Claims Adjustment: The Last Resort - Medical Coding - Medical

Plus: HIPAA • DVT and Venous Emboli • Aiding and Abetting • Gastro • 5010

Aug

ust

2011

Wendy Grant, CPC

Claims Adjustment:

The Last Resort

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www.aapc.com August 2011 3

[contents] 7 Letter from the Chairman and CEO

8 Coding News

11 Letter from Member Leadership

12 Letters to the Editor

28 Kudos

In Every Issue

18 Diagnosis Coding Done Right DebraMitchell,MSPH,CPC-H

21 Now Is the Time to Review Your HIPAA Compliance MarciaL.Brauchler,MPH,CPC-P,CPC-H,CPC-I,CPHQ

24 Get the Latest on Abdomen and Pelvis CT Scan Codes NancyG.Higgins,CPC,CPC-I,CIRCC,CPMA,CEMC

26 Claims Adjustments: The Last Resort WendyGrant,CPC

30 Two Criteria Determine DVT and Venous Emboli Dx SaraWolf,BA,CPC-H,CCS,andG.J.Verhovshek,MA,CPC

34 Good Grief! ICD-10-CM Is My New Adventure BrendaEdwards,CPC,CPMA,CPC-I,CEMC

36 Stay On Top of 5010 RhondaBuckholtz,CPC,CPMA,CPC-I,CENTC,CGSC,COBGC,CPEDC

41 Begin Your Own CDI Program KarenStanley,MBA,RN

44 Know Your Liability for Aiding and Abetting DavidM.Vaughn,JD,CPC

On the Cover: Wendy Grant, CPC, of Little Rock, Ark. learns the hard way that taking an adjustment should always be the last resort. Cover photo by Tammie Thessing Photography (www.tammiethessing.com).

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Education

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August 201144

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9 Hot Topic: Medicare Fraud and Abuse

14 AAPCCA

16 May MAYnia 2011

32 ICD-10 Road Map

50 Minute With a Member

38 Newly Credentialed Members

46 Align Your Credentials

24

• Intestinal Diverticulitis

• Teacher Tips

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• Behavioral Health

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Features

26

21

4 AAPCCodingEdge

Volume 22 Number 8 August 1, 2011

CodingEdge(ISSN:1941-5036)ispublishedmonthlybyAAPC,2480South3850West,SuiteB.SaltLakeCity,Utah,84120,foritspaidmembers.PeriodicalpostagepaidattheSaltLakeCitymailingofficeandothers.POSTMASTER:Sendaddresschangesto:CodingEdgec/oAAPC,2480South3850West,SuiteB,SaltLakeCity,UT,84120.

Chairman and CEOReedE.Pew

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©2011AAPC,CodingEdge.Allrightsreserved.Reproductioninwholeorinpart,inanyform,withoutwrittenpermissionfromAAPCisprohibited.Contributionsarewelcome.CodingEdgeisapublicationformembersofAAPC.StatementsoffactoropinionaretheresponsibilityoftheauthorsaloneanddonotrepresentanopinionofAAPC,orsponsoringorganizations.Cur-rentProceduralTerminology(CPT®)iscopyright2010AmericanMedicalAssociation.AllRightsReserved.Nofeeschedules,basicunits,relativevaluesorrelatedlistingsareincludedinCPT®.TheAMAassumesnoliabilityforthedatacontainedherein.

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Beginning coding with common technologies, basic anatomy and physiology, and using standard code guidelines and regulations.

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Advanced anatomy and physiology, procedures and disorders for which codes or official rules do not exist, appeals, and payer specific variables.

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AAPC is full of incredible employees. From the dedicated workers that answer each of your phone calls to those who process ex-ams, help students and teachers, or program computers; they all deserve a huge “Thank you!” from all members and myself. They work tirelessly on your behalf.Here are just a few examples of how AAPC employees go the extra mile to ensure we are here for your needs, exude excellence, and operate at optimal capacity:

• Someone from our exam team is available every Saturday to answer phone calls from proctors who have unexpected problems that invariably pop up.

• Examinees are called by staff prior to their examination to make sure they know its time, location, what books to bring, etc. That’s an average of about 500 calls per week.

• Our small call center handles about 1,800 inbound calls and 550 emails per week to answer members’ questions. And, the rest of our staff handles an average of 3,100 calls a week.

• We have distance learning coaches, ICD-10 trainers, and other Certified Professional Coders (CPCs®) who travel late at night, respond to emails in the early morning hours, and volunteer for many other tasks to help members.

• Our computer programmers work late into the night many times to resolve technical issues, help members, or make a website change so we can launch a new service. The Jobs portion of our website alone took about 200 man hours to build.

• Conference organizers are committed to offering you the best national

and regional conferences possible—even when a natural disaster (e.g., 2010 Nashville flood) requires a last-minute change of venue and, to pull it together, sleep is no longer an option.

• Local Chapter Support is always there to answer and help out local chapter officers and members to strengthen and grow our coding profession’s infrastructure.

• Our staff works under tight production deadlines to ensure newly released coding changes and timely news is available to you through coding books, webinars, workshops, Coding Edge, and Edgeblast.

Without our dedicated employees, AAPC would not be the leading medical coding or-ganization and have members who passion-ately support it.Here is a huge public “THANK YOU!” to each of our people who have your best in-terests at heart, respond to your emails and phone calls quickly and cheerfully, make our conferences, webinars, and workshops run smoothly, and have our books shipped quickly to you. If you have been to our na-tional office, I’m sure you agree that we have a great group. My hat is off to each employee. You are the best of the best. This comes heartfelt from someone who, years ago, demanded more than you thought you had in you, and then watched you deliver more than was demanded.

Your friend,

Reed E. Pew Chairman and CEO

AAPC Employees Deliver the Best to You

LetterfromtheChairmanandCEO

8 AAPCCodingEdge

CodingNews

2012 New, Revised, and Deleted ICD-9 CodesYou’ll want to take note of 169 new, 42 revised, and 34 deleted ICD-9-CM codes recently finalized for 2012. The changes take effect Oct. 1, 2011.

New CodesSome new additions for 2012 that will help you to pro-vide greater detail to your diagnosis coding include:

• Several new codes for malignant neoplasms of the skin (173), which will expand with new fifth-digit subclassification codes for 0 Unspecified malignant neoplasm, 1 Basal cell carcinoma, 2 Squamous cell carcinoma, and 9 Other specified malignant neoplasm

• Six new thalassemia (282.4x) codes• Three new codes to capture Lambert-Eaton

syndrome (358.3x) diagnoses• Many new codes added to 516 Other alveolar

and parietoaveolar pneumonopathy, including expanding 516.3 to a fifth digit and new codes 516.4, 516.5, and 516.6x

• New unspecified bladder disorder and complication due to cystostomy codes 596.81, 596.82, 596.83, and 596.89

• Postoperative shock fifth-digit codes (998.00-998.09)

There are also new codes for dementia, glaucoma, heart disease, cardiomyopathy, influenza, pulmonary, pel-vic fractures, anaphylactic reaction, and pregnancy, to name a few.

RevisionsOut of the 42 revised codes for 2012, here are some no-table changes:

• The verbiage “mental retardation” in the code descriptions for 317, 318.x, 319, V18.4, and V79.2 has changed to “intellectual disabilities.”

• The fifth digit of “1” in migraine codes 346.0x-346.9x is changing to “with intractable migraine, so stated, without mention of status migrainosus.”

• The verbiage “anaphylactic shock” in the code descriptions for 995.0 and 995.60-995.69 is changing to “anaphylactic reaction.”

Other code revisions include those for liver and biliary tract disorders in pregnancy, influenza due to identified 2009 H1N1 influenza virus, and pelvic fractures.

DeletionsThe short list of deleted codes include 10 classified under “other malignant neoplasms of skin” (173.0-9). For the latest on diagnosis coding changes in 2012, look for future Coding Edge and EdgeBlast coverage.

2012 MPFS Policy and Payment Rate ChangesThe Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 1 that would update pay-ment policies and rates for physicians and non-physician practitioners for services paid under the 2012 Medicare Physician Fee Schedule (MPFS). Under current law, physicians face a 29.5 percent reduc-tion in Medicare payment rates based on the Sustainable Growth Rate (SGR) formula for 2012.“We believe strong efforts are needed to evaluate Medi-care’s fee schedule to ensure that it is paying accurate-ly and ensuring that Medicare beneficiaries continue to have access to vital services, such as primary care servic-es,” said Jonathan Blum, deputy administrator and direc-tor for the Center for Medicare. To do this, CMS is proposing:

• to expand the potentially misvalued code initiative;

• to change how it adjusts payment for geographic variation in the cost of practice;

• to expand its multiple procedure payment reduction for professional interpretation of advance imaging services to recognize overlapping activities that go into valuing these services;

• to make new criteria for a health risk assessment and use it in conjunction with annual wellness visits;

• to expand the list of services that can be furnished through telehealth to include smoking cessation services; and

• to update physician incentive programs.

There Are More Proposed RulesAlso on July 1, CMS proposed 2012 payment changes for outpatient care in hospitals and ambulatory surgical cen-ters and 2012 updates for dialysis facilities. For more information regarding these proposed rules, see the CMS Fact Sheets at www.cms.hhs.gov/apps/media/fact_sheets.asp. The proposed rules are on display in the Federal Register at www.ofr.gov/inspection.aspx.


Hot Topic

No More Pay and Chase for MedicareNew predictive modeling technology stops fraud before it happens.Every year an estimated $120 billion dollars are lost due to fraud and waste in government health programs like Medicare and Medicaid.

With an administration-wide initiative to crack down on waste, fraud, and abuse, the Centers for Medicare & Medicaid Services (CMS) an-nounced that starting July 1 it will begin using innovative predictive modeling technology to fight Medicare fraud.

Predictive modeling, similar to the technology used by credit card companies, helps identify potentially fraudulent Medicare claims before they are paid. The new predictive software approach works like this: There is an initial tier of simple screens, then a predictive model “that identifies improper payments, fraud and abuse by ‘scoring’ the claim, based on its characteristics,” according to a Lewin Group report from 2009 (www.lewin.com/content/publications/PredictiveModelingMedicaidOverpymnt.pdf). Using predictive modeling “can be significantly more effective” than the after-the-fact system, the report says.

This initiative builds on the new anti-fraud tools and resources provid-ed by the Affordable Care Act to move CMS beyond the “pay & chase” recovery approach to one that focuses on preventing fraud and abuse before payment is made.

Will the New Approach Work?

According to The Wall Street Journal’s Health Blog, “Medicare Will

Start Flagging Suspicious Claims — Before They’re Paid,” “… payers can customize the software’s filters to flag different types of facilities, geographic areas, services or equipment. (For example, the software could be set to aim at the ever-popular durable medical equipment frauds in Florida.)” The Lewin Group’s report said that things like unusual procedures performed within a specialty or records showing a provider is making a high volume of claims for the same services on a single day could raise a flag.

Douglas Grimm, a health care attorney at Pillsbury Winthrop Shaw Pitt-man in Washington, D.C., said “pay and then verify later is not work-ing.” But he’ll be watching the new system to see if it produces false positives that lead to delays for legitimate claims. “Providers need to be sure their systems are in place to bill Medicare correctly,” he says.

