American Physician Financial Solutions

10/07/2022

A new Article has been published! If you have Questions like these we have the answers! Feel free to look at our website or give us a call.

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 mon...

09/27/2021

Here is a brief message from AJ, to give you a better understanding of what we are all about.

If you have any further questions, please contact us at (877) 611-1322

08/31/2021

Join AJ this October 7th through the 10th at the Ga***rd Rockies Resort & Convention Center in Aurora, CO for the American Vein & Lymphatic Society Annual Congress. Please stop by our booth and say hello!

The booth hours are relatively short. We are happy to schedule an appointment to discuss any concerns or needs you might have. Just send AJ a quick email so we can get you on our calendar.

02/01/2021

If you are a North Carolina Provider or treat patients with BCBS NC insurance, we recommend you review the following information.

As of 11/2020, Blue Cross Blue Shield of North Carolinas Coverage benefits are listed as such:
Coverage is provided for endovenous procedures used to support the normal function of your veins, and is limited to one procedure per limb per lifetime. Benefits are also provided for sclerotherapy vein treatment and are limited to three procedures per limb per lifetime.

05/07/2020

A CAUTIONARY TALE
by AJ Riviezzo
Over the thirteen years American Physician has been providing billing and consulting services, we always hear about 'the other guy' that is not doing things in a proper fashion. This 'other guy' is promising to treat without charging the patient any money or performing cosmetic sclero and billing as if it is medically necessary.

We have always maintained that it is important to be middle of the road so to speak. When it comes time to face an audit, you do not want to be the nail above the board. While Dr. Mok is innocent until proven guilty, I do believe it is safe to say that some of his practice patterns as outlined in the Criminal Complaint have left him exposed. Click HERE to see the Compliant by Eastern District of Michigan US District Court.

While life is slowly returning to back to business, now is not a bad time at all to reflect upon your practice patterns and processes. Some of these need to be changed to include COVID into your processes. Other elements may need to be scrutinized a bit more to help ensure you are not the nail waiting for a hammer.

If you have questions, do email me ([email protected]). Gratis. I would much rather that all of the phlebology community be safe (from COVID and from governmental audits)!

05/07/2020

THE CASE OF THE MISSING LCD
by Cheryl Nash
Some may be perplexed by the recent disappearance of the Varicose Vein LCD from Palmetto GBA's website and subsequently from CMS.gov. With a little digging the policy L33454 can still be found, but it now carries a status of "Superceded". The question now is how does this effect practices under their jurisdiction?

What it doesn't mean is that anything goes....

Palmetto still expects the requirements for Medical Necessity to be met regardless of the status of the LCD.
A notice was published in the May edition of their Medicare Advisory that states:

Due to the controversies in varicose vein treatment, as well as our desire to more deeply engage stakeholders in the LCD process and maintain consistent coverage policies across MAC jurisdictions, Palmetto GBA is retiring the present draft policy as well as the active policy. There will be no meaningful change in coverage, which reverts to the same criteria present in L33454. Though there will be no expansion of coverage, there will also be no change in denials, except upon individual claim review. Please, be aware that the statutory requirement for reasonable and necessary treatment of varicose veins is still in effect. Medicare requirements for documentation to reflect medical necessity for the services rendered remains even in the absence of LCD policy.

In brief, no changes have been made to the content and all requirements remain the same despite the policy's status.

To review the policy guidelines, you will now need to obtain it through the MCD Archives on CMS.gov. A quick internet search will take you there where the search function will allow access to the old policy or you can view the policy here. (MCD Policy)

To view the details of the policy change you can go to palmettogba.com and select the Medicare Advisory option under Topics.

We are the Phlebology Experts. Learn how American Physician can help grow your practice or give us a call at 877.611.1322.

04/14/2020

CHARTING TELEMEDICINE VISITS
by Cheryl Nash
Now that many providers are implementing Telemedicine services it is imperative to understand the key elements of how to chart and select the proper E&M code. Rules are continuously changing and your documentation will need to evolve.

A few reminders: These charting guidelines are for Telemedicine visits Only. Face-to-Face visits are still documented as you have always done. Waivers allowed during the Public Health Emergency (PHE) will expire when the emergency status is lifted. Always check with your individual payers and the patient's policy prior to selecting or submitting any billing codes.

