hopd facet/mbb denial nonsense

[myrandom2003]

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So, this medicare HOPD Facet issue is becoming the bane of my existence.

Do any of you have specific phrases included with your prior auth submission that has not been giving you issues? It seems what has worked for me until May 17 no longer works, and just about every thing has been getting denied on first pass, and even second pass when notes have been amended to include whatever non-sense they denied initially.

Help!

 

[Laryngospasm]

It’s pretty bad. I’ve been dealing with the same. You can literally include everything they ask for and they will say you didn’t. This has been talked about in previous posts.

 

[DOctorJay]

I submitted for bilateral L3-5 medial branch blocks, reviewer denied stating the imaging didn't show facet arthropathy at the L3-4 facet joints. had to say, "yeah I know, the L3-5 medial branches innervate the L4-5 and L5-S1 facet joints". patient was super pissed about the delay in care. did eventually get approved though.

 

[myrandom2003]

It’s pretty bad. I’ve been dealing with the same. You can literally include everything they ask for and they will say you didn’t. This has been talked about in previous posts.

I was reading the posts from January as well. We had a really good approval rate once my templates were honed in until May and then everything changed and now we are close to a 3/4 denial rate.

 

[JFS]

I’m still a newbie, but I imagine advice is MAC-specific so may help to say which one is yours

 

[blokdoc]

I was reading the posts from January as well. We had a really good approval rate once my templates were honed in until May and then everything changed and now we are close to a 3/4 denial rate.

What are the three top reasons for denial?

 

[clubdeac]

What are the three top reasons for denial?

Idk

Guessing no PT or inadequate PT
No documentation of functional scale
And insurance incompetence

 

[Ducttape]

my top 3 reasons for denial seem to be:

1. no appropriate documentation of physical examination consistent with facet arthropathy - generally, the missing component is i did not document the patient had pain on axial loading (which is such a bogus PE finding)
2. no appropriate documentation of imaging showing facet arthropathy, unless it is included in the note. i guess they cant look at the patient's records of the xrays and MRIs that they already paid for.
3. no appropriate documentation of 8 weeks of conservative care, in particular physical therapy or home exercise program as directed by the physician.

so now my notes are 3 times longer as i copy and paste the last set of xrays or MRI scans and multiple PT notes, or a screenshot of the discharge instructions from the last visit they have with me 8 weeks previously.

 

[RoloTomassi]

Duration >3 mo also

 

[mdo1738]

my top 3 reasons for denial seem to be:

1. no appropriate documentation of physical examination consistent with facet arthropathy - generally, the missing component is i did not document the patient had pain on axial loading (which is such a bogus PE finding)
2. no appropriate documentation of imaging showing facet arthropathy, unless it is included in the note. i guess they cant look at the patient's records of the xrays and MRIs that they already paid for.
3. no appropriate documentation of 8 weeks of conservative care, in particular physical therapy or home exercise program as directed by the physician.

so now my notes are 3 times longer as i copy and paste the last set of xrays or MRI scans and multiple PT notes, or a screenshot of the discharge instructions from the last visit they have with me 8 weeks previously.

I have a dot phrase that just generically says that “imaging shows multilevel facet arthropathy at levels which correlates with their axial spinal pain, and this pain is replicated with facet-loading maneuvers”. Takes 2 seconds and has worked every time so far. No need to dig through old imaging and paste the report.

 

[pastafan]

I submitted for bilateral L3-5 medial branch blocks, reviewer denied stating the imaging didn't show facet arthropathy at the L3-4 facet joints. had to say, "yeah I know, the L3-5 medial branches innervate the L4-5 and L5-S1 facet joints". patient was super pissed about the delay in care. did eventually get approved though.

Always fun to be reviewed by a “peer”.

 

[Ducttape]

I have a dot phrase that just generically says that “imaging shows multilevel facet arthropathy at levels which correlates with their axial spinal pain, and this pain is replicated with facet-loading maneuvers”. Takes 2 seconds and has worked every time so far. No need to dig through old imaging and paste the report.

except when it doesnt.

and admittedly, this is a rare occurrence but there is a carrier that insists on documentation of imaging.

 

[myrandom2003]

My top three denials (Wisconsin Physicians MAC)
1) did not specific if repeat or initial
2) did not specify if therapeutic or diagnostic
3) did not specifically say Axial only low back pain.

My template in the note says word for word:
-pain follows *** facet referral pattern for axial only low back pain without radicular component.
Recommend diagnostic initial medial branch block at *** level.
Patient has an ODI score of ***% placing them in a moderate to severe functional disability.

They just have to open the attached requested note.