If the system works for Medicare and is sufficiently cost-effective, it will be expanded to Medicaid and the Children’s Health Insurance Program (CHIP) by April 1, 2015.

Go to www.HealthCare.gov/news/factsheets/fraud03152011a.html and www.HealthCare.gov, for more information on predictive model-ing and HHS’ effort to detect fraud and abuse.

Read the CMS press release issued June 17 at www.cms.gov/apps/media/press_releases.asp.

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W ith our 2011 National Conference behind us and our Regional Con-ference in Nashville next month,

now is the perfect time to discuss some strat-egies for you to get the most out of your con-ference experience. Let’s start with a list of distracting behavior that you should NOT do.

Top 10 Ways to Get Noticed at Conference (Not in the Best Light)10. Dress like you’re going to muck stalls. 9. Have inappropriate conversations dur-

ing lunch in tones loud enough to reach several tables away.

8. Wear nightclub attire.7. Share the events of last night’s dinner

with everyone around you during a ses-sion because what you have to share is more important than the presentation.

6. Take an “important” call during a ses-sion—after all, it might be Publishers Clearing House®.

5. Be rude and/or disrespectful to those volunteering at conference because common courtesy is overrated.

4. Attend a session only long enough to re-ceive the Continuing Education Unit (CEU) code.

3. Ask your friends or others attending the entire session for the CEU code you missed.

2. Make sure all in the room, including the speaker, know you are an expert on the session topic.

1. During a session, use an electronic de-vice to check email, Facebook®, play Angry Birds, or read the latest Tess Gerritsen novel.

This is an exaggerated list of behaviors ex-hibited at past conferences but, unfortu-nately, there is a bit of truth in each.

Use Technology to Your BenefitMore often than not, presenters ask the au-dience to turn off or silence cell phones. Two

good reasons for doing this are: the ringing interrupts the presenter and distracts the audience, and the call or text receiver miss-es important session information. Most ses-sions are short and packed with informa-tion, and not paying attention for even a brief period can result in missing impor-tant concepts.For some attendees, their employer’s condi-tion for attending the conference is that the employee must be available to answer ques-tions or take calls during the day, while oth-er attendees may have family interruptions. If either is your situation, consider taking the following steps so you can shut off your electronic device and get the most out of your sessions:

• Prior to conference, discuss with your employer the importance of attending entire sessions and give them a copy of your conference schedule so they know when it is or isn’t a good time to call.

• Establish with your employer and staff what constitutes an emergency.

• Set prearranged “family call” times and explain what constitutes a family emergency.

Whereas cell phones can be a source of dis-traction, laptops and iPads can be an invalu-able resource. Many members like to down-load presentations to these types of devic-es prior to conference and add notes during sessions. This reduces waste, packing space and weight, and the time spent preparing information to be shared with employers.

Top 10 List of Do’sLet’s conclude with a list of the top 10 ways to make the most out of your conference ex-perience:10. Dress in appropriate business attire—

your future employer may be sitting next to you.

9. Ask focused and attentive questions when the time is right.

8. Make new members/attendees feel wel-come.

7. Build your network of both experts and novice coders.

6. Use common courtesy.5. Share your expertise.4. Earn CEUs by attending entire ses-

sions.3. Schedule calls, texting, and email time

with employers and family prior to conference.

2. Turn off or silence electronic devices not being used as an aide during ses-sions.

1. Enjoy yourself while taking full advan-tage of this educational opportunity.

Hope to see y’all in Nashville, Sept. 7-9! Best Wishes,

Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-PPresident, National Advisory Board

Get the Most Out of Conference

LetterfromMemberLeadership

12 AAPCCodingEdge

LetterstotheEditor Pleasesendyourletterstotheeditorto:[email protected]

Points Need to Add Up for ED LevelingI noticed a possible error in Jim Strafford’s, CEDC, MCS-P, article “Next Step in ED Leveling” (May 2011). At the bottom of page 22, the article states, “In our example, if points exceed 60, 99283 Emer-gency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical de-cision making of moderate complexity is assigned; if they exceed 100, 99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity is assigned.” However, the points do not match the example as provided in Table 1 on page 23. The Table states: “99283 = 30-40 points” and “99291 = 60 or more.” Rita Kauffman, CPC-A

Yes, there is an inconsistency between the article’s body of text and the table. In a way, it proves that the trickiest part of the point system is getting the math right!When I wrote the article, I had in mind a system that assigned higher points to services. In that context, 60 points would have resulted in a 99283. When I devised the table, I decided on a system that assigned fewer points to each service rendered, with a range of points for each level. Unfortunately, I failed to change the points in the narrative to match the points in the table. The narrative should’ve stated 30-40 points for 99283 and 50 or more points for 99285. Note that the assigning of points is arbitrary. The key is for the points assigned to the services and supplies to result in reasonable and com-pliant coding. I’m glad, however, that you paid such close attention to my article!Jim Strafford, CEDC, MCS-P

IPPE May Be Reported With Other Preventive ServicesI appreciate your recent coverage of the Medicare Initial Preventive Physical Examination (IPPE) (April 2011, “Code Medicare’s Pre-ventive Visits from Head to Toe”), but I have a question that the ar-ticle did not address: Can a physician perform the IPPE along with other Medicare preventive services, such as a screening pelvic exam or prostate exam?Christine Dunleavy, CPC, CEMC

Yes, you may report an IPPE, also referred to as the “welcome to Medicare” visit, at the same visit as other preventive services. The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals notes, “The HCPCS codes for the IPPE [G0402, and G0403, G0404, or G0405 for screening EKG as a result of a referral from an IPPE] do not include other preventive services that are currently paid separately under

Medicare Part B screening benefits. When Medicare providers per-form these other preventive services, they must identify the servic-es using the appropriate existing codes.” The guide further speci-fies, “Other covered preventive services that are performed may be billed in addition to HCPCS code G0402 and the appropriate EKG HCPCS G code.”The third and most current edition of the Guide, available from the Centers for Medicare & Medicaid Services (CMS) website (www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf), provides complete instruction for the following Medicare preven-tive services:

• The IPPE • Ultrasound Screening for Abdominal Aortic Aneurysm

(AAA)• Cardiovascular Screening Blood Tests• Diabetes Screening Tests, Supplies, Self-Management

Training, Medical Nutrition Therapy, and Other Medicare-Covered Services for People with Diabetes

• Screening Mammography • Screening Pap Test• Screening Pelvic Examination• Colorectal Cancer Screening• Prostate Cancer Screening • Influenza Virus, Pneumococcal, and Hepatitis B

Vaccinations• Bone Mass Measurements• Glaucoma Screening• Smoking and Tobacco-Use Cessation Counseling Services

CMS is in the process of updating the Guide to reflect the inclusion of the annual wellness visit (AWV), including Personalized Preven-tion Plan Services (PPPS) as a covered Medicare preventive service, as mandated under the Affordable Care Act. For additional informa-tion, visit the CMS website at: www.cms.gov/MLNProducts/35_PreventiveServices.asp.Coding Edge

Coding Network Makes Us StrongerRecent discussions in Coding Edge about the value of networking have really struck a chord with me [e.g., see “Understand the Value of Networking,” March 2011]—so much so that I recently present-ed on networking at my local Tulsa, Okla. chapter.Stedman’s Medical Dictionary defines “network” as a structure bear-ing a resemblance to a woven fabric. I think this is a great analogy: One strand touches the strands on either side, as well as those that cross over and under it. In this way, the whole of the structure is greater than the individual strands. This structure becomes a cloth that is useful, strong, and efficient because of the way the strands work together for the common good.


Each AAPC member is like a strand. Together we make up a cloth that stretches across this country with the common goals of promot-ing excellence, providing education, and uniform standards to any-one who joins us.I am fairly new to coding, but as part of a network I have access to resources beyond my individual reach. I can learn about things I wouldn’t experience on my own through each of you in my nation-al network. Each of us brings our experiences, knowledge, and con-tacts. Together, we are stronger than any single individual. We are a whole cloth. I’d like to offer my appreciation to each of you. You have been places I will never see, talked to people I will never meet, and learned what I have not yet learned—and you share these things with me. You are my AAPC network.Mary Kincaid, CPA, CPC-A

Well said, Mary. Thank you!Coding Edge

PT and What Code?Coding Edge received several requests to clarify an issue raised in the May article “Modifier 33 Arrives Quietly But Packs a Punch” re-garding the use of modifier PT Colorectal cancer screening test; con-verted to diagnostic test or other procedure. Modifier PT indicates the reporting of a diagnostic procedure code (for example, 45383 Colo-noscopy, flexible, proximal to splenic flexure; with ablation of tumor(s). polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) instead of the screening colonosco-py or screening sigmoidoscopy HCPCS Level II code when the visit began as a screening service. The modifier should not be used with a screening colonoscopy or sigmoidoscopy HCPCS Level II code. When a patient is scheduled for a G0104 Colorectal cancer screening; flexible sigmoidoscopy, G0105 Colorectal cancer screening; colonoscopy on individual at high risk, or G0121 Colorectal cancer screening; colo-noscopy on individual not meeting criteria for high risk, but a positive finding changes the procedure to a diagnostic colposcopy, Medi-care will waive the patient deductible for the diagnostic colonosco-py performed on the same day as a scheduled screening colonosco-py. In such a case, patients still are responsible for the co-pay for the diagnostic colonoscopy.Coding Edge

To discuss this article or topic, go to www.aapc.com LetterstotheEditor

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14 AAPCCodingEdge

Throughout their term, the AAPC Chapter Association (AAPCCA) Board of Directors (BOD), in cooperation with the AAPC Local Chapter department, visits chapters across

the country. They later convene to share their stories from these vis-its and glean information from other sources. The goal is to learn about what growing and thriving chapters do to succeed, as well as why struggling chapters are failing. Here is what they have learned.

The Key Contributing Factor to a Chapter’s SuccessThere are more than 477 local chapters across the United States, Guam, Puerto Rico, and the Bahamas (as of July 1). With nearly 105,000 members, this is an average of 224 members per chapter. Chapter analysis shows that, although there are many contributing factors to the success or failure of a chapter, the single most impor-tant factor to a chapter’s success is (drum roll, please) … its members.

MembersOver and over, we see the difference one member can make. The drive, creativity, or skills of a particular officer can elevate a chapter to the next level. Problems arise, however, when this one member is the ONLY person making a difference. When that one person leaves office, so does the foundation for the chapter’s success. With no one in line to take over the leadership role, there are inherent problems in store for the chapter.

LongevityAnother important concept to local chapter success is longevity. To endure, new officers must continue to use the skills and experience of former, successful officers. Keep this resource close and make the most of it. We’ve heard from past officers who loved working to help grow their chapter that they have since stopped coming to chapter meetings because they were never involved or engaged by the new of-ficers. These are sad stories without happy endings.