The first item that should be addressed is patient initiation and consent. All telemedicine services either via audio/visual or telephone only requires the service to be patient initiated and that the patient give consent before the visit moves forward.

Patient initiation can be at any time a patient has contact with your office regarding their appointment. The practice can offer a virtual visit instead of a standard face-to-face and, if the patient chooses this, that is considered patient initiated. If they are not comfortable then other options must be given such as an in-office appointment or availability to reschedule.

Consent, however, must still be given at the time of service. During the current PHE this can be either written of verbal. A verbal consent needs to be noted and is ideally the first thing in the visit note. Best practice is to also record the consent, but if this is not possible having a witness is recommended. An example statement would be: "A verbal Consent was requested from the patient and was granted at (xx time). This was witnessed by: ###." Or if recorded: "A Consent was requested from the patient and the patient was made aware the visit was being recorded. Consent was granted at (xx time)." If no witness or recording is available then note with as much detail as possible.

The next item is the platform, or more specifically, non-HIPPA compliant platforms allowed during the PHE. The patient must be made aware that the technology can present a privacy issue if one of these is used. That includes FaceTime, Zoom, Skype, FB Messenger Video Chat and the like. Be sure to note this with the consent.

As is customary you will note in the Chief Complaint or History of Present Illness, the reason for the visit. Other elements may be noted depending upon the availability of the information such as pertinent history, medications, or other data. An exam portion is not required for obvious reasons, but if a visual of a problem area is performed be sure to chart this. Be as thorough as possible when you summarize the content of your discussion with the patient.

Medical Decision Making (MDM) will be one of the two main elements your code selection will be determined by. The other primary element is Time. While start and stop times are not required, they are helpful in final code selection. Telemedicine is different than face-to-face visits in that pre and post time are counted. For example: If two minutes are spent reviewing the chart prior to the start of the visit and five minutes are spent completing the note after the visit has concluded, these seven minutes will be counted in the total time. Be sure to include both the pre and post time spent along with the visit time in your note.

The CPT selection will be based upon either MDM or Time, whichever is higher. MDM follows standard CPT guidelines for all payers while Time charts for Medicare are different than for commercial. Medicare has released a new time chart for telehealth visits that is different than face to face times; Commercial is still following the guidelines noted in the CPT book. It is very important to have both charts available to your office.

Please find the TimeChart here.

The government has made all of this rather confusing and has noted they will conduct audits when the PHE is over to ensure the guidelines they have set forth are being followed and to reduce instances of Fraud and Abuse. We always recommend taking a Too Much Info approach when charting to ensure compliance.


American Physician Financial Solutions, LLC | | [email protected] | http://www.apfsbilling.com
1125 Kelly Johnson Blvd., Suite 300
Colorado Springs, CO 80920

We are the Phlebology Experts. Learn how American Physician can help grow your practice or give us a call at 877.611.1322.

04/09/2020

TELEMEDICINE CHANGES AND UPDATES
by AJ Riviezzo and Cheryl Nash
Medicare has changed how you submit claims for telemedicine. Rather than changing the Place of Service (POS), you would now bill with the normal office-based POS. Your typical Evaluation and Management (E&M) codes, 99201 - 99215, would now have a 95 modifier appended to the code. This is only for audio/visual communications.

Medicare has also finally noted that not all Medicare recipients have a smart phone or a computer with a camera system. They are now allowing telephone-only consultations. These codes are 99441 thru 99443 which are billed at POS 11 without any modifiers or G2012 which is billed using POS 02.

The 99441-99443 codes are defined as:
Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

Code 99441 is 5 - 10 minutes
Code 99442 is 11 - 20 minutes
Code 99443 is 21 - 30 minutes

Code G2012 is defined as:
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
G2012 is only for 5-10 minutes.

Please see our TimeChart here.