 

[cowboydoc]

Latest denial is a 49 yo female with clbp, bilateral pars defect with trace spondy at L5-S1. Denied MBBs because of pars defect. Must see surgeon.🙄

 

[SSdoc33]

Latest denial is a 49 yo female with clbp, bilateral pars defect with trace spondy at L5-S1. Denied MBBs because of pars defect. Must see surgeon.🙄

i am at the point where i dont even mention other diagnoses. dont mention stenosis, or DDD or modic changes, or leg pain if it radiates to thigh at all. not really lying, but not telling the whole truth.

if i use marcaine at the relief lasts 2 days? well, then the relief also lasted the 5 hours that the marcaine was active, right?

 

[callmeanesthesia]

i am at the point where i dont even mention other diagnoses. dont mention stenosis, or DDD or modic changes, or leg pain if it radiates to thigh at all. not really lying, but not telling the whole truth.

if i use marcaine at the relief lasts 2 days? well, then the relief also lasted the 5 hours that the marcaine was active, right?

Same. I figure if they wanted better quality notes they’d pay for them. They pretty much get their medical necessity criteria in a list as part of the assessment and plan.

“Patient reports >80% pain relief for the expected duration of action of the local anesthetic.”

 

[powermd]

i am at the point where i dont even mention other diagnoses. dont mention stenosis, or DDD or modic changes, or leg pain if it radiates to thigh at all. not really lying, but not telling the whole truth.

if i use marcaine at the relief lasts 2 days? well, then the relief also lasted the 5 hours that the marcaine was active, right?

Abso-freakin' lutely. Why shoot yourself in the foot by playing the "good doctor" game when what you really need is your "good biller" hat on.

 

[DrLefty]

Abso-freakin' lutely. Why shoot yourself in the foot by playing the "good doctor" game when what you really need is your "good biller" hat on.

I wish I didn't agree with this. It sucks that this is just how things are, and the sad part it I don't really think I care. I'm a new attending out of fellowship this year and everything just comes down to make sure billing is locked and and having just the right documentation to get approved for my procedures, and meet at the criteria for whatever service level I'm billing for. There is so little within the system that actually has to do with optimizing patient care

 

[powermd]

It took me a while to come around to this. I partly wish the EHR would have two sections, one for insurance, and one for the real medical notes.

 

[callmeanesthesia]

It took me a while to come around to this. I partly wish the EHR would have two sections, one for insurance, and one for the real medical notes.

There is often an internal notes section. I made one in the history section of the chart (we use Aprima - very customizable for things like this but otherwise would not recommend). I use it for those sorts of notes, a concise summary of the patient’s history, notes on how they’ve tolerated injections, and to give my PA/NP direction on what to do next.

 

[Scottie_Dog]

There is often an internal notes section. I made one in the history section of the chart (we use Aprima - very customizable for things like this but otherwise would not recommend). I use it for those sorts of notes, a concise summary of the patient’s history, notes on how they’ve tolerated injections, and to give my PA/NP direction on what to do next.

That's a nice feature of your EMR. We use Epic, I don't think we have this feature but I am going to look into it. I typically put a little blurb at the bottom of my note that lays out a clear treatment plan so that if anyone reads my note they can skip all the garbage above and have a general understanding of what I am doing. There is so much BS fluff that goes into documentation that often times notes are just filled with useless dot phrases. That being said, I have a dot phrase for MBB and RFA that has been incredibly successful getting things approved

Example of MBB dot phrase

This is a patient with chronic axial/mechanical bilateral low back pain. Symptoms have been present for more than 3 months and have persisted despite more than 6 weeks of conservative treatment which included activity modification, formal physical therapy, physician guided home exercise program and several medications. Pain is located bilaterally in the low back at the lumbosacral junction. The patient has no radicular leg pain, no numbness/tingling, no lower extremity weakness. On exam, the patient continues to be neurologically intact without focal motor/neurologic deficits. Facet loading is positive bilaterally. Imaging demonstrates degenerative lumbar spondylosis and facet arthropathy. Plan to move forward with diagnostic bilateral L3-5 medial branch blocks in a double paradigm fashion with hopes to progress to RFA. The patient will be contacted by our clinic after the first diagnostic test block to document pain relief and functional improvement. If the patient has greater than 80% relief for the duration of the local anesthetic, we will move forward with a second diagnostic test block. The patient will then follow-up in clinic after their second diagnostic block to discuss candidacy for RFA

 

[Status Sciaticus]

my top 3 reasons for denial seem to be:

1. no appropriate documentation of physical examination consistent with facet arthropathy - generally, the missing component is i did not document the patient had pain on axial loading (which is such a bogus PE finding)
2. no appropriate documentation of imaging showing facet arthropathy, unless it is included in the note. i guess they cant look at the patient's records of the xrays and MRIs that they already paid for.
3. no appropriate documentation of 8 weeks of conservative care, in particular physical therapy or home exercise program as directed by the physician.

so now my notes are 3 times longer as i copy and paste the last set of xrays or MRI scans and multiple PT notes, or a screenshot of the discharge instructions from the last visit they have with me 8 weeks previously.

Dotphrase everything?
Pain in the ass but checks the boxes.