These are additional filing tips in addition to the Reimbursement Checklist.
| 0.1 | Intro | In general I have short, one or two-page checklists and then much longer and detailed explainations of nearly everything. Work the checklists first and then look to the Guidebook or the Policy Evaluation Document for more information and clarification. I also have several one-page graphics; these show relationships and are very dense with information. You can spend an hour reviewing any one. This is in addition to the Checklist not a replacement. | |
| 1 | Dx | Dx | Diagnoses between doctors must match! I have seen where they the stages do not match and this could cause a problem. The ins. co. will use any excuse not to pay and inconsistent diagnoses is a good one. |
| 2 | Dx | Dx stage | If the lipedema stage changes in the documentation it should be clear that this is a worsening and a progression of the disease that is not being controlled with current measures. This type of documentation helps your case immeasurably. |
| 3 | Dx | dx | Diagnoses between doctors must match! I have seen where the stages do not match and this could cause a problem. The ins. co. will use any excuse not to pay and inconsistent diagnoses is a good one. |
| 4 | Dx | Disease Status | Every word indicating a worsening helps your case. Every progress note with no status information hurts it. |
| 5 | procedures | Anesthesia | general anesthesia; if there is a separate anesthesia charge then if the claim is paid the anesthesia should be paid as well. We need as much information from the anesthesiologist what was performed, a CPT code if possible, any units or time information and if any modifier was used, for a high risk patient, for example. |
| 6 | Doco | interpretation and report I/R | Provide the Interpretation and Report (I/R) for all Ultrasound (any imagin) and EKGs. This explains what was done, the actual results, their comparative importance (normal or stage or severity) implication and the plan. The I/R is separate from the office notes–not part of it. It is required documentation for all images and tests. |
| 7 | Doco | Watch for Cloned Notes | And cut and paste errors. If there anything in the notes that does not belong? Check for other names or an unusually long list of diseases. Are they are all necessary and relevant? Since many cosmetic surgeons do not emply a billing and coding staff and don’t deal with insurance company rules their documentation may be more informal. No one is audting their notes. |
| 8 | Doco | Worsening | The managing physician must document the disease is progressing, something that indicates that the only alternative is liposuction, that the conservative measures are exhausted / and are not sufficient. Just listing the diagnosis is not enough for reimbursement. Not every case is reimbursable. |
| 9 | Doco | LMN VS Clearance | There is difference between a Letter of Medical Necessity and the Clearance for Surgery letter. The LMN explains why the surgery is medically necessary (see above). The clearance explains why the patient is healthy enough for the operation. One says patient is getting sicker; the other that they are not TOO sick for the operation . The difference is VERY important. |
| 10 | Doco | signed by MD | Only documentation signed by the MD helps your case. Your commentary is not as strong. It’s okay to provide a short introduction of your situation but it should reference the documentation by the providers that supports your case. Share the Expert Opinion Letter Template with all your docs. |
| 11 | Doco | Managing Doc | The notes from the physician managing your lipedema are most critical. You need the doctor’s notes relating to the conservative treatment, compliance, progression of the disease and need for surgery. If the documentation does not support the need, then you do not qualify. The ins. co. may only use documentation signed by a provider–not the patient’s testimony. |
| 12 | Doco | Gaps in Care or Notes | Missing months of progress notes is not helpful; a clear progression of worsening is best. The physician should explicitly state the patient is compliant with diet and exercise and following all conservative treatments and that they are exhausted and the disease will continue to progress, reduce functionality, and decrease quality of life without liposuction surgery. |
| 13 | Coding | Modifier for Laterality | Using modifiers on the procedure codes: MOD-50 means both right and left. That should be sufficient if the surgery is applied on the right and left side. Appending MOD-RT and MOD-Lt is an alternative way to report both sides–never use both! Quantity of 2 is unnecessary and redundant. |
| 14 | Coding | Procedure Name | Names of procedures; be specific; note that everyone has a different name and the CPT definition of “suction-assisted lipectomy” is generic and often considered a “cosmetic” code. It is not, but you must both report a code and then explain why it is more complicated and time consuming and not cosmetic. Some use an unlisted CPT code but that also presents new issues. See the Reimbursement Guidebook for additional information on this and all topics in this document. |
| 15 | Coding | Modifier for Complicated Tx | Adding modifier 22 to the CPT code means “more complicated procedure.” While technically accurate it could complicate matters since the liposuction codes do not have any RVU’s or standard fee-schedule amounts. In other words, more extensive than what? Essentially you want them to pay a percent of the doctor’s fee–the higher the better. |
| 16 | billing | Itemization of services | If multiple services were rendeded: liposuction, removal of excess skin and anesthesia, these technically are reported with separate codes and billed separately. |
| 17 | billing | Place of Service Code: | Each location has a specific Place of Service (POS) code. Office=11; Ambulatory Surgery Center = 24, Hospital = 21, Outpatient surgery facility attached to a hospital = 22, Emergency Room = 23. Always be clear where the surgery was performed. |
| 18 | Resources | One-Page Checklist | Read this document first; read it carefully; the earlier you read it, study it and apply it the better. |
| 19 | Resources | Data Sheet | This is for the patient to fill out; it includes information you will need to be reimbursed. Very important. |
| 20 | Resources | Top Denial Reasons | Top Denial Reason List spreadsheet and graphic. This explains what I am preparing you for. In other words, all my recommendations and documentation requests are designed to ward off specific denial reasons. Some have nothing to do with one another and some (E/I/U) has little to do with your lack of documentation (although it could be argued that constantly using the reconstructive verbiage throughout all documentation might help). |
| 21 | Resources | Sample Expert Opinion Letter | sample Expert Opinion Letter template. This includes specific verbiate that will reinforce the reconstructive nature and medical necessity of the liposuction. Only use what is clinically accurate. |
| 22 | Resources | GOTCHA! | Gotcha! List. This is a spreadsheet of comfusing and contradictory issues that will trip up those new to coding, billing, documentation and insurance companies. I’ve spent thousands of hours and over 25 years learning the ropes to skip and the ropes to know; I’m trying to condense it and simplify it for the layman. |
| 23 | Resources | SOAP note Doco tips | A primer on provider documentation and SOAP notes. |
| 24 | Resources | Reimbursement Guidebook. | The most comprehensive Reimbursement Manual. It includes most but not all one-pagers. Also it only includes short summaries of the spreadsheets. |
| 25 | Resources | Policy Evaluation Request | This has a lot of information from the Guidebook but it has specifically 50 research citations and is short, at 14 pages. It could be sent to your insurance carrier as a request for them to change their policy, or as a cut-and-paste document as a template for your first appeal. |