New Medicare and Insurance Billing Changes

Recently, I sat down with two of my ultrasound colleagues to discuss some hot topics for anyone performing insurance billing, Medicare or third party billing related to venous ultrasound or vein therapy.

Gail Size and Rita Shugart are well known in the vascular ultrasound community, and both assist practices with accreditation, policies, QA and related issues. The three of us discussed some of this at the recent SVS-SVU meeting in Washington, DC, in June, which makes for a timely article on the topic. There are many changes on the Medicare and insurance horizon and we wanted to share information about recent and upcoming changes. This exchange covers many issues pertinent to a vein clinic or phlebology practice.

JZ: Rita, how has Medicare reorganized?

RS: Since 2006, Medicare has been reducing the number of insurance companies that process claims and establish policy for beneficiaries (called Medicare Administrative Contractors or MAC s) from 43 to what will be, within the next couple of years, just 10 companies.

JZ: Gail, I’m curious, how will this Medicare reorganization affect vein practices?

GS: One of the ways that MAC s control costs to the Medicare program is by issuing Local Coverage Determinations (LCD s) that explain the circumstances under which services can be properly provided, coded, and billed to the Medicare system. Most states have LCD s that apply to Noninvasive Vascular Testing (NIVT ) and Varicose Veins. Under the new format, there will be 10 companies and hopefully this will lead to more uniformity, as compared to the 43 versions of LCD s that are currently possible.

JZ: Rita, there has been a move by more physicians to perform hospital-based procedures. Do the new LCDs address this?

RS: In the past, Noninvasive Vascular Testing LCD s and LE Varicose Vein LCD s usually only applied to officebased vascular labs and IDT Fs (independent diagnostic testing facilities). Now, in most states, these LCD s apply to hospital-based labs as well, and the hospitals often aren’t even aware of the existence of these policies. But what I find most interesting is that officebased physicians are often aware of the LCD for vein treatment, but not about those for diagnostic testing!

JZ: Yes, the “testing” LCDs are often forgotten. Gail, how restrictive are the LCDs, both for testing and treatment?

GS: The NIVT LCD s contain regulations about what tests can be performed, the credentialing requirements for those performing the tests, frequency of exams, and the diagnoses for which Medicare considers each type of exam to be “medically necessary.” The LE Varicose Vein LCD s specify which types of therapy are reimbursable and what conditions must be met for coverage. These regulations may have significant impact on operational issues such as who can take calls for vascular labs and when and how varicose vein treatments are scheduled. The impact of LCD s is profound, and it is imperative that every vascular lab and every facility performing varicose vein treatments determine if there are LCD s that apply to them.

JZ: Ok, Gail, so what happens if a practice doesn’t follow the provisions of an LCD?

GS: Performing an exam or procedure for reasons that Medicare does not consider “medically necessary” may lead to denial of payment. If this is/was done without an ABN (Advanced Beneficiary Notice), you will not be able to balance bill the patient – basically you’ve done a service without reimbursement. More significantly, however, a pattern of noncompliance may lead to charges of overuse, abuse, and/or fraud.

JZ: So, ladies, how can someone find out if there is an LCD for their state and practice setting?

RS: Go to the CM S website ( medicare-coverage-database/). Select your state and your provider type. Scroll through the list of active LCD s. The best recommendation is to have your own in-house expert and not to rely on a comment or discussion you’ve heard at a conference or from a colleague because your LCD may be different.

JZ: That’s great info on Medicare, but for most physicians, their practice also involves patients with private insurance. How does one find those policies?

GS: Although many private insurance companies generally follow Medicare’s LCD s, there are differences, especially with the Major Carriers. Some like Aetna, United Healthcare and the Blues have policies that can be more (or less) restrictive than Medicare. Check the websites of the major insurance companies you deal with to see if they publish their policies. As a participating physician, these are available to you, but as a nonparticipaing physician it may be more difficult for a physician’s office to obtain a copy. In some cases, the patient may have access, but may need you to “explain” the nuances of the coverage policy. And although it is ultimately each patient’s responsibility to know the provisions of his or her insurance policy, it is often wise to check with a specific company about the specific provisions for an individual patient. Two patients with policies from the same insurance company may have very different plans, coverage, and benefits.

JZ: What can a physician start to do today to ensure their practice is following the rules?


  1. Determine if there is a Medicare LCD that applies to your facility.
  2. If you perform varicose vein treatments, investigate the websites of the major insurance companies in your area to see if they have policies and regulations.
  3. Follow the provisions of the applicable policies.
  4. Document, document, document!

JZ: Rita, I hear that Medicare is increasing the number of audits it performs. What are you hearing and how are they doing this?

RS: In addition to its existing anti-fraud and abuse education, prevention, and detection programs, Medicare has many new methods, including the Senior Medicare Patrol, hiring private investigators to conduct on site surveys, Fraud Strike Forces, and “secret shopper” patients.

Several factors contribute to this recent increase in efforts. Health Care legislation has provided additional funding. A former state insurance commissioner, Health and Human Services Secretary Kathleen Sibelius, has joined Attorney General Holder and the Department of Justice in promoting well-publicized sweeps of fraudulent Medicare operations. And aging baby-boomers, rapidly reaching Medicare age, have a sudden and intense interest in preserving the benefits they have been counting on.

