Wiki Providers splitting bilateral procedures to different days

[Walker22]

I have several pain mgmt providers that refuse to perform bilateral procedures. The bring the patient in for one side, then a few days later, they bring them back for the other side. I can find no documented reason not doing it bilateral on the same day. I'm worried that this represents an audit risk. Does anyone know of documentation from CMS or other payers specifically addressing this issue?

 

[CodingKing]

Off the top of my head, closest i can find right now is NCCI manual was updated not to inconvenience patients or put health in jeopardy to get around edits.

 

[thomas7331]

I think you're right that this could be a potential audit risk since your provider could show up as outliers, but if your documentation supports the services billed, the risk of negative consequences is low. There aren't any CMS regulations for this beyond the generic 'medical necessity' guideline and providers have a lot of latitude to make decisions as to how they choose to practice. I think to take any action against a provider for doing this would have to involve an investigation with peer review by other providers and would only be likely if there was a really serious allegation and/or a lot of money at stake. However, for pain management, you might want to have them consider that some of those services have frequency limits in the LCDs or payer policies, and bringing the patients in more often than necessary could negatively impact or limit the treatments that are available to them. You could also discuss with them that while this practice might benefit them in the short term, it could actually hurt them in the long run. Payers will catch on that these providers are costing more for the same care and that could impact their contract rates. And as shared savings and capitated programs grow, having a higher cost of care could also put your providers at a competitive disadvantage.

As a coder, I've been in this situation myself and as much as this bothers me too from an ethical perspective, my experience had taught me to steer away from addressing this kind of thing too directly with providers because I've found that going there can easily be taken the wrong way only makes a working relationship with them more difficult. I'll sometimes bring up that being outside of their peer group can bring scrutiny to the practice and try to leave it at that. But ultimately, deciding what is medically necessary and being able to defend their treatment decisions is the provider's professional responsibility and it's up to them to choose how they practice.

 

[Walker22]

Thank you both. Thomas, I pretty much feel the same way. Without solid evidence that the practice is wrong, I would never mention it, unless my opinion was specifically asked for. Just trying to be careful and protect my providers any way I can!