SupportSuccessful chapters support departing officers and mentor future leaders. This practice lifts the weight of responsibility from just one officer to two, or maybe an entire committee.According to the Local Chapter Handbook, there are six official offi-cer positions. That does not mean you cannot have more. For exam-ple, you may already have a meeting coordinator, but why not form an entire snack or refreshment committee? You might also think about enlisting a speaker host who would serve as the contact person for chapter speakers. This person would be responsible for obtaining lecture handouts, making sure scheduled speakers finds their way to meetings, and perhaps introducing speakers before lectures. The more people involved, the easier the task is.

Small jobs are easy to accomplish and help the chapter immeasur-ably. It’s intimidating to be an officer and plan meetings for an entire year. It is much easier to agree to a year’s commitment if you know there will be three people to help with the details and you won’t be solely responsible. Those three people who are involved are learning, as well, and could be potential officers. Camaraderie is contagious. As chapter members continue to support each other, they grow into leaders. Others are content to work behind the scenes, utilizing their skills in other settings. All are assets to the chapter.

Hone in on Organization, Communication, and Relationship SkillsOther important aspects that contribute to a chapter’s growth:

• Good communication with members (For example, pay attention to what is going on at chapter meetings, ask for suggestions, and know what your chapter members want.)

• Identifying new chapter members• Recognizing newly-certified members• Holding a yearend event to acknowledge and thank all those

who helped make the past year a successAnother idea for chapter success is to foster good relationships with Medicare and other insurance carriers. These associations can re-sult in speakers for chapter meetings and can give a chapter the rep-utation for offering excellent speakers on timely topics. Relation-ships developed and fostered with local community college coding programs and other schools in your area also can aid in bringing in new members—not to mention, new skills and talents to your lo-cal chapter.

Stay InvolvedGet individual members involved and keep them engaged and your chapter will flourish. The creativity, talent, and skills your mem-bers offer will help perpetuate chapter success, as well as individual growth. An organization’s longtime success is due to the work of all members, not just one.Local chapters are the single best place to learn more about coding, earn CEUs, and make friends in a relaxed, peer-to-peer environ-ment. What a great benefit! Find out when your next meeting is, plan on attending, and plug yourself in to get all of the benefits an AAPC local chapter meeting has to offer.

Jill M. Young, CPC, CEDC, CIMC, has over 30 years of experience working in all areas of medical practice including clinical, billing, and rounding with physicians. This gives her a unique style of teaching using real life examples of coding and bill -ing situations in her lectures. She is the principal of Young Medical Consulting, LLC, and served as 2009-2010 chair of AAPC Chapter Association (AAPCCA).

The Secret to Local Chapter GrowthIt’s you, the members.

AAPCCA

By Jill M. Young, CPC, CEDC, CIMC


Handbook Quick Tip:

Correctly Cash In on Local Chapter CEUs

AAPCCA Handbook Corner

By Brenda Edwards, CPC, CPMA, CPC-I, CEMC

Part of the mission of local chapters is to promote and expand the medical coding profession. This is accomplished by providing an educational forum for AAPC members to receive low-cost or no-cost Continuing Educa-tion Units (CEUs).

A local chapter meeting is a great place for networking opportunities among AAPC members and a place where less experienced members may interact, learn, and be men-tored by those members with more experi-ence.

You are awarded one CEU per hour of coding-related education while physically attending local chapter meetings. No CEUs are avail-able for members attending the meeting via

teleconference or when viewing or listening to a recorded version of a chapter meeting or event.

It is the responsibility of each member to accurately report the number of CEUs earned for education received. For example, if a chapter meeting approved for 2 CEUs begins at 9 a.m., but you arrive 30 minutes late, you would be correct in reporting 1.5 CEUs (less .5 CEUs for the portion of the meeting you missed).

Thank you for helping your local chapter pro-mote the profession of coding and stay true to AAPC’s mission of “Upholding a Higher Standard.”

MODIFIERS – THE REST OF THE STORYUp to 6 CEUs | Author: Jennifer R. Swindle, RHIT, CPC, CEMC, CFPC, CPMA, CCS-P, CCPAttend AAPC’s workshop and brush up on the accurate and appropriate use of modifiers and how they impact appropriate reimbursement. CPT®, HCPCS Level II, and ICD-9-CM codes tell most of the story – but modifiers are utilized to further clarify, identify, or explain more detail about what transpired during the patient’s encounter. Modifiers help tell the rest of the story.

You’ll Learn To:• IdentifyALL allowable charges with modifiers• Mastertherulessurroundingmodifieruse• Recognizethespecificcircumstancesinwhicha modifier is NOT appropriate• Teachstaffandphysiciansonappropriatemodifier use with confidence

Select dates between August 17 and September 10

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16 AAPCCodingEdge

Local Chapters

Surf’s Up for May MAYnia 2011, Dude!AAPC local chapters responded well to the theme of this year’s May MAYnia, “Ride the Waves to Your Local Chap-ter,” where chapters gathered their members for special in-formative and fun meetings. Celebrating like surfers on Oa-hu’s North Shore, the month’s meetings prompted chap-ters to not only get all their members together but also in-

vite coders who hadn’t experienced the benefits of AAPC membership yet.“This was our most successful May MAYnia, yet,” said Mar-ti Johnson, director of local chapters at AAPC. “We heard so many stories about chapters celebrating by hosting great speakers, eating great food, and making new friends.”

The Monmouth, N.J. Chapter, for instance, decided to fore-go their normal Thursday night meeting and have brunch instead, inviting two speakers and vendors to participate. AAPC chapter members were pleased when speakers and vendors brought giveaway prizes.The St. Louis West Local Chapter celebrated their May MAYnia meeting with dinner, a presentation, and really good cake.In addition to the gifts provided by AAPC, chapters compet-ed for prizes donated by the American Medical Association (AMA), Contexo, Mag Mutual, and Ingenix OptumInsight.

And the Winners AreGrand Prize – Most Non-AAPC Members Attending:

• Dallas, Texas

Highest Percentage of Members Attending Meeting:• Little Rock, Ark.• Lawrence, Kan.• Tulsa, Okla.• Little Rock Central, Ark.• Winchester, Va.• Virginia Beach, Va.• Portland Columbia River, Ore.• St. Louis West, Mo.• Greensboro, N.C.• Chesapeake, Va.

16 AAPCCodingEdge

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18 AAPCCodingEdge

Feature Apprentice

Diagnosis Coding Done Right

By Debra Mitchell, MSPH, CPC-H

Imagine this patient encounter: A 67-year-old female complains of a painful lump on her elbow. The physician performs an assessment and takes a biopsy. Both the office visit and the biopsy are linked to ICD-9-CM code 757.8 Other specified congenital anomalies of the integument, and the claim is paid. Pathology results later reveal a diagnosis of giant cell tumor.The physician refers the patient to a specialist to have the tumor removed. Prior to receiving a pathology report, the re-moval claim is submitted with ICD-9-CM code 215.2 Other benign neoplasm of connective and other soft tissue; upper limb, including shoulder. When the pathology results arrive, they indicate a diagnosis of osteosarcoma.The specialist now recommends amputation of the arm, but the payer will not authorize the procedure as medically nec-essary, based on previous diagnoses submitted. From the payer’s point of view, the information does not add up. Why would amputation be necessary for a benign congenital anomaly? Although the previous claims were paid, the coding was incorrect. Sorting out the confusion will cause delays for the patient and provider.

Report what documentation tells you, or you could be hurting the patient.

Such a scenario is distressingly common. Claims often are submitted for payment with incor-rect or unconfirmed diagnoses not based on documentation.

More Distressing Coding ExamplesTo cite another example, an office may choose not to report V codes based on a rationale that payers have stated V codes are not acceptable as a primary diagnosis. When a patient under-goes pre-employment hepatitis screening, for instance, the claim is submitted with 573.3 Hep-atitis, unspecified. The claim gets paid, but the patient has been falsely labeled with a condi-tion that will inappropriately increase his risk factor and premiums, and may negatively af-fect his benefits.Or, perhaps the provider understands that V codes can gain payment, but applies them im-properly. For example, when submitting lab work for HIV screening, a diagnosis of V08 As-ymptomatic human immunodeficiency virus [HIV] infection status is submitted. The claim gets paid, but the harm to the patient’s file is enormous.Here’s another scenario: A patient is taking a medication as prescribed by her physician. She experiences a severe reaction to the medication and is hospitalized. Her codes upon discharge are 965.00 Poisoning by analgesics, antipyretics, and antirheumatics; opium (alkaloids), unspeci-fied, 570 Acute and subacute necrosis of liver, 304.0 Opioid type dependence, and E850.2 Acciden-tal poisoning by analgesics, antipyretics, and antirheumatics; other opiates and related narcotics. The only problem with this coding summary is none of it is true and none of it is document-ed—with the exception of the liver necrosis. The patient is hospitalized in a different facil-ity, which receives the old chart with the coding summary. As explained to the family, pain drugs are withheld due to the patient’s IV drug abuse. In reality, the patient was never an IV drug abuser.

Lessons to LearnCoding for payment (rather than for accuracy) has serious repercussions—not just because of payer audits or repayment demands, but for patients as well. Patients’ insurance collects data


Codingforpayment(ratherthanforaccuracy)hasserious

repercussions—notjustbecauseofpayerauditsorrepay-

mentdemands,butforpatients,aswell.

from our claims regarding their subscriber. This data is used to establish patients’ risk pro-files, which will help the payer establish the premium amounts and access to benefits. Choos-ing diagnosis codes based on whether they will be paid can artificially and incorrectly cause a patient’s risk to be higher than it is suppose to be. How can you help prevent this?For starters, when selecting an ICD-9-CM code, there is no substitute for using an official ICD-9-CM code book (be it electronic or paper). Codes cannot be selected from memory or from a cheat sheet. Code books have important instructions and structure that can assist with code selection. A code never should be taken out of context.Forexample: 964.2 Anticoagulants might seem to be appropriate for a patient on anticoagu-lants, but it is in the category 964 Poisoning by agents primarily affecting blood constituents, in the chapter for Injury And Poisoning. It should not be used to indicate a patient is on an an-ticoagulant, as you might expect, but rather to indicate poisoning by anticoagulates. Anoth-er code frequently used for prothrombin time and international normalized ratio (PT/INR) tests for patients on anticoagulation therapy is 286.9 Other and unspecified coagulation defects. This code should not be used just because the patient is on an anticoagulant if the provider did not document the specific condition of coagulation defect. Above all, remember that the diagnosis belongs to the patient. Payers can make policy based on what they consider appropriate medical necessity for a procedure or service, or what diag-nosis they consider to be covered, but a payer cannot tell the provider which diagnosis code to select for the claim. As well, the code we select must match the provider’s documentation, following coding guidelines and ICD-9-CM conventions. Do not assign codes without com-plete documentation (e.g., relevant pathology results). When in doubt, query the provider for more information. As a professional medical coder, it is your responsibility to strive to be 100 percent correct with diagnosis code selection.

Debra Mitchell, MSPH, CPC-H, is a consultant and auditor for coding and compliance and a professional cod-ing instructor. Her educational experiences coincide with her 34 years of medical records and billing experience at every level of responsibility. She was recently named to “Who’s Who in America’s Professional Women.”

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FeatureProfessional

Now Is the Time to …Review Your HIPAA CompliancePart 1: Updating your privacy policies.

