Reimbursement Basics Guide for Documentation Practices

Reimbursement Basics Guide for Documentation Practices

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This example is a guide for documentation and not to be used as a template. The provider should review, initiate their own wording in accordance to their practice standards being mindful that patient documentation must be clear, concise, and demonstrate the medical need for a procedure. Documentation of a medical record may be subject to insurance reviewers, peer-to-peer conversations and auditors who are unable to justify a service if medical necessity, treatment plans, and physician decision-making process has not been documented. Remember: If it is not documented…it’s not done!

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Patient Encounter Documentation – Example . . . . . . . . . . . . . . . . . . . . . . 2

Authorization/Appeal Rebuttal – Example . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Appeal Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Procedure Inventory Cost Calculator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Diagnostic Tool – Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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Table of Contents

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Patient Encounter Documentation – Example

Physician documentation is required to present a clear description of the patient encounter and disease process . The

thought process, objectives and expectations of the physician are a supporting element of medical necessity . Medical

Policy requirements vary per payer; the provider should be aware of policy guidelines .

Patient Name

Respiration

DOB

Pulse(both limbs)

Date

Temp

Medical Record

WT BMI BP

Chief Complaint: (CC) (in patients own words what brought them to the office, who referred for treatment)

History of Presenting Problem (HPI): Age, sex, social status, nationality, new or established, occupation, % of time sitting, standing, activity level. How long has the problem been present, intensity, duration, location, what relieves or contributes to pain or symptoms. Has the patient tried conservative measures, weight management, exercise, elevation, prescription grade hose include dates?

Social History (SH): Smoker, consumes alcohol, engages in recreational drugs, activity level.

Family History (FH): Exposure to possible toxins, anticoagulation factors, father, mother, siblings, pertinent vascular system positive and negatives.

Past Surgical History (PSH): Include all previous surgeries and dates (i.e.: orthopedic, GYN, injury to extremities)

Past Medical History: Include gynecological history, arthritis or orthopedic limitations; expand on any positives noted in Review of Systems, note negatives. Follow up examinations document any changes, co-morbidities. Documentation contributes to decision-making process.

Medications: OTC Pain meds, Vitamins, Herbs, and RX meds need to be noted. In Review of Systems, note who is managing these treatments. Update at each encounter.

ALLERGIES: List with reactions and the date of last incident. Update at each encounter.

EXAMINATION: Evaluate and comment on positives from ROS; however, examination system is specific to the specialty focus.

Skin appearance: Contributes to medical necessity; describe appearance, density, discoloration, abnormalities, location, and tenderness. Take photographs of the limbs with a ruler to visualize affected area and support the documentation. Specify location, size, length, diameters of the affected limbs. Record pulses and refluxes of limbs along with CEAP classification, VSS (Venous Severity Score) or VSDS (venous segmental disease score)

Ultrasound: Document when performed; results, comparison to previous ultrasound. Provide an anatomical drawing (blue/red scaling) to demonstrate reflux, vessel size, diameter, length, location and reflux in seconds. Formal ultrasound report is required.

Diagnosis: Should confirm exam and diagnostic findings.

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PLAN: Name the procedure to be performed and identify extremity and location including reason for chosen modality

RECOMMENDATION: Document physician thought process; why the selection of the procedure, how the procedure will address patient problem, state the positives of the procedure and how it will address the patient comorbidities, anxieties and return to daily life activities.

Describe the Procedure: A reviewer or auditor may not be familiar with the technology. Identify advantages of this procedure for this patient including: recovery time, time to return to normal activities, patient pathology and patient risk factors influencing the choice of the procedure. Outline any area of concerns for the patient anatomy that will not allow other techniques. Document patient education regarding the procedures, risks, benefits and reasonable expectations. Acknowledge the patient concerns; status of appointing procedural date along with courtesy to primary care physician

Patient Encounter Documentation – Example: Continued

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Authorization/ Request for Appeal – Example

This physician with prudent medical obligation and the best interest of my patient has elected to perform a mechanical infusion of the peripheral vasculature in the RIGHT/ LEFT extremity. This procedure avoids the use of anesthesia, avoids skin burns, and eliminates nerve damage ultimately returns the patient to her normal life activities immediately.

