Prior Authorization, Precertification & Billing Process for Hyaluronan Acid & Visco Therapies for Osteoarthritis of the knee
Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative, "wear-and-tear" type of arthritis that occurs most often in people 50 years of age and older, although it may occur in younger people, too.
In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.
Osteoarthritis usually develops slowly and the pain it causes worsens over time.
I know it can be hard to determine if your patient's injection would need a prior authorization or precertificaton. It is always best that we verify our patients' coverage, benefits and eligibility.
PRIOR AUTHORIZATION, PRECERTIFICATION & BILLING PROCESS - HYALURONAN ACID & VISCO THERAPIES FOR OSTEOARTHRITIS OF THE KNEE
CPT CODES: 20605, 20606, 20610, 20611
HCPCS CODES: J7318, J7323, J7328, J3490, J7320, J7321, J7322, J7324, J7325, J7326, J7327, J7329, J7331, J7332
Let's look at a commonly published clinical policy and guideline for these visco and hyaluronan acid therapies. Pay attention to everything on this post because these can all be very helpful for your billing and in order to maximize reimbursement.
Physical therapy or pharmacotherapy/NSAIDs (e.g., non-steroidal anti-inflammatory drugs [NSAIDs], acetaminophen and/or topical capsaicin cream)
Understanding Indications and Dosing:
Intra-articular injections of sodium hyaluronate are proven and medically necessary when all of the following are met:
1. Diagnosis of knee osteoarthritis
2. Member has not responded adequately to conservative therapy which may include physical therapy or pharmacotherapy or injection of intra-articular steroids or member is unable to tolerate conservative therapy because of adverse side effects
3. The member reports pain which interferes with functional activities.
--- ambulation, prolonged standing
4. The pain is attributed to degenerative joint disease/primary osteoarthritis of the knee.
5. There are no contraindications to the injections
--- active joint infection, bleeding disorder
6. Dosing is in accordance with the US FDA approved labeling as follows.
--- Durolane: Approved as a single injection
--- Euflexxa: Approved for 3 injections
--- Gel-One: Approved as a single injection
--- Gelsyn-3: Approved for 3 injections
--- GenVisc 850: Approved for 3-5 injections
--- Hyalgan: Approved for 5 injections
--- Hymovis: Approved for 2 injections
--- Monovisc: Approved as a single injection
--- Orthovisc: Approved for 3-4 injections
--- Supartz: Approved for 3-5 injections
--- Synojoynt: Approved for 3 injections
--- Synvisc One: Approved as a single injection
--- Synvisc: Approved for 3 injections
--- Triluron: Approved for 3 injections
--- TriVisc: Approved for 3 injections
--- Visco-3: Approved for 3 injections
Learn how to properly bill and report these HCPCS codes for maximized reimbursement. READ HERE!
Common Criteria and Utilization Limitations:
--- therapy has not resulted in functional improvement after at least 3 months
--- At least 6 months have passed since the prior course of treatment for the respective joint
Intra-articular injections of sodium hyaluronate are unproven and not medically necessary for treating any other indication due to insufficient evidence of efficacy including, but not limited to the following:
----- Hip osteoarthritis
----- Temporomandibular joint osteoarthritis
----- Temporomandibular joint disc displacement
Hyaluronic acid gel preparations to improve the skin's appearance, contour and/or reduce depressions due to acne, scars, injury or wrinkles are considered cosmetic and are not covered.
1. Do not administer to patients with known hypersensitivity (allergy) to hyaluronate preparations or allergies to avian or avian-derived products (including eggs, feathers, or poultry). This contraindication does not apply to Orthovisc.
1. Do not administer to patients with known hypersensitivity (allergy) to gram positive bacterial proteins. This contraindication applies to Orthovisc only.
1. Do not inject sodium hyaluronate into the knees of patients with infections or skin diseases in the area of the injection site or joint.