Commercial payers are coming up with their own rules which are changing as fast if not faster than the Medicare guidelines. Some examples are:
United Healthcare now allowing the use of the E&M code set for audio/visual or telephone calls. It should be billed with normal POS 11 and appended with a 95 modifier.
CIGNA is likewise now allowing the use of the E&M code set for audio/visual or telephone calls. These claims should be billed with POS 11 and appended with a GQ modifier. You can also use the G2012 code for virtual screening. Of note, CIGNA states they will scrutinize any level 4 or 5 claims.
Humana is also allowing the E&M codes for audio/visual or telephone calls. The claims should be billed with the normal 11 POS and appended with a 95 modifier.
Aetna is allowing audio/visual services only using the standard E&M code set and billed with POS 11 followed by a 95 modifier. They may allow telephonic visits, but this is still plan specific.
Blue Cross/Blue Shield is variable. You should review with your local Blues.

All Payers:
The technology allowed includes Facetime, Skype, Zoom, Doxy, Facebook Messenger video chat, Google Hangouts, and similar systems. They must be in some way only be video between the patient and the doctor for some sort of privacy. Providers are also required to notify the patient that the technology platform used may potentially introduce a privacy risk. Any live story platform is not allowed such as FaceBook Live, Twitch, Snapchat, IG Live, or similar public facing video.

Consent requirements are the same with verbal now being approved. If the visit is not recorded it is recommended to have a witness for this portion if possible. Be sure to chart both the verbal consent and who, if present, the witness' name. Medicaid programs still require written consent, but this may change. We recommend reviewing the Medicaid program for your state if you take Medicaid.

Please also note that, at this time, the guidelines are only allowed during the PHE window of time.


American Physician Financial Solutions, LLC | | [email protected] | http://www.apfsbilling.com
1125 Kelly Johnson Blvd., Suite 300
Colorado Springs, CO 80920

We are the Phlebology Experts. Learn how American Physician can help grow your practice or give us a call at 877.611.1322.

04/02/2020

Paycheck Protection Program
by AJ Riviezzo
Beginning April 3rd, small businesses (fewer than 500 employees) may apply for monies through the Small Business Paycheck Protection Program. As the bulk of phlebology practices are small businesses, this may provide some needed assistance during any closures. Some key elements of the program include:

Fully Forgiven - These funds may be fully forgiven when used for payroll costs, interest on mortgages, rent and utilities. However, at least 75% of the forgiven amount must have been used for payroll. The unforgiven amount will be a loan which will be deferred for six months.

Employees - You must keep employees on the payroll or rehire them quickly in order to maximize 'forgiveness'. Forgiveness will be reduced if you reduce staff or if salaries and wages decrease.

How to Apply - Your current bank likely can process your application. I would check with them before using some of the banks that are already advertising their services.

Attached are three documents regarding this program:
PPP Overview
PPP Information Fact Sheet
PPP Application

We are the Phlebology Experts. Learn how American Physician can help grow your practice or give us a call at 877.611.1322.

03/31/2020

AVF INFORMATION CONCERNS
by AJ Riviezzo
Marcy and I attended the AVF meeting in Florida just a bit ago. Some of the information was quite interesting. I was especially interested in the section that was set up for those interested in starting up a new practice (which was up against the golf and tennis outings).

One of the speakers implied that if you just added a little bit more information to your New Patient Examination, that you could then submit claims for a 99205 New Patient E&M code. Here is why I think this is a bad idea.
Medicare and the other commercial payers are expecting to see a bit of a normal bell curve when it comes to billing for your History and Physical. If your bell curve is skewed to the right with many more 99205 codes than 99203 codes, you can be a target for an audit. When I worked for a Medicare/Medicaid plan, this was exactly the type of audit I personally pulled to help identify non-normative practice patterns. This resulted in the physician providing copies of their H and P's for review.
There is a belief that if you document a significant amount of time being spent with the patient that this qualifies you to bill for a 99205 level of service. There are five factors that go into the determination of whether or not you can bill for a level of Evaluation and Management service. All five must reach the level being billed. One element is certainly time, but another is the complexity of the medical decision-making process. In most cases, the venous patient's complexity is typically at a moderate level. This is not to say you do not have the occasional very complex patient with multiple co-morbidities coupled with a history of DVT's and currently on a blood thinner. It just is not every patient.
The same speaker seemed to also note that a practice can generate a lot more revenue if they billed the 93970 bilateral, deep and superficial ultrasound for the follow up review. As we have written in the past, the payers are expecting to see one full, bilateral, deep and superficial ultrasound per course of treatment. Even if you are re-assessing the legs bilaterally, the code for that is still a 93971 which can be for a bilateral or single leg limited diagnostic study or the 76970 follow ultrasound code. The state of Florida in particular and some other states are very aggressive in reviewing codes to determine if over-coded or inflated services are being submitted for payment. Again, this is an audit risk for you and your practice.

