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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

This is a very complex subject and the response is intended only to provide a very broad response.Before you even consider doing telelmedicine, consider: Were you and the patient in the same state where you are licensed or in different states and are you licensed in the state where the patient lives?Are there any limitations based on the interstate compact which preclude you from performing telemedicine?If none of these are problematic, then consider other factors. The total time you spent on line with the patient is crucial to be documented and can easily be documented by the time the visit was initiated and terminated. These should be accompanied by your signature attestation. Why you could not see the patient in person and perhaps even more important, is why the patient could not come to your office is secondary but nevertheless should be documented as well as who initiated the virtual visit. Was the virtual visit audio only or audio and video and what platform software platform was used? All other E/M components as if you saw the patient in your office are also important.Some components to go a step further, for example would be if the patient’s vitals were to be taken, did the patient have a BP cuff and was it done while you observed? What did you observe about the patients ROM?Did the patient show you snap shot of their blood glucose from the past ten day? In other words how did you come to the understanding of certain findings needs to be documented.Some providers even record the audio/video interaction and download it into the patient’s file. From the payment status, depending on the carrier, some pay the same for physical and digital encounters others pay less for virutal visits. Some relaxed co payment rules others did not. For certain telemedicine visits specific modifiers are required on the claim form and use the same E/M CPT codes as for physcial encounters. It is important to understand that many other rules were relaxed during the PHE to allow patients greater access to their doctors. This includes rules regarding HIPAA, locations for both patient and provider and more. The termination of these relaxation rules may no longer afford you the ability to perform telemedicine using non HIPAA compliant platforms such as facetime, zoom, or other free (or almost free) popular video platforms.And most important, the geographic (urban vs rural) may also revert back topre pandemic status.I would suggest you follow this forum for future updates on Telemedicine as this is a constantly evolving issue.

I do a great deal of telemedicine in my practice and am currently being audited. What are the most important things to document?

There are significant functional differences between the Xtern (PDAC L1951) braces with them having various features. My advice would be to discuss these differences as they apply to your patient. Since the devices are custom fitted (PDAC O2 category), there are no additional HCPCS codes which are allowed to be billed. There are also some Xtern braces which are validated as L1932 which pay higher than the L1951.Any additional fees you incur for additional add on’s you order for either coded brace, do not have a separate HCPCS code which can be billed to either Medicare (FFS) or Medicare Advantage plans. However, since all Xtern braces attach to the shoe, if a foot orthotic device is required on the brace side, it is reimbursable under the Orthopedic Footwear policy. The rationale is that under this policy, foot orthotics are covered when they are placed into a shoe which is attached to a brace. The appropriate L-Code for the orthtoic would be first amended with the KX modifier and second with a site modifier (LT or RT). Also the contralateral limb which does not have a brace, if it requires a foot orthotic, will not be covered by traditional Fee for Service Medicare (and likely not by Medicare Part C Plan).That is a cash service and the L-code for that side would be amended with GY (statutorily not covered) as the first modifier and second with a site modifier (LT or RT). Note that the payment limitations cited above (surcharge for additional features you add to the Xtern) are limited to only Medicare recipients. One would need to check the patient’s third party coverage if they are not Medicare beneficiaries.

The answer is NO, as stated they are both PDAC L1951.

The new XTERN Summit is a carbon brace, and the provider pays the product vendor hundreds of dollars more for it than for the XTERN classic, which is made of plastic. Both are PDAC-certified L1951. Because the XTERN summit costs the provider more, can the provider charge the patient cash for the difference in cost if the patient wants the carbon brace over the plastic brace?