Wiki Procedure Documentation Guidelines

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sinman0531

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Can anyone direct me to either general or specific documentation guidelines for cryotherapy that state that the number of lesions treated must be notated?

I have a very petty MA who is fighting me on including the number of lesions treated in the actual procedure note because she feels like its sufficient enough that the number of lesions was notated in the visit findings. We have had a lot of denials, especially when multiple types of cryo are performed on the same day, so I feel like that's a very simple thing to add in to get everything paid.
 
Is the procedure documentation housed within the visit note? Or, is it a separate, stand-alone document? And, as for procedure documentation why is an MA deciding on documentation requirements (and not only acting as a scribe)? Wouldn't the provider be responsible?
If you are looking at the CPT codes the code description itself should be the guideline. They specifically state the number of lesions or size depending on the CPT. An auditor is going to take the CPT description literally and compare it to the procedure document. If there is no # or size it will be denied. If the procedure documentation lives "inside" or at the bottom of the visit note, it may or may not be counted. A procedure document (op note) is supposed to stand alone.

Check the payer you are billing for guidelines.

I have seen this type language in CMS LCDs, those are a good place to look for things like this: "A procedural note, protocol describing indications, diagnosis, methodology of treatment, or modality is advised."

To me, this is almost like saying you are going to bill for complex repair but not state the measurements...
 
amyjph said:
To me, this is almost like saying you are going to bill for complex repair but not state the measurements...
Click to expand...
Yes! We include number of lesions for ILTAC injections, and its really such a small amount of additional work the pushback doesn't make sense at all.

In our practice, the MA's do act as scribes, but for our providers with seniority (this provider in question owned the practice up until about 6 months ago when he sold his majority) they also sometimes act as gatekeepers, this MA in particular.

The procedure notes appears directly below the "Visit Notes" section. The denials (specifically for 17003, but also sometimes 17000 when its billed with 17110) come from most of our payers, not one in particular. So the visit for that day will appear something like this:

Visit Findings Details​

Problem 1: Actinic Keratoses left chest; left forehead; right dorsal hand.
EXAM: The scale or crust is horn-like, dry, and rough, adherent in photodamaged areas, destroyed with cryotherapy.
ASSESSMENT: Actinic Keratoses
PLAN: Procedure - Cryotherapy
Qty: 4

Problem 2: Irritated Seborrheic/Inflamed Keratosis right cheek.
EXAM: Scaly maculopapular stuck on keratotic crusted inflamed erythematous lesion.
ASSESSMENT: Irritated Seborrheic Keratosis
PLAN: Procedure - Cryotherapy
Qty: 1

Destruction Procedure Details:​

Risks and benefits were discussed in detail. Possible short and long-term side effects were discussed to the patient's satisfaction. Hyfrecator was used for removal. Patient tolerated the procedure well. Post procedure effect showed no change. Post operative instructions were given. Patient was instructed to do nothing.

Cryotherapy Procedure AK Only​

Risks and benefits were discussed in detail. Possible short and long-term side effects were discussed to the patient's satisfaction. A high-pressure canister of liquid nitrogen Patient tolerated the procedure well. Post operative instructions were given. apply ointment, cleanse wound.




When we send these notes, the denials are upheld.


I have tried to find an LCD or even just in general an article from the AAP or AAD (since we are dermatologists) but I can't find anything that references back to what actually constitutes a good note (the "What, Where, Why, How Many"), and this MA won't budge unless I can find something "credible"--my opinion as a certified person with 7 years of experience working for insurance companies on medical reviews means nothing.
 
sinman0531 said:
Yes! We include number of lesions for ILTAC injections, and its really such a small amount of additional work the pushback doesn't make sense at all.

In our practice, the MA's do act as scribes, but for our providers with seniority (this provider in question owned the practice up until about 6 months ago when he sold his majority) they also sometimes act as gatekeepers, this MA in particular.