03/31/2020

TELEMEDICINE INFORMATION
by AJ Riviezzo
With the Covid-19 virus, there is a renewed interest in providing services via telemedicine. The situation is rather dynamic with new or proposed guidelines coming virtually every day. As of Tuesday, March 17th, our best information is as follows.

New Patient Examinations: The commercial payers typically do not allow telemedicine if the patient is new to your practice. The Centers for Medicare and Medicaid Services (CMS) put out new information today. Per the new Fact Sheet dated March 17th, codes 99201-99215 are covered for telemedicine services. It is interesting to note that Medicare still has a rule that this is for existing patients only.

However, CMS is saying that "HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency". This new Fact Sheet can be found here: FACTSHEET. Medicare Advantage plans are supposed to follow Medicare guidelines, but we have seen delays in implementation of new guidelines in the past. The most recent CMS information sent to the Medicare Advantage plans can be found here: Advantage.

Existing Patient Evaluation and Management Services: Medicare, as noted above, is covering these services during the public health emergency. Some commercial payers allow an existing patient visit to be performed via telemedicine. This can be very patient plan specific. A PPO plan by XYZ payer may cover it while their POS or HMO plan may not. Unfortunately, this may require contacting the payer to ascertain if the patient's policy truly does pay for telemedicine services.

Billing for Telemedicine Services: Most payers allow you to submit your standard Evaluation and Management code (99211-99215) to the payer with a GT modifier signifying it was telemedicine services. The other two common modifiers are 95 and GQ. However, Blue Cross/Blue Shield of Alabama just came out with a policy effective the 16th of March stating that only codes 99211, 99212 and 99213 could be billed and the Place of Service should be changed from 11 (Office) to 02 (telehealth) without any modifiers. This policy can be found here: BCBSAL. So, while it may be covered, billing can be 'interesting' until you know what each payer requires.

As the healthcare community receives additional information, we will update our readers of any substantial changes. For the time being, it is a bit of a confused pile of competing information. Our best recommendation is to call the commercial plan to ascertain if they are or are not covering new or existing patient office visits provided via telemedicine.

02/28/2020

There have been a couple changes in billing for Sclerotherapy codes 36470 and 36471 that have had big ripples in reimbursement this year and the potential to cause big headaches for your A/R team.

One of the biggest changes is the NCCI edit put into effect on 10/01/2019 against codes 36478 and 36470/1. The edit places 36470 and 36471 as a column 2 code of 36478, meaning they are considered a component of the Laser Ablation with a definition of "Misuse". It also indicates these codes can be billed together when an allowable modifier is submitted.

What this means in brief is that the sclero has to be performed in a separate surgical site than the laser. When this is the case, a modifier can be used to indicate it should be paid for separately, typically modifiers 59 or XS.
There is however no coding guidance on what exactly constitutes a separate surgical site and the payers seem to be just as confused as the rest of us. Some are allowing it when performed on a different leg. Some are accepting it when done in tribs after lasering a truncal vein, and some payers appear to be using this edit as a blanket reason not to pay for sclero and laser in the same session under any circumstances. Essentially, it's anyone's guess how to apply this edit.

Our recommendation is to take a look at your payer mix and billing trends from the last 3 months and review the response to these claims. Once you determine if there is an issue with a particular payer, then a plan can be formulated to adjust your care plan according to your patient's needs.

One other change that is causing claim adjudication issues is UHC's policy update that now limits Sclero sessions to 3 per leg within a 12-month period from the date of the ablation. This is a limitation tied to the code regardless if the service was done at the same time as the ablation or during a separate encounter. Medical necessity doesn't appear to be considered and UHC may or may not give an auth, but will subsequently review records for claim approval. Plan types and Locality may also be a factor. Be aware when setting care plans of this edit and remember that additional sessions will likely need to be charged to the patient.

Don't forget that payer policies can be changed at any time, and be sure to recheck the guidelines frequently!
Haven't seen this limitation yet? That's because it's not in the standard policy. It's located under: Policy Link