By Marcia L. Brauchler, MPH, CPC-P, CPC-H, CPC-I, CPHQ

From its inception in April 2003, the Health Insurance Portability and Accountability Act (HIPAA) was something of a “paper tiger.” But when President Obama signed the American Recovery and Reinvestment Act (ARRA) into law in February 2009, the tiger got teeth. Major changes to the privacy law, as outlined below, were included in the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the larger ARRA. What did ARRA/HITECH change? For starters, it significantly increased liability for not be-ing in compliance with HIPAA. Previously, the maximum fine was $25,000 per violation. Now, that’s just the first level of fines: You can receive up to $1.5 million in fines for a single HIPAA violation. The HITECH Act also mandates that the federal government—specifically the Office for Civil Rights (OCR)—conduct audits on covered entities to ensure compli-ance. Even if no complaints have been filed against you, the government can show up and say, “Let us see your policies.”HITECH allows state attorneys general to bring suits against various covered entities on behalf of “harmed individuals,” and will allow individuals whose rights were violated to participate in any civil monetary penalty if a covered entity is fined (the precise regulations are still being hammered out). There’s also a breach notification law provision in HI-TECH. What that means is, if you lose even just one patient’s unsecured information you have an obligation to tell the affect-ed individual and the federal government. If more than 500 un-secured records are exposed (for instance, due to a missing laptop or a breach into your system), you have an obligation to tell the af-fected individuals and the federal government immediately (and local news media, if the breach affects more than 500 individuals in one area). ARRA/HITECH also applies HIPAA privacy and security regulations to business associates (BAs), creates tighter marketing restrictions, and mandates that the OCR initiate a multi-faceted, national educa-tion campaign to inform the public about its privacy rights as patients.

Identify Weaknesses in Your HIPAA ComplianceMost practices probably haven’t considered the changes brought about by ARRA/HITECH, and are still operating under their original HIPAA pol-icies and procedures. If this is the case in your practice, here are some highlights of what is likely to be out of date, based on our experience with the OCR:

• The Notice of Privacy Practices (NPP) is incorrect, and does not list instances when the provider would be obligated to disclose protected health information (PHI).

• A policy on “Consent for the Use or Disclosure of PHI” is unnecessary (Although patient consent for their PHI use is permitted under the privacy rule, it is not required.).

22 AAPCCodingEdge

Feature

• Safeguards (administrative, technical, and physical) need to be included from the 2005 Security Rule to protect the privacy and security of PHI. (More on this in Part 2 of this series, Security Updates.)

• Due to out-of-date policies, the OCR may suggest intense training to get back in compliance.

• The complaint procedure must list a contact person within the practice.

• Policies may include a form allowing a patient to designate a personal representative, thereby granting the person to have the same rights as the patient under HIPAA. (The form must include all required elements for valid authorization under HIPAA.)

At Physicians’ Ally, Inc., we needed to update our policies that are made available to physician practices. As a baseline, our policies in-clude the five general categories of “Patient Rights” under HIPAA.1. Patients have the right to obtain a copy and review their PHI.2. Patients have the right to request the practice amend PHI

when the information is inaccurate or incomplete.3. Patients have the right to an accounting of the disclosures of

their PHI by the practice or the BAs.4. Patients have the right to request that the practice restricts use

or disclosure of PHI for treatment, payment, and health care operations (TPO) or other disclosures, such as to people in-volved in the payment of health care or notification to family members (The practice does not have an obligation to agree to these requests for restrictions, but if the practice does agree, it must comply.).

5. Patients have the right to complain about the practice’s com-pliance with the policies and procedures required under the Privacy Rule.

During review, the OCR told us that our forms looked good, but we needed more policies. Our work was cut out for us, as it is for every physician practice that has not seriously updated its original HIPAA pol-icies and procedures. We dedicated many months to learning about

recent HIPAA changes and how to incorporate them into the prac-tice’s policies, procedures, and training. We are proud to say that our revised policies and procedures were approved (for use by our client who was undergoing an OCR review).

Get Current, Get CompliantTo get current with HIPAA, we had to create new policies or tweak our existing policies for the following: A new NPP. This is needed specifically to address that HIPAA al-lows the use of PHI in the day-to-day operations of the practice. The new notice describes how PHI can be used for “treatment,” meaning the coordination between providers for the care of a patient. PHI can be used for pursuing “payment” on behalf of a patient, such as call-ing a patient’s insurance company to verify coverage and benefits. PHI can also be used for regular “operations,” such as credentialing, quality improvement, care coordination, and even provider perfor-mance evaluation. If the NPP says the practice will use the PHI in a certain way, then it can (such as appointment reminders or “Thank You” notes). If your office’s notice doesn’t mention the specific uses of PHI, then you can’t use the PHI. It’s not hard to find an NPP to use for your office, but you must cus-tomize the form to be an accurate reflection of your practice. The notice also must contain the date when it first went into effect, and mention how revised notices will be distributed. If you’re just now changing or adopting a new NPP, you should follow the procedure for distributing the notice to all patients: The NPP must be provid-ed to patients at their first visit to your facility; it must be available for anyone who asks for it; and, it should be posted in your waiting room and on your website.A policy indicating the practice would make a “good faith” ef-fort to obtain written acknowledgement of receipt of the NPP by patients. If acknowledgement cannot be obtained (e.g., the patient refuses to sign the Acknowledgement form), the practice will docu-ment its efforts to obtain the acknowledgment, along with the rea-son why the acknowledgment was not obtained. This form must be retained in the medical record for at least six years.

Individual identifiers that constitute PHI under HIPAA

Evenifnocomplaintshavebeenfiledagainstyou,thegovernmentcan

showupandsay,“Letusseeyourpolicies.”

• Name• Address• Social Security number• Family history• Telephone number

• Fax number• Account numbers• Medical record number• Email address• Dates (birthday, etc.)

• Certificate/license numbers

• Vehicle identification (license plate, serial number, etc.)

• Personal assets

• Device identifiers and serial numbers

• Biometric (finger or voice print)

• Photographs

• All other unique identifying numbers, codes, or characteristics


Feature

Identify current BAs, and get updated agreements on file. Un-der the original HIPAA regulation, BAs were under agreement with the practice to protect PHI. Under the ARRA, BAs are directly lia-ble to the federal government for compliance with the privacy and security rules of HIPAA (effective February 2010). Today, even BAs must have policies and procedures in place for how they will handle your practice’s PHI. Examples of BAs are legal counsel, accountants, billing companies, collections agencies, and business consultants. These policies, forms, etc. also were required or highly recommended:

• A policy on allowable disclosures without authorization • A policy on allowable disclosures with authorization,

including a section allowing revocation of the authorization by patients if they change their mind

• A policy for requesting access to PHI and/or obtaining a copy of PHI

• A policy for requesting restrictions on uses and disclosures of PHI

• A Privacy Complaints form • A form for requesting alternative means of communication • A policy regarding how the practice utilizes email contact to

transmit PHI over the internet • A policy regarding marketing uses and disclosures

Under ARRA/HITECH, the government further strength-ened the prohibitions on selling patient information. In gen-eral, you should not sell or trade PHI without patient autho-rization. Face-to-face marketing communication to a patient is allowed, as is providing a promotional gift of nominal val-ue to a patient. You should use the individual authorization form, however, if you intend to receive any kind of direct or in-direct payment (remuneration) for marketing to a patient. Un-der HIPAA, you cannot sell your patient list without each pa-tient’s authorization saying it is OK to do so.

• A policy describing the privacy officer’s position in detail, which includes investigating all suspected HIPAA violations and handling complaints

• A minimum necessary standard policy, directing the staff to only look at records essential to who is being treated

• A non-retaliation policy declaring that the practice will refrain from intimidating or retaliating against any person for exercising any right established by the Privacy Rule, including the filing of a complaint against the practice

• A non-discrimination policy • Designated employee sanctions for violating privacy or failing

to report suspected or actual violations

• Workforce member hiring and termination procedures, such as the practice reserving the right to conduct criminal and/or credit record checks

• An “open door policy” and philosophy: Every manager’s door is open to every employee to encourage open communication, feedback, and discussion about any matter of importance

• Safeguards (physical, administrative and technical security) that prevent people from accessing electronic PHI

• A breach identification process: This requires employees to report breaches or suspected breaches of privacy without fear of retaliation (Under ARRA/HITECH, federal regulations now require that if you think there is a security breach or a potential breach of privacy, you must tell your privacy officer.)

• Patient notification of breach: Required if you lose (breach) unsecured PHI and there is a risk of significant harm to a patient because of the breach (Interim regulations allow a covered entity to go through a risk assessment to determine the level of harm to the individual(s) whose information was breached—notification of the breach to the affected individuals must be done in a specific manner and within a certain timeframe.)

Make Training Part of Your Compliance PlanIn addition to updating your practice’s policies and procedures, of-fer privacy training periodically to all workforce members (defined by HIPAA as full-time, part-time, and temporary employees, as well as volunteers). Keep training documentation, and signed confiden-tiality statements (not required by HIPAA, but a nice touch) on file and maintained for six years.As an employee, be aware of who your practice’s privacy officer is and where the HIPAA policies and procedures are kept. Your prac-tice should have a central location where all HIPAA documents are stored and where staff can access them. Begin using updated forms/policies at once, and immediately undertake the administrative proj-ect of updating your practice’s BA list and filing signed BA agree-ments. Perform a risk analysis to ensure compliance with HIPAA regula-tions. In Part 2 of this series, we’ll address how to do a security risk analysis, which should be performed on a regular basis to keep your practice up to date with changing electronic technology.

Marcia L. Brauchler, MPH, CPC-P, CPC-H, CPC-I, CPHQ, is a health care consultant and founder of Physicians’ Ally, Inc. She advises physicians and prac-tice administrators on managed care contracts, reimbursement, coding, and compliance. Her firm is selling updated HIPAA policies and procedures at www.physicians-ally.com/hipaa_training.html.

WededicatedmanymonthstolearningHIPAAchangesandhowtoincorporate

themintothepractice’spolicies,procedures,andtraining.

24 AAPCCodingEdge

Feature

Get the Latest on Abdomen and Pelvis CT Scan Codes

By Nancy G. Higgins, CPC, CPC-I, CIRCC, CPMA, CEMC

Computed tomography (CT) uses computer imaging and multi-ple, narrow beams of X-rays to produce thin, cross-sectional views or images of various body layers. These images allow visualization of soft tissue, as well as bones, making them useful for evaluating a wide range of conditions. CT imaging of the abdomen and pelvis frequently are performed to-gether during the same encounter. The combined services are use-ful for evaluating a large number of conditions, including abdomi-nal and pelvic pain; infections such as appendicitis or diverticulitis; inflammatory processes such as ulcerative colitis; and cancers of the colon, liver, kidneys, pancreas, and bladder. Combined CTs of the abdomen and pelvis also are performed to quickly identify internal injuries in cases of trauma. During CT of the abdomen, the organs visualized include: the liv-er, spleen, kidneys, pancreas, the top half of the large intestine, the small intestine, and the superior aspect of the ureters. During a CT of the pelvis, the organs visualized include: the remainder of the large intestine, the small intestine, and ure-ters, as well as the bladder, uterus, and ovaries.

