Search Results

In my opinion, your patient should sign a waiver at each visit

ANSWER: You need to separate out the medical portion from the procedure portion. If the patient has cellulitis and you work them up, place, them on a Rx antibiotic, maybe order labs then that is an E/M. If they can't take an oral antibiotic, then you must document what you are offering as medical management to validate billing that E/M. For example Mupirocin is often prescribed if you feel they have a staph infection topically, this counts as part of the medical management. This diagnosis is separate from the procedure. The nail procedure should be for the nail deformity or ingrown nail and is usually paired with pain if that was documented.

False, always is not an option. There are circumstances that allow for it sometimes but if all you do is a minor procedure it has E/M built into it. So, make sure that "New" patient E/M has medical management unrelated to the procedure.

Great answer. Makes more sense now. Thank you!!

Medical records must be kept 10 years if you are billing any Medicare Advantage plans, otherwise with regard to HIPAA, retained for 6 years. If you treat minors for example in MD, medical records must be kept for five years after the record is created or until the patient turns 21, whichever is later. You should always check with your state for any specific requirements as well!

One should always be concerned about any audit coming from the payer, but not to the point that you say, I will never perform this service again. Take a look at the chart note to determine whether or not the chart note met Optum's policy provisions. If not, what were the deficiencies and fix the "template" you may be utilizing. A one chart review resulting in a negative finding, may trigger another probe of more charts or may result in a simple slap on the wrist with the result of do much better next time. On the other hand if the code being reviewed is sujbect to signficiant fraud and abuse, then the one code one chart auit may result in a much larger scaled audit.

Great follow up question. In my opinion, a wound which is undermined is not stable enough to receive a CTP. This should be debrided and packed with a surgical dressing until the undermining or tunneling has resolved. The current policies in my opinion, do not also allow for CTP products to be folded over (double thickness). They are to be used to cover and secured to the wound bed. Thus I believe the amount use to “stuff” into a wound cavity which is being undermined or a folded over to increase the amount used, would not be supported by the current or future LCD. I look forward to the opinions of others.

"Dr. Kesselman, what if there is undermining to the wound? For instance, if the wound is visually 5 cm² and you utilize approximately 15 cm² additional to the undermining areas, can you claim 20 cm² of wastage on a 40 cm² cellular tissue product?" - abassdpm

Medicare MACs have seen an exponential use of CTP and the costs associated with them has grown exponentially along with their use. One of the issues that the Medicare MACs have been looking at is wastage. And this is why there has been a joint task force by the MACs to issue a joint policy on CTP, which should be released very shortly. The short answer to your question is there is no hard and fast rule of a specific numeric value which would be considred excessive waste embedded in the policies covering the application of CTP’s. The question you must satisfactorily document is whether or not you made an effort to use a product which closely matches the wound size?For example, if you have a wound of 40 sq cms and you choose to order a product which is 44 sq cms, you would likely be fine with a wastage of 4 sq cms. Conversely, if you have a wound which is 5 sq cms and you order a 44 sq cms, you had better document why you chose a product which is 44 sq cms in size. Does it come in a smaller size? If so then that’s what you really should have ordered. Another consideration is if there is another suitable product with the same indications which is availalbe in a smaller size, why was that not used? Of course documenting a specific “safe” margin to secure the CTP to the anatomical site must also be figured into the equation. In summary, the Medicare carriers are looking for you to cut costs on wastage. That means ordering smaller size products and minimizing wastage.In some cases a smaller size of one product may actually cost more than a large size (with wastage) of another.Defending the margin of wastage and specifically which product you use in a specific situation will now be part of the required documentation.

We are being told that we need to reduce or “minimize” our wastage when applying Cellular Tissue Products. Is there a hard and fast formula which CMS or other carriers follow to determine an exact value of what that means? - WoodsideDR

During the pandemic Medicare was very lenient on extending deadlines. Even so, during that time, it would have been wise to respond by simply stating you required an extension to respond. Every auditing agency would almost always grant an additional sixty day extension.Now that the PHI has ended one really needs to have a good reason for having more time.Some good reasons include, you are short staffed, delay in receiving (you recevied the letter two weeks after the date of the letter ), etc.But notice these are all prior to the origina deadline. Unfortunately, your only option may be to follow the options given once you are notified that you failed the audit for failure to respond.In some cases, you may be given the option to appeal to the same auditing agency, while in other cases you may have to file to another carrier.In all cases, the next step of appeal may require a financial threshold to meet.This may allow you to proceed on the one chart audit, or may require you to combine other audits proceeding to the same level.

I recently responded to a post payment audit 5 days late. The carrier is insisting that I can no longer appeal. Do I have any recourse? - WoodsideDR