As a certified medical coder and record auditor I have reviewed over 10,000 medical records in my career. While not a doctor, I have researched hundreds of medical acronyms and medical diagnoses. My focus is slightly different from the physician. I am looking for statements that support the medical necessity for liposuction. All roads lead to that conclusion. In the progress notes I look for consistency, instances of cloning (not allowed), vague statements, and incomplete notes.
In regard to supporting liposuction for lipedema, all documentation sent to the insurance carrier must support that the surgery is reconstructive and medically necessary, all conservative measures have been exhausted and are ineffective in halting the progression of the disease—and the patient is well enough to tolerate the procedure.
That’s it in a nutshell. With everyone you speak to be sure to repeat that information over and over again. With every bit of documentation you collect and send, ask if it supports medical necessity.
To provide more insight into this issue I have assembled two additional documents. Both are Excel Spreadsheets.
First is my Top Denial Reason List. This is related to the Gotcha! list but focuses more on the top reasons carriers deny a claim (either pre-authorization or an appeal) and what you need to do about it. The takeaway is that some reasons are discrete and separate from one another.
Denial Examples include Experimental, Investigational or Unproven, conservative measures are sufficient (case not made that liposuction is necessary), and the patient is too sick for the procedure (a safety issue and often listed as a medical necessity denial). Those are all very different reasons and each requires a different strategy.
Second is a Gotcha! list. This is a list of gray areas, hurdles, and Catch-22 events that will trip up those new to the world of carrier reimbursement. I’ve been working with managers, coders, and billers for over 25 years and have been collecting a list of “gray areas” for years. These are reimbursement gold. Frustrating but gold.
A short Primer on Provider Documentation
SOAP is an acronym for Subjective, Objective, Assessment and Plan. More prevalent and obvious with paper claims, this organization is built into the structure of most Electronic Medical Record (EMR) systems. This may be considered to be old school, but it’s an important concept and does cause confusion.
The Chief Complaint, the Review of Systems (ROS), the History of the Present Illness and the Past Family and Social History are all part of the Subjective Section. Known as the History section, this is what the patient tells the Provider. The doctor asks questions and documents the answers.
The Exam is the Objective Section. This is what the Provider does; the exam must be performed by the doctor (although often in the real-world, technicians will take vitals and perform some tests).
As a case in point, the doctor might document pain in the history—as told by the patient, and again in the exam during the examination. In regard to documentation, as an auditor I would want to see it in both places. A reviewer could argue that listing pain in the history is “the patient’s opinion” whereas listing pain in the exam section is the Providers professional assessment. In addition I ask all Providers to give a quantitative status or level of the pain. Both issues are increase the strength of the documentation in making the case for liposuction.
The Assessment: (aka the Impression) is a discussion of what is wrong with the patient and something about it. The biggest omission here, in thousands of records I have reviewed, is that Providers simply list diagnoses here. That’s it—a list. They should also always document something about the condition, in particular its status: improving, worsening, stable, or not responding as expected to treatment. The best case is made when the patient is not responding as expected to treatment or worsening. No status information puts you at the mercy of the medical reviewer. It’s not a particular good case for reimbursement.
In terms of lipedema I would look for documentation confirming compliance with the treatment—signed by the Provider. The patient stating that they are compliant may be ignored by the insurance company. It is not legally binding. It could be hearsay or the patient’s opinion.
In addition, documentation should state that the condition will progress without further treatment and the only remaining treatment is liposuction. Also, the Provider could reference the three key components of reconstructive surgery: improve functionality, restore to normal appearance, and improve quality of life. The fourth is the patient is well enough for the procedure but that should go in a Clearance for Surgery document.
Gotcha! Even though the psychological ramifications of the surgery may be important, they are not necessary and many insurance companies explicitly state that psychological benefits do not support a procedure as reconstructive as opposed to cosmetic.
Plan: This would include notes for recommended treatments. Generally the effectiveness of the treatment would be addressed in the Assessment. The plan is where recommendations for conservative measures are documented and the conclusion that liposuction is the only remaining treatment.
The best specific examples of the verbiage that is beneficial is in the Expert Opinion Template in the Reimbursement Guidebook.