Imaging Requirements: (MRI, CT, XRAY, U/S):X-ray, CT, or MRI reports), Color Doppler ultrasound (CDUS) and synovitis scores
Pain Relief: Knee Osteoarthritis (OA)
--- single 6 ml IA injection of hylan G-F 20 provided better pain relief over 26 weeks
Sodium Hyaluronate Product Therapy Using Preferred Products (Durolane, Euflexxa, and Gelsyn-3)
>>Medical notes documenting all of the following:
--- Current prescription
--- diagnosis of OA of the knee
--- Conservative treatment tried for at least 3 months including response
--- Signs and symptoms
--- Current functional limitations
--- Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports)
--- Previous sodium hyaluronate treatment provided including the brand name of the drug, course of treatment, and response
--- Dose, frequency, interval since previous sodium hyaluronate treatment
--- Physician treatment plan
Medical Necessity Cross-over:
M17.0 -- Bilateral primary osteoarthritis of knee
M17.10 -- Unilateral primary osteoarthritis, unspecified knee
M17.11 -- Unilateral primary osteoarthritis, right knee
M17.12 -- Unilateral primary osteoarthritis, left knee
M17.2 -- Bilateral post-traumatic osteoarthritis of knee
M17.30 -- Unilateral post-traumatic osteoarthritis, unspecified knee
M17.31 -- Unilateral post-traumatic osteoarthritis, right knee
M17.32 -- Unilateral post-traumatic osteoarthritis, left knee
M17.4 -- Other bilateral secondary osteoarthritis of knee
M17.5 -- Other unilateral secondary osteoarthritis of knee
M17.9 -- Osteoarthritis of knee, unspecified
Learn how to Bill for HYALURONAN ACID & VISCO THERAPIES FOR OSTEOARTHRITIS OF THE KNEE
References: Clinical Policies of Commercial Payers and Medicare from published in the public domains. CPT Codes are a trademark and owned by the American Medical Association. ICD-10 Code book of 2022.
Let's start with the PROS to why hire a Virtual Scribe?
Peace of Mind: Hiring a virtual medical scribes may alleviate some pressure on the healthcare professional and the patient. A doctor or other healthcare provider may put their full attention on patient care. A hired virtual medical scribes a professional that attends patient appointments with a doctor virtually, takes detailed notes, and creates detailed records of the visit. To save up doctors' time for direct patient care, they have a "virtual medical scribe" take care of their electronic medical records and clinical charting remotely. While this is going on, the Virtual medical scribe who was hired may take down all the pertinent data. Patients will feel more at ease knowing their doctor can devote full attention to them.
Increased Perception of Privacy: A hired virtual medical scribe enables the doctor and patient to have privacy throughout the exam since the scribe is listening remotely. More privacy is provided, which is particularly welcome for patients uneasy about having a third set of eyes and ears in the room. If the patient feels comfortable, they will be more forthcoming about their symptoms, aiding in diagnosis and leading to better results.
Fewer People to on-board: Having fewer personnel to implement is another crucial advantage of using a hired virtual medical scribe service. To make sure the rollout of your EHR goes off without a hitch, you'll need to train almost all of your employees on how to use it. To save time and effort, you may instead employ and educate a Virtual Medical Scribe who can translate complex medical jargon into language that everyone on the team can understand.
Issues with Scheduling: The schedules of the practitioner and the scribe in a 1:1 or 2:1 relationship must be coordinated. The surgeon will be on their own as long as the scribe is away from the office for vacation or sickness. This issue is resolved when a Virtual Medical Scribe is used.
Face-to-Face Interaction: One of the most significant factors to weigh while weighing the benefits and drawbacks of virtual medical scribes is the amount of face-to-face time they will spend with your patients. Patients still prefer face-to-face connections with medical professionals despite the increased use of telemedicine. Computer software cannot read a patient's mood like a hired virtual medical scribe.
EMR experts: Many e-health record systems are now second nature to the Virtual Medical Scribe (EMRs). This motivates the Virtual Medical Scribe to coach doctors on EMR usage and template implementation. As a bonus, a Virtual Medical Scribe who is already acquainted with the practice's EMR may help train new personnel. The hired virtual medical scribe will help ease the learning curve for the new doctor in this manner.
Reduced Functional Creep: One of the most significant issues with onsite hired virtual medical scribe is the phenomenon known as "functional creep," which occurs when an employee's duties go beyond what was initially expected of them. Faithful and independent scribes may be given more challenging EHR responsibilities to accomplish while doctors concentrate on patient care. Without proper precautions, a doctor may be held legally responsible for malpractice if functional creep occurs in their practice. Fortunately, the distance between the hired virtual medical scribe and the doctor considerably reduces the functional creep danger. Several virtual scribing agencies purposefully restrict staff access to the information they need to complete medical documentation, eliminating room for functional creep.
The Flexibility of Service: As they can work from anywhere, virtual scribes are an excellent option for medical facilities that are located in distant or rural areas where onsite scribes may be scarce. The scheduling challenges often associated with onsite medical scribes are mitigated by the availability of several online medical scribe services, which provide coverage on short notice for employees who are off sick or on vacation. When onsite scribes are in short supply, medical facilities in distant or rural areas might benefit significantly from the services of virtual scribes, who can work from anywhere in the world. Scheduling issues that come with employing onsite medical scribes are mitigated by many online medical scribe firms providing an on-demand covering for absences due to sickness or vacation.