Additionally the presenting patient anatomy is not amenable to other modalities for the following reasons:

A. Summary of patient surgical vascular history dates and outcomes.

B. Skin conditions ulcers: superficial thrombosis or skin changes.

C. Patient Comorbidities: diabetes, CHF, PVD, anticoag Long-term status: Factor 5, Allergies: Latex, antibiotics.

D. Ultrasound reports size, position, diameter, by date to demonstrate progression. Measure flow by seconds.

E. Failed conservative treatment including compression therapy, exercise, OTC pain medications, weight management and elevation with persistent pain that alters daily life style activities and employment.

Please accept the attached clinical documentation and references to support validity of medical necessity and cost factors for this procedure. This office is available to discuss clinical aspects with any representative: (Include office phone/Email address)

Regards,

Office Certified CoderClinical Resources StaffPhysician

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• Identify the Payer language for appeals, reconsiderations, re-openings or payment reversals.

• Acknowledge and obtain specific format for each Payer to initiate an appeal along with time requirements.

• Identify the objective medical evidence as it applies to the specific case.

• Reference the specific LCD or Medical policy Guidelines and terminology.

• If it appears the policy ignored some scientific evidence identify this to the Payer.

• Identify if policy language creates an exception, for a treatment that is considered experimental/investigational.

• (Optional) Attach paid EOBs, from other carriers, with positive payment of the 99 code removing patient identifiers.

• Review documentation carefully, use of Payer medical policy language for the documentation of medical necessity.

• Specify the thought process, to justify the medical decision making process for a rebuttal to the Payer.

• Review for complete, clear, concise documentation of the patient’s need for the proposed procedure, for example include CEAP/VSS scores

• Physician decision making, thought process must be documented to support patient medical necessity.

• Provide photographs of the extremities or targeted areas including a ruler for measurement.

• Provide anatomical drawings of the patient extremity anatomy indicating the vascular presentation.

• Consideration of medical technology and requirements of the Payers, local, state and other regulations should be applied.

• Prior to submittal: ensure documentation is clear, concise, complete description of technology and how it applies to a particular case does not guarantee payment from a Payer.

Appeal Considerations

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Procedure Inventory Cost Calculator – Example Every procedure has a cost value; with exception of “99” codes for unlisted procedures. It is imperative that the practice account for the costs to perform a procedure. This is a tool for a provider to consider when requesting a certain fee or defending the reconsideration of a low payment. This does not guarantee payment from an insurance company.

Table Cover

Pillow Cover

Patient Gown

Patient Sock(s)

Patient Garment (M/F)

Heating Pad

Heating Pad Cover

Sterile Gloves Size: _____

Sterile Latex Free Gloves Size: ____

Ace Bandage Size___

Ultrasound Sterile Gel Packets

Ultrasound Sterile Probe Cover

Blue Towels

18g Needles

25g Needles

5ml Syringe

10ml Syringe

20ml Syringe

Lidocaine ____%

Topical Lidocaine Gel ___%

Sterile Steri Strips

Sterile Scalpel #11

4x4 Sponges #______

Sterile Operative Bowls # _____

Micro access Kit (4 or 5f)

Medication Name ___ % _____ cc

Catheter

Staff Gowns/booties

Sterilization Cost

Hazard Waste Cost

Total Staff Cost: $_______ + Total Supply Cost: $_________ = Actual Cost $ _______

Actual Cost $: __________ x 10-30% *= __________ Desired Reimbursement

*Practice should individually determine (CPT 37799 does not have a fee schedule. Rebuttal requires robust documentation of cost, medical necessity and efficiency of procedure)

Procedure Inventory:______ Physician: NPI :

Patient Name: DOS:

M/F (Circle one) DOB: Start Time: ____:____ End Time: ____:____

Item Units Vendor Cost

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Diagnostic Tool – Sample This tool may be beneficial to summarize a proposed procedure(s) for prior authorization or appeals. It identifies multiple procedures, positions, type of sedatives, pre-op medications and anticoagulations, course of treatment, order of procedures and post operative follow up.

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Contact Information

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www .VascularInsights .com 1 Pine Hill Drive, Two Batterymarch Park, Suite 100, Quincy MA 02169 203-446-5711 M-022 (R1)

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Reimbursement Basics Guide for Documentation Practices