1. Good documentation can prevent medical necessity denials. Insurance companies are looking for more reasons to deny coverage today than ever before, which means surgeons must diligently specify why they recommended surgery.
"It's almost as if surgeons need to state their case," says Kendra McKinley, president of Doctor's Billing, Inc., a medical billing and consulting company. "The medical necessity documentation needs delineated the medical pathways. Most surgeons think it is the primary care physician's responsibility because they oversee the conservative care for their patients. However, surgeons are now being asked to document those pathways to clarify medical necessity."
The documentation of the patient's clinical history begins with the first office notes and should be restated in the medical necessity paragraph for any procedure. Clear documentation of medical necessity will help with coverage for the procedure in real time, as well as support the surgeon's decision in the event of a RAC audit.
"It used to be that surgeons could just see their patients, do the physical and choose the treatment pathway," says Marcy Rogers, president and CEO of SpineMark, a developer of spine centers of excellence and spine research organizations. "Now they need to start thinking about what supports medical efficacy and acuity of the treatment."
2. Practices must be prepared for ICD-10. As the new codes are released for ICD-10, documentation requirements will jump exponentially. Coders should begin preparing surgeons now for the level of detail necessary after the transition.
"One solution I’ve seen is progressive health systems and practices invest in CDI experts," says Danielle Koelbl, president of MedRev Solutions, a healthcare revenue cycle and receivable management company. "Whether or not a physician is affiliated with the hospital or larger system organization, it's time for physicians to take advantage of professionals with education in CDI for on-the-job training. Proper documentation might seem like an argument over semantics, but it's not. CDI professionals can help surgeons navigate payer-specific requirements. This becomes increasingly important with ICD-10 coding specifics"
For example, the policy might say "facet joint injection" is considered medically necessary after the pain diagnosis persists for three months despite conservative treatment. If the patient's three months of conservative treatment isn't indicated in the report, the payer would consider facet joint injections experimental as a therapy because effectiveness wasn't established.
"Payers need to know the elementary details of the patient's progress, why the treatments are failing and what diagnoses are made," says Ms. Koelbl. "Surgeons must put that in their notes even if they weren't the person administering conservative treatment."
3. With specific details surgeons can avoid time-consuming queries. When coding and billing specialists don't have enough information to code a procedure from the documentation, they'll query the physician for additional information. This adds time to the accounts receivable days and impacts revenue at the practice or surgery center.
"If documentation clarification is needed, use templates and create a set of non-leading queries to clarify documentation," says Ms. Koelbl. "There are numerous resources available to help customize templates to help coding staff and CDI specialists work together with physicians on clarifications. If you are seeing trends in reoccurring queries, work with the physician on proper clinical documentation to stop repeat queries moving forward."
This can be on-the-job training for specialists to gain their support for clear documentation that translates into more accurate coding. Dig down to the granular level and develop templates for each payer depending on specific requirements for coverage.
"There are some payers that have guidelines for coverage that are practically unattainable," says Ms. McKinley. "Most providers don't have the resources to go the extra mile to prove medical necessity. The de facto way of going around these requirements is knowing the policies for main payers well, and then create your non-leading queries for your templates accordingly."
4. A strong relationship with payers can help you figure out what you need to include in documentation. Insurance companies often change coverage decisions without notifying physicians or other providers until their claims are denied. Develop a stronger relationship with local payers and become involved in strategies to educate them about the value of your care.
"Someone has to know the contract and track the outcomes," says Ms. Rogers. "Take a proactive step to become involved in knowing as many payers in the region as possible that make decisions on an educational and tracking basis. Talk about the changes they make and how they impact your practice."
Practices can also encourage patients to become more involved with advocating for coverage to the payers. "I've had success with patients who can't move and weren't allowed to have spine surgery putting pressure on the sponsors of their plan," says Ms. Rogers. "Then the employer is unhappy and wants to see the coverage changed."
5. Appropriate documentation keeps RAC audits from taking money back. RAC auditors are looking for past surgeries they deem medically unnecessary to recoup reimbursement. In some cases, auditors are even citing claims that were previously approved for surgery because documentation wasn't performed up to current standards. To avoid negative consequences from RAC audits, it's important to note diagnosis codes.
"Make sure every diagnosis code is put on the bills appropriately so RAC audits are not automatically triggered for not medically necessary," says Ms. Koelbl. "The physician might mention a condition in the documentation but not mention whether the patient was treated for the mentioned condition. This might seem elementary, but it's important for translating the report into diagnosis codes."
When educating physicians on these necessities, give a short and clear presentation; they don't have time to go in-depth, but if you tell them what you need they're more likely to improve. You can also go a step further with reminders to the physician's team about requirements for each payer.
"If you are seeing trends in RAC audits, have someone print out the medical policies so physicians can review outlined requirements and stop take-backs from occurring in the future," says Ms. Koelbl.
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