Technicians as the First Line of Defense in Diagnostic Testing
Documentation For Diagnostic Testing: How Technicians Help Protect Your Practice During an Audit.
When we talk about diagnostic testing, a lot of attention naturally goes to the physician, the diagnosis, and the final results. But there is another person who plays an incredibly important role in making sure the process works the way it should: the technician. Technicians are often on the front line of diagnostic testing. They are the ones working directly with orders, patients, testing protocols, images, and documentation. And when an audit happens, the details they capture along the way can make a major difference. That is why documentation is about much more than simply completing a form. It helps tell the complete story of why a test was performed, how it was performed, and whether the documentation supports the service that was billed.
It Starts With a Valid Order
Before the test even begins, the order matters. If an order is incomplete or invalid, problems can follow later when a claim is submitted or reviewed. That makes it important to verify that the necessary information is there from the beginning. Technicians should understand what information needs to accompany the test and recognize when something may be missing before moving forward. Catching a problem early is much easier than trying to correct it after a claim has been denied or an audit request has arrived.
Not Every Audit Is the Same
Healthcare organizations may encounter several different types of audits and reviews. These can include HEDIS reviews, risk adjustment audits, utilization reviews, prospective audits, retrospective audits, and other payer-specific reviews. Each one may be looking for something slightly different. That is why it is important for technicians and the rest of the healthcare team to understand what documentation may eventually be requested and to make sure it is being collected and retained appropriately. A technician may not be responsible for managing the audit itself, but the documentation created during the testing process can become an important part of the response.
Documentation Creates a Clear Trail
One of the simplest ways to think about documentation is this: Could someone who was not there understand exactly what happened?
The medical order, diagnosis, physician documentation, test performed, images, results, technician information, and other supporting records should work together to create a clear and consistent picture. If pieces are missing or do not match, questions can arise during a claim review. Good documentation helps connect those pieces.
Diagnostic Testing Requires Checks and Balances
Technicians should also be comfortable performing basic checks before and during diagnostic testing. That can include confirming that the correct patient and identifiers are present, reviewing the order, making sure the requested test matches what is being performed, and ensuring the necessary information is captured and retained. The diagnosis information also needs to make sense in relation to the physician's documentation and the medical necessity of the test. These may seem like small details in the moment, but during an audit, those details can become extremely important.
Understanding LCDs and Coverage Requirements
Medicare's Local Coverage Determinations, commonly known as LCDs, can be valuable resources for understanding coverage and documentation requirements for certain services. Related Local Coverage Articles may provide additional guidance.
Because requirements can vary depending on the service and jurisdiction, healthcare teams should know where to locate the applicable guidance and periodically review it for changes. Technicians do not need to become billing experts, but having a basic understanding of the requirements surrounding the tests they perform can help prevent avoidable problems.
Communication Makes the Entire Team Stronger
Compliance should never fall on one person. Physicians, technicians, billing teams, administrators, and compliance professionals all contribute different pieces of the process. When those teams communicate well, problems are much easier to identify before they become larger issues.
If something does not look right with an order, ask.
If documentation is missing, address it.
If requirements have changed, make sure the people performing the work know about those changes.
Creating that type of communication and accountability helps protect the practice while also making the entire workflow more efficient.
Technicians Really Are the First Line of Defense
Technicians may not always be the first people who come to mind when discussing compliance and audits, but their role is incredibly important. The information captured during diagnostic testing can ultimately help demonstrate that a service was ordered correctly, performed appropriately, medically supported, and properly documented. That makes the technician one of the earliest opportunities to catch an issue before it becomes a denial, repayment request, or audit problem.
And in healthcare compliance, catching a problem early can make all the difference.
Watch the full video above for a deeper discussion on the technician's role in diagnostic testing, documentation, and audit preparedness.
If you have questions about this topic or would like MEDCO to cover another area of healthcare compliance, reach out to our team and let us know.