Combined Services Call for New CPT® CodesPrior to 2011, two CPT® codes had to be selected to re-flect the combined services when CTs of both the abdo-men and pelvis were taken during the same encoun-ter. Because of an increased frequency of these services performed during the same encounter, the American Medical Association (AMA) developed three new CPT® codes for 2011 that reflect cur-rent practice.

Use these codes for a CT of the abdomen alone:

74150 Computedtomography,abdomen;withoutcontrastmaterial

74160 withcontrastmaterial(s)

74170 withoutcontrastmaterial,followedbycontrastmaterial(s)andfurthersections

Use these codes for a CT of the pelvis alone:

72192 Computedtomography,pelvis;withoutcontrastmaterial

72193 contrastmaterial(s)

72194 withoutcontrastmaterial,followedbycontrastmaterial(s)andfurthersections

The following codes should be used only if both the abdominal and pelvic CT are performed during the same encounter.

74176 Computedtomography,abdomenandpelvis;withoutcontrastmaterial

74177 withcontrastmaterial

74178 withoutcontrastmaterialinoneorbothbodyregions,followedbycontrastmaterial(s)andfurthersectionsinoneorbothbodyregions

The AMA includes the following table in CPT® 2011 to help you de-termine the correct code:

Standalone Code

74150 CT Abdomen w/o Contrast

74160 CT Abdomen w/ Contrast

74170 CT Abdomen w/wo Contrast

72192 CT Pelvis w/o Contrast

74176 74178 74178

72193 CT Pelvis w/ Contrast

74178 74177 74178

72194 CT Pelvis w/wo Contrast

74178 74178 74178

The table above illustrates that CPT® 74176 should be used only if both studies are done without contrast. Use CPT® 74177 only if both studies are done with contrast.

Apprentice

CT unit

CT images of the pelvis are performed. Report 72192 when no contrast is used, and 72193 when

contrast is used.

Iliaccrest

SacrumCoccyx

2011 CPT® codes accommodate more and more of these services performed during the same encounter.

Illustration©IngenixOptumInsight


Feature

Code 74178 should be used in two situations:• One or both studies are done without contrast, followed by contrast

material(s) and further sections.• One study is done without contrast, while the other study is done

with contrast.

Scenarios Help Show Correct Coding

Example one: A 34-year-old male presents with 48 hours of lower ab-dominal and pelvic pain. The patient also has a low-grade tempera-ture. His physician orders a CT of the abdomen and pelvis without in-travenous contrast. The radiologist supervises the process of providing the CT, and then interprets the images acquired. He also dictates a re-port of his findings. The radiologist should report 74176.Example two: A 48-year-old female presents with flank pain and persis-tent gross hematuria. The patient’s urologist conducts a cystoscopy and is unable to identify the cause of the patient’s symptoms. He orders a CT of the abdomen and pelvis without and with intravenous contrast. The radi-ologist supervises the process of providing the CT, and then interprets the images acquired. He also dictates a report of his findings. The radiologist should report 74178.

Coding Tips to Remember

• IfbothaCToftheabdomenandaCTofthepelvisareperformedduringthesamesession,useoneofthenewcodesthatdescribesthatcombinationofservices(74176,74177,and74178).

• RefertothetableprovidedintheCPT®booktodeterminethecorrectcode.

• Report74176,74177,or74178onlyoncepersession.

• Codes74176,74177,and74178canneverbereportedtogetherwithanyofthecodesforCToftheabdomenalone(74150,74160,and74170),orCTofthepelvisalone(72192,72193,and72194).

Nancy Higgins, CPC, CPC-I, CIRCC, CPMA, CEMC, has over 20 years of experience in the health care industry and is a manager in the Corporate Compliance department at Carolinas Healthcare System in Charlotte, N.C. Nancy is past president of the Charlotte, N.C. AAPC lo-cal chapter and was AAPC’s 2009 Coder of the Year. She can be reached at [email protected].

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26 AAPCCodingEdge

Professional

By Wendy Grant, CPC

Claims adjustments—not contractual adjustments when billed fees are over the payer’s allowable, rather the adjust-ments that occur when entire services are disallowed—are

a primary concern for all providers. Physicians provide services to their patients expecting in good faith to receive compensation. If a payer processes a claim and advises the services be adjusted, the provider will not receive payment as expected. This type of claims adjustment is not written in stone, however. Although a denial poses a special challenge to the billing staff, usually the challenge can be met and the denial overturned by providing the payer with additional information.

Claims Adjustments:

The Last ResortWith appropriate research and communication, you can uncover the problem and overturn the denial.

Cover Story

Successful Strategies for Common DenialsHere are the most commonly seen denials and the tactics you can use to deal with them successfully: ■ Claim was included in the allowable of another service – In other words, the service was bundled. It is essential to know and understand global periods and National Correct Coding Initia-tive (NCCI) edits when working bundling denials. These types of denials should be handed over to the coders of the practice to an-swer these questions: Was the service bundled with another proce-dure billed during the same operative session? Or, was it bundled in a previous surgery that was performed 89 days prior? Were nec-essary modifiers omitted? Find the answer and resubmit the “cor-rected” claim to the payer. ■ Not medically necessary – The physician orders tests neces-sary to diagnose the patient’s condition, but the claim is denied with an error code CO50. The payer is saying that the tests were not medically necessary. This type of denial usually occurs be-cause there was a failure to include all of the necessary diagno-ses on the claim. Before this charge is adjusted, research the doc-umentation to see if a documented diagnosis was omitted from the claim. For example, a Medicare patient is given an injection of Botox in his vocal cords by an otolaryngologist for a diagnosis of dyspha-gia. Medicare denies the Botox as not medically necessary. Botox is very expensive, so accounts receivable conducted extensive re-search into the patient’s record. It was found that the patient had larynx cancer, and that Medicare covers the Botox injection for this diagnosis. The physician was notified that the patient’s cancer condition must be mentioned in the chart documentation when the Botox is administered.■ Service not covered – Some services simply aren’t covered, such as voluntary cosmetic procedures and most weight loss plans. If we bill these services to an insurance company and receive a deni-al that the service is not covered, don’t adjust them off. These ser-vices must be billed to the patient.When Medicare denies a service, you will receive an explana-tion of benefits (EOB) with American National Standards Insti-tute (ANSI) code PR-49. “PR” means patient responsible. In oth-er words, Medicare is telling you to bill the patient. Do not write


Separate Service

Medical Necessity

Covered Service

Timely Filed

Prior Authorization

Non-duplicated

Cover Story

ThemonthofJanuarycanwreakhavocontimelyfilingdenials.As

happenswithallcreaturesofhabit,rememberingtochangethe

datefromoneyeartothenextsometimestakesusawhile.

these off. When you adjust them, the services that were provided are basically given “free of charge” to the patient.■ No prior authorization – When you see this, your No. 1 resource is the local hospital business office where the test/procedure was performed. They may have obtained a prior authorization num-ber. The claim can be re-filed with this number in the appropriate field on the CMS 1500 form.Some payers approve retro-authorizations. Always call and ask. There may be extenuating circumstances that, when fully explained to the payer, may result in the claim being paid. For example, a patient may be visiting friends 90 miles away from home when he becomes ill and isn’t able to drive back home to see his network provider. Payers will make exceptions, but they need to see the whole picture. ■ Timely filing – Know the timely filing periods of your most common payers. The filing period could be as short as 90 days or up to 365 days. Timely filing denials are commonly seen when corrected claims are filed. For example, a denial is received and it is placed in a “Denials to Work” pile. A month later, this denial is looked at, and research shows that a code needs correction. The ac-count is updated and the claim is resubmitted; however, the claim submission date is now 95 days from the actual date of service. A payer with a 90-day timely filing period will deny this claim for timely filing. When filing a corrected claim, always include the payer’s previous claim number that was issued on the denial. This previously issued claim number tells the payer immediately that this corrected claim was initially filed on time.The month of January can wreak havoc on timely filing denials. As happens with all creatures of habit, remembering to change the date from one year to the next sometimes takes us awhile. This not only happens with our checkbook, but also for billers who forget to enter the new year when keying charges. For example, January 2011 charges may be entered as January 2010. Consequently, the payer receives the initial claim submission as being one year old and the claim is denied as untimely. Appropriate research should uncover this sort of problem.

Very rarely should there ever be a denial for lack of time-ly filing, though, because most provider offices file claims electronically. Electronic clearinghous-es provide daily reports called “Claims Acknowl-edgements.” These reports list each and every claim that comes through their portal. Store these reports chronologically and where they are easily accessi-ble. Use these reports to provide proof to payers that a claim was submitted to them in a timely fashion.

■ Duplicate – Denials for duplicate claims are seen quite often. The denial could be a result of an actual du-

plicate—a charge entered twice—but it could be something such as a bilateral procedure billed on two lines where the payer incor-rectly processed the second line as a duplicate. Or, was it a date of service issue? Sometimes subsequent hospital visits are keyed using the same date instead of consecutive dates. Always check to see if a keying error caused the denial.

When All Else Fails, Pick Up the PhoneIf after researching a patient’s account you do not find any evi-dence that payment was received or the deductible was applied, call the payer. Find out when the payment was issued. Did it clear the bank? Who was the check made out to, and where did they send the check? It could very well be a processing error by the pay-er that one phone call from the provider’s office can clear up.Typically, these types of denials are communication issues. By communicating the right information to the payer, claim deni-als can be overturned. If you find during your research that noth-ing further can be done, and that you must adjust the service, turn it into a learning experience. Everyone involved should be made aware—the physician, nurse, and the coder or biller—so this nev-er happens again. Remember, taking an adjustment should always be the last resort.

Wendy Grant, CPC, is the accounts receivable manager for a large hospi-tal/physician system with 34 years of experience in the physician side of health care. Residing in Little Rock, Ark., she is a member of her local AAPC chapter, currently serving as president-elect. She has also served on the AAPC Chapter Association (AAPCCA) board since 2009, and is serving as secretary for the AAPCCA Executive Committee for the 2011-2012 term.

28 AAPCCodingEdge

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30 AAPCCodingEdge

Feature Expert

Two Criteria Determine

DVT and Venous Emboli DxProper diagnosis documentation will help you make the distinction.

By Sara Wolf, BA, CPC-H, CCS, and G. J. Verhovshek, MA, CPC

Deep vein thrombosis or deep venous thrombosis (DVT) describes the formation of a blood clot (thrombus) in a “deep” vein. The con-dition is most common in the large veins of the lower extremities (for example, the femoral vein), but may occur in veins of the upper ex-tremities, as well.

DVT may be asymptomatic, but more frequently exhibits symptoms of pain, swelling, and discoloration in the affected extremity. Three broad mechanisms—called “Virchow’s triad” in honor of German physician Rudolf Virchow—are the primary causes of DVT:1. Decreased blood flow2. Damage to the wall of the vein3. Increased blood clotting (hypercoagulability)Many specific circumstances may contribute to the formation of DVT. Recent surgery—especially hip, pelvic, or prostate surgery—is a risk factor (see “DVT Linked to Surgery Calls for Unique Cod-ing” for more information), as is inactivity, obesity, smoking, a his-tory of cardiovascular disease, or other medical conditions ranging from cancer to bone fracture. Women who are pregnant or who have recently been pregnant are more prone to DVT, as are those who use estrogen or oral contraceptives.