JZ: Gail, you mentioned something about billing patterns. Explain what steps can I take to minimize my risk of audit?

GS: There are many potential billing patterns that may trigger an audit: claims sampling – anything that identifies you as an outlier, a change in billing patterns, pattern recognition (e.g., always billing for complete exams) continuing to bill for denied services, claims differences, Part A vs. Part B, practicing in an OIG Target State (i.e., NY , NJ, FL) practice setting (e.g., IDT Fs); CPT Coding - routine use of modifiers to increase reimbursement; Diagnosis Coding – frequently/always using the same code, RAC Target, Qui Tam suits.

Many believe that audits are virtually inevitable – that it’s not a matter of if you’ll be audited, but when you’ll be audited. The best defense is the best documentation of the medical necessity of the test, documentation of the order for the test, and that the test was performed and correctly billed.

JZ: Rita, I am often asked, “What will happen if my practice gets audited?” Can you explain what key items they should be prepared to show from their charts?

RS: In the event of a vascular lab audit, you will likely be asked to send these items to Medicare:

  • The written order for the test
  • The complete final report of the test
  • Records/office notes from the physician ordering the test that document his or her intent to order a diagnostic test and the reason for ordering the test
  • Documentation of required personnel training, experience, and certification, and other documentation as required by an LCD It is important to keep in mind that Medicare typically performs “post-payment” audits, so simply getting paid for a service does not necessarily mean that you’ve done well. Typically, if an audit takes place, Medicare will look back at a group of services (chart review) and based on the percentages of things done incorrectly, they will extrapolate backwards for a period of 2 to 3 years. If a pattern of fraud or abuse exists, it could go back further.

JZ: Gail, physicians and techs often ask, “How do I know if I am documenting properly?” What are your thoughts on this?

GS: NOTHING is more important than proper documentation. In addition to providing accurate, clinically relevant information that is useful in patient care, the final report of a Vascular Lab exam must document the reason for the test and contain information about the patient’s symptoms, condition, or diagnosis that support the medical necessity of the billed ICD 9 code. The website of the Intersocietal Accreditation Commission ( can provide helpful information on the appropriate components of reporting for vascular lab testing.

There must be documentation of all the required components of the billed CPT code, and there must be a clear, precise impression/conclusion.

JZ: And I would add that this is also vital for documentation of treatment, which should also include things like differential diagnosis, failed conservative therapy and rationale for the specific treatment to be provided.

RS: One flag that always gets attention is inconsistency in the medical record – which is where EMR templates can be problematic. If your record indicates a particular clinical sign or symptom in one area of the chart, and not another, that’s a problem. Also discrepancies of right versus left can lead to problems.

JZ: Gail, I have heard accreditationfor vein centers is coming...

GS: Yes, the Intersocietal Accreditation Commission is developing an accreditation for vein centers. The IAC- Vascular Testing Division already accredits diagnostic ultrasound testing, including peripheral venous duplex and venous physiologic studies. The new Division will evaluate and accredit an entire vein center facility and is an excellent way for vein centers to demonstrate to patients, payers, and the medical community their commitment to offering comprehensive, high quality services. The first meeting of this new division was held the first week of June, 2012. Much progress seems to have been made and the IAC ’s new accreditation should be available in late 2012 or early 2013. Watch for announcements at

JZ: Rita, Will the IAC’s new Vein Center Accreditation be required for reimbursement?

RS: The Intersocietal Accreditation Commission provides voluntary accreditation for diagnostic testing in vascular ultrasound, echocardiography, nuclear/PET, MRI, CT, and CT dental testing and for carotid stenting facilities. Effective January 1, 2012, CM S requires that facilities providing the technical component of nuclear/PET, MRI, CT, and CT dental testing to Medicare beneficiaries must be accredited by one of three approved accrediting organizations. Interestingly, vascular ultrasound has escaped this provision for the time being, and no one really knows what will happen in the future. As for the new Vein Center Accreditation, it is currently not known if CM S or any other payers will require accreditation for vein centers as a condition of payment.

JZ: Ladies, in closing it’s my hope that we’ve provided some good information to the readers, and I would like to thank you for your time and knowledge on this subject!

Gail Size has more than 30 years of technical and managerial experience in both clinical and private vascular laboratories. She is the founder and president of Inside Ultrasound, Inc., a provider of Vascular Accreditation assistance, Basic Training in Noninvasive Vascular Testing, Adult and Stress Echocardiography Testing, and Vascular Interpretation of Physicians and www.vascularweb. com, a provider of online continuing education. Rita Shugart, RN , RVT , FSVU, President, Shugart Consulting, is nationally recognized as a leader in the field of vascular ultrasound. During more than 30 years in the field, Rita has managed both hospital and office-based vascular labs. In 2008, she formed Shugart Consulting, a vascular lab practice management consulting firm, dedicated to assisting labs with: maintaining regulatory compliance, maximizing legitimate reimbursement, minimizing expenses, and providing quality patient services.

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