Reduced Intrusiveness: Since hired virtual medical scribe no longer need to physically be present in the exam room, patients report feeling more at ease throughout their appointments. According to some research, patient anxiety and reluctance to provide private information have been linked to the presence of in-person scribes. This feeling of intrusion is much mitigated when using an online scribe.
Cons of hiring Virtual Medical Scribes
Lack of Streamlined Workflow: It is common knowledge that we'll discover methods to automate various jobs as our technological capabilities increase. This is why many hospitals are switching to EHRs instead of continuing to use a hired virtual medical scribe. One of the major drawbacks of hiring Virtual medical scribes, in the eyes of many, is that a computer program can replace them. Each individual who has contact with a patient may share what they learn instead of relying on a central repository. This approach may compile and make data available to doctors and patients.
Medical errors: The fact that hiring Virtual medical scribes is human is one of the major "cons" when weighing the benefits of using virtual medical scribes. Humans are fallible, and you want as few errors as possible to occur in the medical industry. When adding a medical scribe to the mix, there is an increased risk of information being lost in translation.
Weary Patients: Finally, when weighing the benefits and drawbacks of using hired virtual medical scribe, it is important to remember that some patients may be hesitant to open up to a healthcare provider they haven't met in person. They may experience frequent anxiety when there is more than one person present.
Lack of Standardized Training: While demand for scribes continues to rise, standardized training has not kept pace. Some private employment organizations require onsite and remote scribes to complete in-house training programs, but the federal government provides no oversight or guidance for these initiatives. The scribes themselves have a vast range of expertise. According to a recent survey, 22% of scribes have formal training or certification, while 44% have no such background.
Band-Aiding the Larger Problem: Even though scribes often help doctors, they are essentially only a stopgap solution to the much broader documentation issue. Although scribes may help speed up the note-taking process, doctors are still responsible for entering the scribe's work into the electronic health record (EHR). It is time to reassess our strategy for assisting doctors with note-taking and recordkeeping. From the minute a patient comes through the door until the final entry in the electronic health record is entered, the insurance claim is submitted, or the medication is dispensed, our solutions must meet concerns about cost and data security. This resulted in the study's main conclusion: that different scribes recorded varied data regarding duplicate patient contacts. Possibility of stifling EHR advances: While working with scribes may benefit doctors and hospitals in the short term, in the long run, it may have the unintended consequence of slowing down advancements in electronic health record technology and perhaps putting patients in danger.
Lack of oversight: It is human nature to be a little reserved when one cannot physically see the new team member. However, Virtual medical scribes are experienced professionals who thrive in quiet, self-contained workspaces where they can set their own pace. This independence and control over their working day keep them far more motivated and productive than they would be if they were forced to stick to the rules in a typical office. So this may not be the downside as thought.
Lack of availability is another standard reservation: To combat this issue, it is essential to not only explain tasks clearly, give clear briefs, and lay out what the expectations about their capacity to support the will be from the very start, but also to let them know the actual hours in the day one requires them to be contactable.
Virtual Medical Scribes: Understanding Telescribes and Remote Scribes
Virtual Medical Scribes: Understanding Telescribes and Remote Scribes
A Virtual Medical Scribe is a professional who documents the patient's encounter with the physician, irrespective of the location and time. Remote Scribing comprises of a real-time working as a writer while connected to a doctor’s office who is attending a patient or performing a simple procedure on a patient in the office. The remote scribe can view and listen to the proceedings and must meticulously enter all the relevant data into the EHR. The scribe must be well versed in medical terminology and drug names and be computer savvy to quickly enter details while the doctor is attending to the patient. Remote scribing is a growing field essential to the healthcare industry's future. Whether someone wants a new career or a place to gain experience, remote scribing presents an exciting opportunity to learn and contribute to healthcare in various ways. Scribes ease the burden on healthcare teams, help medicine progress into the electronic age, and improve patient care.
With the approval of the Texas Christian University's administration, the Virtual medical scribe was invented by John Geesbreght, which led to the recruitment of pre-med TCU students for the establishment medicine. Upon invention, the Virtual or tech-enabled-remote scribes proved to offer more ROI and benefit to doctors in 2019. The innovations of the remote scribing purported to elevate the natural conversation between a doctor and a patient and decode it into structural noted in the HER as an output. Through the year of 2019, there was a high demand for a high ratio of human in the loop are required earnestly. Tele-scribing is also about the execution of simple peripheral tasks. These domains generally appeal to medical technician investors and resemble the Alexa-like workflows that consumers experience at home. In practice, these workflows did not save much time and offered doctors a lot of ROI in 2019. Further, there are a lot of workflows that are best done in expert user interfaces. For example, imagine ordering a flight ticket through a phone tree voice interface.
