MULTIPLE PROCEDURES DONE DURING FSE

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Help please! Providers in practice continue to do multiple procedures during annual full skin exams and with new e/m guidelines certain insurances are starting to deny the office visit. (Anthem). Providers are really bucking the new way of looking at things and not sure how to go about explaining it to them any clearer. Also most of the dx for the fse's are benign.
 

thomas7331

True Blue
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If payers are denying your office visits, that really doesn't have anything to do with the new guidelines. The guidelines only affect how E&M levels are assigned based on documentation, and the payers haven't even had time to start auditing documentation for guidelines that have only been in effect for less than two weeks so far. The fact that 'most' of your diagnoses are benign should also not cause an office visit to deny as that is not a determining factor in whether or not something requires treatment.

For denials of office visits done in the same session as a procedure, I'd recommend reviewing at your payers' reimbursement policies for additional information. For anything that a payer denies, there should be something published in writing explaining their policy and rules for making that determination. If they are not following their policy, then you should be able to appeal the denial or request a reconsideration.
 
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Thank you, I agree they have not had time to audit documentation and I am going to appeal the claim. I think I am more concerned about future fse appts and providers wanting to continue to do multiple procedures along with the e/m. I just want to make sure we are following all of the mdm guidelines. Should providers have pts come back for biopsies, cryo of ak's and sk's or do all during the fse. Thank you so much for your feedback
 

thomas7331

True Blue
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3,146
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Thank you, I agree they have not had time to audit documentation and I am going to appeal the claim. I think I am more concerned about future fse appts and providers wanting to continue to do multiple procedures along with the e/m. I just want to make sure we are following all of the mdm guidelines. Should providers have pts come back for biopsies, cryo of ak's and sk's or do all during the fse. Thank you so much for your feedback
Coding has no say in what a provider should do or what their decisions should be - we only report what is documented.

Providers should always make treatment decisions based on the needs and best interests of the patients and not based on coding rules or expected reimbursement. Remember that the CMS definition of medical necessity covers that which is reasonable and necessary for the treatment of the patient, and not what is done for the convenience of the patient or provider.
 
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