Verify Criteria to Determine CodesICD-9-CM groups DVT by two criteria: vein location and chron-ic vs. acute. The determination of chronic vs. acute must be made by the documenting provider, based on the clinical evidence. For exam-ple, the diameter of a vein as measured by duplex scan may increase in acute conditions, but will decrease to less than normal over time.

Chronic vs. Acute: Make the DistinctionHere are the acute and chronic DVT codes for upper and lower ex-tremities:

DVT Lower Extremities• Acute: femoral, iliac, popliteal, and vein of thigh or upper leg

not otherwise specified (453.41 Acute venous embolism and thrombosis of deep vessels of proximal lower extremity)

• Acute: peroneal, tibial, and vein of calf or lower leg not otherwise specified (453.42 Acute venous embolism and thrombosis of deep vessels of distal lower extremity)

• Acute: unspecified vein of lower extremity and DVT not otherwise specified (453.40 Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity)

• Chronic: femoral, iliac, popliteal, and vein of thigh or upper leg not otherwise specified (453.51 Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity)

• Chronic: peroneal, tibial, and vein of calf or lower leg not

Internal carotid

Exte rnal carotid

Vertebral

Thyrocervical trunk

Internal mammary

Subclavian

Axillary

Brachial

Intercostal

Celiac trunk

SplenicRenalSuperior mesenteric

Inferior mesenteric

Radial

Ulnar

Digital

Deep femoral

Femoral

Popliteal

Posterior tibial

Anterior tibial

Peroneal

Dorsalis pedia

Plantar

Digital

Left colicSuperior rectal

Inferior mesenteric

IleocolicColic

Superior mesenteric

Gastroepiploic

Splenic

Short gastricLeft gastricCeliac trunk

Right gastric

Cystic

Hepatic

Common hepatic

Branches ofAbdominal Aorta Exte rnal iliac

Internal iliac

Common iliac

Ovarian/testicular

Aorta

Pulmonary

Subclavian

Brachiocephalic

Right and left commoncarotid

Facial

Major Arteries

Thoracic

Abdominal



Feature

otherwise specified (453.52 Chronic venous embolism and thrombosis of deep vessels of distal lower extremity)

• Chronic: unspecified vein of lower extremity (453.50 Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity)

DVT Upper Extremities• Acute: brachial, radial, and ulnar vein (453.82 Acute venous embolism and

thrombosis of deep veins of upper extremity)• Chronic: brachial, radial, and ulnar vein (453.72 Chronic venous embolism and

thrombosis of deep veins of upper extremity)

Note that the default code for DVT of an unspecified site is 453.40. ICD-9-CM also contains codes to report embolism/thrombosis of superficial and/or other spec-ified (not deep) veins (e.g., 453.6 Venous embolism and thrombosis of superficial ves-sels of lower extremity and 453.76 Chronic venous embolism and thrombosis of internal jugular veins).The distinction between acute and chronic is important because patients with DVT may require anticoagulant therapy for six months or more; an acute diagnosis would support initiation of such therapy, while a chronic diagnosis would support its continuation. Code V58.61 Long term (current) use of anticoagulants may be reported in addition to the code describing the DVT if the patient cur-rently is undergoing anticoagulant therapy.If a patient has a history of venous thrombosis that is no longer present, you may assign personal history code V12.51 Personal history of venous throm-bosis and embolism, pulmonary embolism.

PE Complicates DVT and CodingAn embolism occurs when a thrombus dislodges and is carried by the cir-culatory system to a different part of the body. The clot travels through progressively smaller vessels until it becomes stuck in place. An embolism resulting from DVT most often affects vessels of the lungs after traveling through the heart. This is called a pulmonary embolism (PE), and it may result in labored breathing, chest pains, and death. An acute PE may be reported from ICD-9-CM category 415.1x Pulmonary embo-lism and infarction. Note that septic pulmonary embolism code (415.12 Septic pulmo-nary embolism) requires you to sequence the underlying infection before the PE code. Chronic PE is reported using 416.2 Chronic pulmonary embolism.

Sara Wolf, BA, CPC-H, CCS, has nearly 30 years of coding experience. She is executive director for ZHealth, provid-ing coding consulting and reimbursement evaluation for facility and physician services.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

Thedistinctionbetweenacuteandchronicisimportant

becausepatientswithDVTmayrequireanticoagulant

therapyforsixmonthsormore;anacutediagnosiswould

supportinitiationofsuchtherapy,whileachronicdiagno-

siswouldsupportitscontinuation.

DVT Linked to Surgery Calls for Unique CodingDVT may arise as a complication of surgery. If DVT is confirmed and documented by the physician as a postoperative complication, other codes apply. For example, category 996.7x is assigned for embolism and throm-bosis due to a device, implant or graft, while 999.2 describes thromboembolism follow-ing infusion, perfusion, transfusion, etc. Re-view the physician documentation carefully to be sure you assign codes for DVT appro-priately.

Thrombus (clot)forming in lumen

Arteriovenous fistula

Calcium depositsLipids

Intimal proliferation

Atherosclerosisnarrowing lumen

Organization ofthrombus andrecanalization

Embolus(from elsewhere)occluding lumen

Aneurysm bypasseslumen or...

...bulges fromarterial wall


32 AAPCCodingEdge

ICD-10 Road Map

THREE GASTRO CASES SHOW

ICD-10’s Coding SignificanceChanges in coding guidelines will make documentation far more critical.

By Essie White, CPC, CPC-H, CPC-I, CGSC, CPMA

Those of us who have been around for decades have seen many changes in the medical profession. I remember working with the first CPT® book. Since then, the Centers for Medicare &

Medicaid Services (CMS) has mandated ICD-9-CM codes for claim forms, HCPCS Level II codes came into effect, electronic health re-cords (EHRs) have become a reality, and changes to codes and cod-ing regulations occur nearly every week. I tell my students, if you can’t handle change, or if you expect everything to be black and white, you chose the wrong profession.Effective Oct. 1, 2013, we face yet another, massive change: the im-plementation of ICD-10-CM and ICD-10-PCS. Outpatient cod-ers must learn a completely new diagnosis coding system. Inpatient coders will have to learn both the diagnosis codes and the proce-dures system.To illustrate the coding significance of the transition from ICD-9 to ICD-10, consider the following examples taken from gastroenterol-ogy, a favorite specialty of mine. Case 1: A 50-year-old patient without complaints or symptoms comes in for a screening colonoscopy. The physician performs the procedure with normal findings and tells the patient to return in five years for a repeat screening. To code this scenario using ICD-9-CM, begin your search in Vol-ume 2 Index. Look up “screening,” scan alphabetically to “colon,” and find V76.51. After finding the code in the index, always re-fer to the code in the Volume 1 Tabular List. Here you can see that V76.51Special screening for malignant neoplasms; colon is indeed for a screening colonoscopy. If you are looking for rec-tum or small intestine, however, you can see that this is not the correct code.Now, let’s code the same scenario using ICD-10-CM. Some of the same rules apply: Begin your search by looking in Volume 2 Index. Start with “screen-ing” and then scan down to “colon” to find Z12.11. Then go to the Volume 1 Tabular List to find Z12.11 Encounter for screening for malignant neoplasm of colon. You will find there is a parenthet-

ical note that defines “screening,” and also a “use additional” note reminding you to also code if there is a family history of malignant neoplasm from the Z80-section of codes. Case 2: A 60-year-old patient without complaints or symptoms comes in for a screening colonoscopy. The physician performs the procedure and snares a tubular adenoma in the cecum.Looking first at ICD-9-CM, the primary diagnosis is the screening, V76.51. Next, look in the index under “Adenoma” and then scan down to “Tubular.” You are instructed to “see also Neoplasm by site, benign.” In the ICD-9-CM Neoplasm Table, you will find “colon,” which instructs you to “see also Neoplasm, intestine, large.” Look to “intestine, large, cecum” in the benign column to locate 211.3. Ver-ify this code in the Tabular List as Benign neoplasm of other parts of digestive system; Colon.Switching to ICD-10-CM, the primary diagnosis is Z12.11. Find “adenoma” by looking in Volume 2 under “adenoma, tubular.” You are instructed to “see also Neoplasm, benign, by site.” ICD-10-CM does not include an alphabetical Neoplasm Table like the one in ICD-9-CM. The table instead is found at the end of the alphabet-ic list, before the Table of Drugs and Chemicals. In this table, look under “colon” to find the codes for primary and secondary malig-nancies only. Search under “intestine, large” to find “cecum.” In the “benign” column, find D12.0, which must be verified in the Tabu-lar List. D12.0 Benign neoplasm of the cecum has an “excludes” note to remind you that if you are looking for benign carcinoid tumor of

the large intestine and rectum, to see instead D3a.02-.Case 3: A 55-year-old patient with a family history of colon cancer arrives complaining of abdominal pain and rectal bleeding. The physician passes the colonoscope and encounters a mass at the hepatic flexure. He takes a biop-sy and the pathology is reported as ma-lignant. He stops the scope procedure and (with prior consent) performs a partial colectomy with colostomy.The primary diagnosis is cancer of the hepatic flexure. To code this diagnosis

CecumHepaticflexure

Splenicflexure

Sigmoid colon

Rectosigmoidcolon

Transversecolon

Descendingcolon


Professional


ICD-10 Road Map

ICD-10 Demands More Precise DocumentationWith the adoption of ICD-10, changes in coding guidelines will make documentation far more critical. Related to gastroenterology, for instance, Crohn’s disease, ulcerative colitis, and polyps all have criteria that must be indicated as “with or without” complication in the documentation. If there are complications, such as an ab-scess, bleeding, obstruction, fistulas, or other specified or unspecified complications, they have to be stated, as well. Diverticulitis and diverticulosis need to be documented as “with or without” perforation or abscess, and “with or without” bleeding. Irritable bowel syndrome (IBS) will need to be indicated as “with or without” diarrhea. Parasitic disease may be reported using a code from chapter 1, chapter 11, or using both chapters, depending on the causative agent or associated organism.

Many coding conventions will remain the same in the transition from ICD-9 to ICD-10, but there are excep-tions. We will no longer indicate that an additional digit is necessary by using an “x” as a placeholder. Instead, an additional character is shown as necessary by using a dash “–.” ICD-10-CM uses both the number zero (0) and the letter “O.” The beginning character will be a letter followed by either letters or numbers (letters will not be case sensitive).

from ICD-9-CM, reference the Neoplasm Table. Look to “intestine, large, colon, hepatic flexure, malignant,” to find 153.0 Malignant neoplasm of colon; Hepatic flexure. Family history of colon cancer is coded to V16.0 Family history of malignant neoplasm; Gastrointestinal tract. There is no need to code the incidental symptoms of abdominal pain or rectal bleeding.Using ICD-10-CM, scan the Neoplasm Table to find “colon” and code C18.9 Malignant neoplasm of colon, unspecified. The physician stated neoplasm of the hepatic flexure; therefore C18.9 Unspecified is inappropri-ate. Glance at the C18- code range and locate C18.3 Malignant neoplasm of hepatic flexure. The family histo-ry of colon cancer is coded to Z80.0.

