This may be too late, but Thomas gave you some great advice. You said that you were stumped on how to write an appeal letter when the documentation is incomplete. Don't waste your time. If the documentation truly does not support the code/s submitted appealing them is not going to get them paid. It will be a waste of time. I agree with Thomas, if you have the resources and ability separate the encounters where you feel the documentation does support the code/s, focus on those. At the very least this should be a teaching experience for providers. Quality documentation matters.
Thank you for your input. Thomas did have a great suggestion, and I did as he suggested. Separating the codes was easy since we only have four codes.
Instead of separating the codes for an appeal, I separated the codes to be able to write a response to my provider. I explained to him that I looked at our codes separately, looked at the documentation, and tried to combine two of our codes together. Still no supporting documentation for these codes. I explained that we could appeal the E/M code, but it was up-coded, and BSCA would still want a partial refund for that code. He was confused and said he didn’t know what BSCA wanted. I explained that all of our encounters said, ‘patient tolerated treatment.’ BSCA was looking for patient-specific documentation. They wanted to know what equipment was used, what techniques were implemented, and how the patient tolerated the treatment. I sent my provider a copy of a colonoscopy note I had. The colonoscopy note said what techniques were used, what equipment, and how it was advanced through the colon. I was hoping my provider would get a clearer understanding of patient specifics. I received a response from him saying, ‘So am I to just give away my trade secrets?’ I said, ‘no, but BSCA will continue asking for their money back.’
To bring you up-to-date, my provider is now writing addendums to all the notes we faxed to BSCA. I pointed out that BSCA’s ongoing correspondence says, ‘any additional documentation will not be accepted.’ He says BSCA has to take these addendums.
During this process with BSCA, Medicare requested 21 encounter notes to review. The contracted auditor sent letters to our patients asking all kinds of questions. The letter said something about fraudulent billing. Some patients got scared and stopped treatment. The CEO of the company wrote a nasty complaint letter to our MAC. I’ve reached out a few times to the contracted auditor, and they will be taking their finding to CMS on 3/15/23. CMS will decide that day if the case will be closed or if CMS will be requesting additional records. I think they will be pulling a lot more of our notes. And yes, I've been looking for new employment.