Preventing Prior-Authorization Denials in Your Vein Practice

Attention to Detail Makes a Difference:Paying careful attention to detail to your upcoming patient cases, your applications for prior authorization, your documentation and the CPT codes charged can speed up your cash flow and prevent lost revenue…

Vein practices are currently confronted with the reality of declining reimbursement for their bread and butter vein ablation cases.  CMS re-evaluated the practice expense (PE) component of the RVU reimbursement formula and are cutting reimbursement for ablation cases by approximately 24 % over the next 4 years.  To adapt, it is critical to make many adjustments in your vein practice to either increase revenue or decrease costs, or both, going forward.

One way to increase revenue is to reduce or eliminate prior authorization denials.  We’ve noticed that it is common for insurance companies to deny claims for lack of prior authorization because of simple single digit errors in the CPT code in the application.  Specifically, we’ve noticed a trend in prior authorization denials for the CPT codes 36465 and 36466.  Providers are requesting prior authorization for 36466 but are billing 36465.

You would not think one number off would make much difference, but it is all in the CPT description:

• 36465:  Injection of noncompounded foam sclerosant…”SINGLE incompetent extremity truncal vein”
• 36466:  Injection of noncompounded foam sclerosant…”MULTIPLE incompetent extremity truncal veins”

Many insurance companies are denying such claims because the exact CPT code that was authorized was not the exact CPT code that was billed.  This results in the submission of an appeal, which at best slows down your cash flow.  However, appeals are not always successful, depending on the patient’s insurance plan.  Also, one cannot simply re-file the denied claim with the CPT code that was authorized without also amending the medical record documentation.  Moreover, one cannot bill for a 36466 if the records do not state that multiple veins were treated.  And, of course, the documentation and codes must reflect the actual treatment the patient received and cannot be amended just to get a claim paid. Doing this would be considered fraud. So, such cases often lead to lost revenue.

The Takeaway:

1. Consider your upcoming patient cases and think carefully about whether the patient will need single or multiple vein ablation.
2. Give special attention to detail in preparing your prior authorization applications to ensure the CPT Codes on your application match precisely the case you plan to perform.
3. On the date of service, review the prior authorization approval to ensure the approval matches the procedure you will perform that day.
4. Confirm that your documentation accurately reflects the exact procedure you performed.
5. Finally, ensure that the CPT and ICD-10 codes filed on the claim are consistent with your documentation.
6. Alternatively, depending on the payer and payer guidelines, consider adding several possible CPT’s to your Prior Authorization request to cover various possible scenarios that could play out on the date of service.  For example, include both 36465 and 36466.  Some payers will allow this, while others will not.

Following these steps carefully will help you increase your rate of cash flow and prevent lost revenue.

Click here to see what StreamlineMD can offer your vein practice: StreamlineMDVein.pdf

If you have any questions, please contact your StreamlineMD client rep or StreamlineMD sales at 866-406-2224 or sales@streamlinemd.com.