The role of a virtual scribe determines a smooth route for physicians to assess and evaluate patients comprehensively. This is accomplished by the detailed description of clinical synopsis documented by a respective virtual scribe assigned to a certain physician. These processes are performed under high-security parameters in a HIPAA-compliant data management center and are connected to examination rooms through secure internet and VoIP connections. Only a few companies are into this at the moment across the world. The services require a lot of compliance, most importantly HIPAA, since it deals with sensitive information and exposure to the clinic setting. Telescribes is almost like a doctor's assistant but works virtually for the doctor and is connected via webcam. The work usually happens when the doctor is in session, corresponding to business hours. Given their familiarity with medical reports, Telescribes can be a good alternative for medical transcriptionist although strenuous if the partake does not have a passion in the field.
While Telescribes video promotes patient-doctor privacy, it also allows a live scribe to listen to and decode the conversation from a different room through a secure and easy-to-use app on a mobile tablet. The viewer will hear the dialogue between the doctor and patient as the video shows the remote scribe documenting the visit. Tracking information from doctor visits. Scribe works as an assistant to doctors and collects lab results on patient scribes are focused on patient interaction. In this example of a clinical scenario, one will see the documentation for subjective and objective patient data, including the HPI, ROS, Physical exam (PEx), Assessment, and Plan. Through this system, a remote scribe can easily fulfill different duties such as appointment scheduling, billing, phone call reception, and another sort of inquiries. They note down all the key points, which reduces the physician's additional time spent on notes and documentation.
In the clinical setting, a virtual medical scribe may have more responsibilities since the pace is slower and patients are more likely to be stable. Some of these responsibilities include reporting the quality codes mentioned earlier and putting in orders and charges, all under the physician's close supervision, of course. This provides great exposure to medical decision-making for scribes seeking experience in advanced healthcare careers. Through tele-scribing and webcam, the scribe can know and see what tests physicians order for which symptoms and the variety of treatments they provide for different ailments and conditions. However, scribes are heavily used in the emergency department in a hospital setting, although some hospitals utilize them in other areas.
Medical scribes can be considered paraprofessionals, making the job easy for doctors by watching and documenting doctor-patient encounters. Currently, there are Virtual Scribes present online and work for physicians. Scribes improve documentation.
While being a Virtual Medical Scribe does not require one to attain a college degree, they should be well trained in speed typing, English language, grammar, medical coding, medical conversations, listening, analytical and reasonable skills, and software navigation skill. Working remotely, a medical scribe is a clinical experience through the tele-scribing system. A medical scribe performs a wide range of transcription-related tasks. A personal assistant to the physician performs electric record-keeping responsibilities for the physicians during patient encounters, ensuring the best patient care cannot be accomplished in time. Subsequently, computer competence is also an essential skill for virtual Medical Scribe jobs. It is important not only to be able to type at an above-average speed but to do so while multitasking. The profession needs one to be able to type, listen, and take notes as the physician bounces between dialogue with the patient while giving notes and findings in various parts of the chart.
Conclusively, remote scribing is the process where the words and actions of a doctor, surgeon, nurse practitioner, or other medical professional are charted and documented. Medical scribing is an organized and well-esteemed fragment of the US healthcare system; personal assistant helps the physician deliver a high-quality healthcare system. Scribing in a clinic involves a more predictable setting, although sometimes it can be just as intense as in the ER. The benefits and drawbacks of scribing in each setting depend greatly on what one is seeking. Since a Virtual medical scribe works on the documentation of patients' records, the hospital offers scribes more action in which they can promote the work of the doctor. This provides a lot of flexibility in scheduling. They must be quick and not miss out on critical data, as everything happens in real time. The ability to comprehend and good writing abilities all come in handy. Virtual Nurse RX has a team of registered nurses who can help one run a more efficient practice. The virtual scribes are a vital asset to the team by watching and listening to the patient's needs. A medical scribe is a person who assists doctors in charting prescriptions and adding data to EHR.
ABOUT THE AUTHOR:
Ms. Pinky Maniri-Pescasio is the Founder of GoHealthcare Consulting. She is a National Speaker on Practice Reimbursement and a Physician Advocate. She has served the Medical Practice Industry for more than 25 years as a Professional Medical Practice Consultant.