Get Started with ICD-10By now you should be preparing your providers, staff, data entry, billing departments, and information tech-nology (IT) staff for the change to ICD-10. Although it may be too early to begin learning ICD-10-CM codes, now is a good time to learn about the administrative changes that will be necessary to accommodate it. For example, how will you train your providers to be more specific? Sometimes all that is required is an ad-ditional word or two. In Case No. 3, the physician was specific in the type and location of the malignancy. If he had documented a colon polyp, you would have found K63.5. An inflammatory polyp would be coded as K51.4-, which needs further clarification of bleeding, obstruction, fistula, abscess, or other complications.As a coder, it is up to you to educate yourself and be ready for the changes ICD-10 will bring. For instance, you could choose five charts per week, per provider, and code using both ICD-9-CM and ICD-10-CM. Use the knowledge you gain to conduct training sessions with the staff and introduce everyone to the required changes. As an instructor, I see the need for better understanding terminology and physiology. As such, another good starting point would be to take a class or study online through AAPC. During your local chapter meetings, re-view the anatomy and terminology for a different body system each month. Most importantly, don’t sit back and expect the information to be handed to you. Get involved in the process and uphold the ethics and standards you swore to when you became a member of AAPC. Lastly, be ready to take the proficiency exam by October 2013 to keep your well-earned credentials.

Essie White, CPC, CPC-H, CPC-I, CGSC, CPMA, is senior coding consultant for Healthcare Coding Consultants of Hawaii, LLC. Her respon-sibilities include coding, auditing, and training. Formerly, she was a bill reviewer of worker’s compensation and auto insurance claims, and has 18 years of administration and clinical experience in general and plastic surgery. She is also a part-time coding instructor at the University of Hawaii Kapi’olani Community College and an AAPC ICD-10 implementation instructor.

Itellmystudents,ifyoucan’thandlechange,or

ifyouexpecteverythingtobeblackandwhite,

youchosethewrongprofession.

34 AAPCCodingEdge

Coder’s Voice

By Brenda Edwards, CPC, CPMA, CPC-I, CEMC

Good Grief!ICD-10-CM Is My New AdventureAccepting the upcoming code set has been an emotional experience for this seasoned diagnosis coder.

New Code Set Inflicts Grieving ProcessAs ICD-10-CM started to become a reality, however, I went through the stages of grief.

Stage 1: Denial“This can’t be happening, not to me. There is no way I have to learn a new code set.”

Stage 2: Anger “Why me? It’s not fair! I already have to do so much to get the claim paid.”

Stage 3: Bargaining“Let me retire before it gets here. Please delay this, so it won’t happen before I retire and I can ignore it.”

Stage 4: Depression “Why bother, I’ll never learn this stuff? This is too overwhelming. How do they expect us to learn all of this?”

Stage 5: Acceptance“I can’t fight it. I must prepare for it. I may need to take it a little at a time, but I can do this.”I’m sure you have had similar thoughts. To ease your pain and suffering, you may find it helpful to hear about ICD-10’s impact on me. Perhaps my breakthrough can help you overcome your own grief.

Denial and AngerI remember my first introduction to ICD-10-CM a few years back. I had my first draft copy and began pag-ing through the book. When I tried to look up my first code, which was in the musculoskeletal system, I shut the book, got up, and told my friend, “There is no way I’m doing this.” These were the first stages of denial and anger.

BargainingI didn’t touch “the book” for quite some time, about a couple of years. Like many, I thought the implementa-tion would be bumped back like the Health Insurance Portability and Accountability Act (HIPAA) and the Red Flags Rule. That was my bargaining stage.Then, the Centers for Medicare & Medicaid Services (CMS) clearly informed us that “the compliance dates are firm and not subject to change.”

DepressionI finally decided to go back to “the book.” What I mean by this is that I gave it a half-hearted attempt. This was my depression stage. I tried to find shortcuts to learn this massive book. (Now, don’t laugh at me because you would never look for shortcuts!) What I found instead is that if I use the resources available at World Health Or-

I’ve been assigning ICD-9-CM codes for quite some time … okay, a really long time—over 25 years. I’m quite comfortable with the codes. In fact, I’m better at using the tabular index than the alpha-betic index (I’m proud of that achievement!). I have been an ap-proved instructor for the Professional Medical Coding Curricu-

lum (PMCC) for 10 years and I have taught many people how to use ICD-9-CM. I even entertain my son and husband by reading li-cense plates and telling them the diagnosis code description. My fa-vorite license plate is on my friend’s car, 311 AWD (depression, all wheel drive).


Ishutthebook,gotup,andtoldmyfriend,

“ThereisnowayI’mdoingthis.”

Coder’s Voice

Brenda Edwards, CPC, CPMA, CPC-I, CEMC, serves on the AAPCCA board of directors and is coding and compliance specialist at Kan-sas Medical Mutual Insurance Company. After starting at an

entry level position nearly 25 years ago, she progressed through chart auditing, compli-ance education, ICD-9-CM and CPT® coding, accounts receivable, billing and insurance, coding education, and medical records. Bren-da has spoken to coding chapters throughout Kansas and presented at AAPC regional con-ferences in Springfield, Massachusetts, Kan-sas City and Des Moines, Iowa. She is co-founder and past-president of the Northeast Kansas local chapter.

ganization (WHO), CMS, AAPC, the American Medical Association (AMA), and other reputable sourc-es, I can use this code set with great accuracy.

AcceptanceMy acceptance has made the transformation to ICD-10-CM manageable. How do you eat an elephant? One bite at a time. The same is true with learning the code set. It is possible, just as it was possible to learn ICD-9-CM. Use one of those quiet Friday evenings to read the ICD-10-CM Official Guidelines for Coding and Reporting. Once you’ve read them, read them again and again. Then read and highlight key points for quick reference. Look up the most common diagnosis codes you currently use in the alphabetic index, and then look for the code in the tabular index to see what additional specificity is required.I may not be able to play a good game of “license plate coding” for awhile, but I am looking forward to a new adventure. I know I’ll be able to solve the mysteries that lie ahead with greater detail than ever before!

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36 AAPCCodingEdge

Hot Topic

Stay On Top of 5010It’s crucial to your ICD-10 plan.

The conversion to 5010 has gotten much less notoriety than that giv-en to ICD-10, but to make ICD-10 work, you will first need to tack-le 5010. The most widely recognized change in the 5010 electronic data interchange (EDI) architecture is the version indicator allow-ing EDI transactions to differentiate between ICD-9 and ICD-10. This, however, is only a small part of the reason why implementing 5010 is crucial to an organization’s overall ICD-10 plan.

Know Its HistoryThe Centers for Medicare & Medicaid Services (CMS) Office of E-Health Standards & Services (OESS) is responsible for the policies and enforcement of the Administrative Simplification provisions for transactions and code sets and the National Provider Identifier (NPI) covered under the Health Insurance Portability and Account-ability Act (HIPAA) of 2003.HIPAA 5010 was adopted to replace the current version of the X12 standards that covered entities (health plans, health care clearing-houses, and certain health care providers) must use when conduct-ing electronic transactions. Version 4010 is currently being used un-der HIPAA standards.Simply put, transactions are electronics exchanges involving the transfer of health care information between two parties for a specif-ic purpose, such as a health care provider submitting medical claims to a health plan for payment. HIPAA named certain organizations as covered entities, including health plans, health care clearinghouses, and some health care pro-viders. HIPAA also adopted certain standard transactions for EDI for the transmission of health care data. These transactions include:

• claims and encounter information• payment and remittance advice• claims status• eligibility• enrollment and disenrollment• referrals and authorizations

Don’t DelayIf you haven’t initiated a plan to adopt 5010, it’s not too late, but there are key items that need your immediate attention. First, realize that 5010 is not just an infor-mation technology (IT) project. Second, understand that working with your ven-dors is an important part of the process.

• Talk to your vendor, billing service, and/or clearinghouse about

resources they have on the 5010 changes and how the changes and upgrades can be incorporated in your existing system. Find out how much additional training will be required for system users.

• Talk to your vendors about testing timelines: { Jan. 1, 2011 Level I compliance—ability to process 5010

transactions for testing and transition with able trading partners

{ Jan. 1, 2012 Level II compliance—all HIPAA-covered enti-ties must begin using 5010 transactions

• Identify the data reporting changes and revisions that you should be aware of. Here are a few of the changes that may affect your practice:

{ You can no longer report a post office box in the Billing Pro-vider Address field. Physicians who want their payments sent to a separate address will use the Pay-to-Provider name and address fields.

{ You must report a nine-digit ZIP code in the Billing Provid-er and Service Facility Location Address fields. This could pose problems for rural providers.

{ Transactions have been revised to allow the reporting of ICD-10 diagnosis and procedure codes.

{ A patient with a unique health plan member ID is now re-ported as the subscriber. Front office staff will need to be trained on these changes.

{ You can no longer report units of anesthesia time. Only min-utes can be reported. Physicians need to verify that their sys-tems only provide minutes for anesthesia time-based pro-

cedure codes that do not have a time period in the description, and work with vendors on any neces-sary solutions.Your practice management system may need to be upgraded so it can capture the required 5010 data.

• Work with your vendor to have the necessary practice management system upgrades completed.

• Determine the costs for the vendor upgrades.• Complete internal testing of the upgrades to

make sure your system can generate the 5010 transactions. Ask your vendor if they will complete the internal testing for you. Don’t forget the aforementioned important testing deadlines.

By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC

Professional


Hot Topic

• Work with your vendor to see what types of training they may have available for staff education.

Prepare for DisruptionsYou may remember the NPI transition and its payment disruptions. Even if you are prepared internally for the 5010 transactions, there may still be unforeseen problems. For example, a problem with the transmission of transac-tions may cause delays of claims being received by payers and/or remittance advices and payments being received by practices.Here are some additional steps you can take to sustain your practice’s revenue during those crucial first weeks after the Jan. 1, 2012 deadline:

• Talk to your Medicare administrative contractor (MAC) about their advance payment policy. Ask

about the format for a request, where to send a request, timeframes for money distribution, etc.

• Talk to your commercial payers to see if they have any advance payment policies.

• Establish a line of credit with a financial institution.• Save money during the next few months to help

carry you over if necessary.If you have not begun preparing for 5010, you must start right away. Compliance deadlines are not being pushed back; practices will suffer significant cash flow issues if they are not ready.

Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is the vice president of ICD-10 education and training at AAPC.