Video: E/M Changes 2021
By:Jacqueline Thelian, CPC, CPC-I, CHCA, CPMA
2021 E/M Outpatient Documentation & Coding Changes
- Key Changes to Definitions & Concepts
- Elimination of History & Physical Elements for Level of Code selection
- Code selection Based on Medical Decision Making (MDM) or Time
- Criteria changes to determining the Level of Medical Decision Making (MDM)
- Criteria changes to determining the Level of service based on Time
Video: ICD-10-CM Updates 2021
By:Jacqueline Thelian, CPC, CPC-I, CHCA, CPMA
In this video we will go over:
- ICD-10-CM overview of Updates
- Most Notable Updates
- Chapter 22 – Codes for Special Purposes – New Chapter!
- Where you can go to learn more
New HCPCS Codes for COVID-19 Laboratory Testing
By:Jacqueline Thelian, CPC, CPC-I, CHCA, CPMA
Effective April 1, 2020 there are two new HCPCS codes for COVID-19 Laboratory testing.
U0001 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
For tests developed only by the CDC (reporting allows CDC testing laboratories to test new patients and track new cases).
U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC
For laboratories performing non-CDC testing.
As a reminder the CPT code for COVID-19 Laboratory which is effective as of March 13, 2020 is:
87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
As always different insurers may require reporting either a CPT® or a HCPCS code, so please check with your payers as to their preference.
The ICD-10-CM code for COVID-19 effective April 1, 2020:
U07.1 COVID-19
Can I Provide Physical & Occupational Therapy Via Telehealth?
By:Jacqueline Thelian, CPC, CPC-I, CHCA, CPMA
As per CMS (Centers for Medicare and Medicaid Services) the answer is yes!
CMS has approved on a temporary basis during the COVID-19 Pandemic the following CPT Codes:
97110 Therapeutic exercises
97112 Neuromusulcar reeducation
97116 Gait training therapy
97161 PT Eval low complexity 20 min
97162 PT Eval mod complexity 30 min
97163 PT Eval high complexity 45 min
97164 PT re-eval established plan care
97165 OT eval low complexity 30 min
97166 OT eval mod complexity 45 min
97167 OT eval high complexity 60 min
97168 OT re-eval established plan care
97535 Self-care management training
97750 Physical Performance Test
97755 Assistive Technology Assess
97760 Orthotic management & training initial encounter
97761 Prosthetic training 1st enc
It is important to note the following when reporting these services via telehealth:
The telehealth waiver for Medicare, authorized under HR 6074 (attached), removes the requirement that telehealth services be rendered from an “eligible originating site” and relaxes certain technology requirements, permitting services via Skype and FaceTime with a cell phone.
This allows telehealth services to be provided in all settings, including at a patient’s home, for the duration of the COVID-19 emergency. Importantly, there is no requirement that the services provided under the waiver be related to treatment of COVID-19. The waiver is designed to assist providers with social distancing protocols and to allow patients to continue to seek treatment of chronic and acute conditions during the pandemic.
To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during the COVID-19 emergency.
In addition, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype.
Remember to report Place of service Code 02 Telehealth on telehealth services.
Medicare does not require the use of modifier 95 Synchronous Telemedicine Service Rendered Via a Real Time Interactive Audio and Video Telecommunication
Source:
For a full list of CMS Telehealth Approved CPT codes:
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
Video: How-to Provide Telehealth Services During the COVID-19 Crisis
By:Jacqueline Thelian, CPC, CPC-I, CHCA, CPMA
What you need to know During this unprecedented healthcare crisis with the COVID-19 pandemic, healthcare services are rapidly changing to make expanded access to Telehealth services to allow patients the opportunity to receive services from their doctors without having to travel to a healthcare facility and risk potential exposure to the virus.
As a service to our clients and the healthcare providers courageously serving the population, I have created a video detailing what you need to know to provide Telehealth, telephone and remote services to your patients.
