A few decades ago, vascular surgery inevitably meant a trip to the hospital. Now, many vascular procedures are actually done at office-based labs (OBLs). Out-patient procedures often mean less stress for patients, more control for the physician, and a better overall experience.
In 2008, the US Centers for Medicare and Medicaid Services began reimbursing for peripheral vascular interventions at OBLs. If you are billing for OBLs, here are a few things to keep in mind.
Make Sure Treatments are Medically Necessary
Vein treatments can be medically necessary, and even lifesaving: out-patient procedures can prevent amputation, complications from blood clots, and more. But they can also be cosmetic: some people just don’t like how their veins look.
From a billing perspective, that means it is important to show that the treatment is actually a medical necessity, not just cosmetic. Varicose veins are a good example of a condition where it is important to make that distinction.
Varicose veins alone are not by themselves a medically necessary reason for an intervention. They can, however, lead to complications that do require treatment, like pain and skin ulcers. When coding, it is important to code the complications that actually require treatment to avoid claim denials.
Provide a Clear Roadmap
When a procedure is medically necessary, it’s important to let the payer know exactly what happened. Payers want to be confident that you’ve actually done the work that you are billing for and that it meets the standard of care the patient deserves.
For example, a patient with vascular occlusion may need a vascular intervention to reduce the risk of complications like heart attacks. These interventions require navigating the patient’s veins with a catheter—a long tube—then keeping arteries open with balloons or stents or clearing plaque with lasers or blades.
Strong documentation helps the payer visualize exactly what happened. In fact, it can be helpful to think of this documentation as a literal roadmap. Which vein did the catheter enter first? Did it move straight to the next vein, or pull back first? What happened at each stop? Where did it exit? Payers should be able to visualize the entire journey.
Think About Both Sides
Often, patients may require interventions on both sides of their body, usually on both legs. Payers will usually only pay for one primary procedure; a similar secondary procedure on the other side of the body will likely be paid at 50%. This is expected. What can be easier to overlook is how quickly bilateral treatments can impact the number of procedures in one visit.
For example, a payer may have limits on the number of veins that can be entered in one visit, or the number of ultrasounds that can be taken. For procedures that require work on both legs, those little things can add up fast. It’s important to pay attention to the payer policy and plan ahead.
It’s a similar situation with authorizations. It’s important to remember that authorizations for one side of the body do not cover identical work on the other side. From an authorization and billing perspective, these are entirely different procedures that will need separate approvals. Getting the authorizations right can help you avoid having to correct or appeal denials down the road.
Keeping track of all the details in billing for OBLs is complicated, especially since each payer has different strategies for flagging and denying claims. Gentem uses data analytics and dedicated support staff to help your billing team stay ahead.