Tip: Start with the 4 “A’s” at each visit.
Thorough documentation is your key to getting any reimbursement for your provider, but certain services have specific documentation requirements you don’t want to miss. Such is the case with chronic opioid therapy, where making notes of certain things help providers maintain high-quality care by following a structured protocol. Know you’re on the right path by keeping three expert steps in mind.
Step 1: Focus on 4 A’s Every Time
Because the patient is having opioid therapy for pain relief, that should be a primary focus for your provider at each visit. An easy way to remember the domains of pain that should be addressed and documented at each visit is with four A’s:
Step 2: Follow Medical Necessity Guidelines
Many payers will have policies regarding monitoring chronic opioid therapy (COT) and medical necessity requirements. For example, Palmetto’s “Controlled Substance Monitoring and Drugs of Abuse Testing” states that, “Ongoing testing may be medically reasonable and necessary based on the patient history, clinical assessment, including medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect or behavioral pattern.”
Drug screening test frequency must be based on a complete clinical assessment of the patient’s risk potential for abuse and diversion using a validated risk assessment interview or questionnaire. Keep these tips in mind when evaluating the patient:
Step 3: Verify Appropriate Diagnosis Codes
Appropriate ICD-9 codes that support medical necessity must be included in your claim. Palmetto offers the following guidance:
Remember that the physician should select the most appropriate diagnosis code. And, remember that labs are not to pre-populate requisition forms with a diagnosis. LCDs will prohibit “hard coding” a single ICD-9 code for every lab requisition, such as V58.83 (Encounter for therapeutic drug monitoring), rather than reporting a diagnosis specific to the patient.
Important update: A recent revision to the CCI Manual included information regarding validity testing on urine specimens. According to CCI, providers who perform validity testing on urine specimens used for drug testing should not separately bill the validity tests.
For example, the Manual states, “if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. The Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), Section 10 (Background) indicates that a laboratory test is a covered benefit only if the test result is utilized for management of the beneficiary’s specific medical problem. Testing to confirm that a urine specimen is unadulterated is an internal control process that is not separately reportable.”
“Not all of the Medicare contractors specifically addressed validity testing billing in their drug screen coverage policy,” Hammer notes. “Now this addition will make it nationwide Medicare non-coverage.”