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The practice of vascular medicine has faced many challenges over the last decade. With the increasing competition from radiologists and cardiovascular physicians, the role of the role of the vascular practice is more significant than ever in terms of vascular medicine as a whole. Vascular surgeons have seen a decrease in their reimbursement rates for vascular procedures due to the passage of the Deficit Reduction Act of 2005. As a result, many vascular physicians are opting to perform more percutaneous procedures in their offices. The private vascular practice has evolved into the core and the future of the specialty. As vascular practices continue to evolve there many will continue to face challenges in terms of reimbursement rates. Physicians, nursing staff, practice managers and anyone responsible for any aspect of billing must consider not just what they are billing but how. Millions of revenue dollars are lost by vascular practices each quarter because they fail to charge for the specialized treatments that they provide, and code properly. Here are some of the most common mistakes made by personnel in vascular offices.

1. Codes don’t support report.
Often times physicians will code that a patient has diminished DP and PT pulses in a foot, but don’t provide any if the necessary elements of their examination to support their claim. If a handheld Doppler was to help determine the diagnoses then it should be coded. If the patient is diabetic and the initial evaluation was performed using a monofilament was used, it should also be documented and coded. Keep in mind certain tests such as dopplers and ABI (Ankle Brachial Index) require special training and certification if you are not a Physician or NPP in scope.

2.The Little Things are Often Forgotten.
Far too often the back offices staff in vascular offices unintentionally discount or fail to recognize many of the specialized procedures they perform on their patients. A debridement is a procedure that is often performed in vascular offices, however it is often overlooked when patient’s visits are being billed. The debridement of eschar or necrotic tissue can be time consuming, but far too often the time spent removing tissue to prepare for the application of a wet to dry dressing is often overlooked and not accounted for. Clear documentation describing details regarding the debridement and the time that it took to perform it along with the application of the proper codes could make a huge difference in reimbursement rates. (There are very specific rules for billing and coding debridement. Make certain all requirements are met—these are outlined in the attached document.

3. Unna Boots.
The application of an Unna boot takes time, and justifiably so. If it is applied too tightly it could cut off the circulation of a limb, if it is not applied using enough tension, the patient will not receive the benefit of the compression necessary to heal. Details indicating the reason for Unna boot application, along with the time that it took to apply it are required.

4. Central Line Placements and Removals.
The placement and removal of a central line used to be done in a hospital setting, however these are procedures that are commonly done in vascular offices. Physicians and nursing staff need to be mindful of the time that it took to place or remove the line and also the type of visit that they code. For example, the patient may have been blocked for a 20 minute visit, but you certainly would not want to charge for a 20 minute visit if you were removing a central line, as you would need to allot for the amount of time that it takes for the patient to form a clot. There are many variances to consider like whether the patient is taking an anticoagulant, and how long they had been off of it when the line was removed. The number of sponges, needles and any instruments used, and the amount of blood secreted should be included in the documentation of the visit. Procedures such as this you may want to code based on time, rather than bullets or organ systems given the complexity and time involved.

5. Patient Education.
Another area where vascular offices fail to bill properly is when they are educating their patients. A normal explanation of medications or minor procedures can reasonably be rolled into a normal office visit. Where many offices lose out is when the doctor or nurse spends an extended amount of time scheduling and then explaining the diagnoses and procedure to the patient. Example a patient who has just been diagnosed with carotid artery stenosis who is 54% occluded in the left and 60% occluded in the would require more than a 10 minute conversation. Another area where coding  based on time would be the better choice.  Keep in mind you need to document time appropriately: Example: Over 50% of this ______ minute visit was spent in counseling and coordination of care for this patient. The patient lacked understanding of stenosis and the severity of the condition.  This is face to face time with the provider.

These are only a few of the most common mistakes made when visits are billed in vascular practices. The focus on time and documentation to support the codes used are an integral part of ensuring that reimbursements are maximized.