by AJ Riviezzo, MBA
The difference between good cash flow and great cash flow does not always entail seeing more patients. Rather, it involves assuring that you are appropriately and fully recompensed for the services you are already delivering. AJ Riviezzo, CEO of American Physician Financial Solutions, shares his insights from assisting nearly 20 phlebology practices nationwide streamline their billing and collections systems. Apply these specific guidelines and recommendations to your practice to ensure that you capture and appropriately bill for your time.
1. Initial Patient Encounters – If a patient is referred to you by another physician, you should forgo the ‘free consultation’ if you are doing those and immediately schedule the patient for an ultrasound and initial office visit. The code for a referred initial office visit is typically 99243 or 99244. This is different, and reimburses at a higher rate, that the standard 99203 or 99204 initial visit used for a self-referred patient.
2. Authorizations – Obtaining an initial authorization is crucial to ensuring payment for your services. If an authorization is required, and you do not obtain one, you are giving your services away. Your authorization coordinator needs to call on every patient one week prior to the delivery of services (Medicare patients excepted as there is no authorization requirement). Benefits and eligibility should be determined and they must ask if an authorization for the service(s) is required. A note should be made in the financial chart noting the date, time, the conversation, and with whom they spoke. Sometimes the insurance clerk is wrong. If you know that your local Blues or Medicare Advantage Plan typically requires an authorization, have the authorization coordinator re-call the payer and speak directly to someone in the authorization department to clarify whether an authorization is or is not required. Again, make certain that the call is documented. You must also ensure you are requesting an authorization for all possible services including phlebectomies and sclerotherapy.
3. Follow Up Authorizations – If a patient is being brought back for a 3 to 4 month review (or later), a new authorization may be required before performing additional services (typically sclerotherapy). This little bit of double checking will save you money, time and aggravation later.
4. Second Insertion – If you perform a second insertion while doing an ablation – either into the same vein or a second vein – there is a code that allows for additional reimbursement for your time. The codes are 36476 for RF ablation and 36479 for laser ablation. Neither of these codes is subject to the 50% reduction rule for secondary procedures. As such, they will reimburse between $350 and $450. We recommend billing this code immediately below the 36475 RF ablation or the 36478 laser ablation CPT code. Your clinical documentation must note the second insertion, where and how performed (micro-puncture , etc.).
5. Sclerotherapy Billing – One of the major misconceptions centers on billing and reimbursement for sclerotherapy. You can be paid for medically indicated sclerotherapy. Examples of medically indicated sclerotherapy would be closing off the distal portion of the greater saphenous vein or chemical ablation of a perforator if reflux is present. There are three codes that should be used for medical sclerotherapy.
a. The first is a 93971 (LT or RT). You have to review and map the leg prior to performing the sclerotherapy.
b. The second code is 76942 (LT or RT) – ultrasound needle guided placement. If you are performing sclerotherapy without the ultrasound, you would not bill this code, for example, a bulging incompetent tributary. However, if you are doing visual sclerotherapy, the payer may question the medical necessity of the procedure as it looks very much
like cosmetic services. As always, your documentation must clearly support the service(s) performed.
c. Finally, you would bill for the sclerotherapy itself using code 36471 (LT or RT) as you are typically injecting more than one vein in a session.
6. Follow Up Ultrasound – Most every practice reviews the patient one week or so after an ablation. During that time it is standard to perform an ultrasound to rule out a DVT and to ensure closure. Many practices, however, fail to properly bill for this review. You can use code 76970, follow-up ultrasound, to both document to the payer that you have performed this service and to be appropriately reimbursed for your time.
7. Office Visits – Office visit coding can be tricky. Many practices always bill at the highest levels – 99214 or 99215. Unless the patient has major new symptoms that require testing and diagnostic work, the level should more likely be a 99212. If the patient complains of pain or swelling or you are reviewing the patient due to a DVT, you must ensure that your diagnosis for the encounter matches the clinical notes. All too often practices use the same diagnosis for all services performed during that patient’s treatment plan which results in decreased reimbursement
and a mis-match in notes versus diagnosis.
8. Global Time Frames – Many services have a global time frame during which additional services may be considered to be part of the initial service unless modified correctly. For
the phlebology practice, a stab phlebectomy (regardless of number of incisions) has a 90 day global period. Sclerotherapy has a 10 day global period. Oddly enough, an ablation by RF or
laser carries no global period. The billing department should review what services were performed prior to billing any new services and attaching the correct modifiers.
9. Modifiers – If a service is performed during a global period, a modifier must be attached. The most commonly used modifiers for procedures are 58 (staged or related procedure) or 79 (unrelated procedure within a global). If you bill an office visit during a global period, you will need to modify this with a 24 (unrelated evaluation).
10. Clinical Notes – More and more payers are requesting notes before they will process the claim. Two factors come into play here.
a. You must make sure your notes will pass muster if reviewed. We recommend having an external source do a quick review for you. The notes must be clear, concise, document the treatment(s) appropriately, and match the level of service you have billed. Poor documentation will very quickly sink a medical necessity appeal.
b. You must also make sure the notes are sent in a timely fashion. Most payers will only allow a 90 day window during which the notes must be sent. If the notes are not sent during that time frame, you may never be recompensed appropriately. As your staff has a million other things going on in your office, notes are sometimes pushed off until the last minute. This can dramatically and negatively impact your cash flow.
Share these guidelines with your office manager and staff that manage your billing, collections and contracting. With appropriate direction, you can help your practice achieve the compensation that is rightfully yours – without increasing the volume of your patients or your insurance paperwork.