The video will also provide you the links to the source documents from CMS and NYS Medicaid and show you where to go to sign up for updates.
I hope this information helps clear up any confusion you may have regarding remote office visits and services. And if you have any addition questions, we are here to help.
Thank you and be safe,
- Jacqueline Thelian
Video Links:
The latest NYS specific information can be found on the NYSDOH website at the following link:
https://www.health.ny.gov/diseases/communicable/coronavirus/
The latest Centers for Disease Control and Prevention (CDC) guidance for healthcare professionals is available at the following link:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.htmlMore information on the current telehealth policy can be found in the February 2019 Medicaid Update at the following link:
https://www.health.ny.gov/health_care/medicaid/program/update/2019/2019-02_speced.htmAdditional guidance can be found on the filling CDC websites:
When services are provided by an Article 28 facility, the telehealth practitioner must be credentialed and privileged at both the originating and distant sites in accordance with Section 2805-u of PHL. The law can be viewed at the following link:
http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWOMMC general coverage questions may be directed to the Division of Healthcare Planning Contracting and Oversight (DHPCO) at covques@health.nt.gov
Fact Sheet visit: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
Frequently Asked Questions visit: https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
CMS Coronavirus Partner Virtual Toolkit https://www.cms.gov/outreach-education/partner-resources/coronavirus-covid-19-partner-toolkit
Sign up for CMS Updates https://public.govdelivery.com/accounts/USCMS/subscriber/new?preferences=true#tab1
Telehealth Benefits in Medicare are a Lifeline for Patients During Coronavirus Outbreak
Coverage and Payment Related to COVID-19 Medicare
https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf
List of Medicare Telehealth Services
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
E/M Changes On The Horizon For 2021?
By:Jacqueline Thelian, CPC, CPC-I, CHCA
Significant changes to the E/M Documentation Guidelines for “outpatient visits” will an important change in 2021.
CMS, the AMA and most physicians agree the cognitive work of physicians and qualified healthcare professionals for E/M office visits is best determined by the time and the level of medical decision making. Therefore, the proposed guidelines for 2021 allow the physician/QHP to select the level of service based upon time or the level of medical decision making.
The AMA has updated the Table of Risk (download below) to include clearer definitions relating to the Number and Complexity of Problems Addressed, the inclusion of Categories regarding Options for the Amount and/or Complexity of Data to be Reviewed and Analyzed as well as straightforward definitions of Risk on the Risk of Complications and/or Morbidity or Mortality of Patient Management.
2021 will also include the deletion of CPT code 99201 Outpatient Office Visit for a New Patient at the lowest level, and a new HCPCS Level II code GPC1X Visit complexity inherit to evaluation and management associated with primary medical care would be added to established office/outpatient CPT® codes. This new add on code will reimburse $15.00.
Are Your Orders Validated?
By:Jacqueline Thelian, CPC, CPC-I, CHCA
Whether you are a Diagnostic Testing Facility, an Independent Laboratory or a Physician who received referrals, you need to make sure your orders are valid and validated.
Valid orders include at minimum, the patient’s name, test(s) ordered, indication for the test(s), a clear and legible name of the ordering physician, the ordering physician’s signature and date of the signature. Remember signature stamps are not valid.
However, on many occasions the order is incomplete and/or illegible.
CMS as well as many other insurers are now asking the “rendering” provider to validate the order.
As per CMS, “The physician who treats a beneficiary must order all diagnostic x‐ray tests, diagnostic
laboratory tests, and other diagnostic tests for a specific medical problem. Documentation in the patient’s medical record must support the medical necessity for ordering the service(s)”
CMS goes on to say, “However, it remains the responsibility of the individual or entity upon whom/which the request has been made to provide documentation.”
Therefore, in order to validate the request for the test, it is the responsibility of the rendering/servicing provider to produce the patient’s medical progress note from the ordering physician which documents the test(s) ordered as well and the medical necessity and indication for the test.