphatic Disorders, Volume 12, Number 1, Gloviczki et al, dated January 2024 in section 11, Management of ablation-related thrombus extension (ARTE) and deep vein thrombosis (DVT) after endovenous ablations noted on 11.14 a recommendation of Strong and Quality of Evidence as High for performing a post-operative ultrasound for patients who are symptomatic. Perhaps there are other studies that support a post-operative ultrasound for asymptomatic patients, but I am unaware of any at this time.
As such, we do recommend that either in an Evaluation and Management note or, at the very least, a note in the post-operative ultrasound be written noting WHY the ultrasound is medically necessary. If Medicare is pushing back on this, it is usually not too long after that commercial payers begin to do so as well.
Needle Guidance, 76942 – Finally, the Medicare auditor pushed back on the lack of documentation regarding the needle guidance images. They noted an image should be captured and the procedure note should state that the image was indeed captured and is retained in whatever storage system is used. We know that our standard answer for most issues we write about is more or better documentation. However, the results of the Medicare audit are pretty clear. Rather than the expensive and lengthy process of having to appeal and justify your patient’s care, the extra bit of time and attention on noting why you are doing a procedure or ultrasound is likely worth it.