The procedure notes appears directly below the "Visit Notes" section. The denials (specifically for 17003, but also sometimes 17000 when its billed with 17110) come from most of our payers, not one in particular. So the visit for that day will appear something like this:

Visit Findings Details​

Problem 1: Actinic Keratoses left chest; left forehead; right dorsal hand.
EXAM: The scale or crust is horn-like, dry, and rough, adherent in photodamaged areas, destroyed with cryotherapy.
ASSESSMENT: Actinic Keratoses
PLAN: Procedure - Cryotherapy
Qty: 4

Problem 2: Irritated Seborrheic/Inflamed Keratosis right cheek.
EXAM: Scaly maculopapular stuck on keratotic crusted inflamed erythematous lesion.
ASSESSMENT: Irritated Seborrheic Keratosis
PLAN: Procedure - Cryotherapy
Qty: 1

Destruction Procedure Details:​

Risks and benefits were discussed in detail. Possible short and long-term side effects were discussed to the patient's satisfaction. Hyfrecator was used for removal. Patient tolerated the procedure well. Post procedure effect showed no change. Post operative instructions were given. Patient was instructed to do nothing.

Cryotherapy Procedure AK Only​

Risks and benefits were discussed in detail. Possible short and long-term side effects were discussed to the patient's satisfaction. A high-pressure canister of liquid nitrogen Patient tolerated the procedure well. Post operative instructions were given. apply ointment, cleanse wound.




When we send these notes, the denials are upheld.


I have tried to find an LCD or even just in general an article from the AAP or AAD (since we are dermatologists) but I can't find anything that references back to what actually constitutes a good note (the "What, Where, Why, How Many"), and this MA won't budge unless I can find something "credible"--my opinion as a certified person with 7 years of experience working for insurance companies on medical reviews means nothing.
Click to expand...
That's frustrating. What do the denials cite as the exact reason? The CPT description in the book is the credible source in my opinion where the number has to be stated for the actual code billed. What I would do is approach it from a different angle and run data analytics on how many denials over a time span you are getting and show the provider in dollars and numbers. Think of the added time and money spent on staff having to work these when you could fix one small documentation issue and they would probably go through first pass. Is it every single time one of these CPT is billed? I would be concerned that my provider was on pre-pay review if it was. If I was auditing this I would deny it too (as you know). Just because a quantity is found in the visit findings, it doesn't mean the procedure performed addressed all of those. It has to be stated in the procedure note. I would question if both of the "problems" stated in the findings section were addressed during the procedure. The procedure documentation above doesn't even state the anatomical location of removal. How does the reader know if they were removed from the chest/forehead/hand and cheek? How do we know it wasn't only one, two or all five for example?

Maybe here, not technically "official" but reputable: https://shop.aad.org/products/principles-of-documentation-for-dermatology-fifth-edition
Have you checked CPT Assistant?

This speaks directly to how to document: https://www.karenzupko.com/actinic-keratoses/
This is a good derm resource you might find something here: (this is just a link to a question but they have more info) https://www.karenzupko.com/report-actinic-keratosis-seborrheic-keratosis-17000-17004-codes/
 
amyjph said:
That's frustrating. What do the denials cite as the exact reason? The CPT description in the book is the credible source in my opinion where the number has to be stated for the actual code billed. What I would do is approach it from a different angle and run data analytics on how many denials over a time span you are getting and show the provider in dollars and numbers. Think of the added time and money spent on staff having to work these when you could fix one small documentation issue and they would probably go through first pass. Is it every single time one of these CPT is billed? I would be concerned that my provider was on pre-pay review if it was. If I was auditing this I would deny it too (as you know). Just because a quantity is found in the visit findings, it doesn't mean the procedure performed addressed all of those. It has to be stated in the procedure note. I would question if both of the "problems" stated in the findings section were addressed during the procedure. The procedure documentation above doesn't even state the anatomical location of removal. How does the reader know if they were removed from the chest/forehead/hand and cheek? How do we know it wasn't only one, two or all five for example?

Maybe here, not technically "official" but reputable: https://shop.aad.org/products/principles-of-documentation-for-dermatology-fifth-edition
Have you checked CPT Assistant?

This speaks directly to how to document: https://www.karenzupko.com/actinic-keratoses/
This is a good derm resource you might find something here: (this is just a link to a question but they have more info) https://www.karenzupko.com/report-actinic-keratosis-seborrheic-keratosis-17000-17004-codes/
Click to expand...


This provider in particular is A++ with most of his documentation,, so he personally would not be on pre-pay review, which is part of the problem. A couple of our providers are on pre-pay review with some insurance companies...but those providers also don't second-guess me when I tell them "fix this so its documented correctly".

The denials we get are very generalized; usually on the first denial its denied as inclusive, then on an appeal with records its denied as "does not support charges billed", or they just uphold the inclusive reason.
 
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