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38 AAPCCodingEdge

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ApprenticesGeorgeWatson,CPC-AAlabasterALBeverlyHollingsworth,CPC-AAnnistonALKayeSmith,CPC-ABirminghamALJasmineHall,CPC-AAvondaleAZCrystalReidhead,CPC-AChandlerAZLarryMerrill,CPC-AElMirageAZDianeTrovato,CPC-AFountainHillsAZChristopherJKipiani,CPC-H-AGilbertAZBozenaJurczyk,CPC-AGlendaleAZRhondaZvara,CPC-ALitchfieldParkAZAnitaParma,CPC-AMesaAZCindyKamm,CPC-AQueenCreekAZSeanaPerea,CPC-ASanTanValleyAZLisaBalbona,CPC-A,CPC-H-AScottsdaleAZMarkEgge,CPC-AScottsdaleAZElizabethHembree,CPC-ASurpriseAZDavidJamesThomas,CPC-ATucsonAZAshleyMichelleTimmons,CPC-ATucsonAZKelliMarieKronenbitter,CPC-AYumaAZPamelaDLarge,CPC-AAltaLomaCASuzanneCrider,CPC-AAnaheimCAMaribelSandoval,CPC-ABellflowerCAKimberlySandoval,CPC-ABurbankCAYeseniaRivera,CPC-ACarsonCADerrickQuon,CPC-ACerritosCAAprilCano,CPC-ACoronaCALisaValdez,CPC-ACulverCityCAGraceVilches,CPC-ADalyCityCAXiomaraMenjivar,CPC-ADowneyCAAfsanehGuilardi,CPC-AEncinoCASarahCastle,CPC-AFolsomCAAngelaPratt,CPC-AForesthillCAStacyShults,CPC-AForesthillCAJulietaRabinoPingue,CPC-AGranadaHillsCAFilipinaSorianoTong,CPC-AHawthoneCA

newly credentialed members


CherylLyles,CPC-H-AHaywardCATimKuck,CPC-AIrvineCALilaGee,CPC-ALaPalmaCAKimberlyCowen,CPC-ALakewoodCAMichaelGaran,CPC-ALakewoodCAAgnesPCooper,CPC-ALomitaCAJeffHower,CPC-ALongBeachCALaurenAlmeida,CPC-ALosAngelesCAAtulDahra,CPC-ALosAngelesCABabitaRawat,CPC-ALosAngelesCAAmyRoberts,CPC-H-ALosAngelesCADawaTsering,CPC-ALosAngelesCAFeliciaRodgers,CPC-ALynwoodCALorraineDeSousa-Rich,CPC-H-AMartinezCAAnneMarieBalliet,CPC-AMissionViejoCAChandniPatel,CPC-AMorganHillCATracyGallo,CPC-AMurrietaCAMeinradoApuya,CPC-ANewhallCANormaCTalamantes,CPC-ANorthHollywoodCARaizaPangaCarranza,CPC-ANorwalkCAMichaelBailey,CPC-AOaklandCALauraFoley-Colvin,CPC-AOntarioCARebeccaPak,CPC-ARanchoPalosVerdesCAKaiMortensen,CPC-ARosevilleCAJenniferClemente,CPC-ASanDiegoCAFilippoPetralia,CPC-ASanDiegoCAKathrynLynnBanks,CPC-ASanFranciscoCALoriHauersley,CPC-ASanFranciscoCALisaGoodey,CPC-ASanJacintoCATheresaMaeGuhit,CPC-ATorranceCAKristellaPagbilao,CPC-ATorranceCAKimberlyAnnJohnson,CPC-AVictorvilleCALoriSutherland,CPC-AArvadaCOLourdesVelazquez,CPC-ABrightonCOPattiYoung,CPC-ADenverCOCherylBishop,CPC-AEatonCOTashawnaLJohnson,CPC-AEnglewoodCOChristyMero,CPC-AFederalHeightsCODanaChristensen,CPC-AFrederickCOAmberThrailkill,CPC-AFtCollinsCOKaylaMares,CPC-AGreeleyCOJanetBischoff,CPC-ALouisvilleCOHeatherKey,CPC-AParkerCONayanaBhatt,CPC-AAvonCTKavithaIyer,CPC-AAvonCTAprilCadrain,CPC-ABarkhamstedCTRebeccaRode,CPC-ABranfordCTJenniferParmelee,CPC-AEastBerlinCTCharmaleeTulloch,CPC-AEsatHartfordCTLalaniaDavison,CPC-AMeridenCTAgnieszkaMozerowska,CPC-ANewBritainCTSusanMAucoin,CPC-ANorthGrosvenordaleCTLisaPalmer,CPC-AWindsorCTAntonioOArias,CPC-AAltamonteSpringsFLCarrieLynneWhitfill,CPC-AAltamonteSpringsFLAmyShane,CPC-AApopkaFLTatianaDiaz,CPC-AAventuraFLEricaTorivio,CPC-ABradentonFLShannonBennett,CPC-ABrandonFLLaurieDavis,CPC-ACapeCoralFLCorinnGrahl,CPC-ACapeCoralFLAndreaRobinson,CPC-ACapeCoralFLGloriaSchmidt-Karls,CPC-ACapeCoralFLKarenReimanSmith,CPC-ACapeCoralFLJudithTremonti,CPC-ACapeCoralFLStephenGager,CPC-AClearwaterFLLeilaJalajel,CPC-AClearwaterFLVickiRaines,CPC-AClearwaterFLMarisolOhlrich,CPC-AClermontFLTyronePedereaux,CPC-AClermontFLPeggyEllenSmith,CPC-ACrawfordvilleFLJeanKent,CPC-ADeltonaFLBellaRosa,CPC-ADeltonaFLRachelColvin,CPC-AEsteroFLDonnaBaehrle,CPC-AFtMyersFLJocelynHernandez,CPC-AHialeahFLMichaelMcKinley,CPC-AHudsonFLMeganCovington,CPC-AJacksonvilleFLSarahCox,CPC-AJacksonvilleFLAndreaLillie,CPC-AJacksonvilleFLMichaelSwinton,CPC-AJacksonvilleFLFeliciaWashington,CPC-AJacksonvilleFLAmeliaWhitmore,CPC-AJacksonvilleFLEverBartolomey,CPC-AKissimmeeFLWandaColondres,CPC-AKissimmeeFL

ElizabethCruz,CPC-AKissimmeeFLNellisCruz,CPC-AKissimmeeFLAmbahJameson,CPC-AKissimmeeFLIvetteRodriguez,CPC-AKissimmeeFLSaraRodriguez,CPC-AKissimmeeFLStephanieMartin,CPC-ALakelandFLMaryPatrick,CPC-ALantanaFLPeggyCox,CPC-ALargoFLSandiWebb,CPC-ALargoFLSomerSoto,CPC-ALehighAcresFLLauraESahyoun,CPC-ALongwoodFLToddSzakacs,CPC-ALongwoodFLAnnalisaPermanan,CPC-AMargateFLNanetteLong,CPC-AMelbourneFLLucymaMartinez,CPC-AMiamiGardensFLMaryConlin,CPC-ANaplesFLHelenShenberger,CPC-ANewPortRicheyFLMichelleLowe,CPC-AOcoeeFLFrancesWang,CPC-AOcoeeFLLaurenLiegel,CPC-AOldsmarFLAlysonBadders,CPC-AOrlandoFLShernaBailey,CPC-AOrlandoFLMarbellyCalero,CPC-AOrlandoFLCarmenDeLaRosa,CPC-AOrlandoFLCarolynEnmond,CPC-AOrlandoFLViolineFrancois,CPC-AOrlandoFLMariaGarcia,CPC-AOrlandoFLJamesAllenGeddes,CPC-AOrlandoFLKennethJohnson,CPC-AOrlandoFLAshleeMeharg,CPC-AOrlandoFLMigdaliaRivera,CPC-AOrlandoFLDianaRosado,CPC-AOrlandoFLEvelynSantiago,CPC-AOrlandoFLDonnaMCarlson,CPC-AOrmondBeachFLVelekaEvetteVazquez,CPC-ARiverviewFLJessicaEspinosa,CPC-ARuskinFLJillAspinwall,CPC-ASarasotaFLShantyMoniqueRobinson,CPC-ASarasotaFLMarilynSmith,CPC-ASarasotaFLEricaRuiz,CPC-ASeffnerFLJulieAMelton,CPC-ASpringHillFLCynthiaAnnMiller,CPC-ASpringHillFLNeryRosas,CPC-AStCloudFLAnnetteRaymond,CPC-AStPetersburgFLAvrilAnderson,CPC-ATampaFLBibiAziz,CPC-ATampaFLKathyrnBarnes,CPC-ATampaFLKathyKDavis,CPC-ATampaFLXiomeidyEchavarria,CPC-ATampaFLPatriciaGonzalez,CPC-ATampaFLLucidaliaGuerra,CPC-ATampaFLLuzGuevara,CPC-ATampaFLJorgeALaureano,CPC-ATampaFLMargaretMayes,CPC-ATampaFLDonAMosley,CPC-ATampaFLPaulaSnead,CPC-ATampaFLIvetUpia,CPC-ATampaFLHelenVaughn,CPC-ATampaFLMaryElizabethGreenwood,CPC-ATempleTerraceFLRochelBaumann,CPC-ATequestaFLSherriAnnKnott,CPC-AThonotosassaFLMyrnaJeanLewis,CPC-ATitusvilleFLJenniferNitz,CPC-ATrinityFLErinChristineLunsford,CPC-AVeroBeachFLMaryReneeWalkup,CPC-A,CPC-P-AVeroBeachFLTraceyWan,CPC-AWesleyChapelFLStephanieDeniseForte,CPC-AWinterHavenFLKellyJeanEllis,CPC-AWinterSpringsFLBrandiLeighMaddox,CPC-AAthensGATiffanyLeighPeeples,CPC-AAthensGAJenniferHarris,CPC-AAugustaGAJoyceKaverenge,CPC-AAugustaGAShondraRichardson,CPC-AAustellGADeborahDean,CPC-ACantonGAPriscillaLisa-MarieAndrews,CPC-AConyersGATerriBeckMcWilliams,CPC-ACummingGALisaWallace,CPC-ADawsonvilleGAAmyWillisAllen,CPC-ADecaturGAAnthonyJosephAllen,CPC-ADecaturGAFeliciaMCephus-Williams,CPC-ADecaturGAColleenRansom,CPC-AFortGordonGAKristenBiskobing,CPC-ALawrencevilleGAPauletteMcIntosh-Brown,CPC-ALawrencevilleGA

MarciaClemons,CPC-ALilburnGATowannaRenaHickerson,CPC-ALithoniaGAJenniferLang,CPC-AMaconGATracyFoster,CPC-AMariettaGAGayleEdmunds,CPC-AMartinezGALatashaShontaStone,CPC-ARiverdaleGAJoyLouiseMiddleton,CPC-ASmyrnaGASusanSteele,CPC-AStatesboroGANadraLHopkins-FungChung,CPC-AStoneMountainGACharisseThompson,CPC-ASuwaneeGADorothyNorton,CPC-AWashingtonGAKimLau,CPC-AHonoluluHIMyraSunada,CPC-AHonoluluHIKathrynMitson,CPC-AKaneoheHIVanQuach,CPC-H-AWaipahuHICarlaBarber,CPC-ABoiseIDErynnGraf,CPC-ABoiseIDKimStolworthy,CPC-ABoiseIDDanaDorsey,CPC-ACaldwellIDJerrieHibbs,CPC-ACaldwellIDTinaHuerta,CPC-AEmmettIDJeffPeterson,CPC-AKunaIDVickiErickson,CPC-AMeridianIDStephanieHaley,CPC-AMeridianIDRondaYandle,CPC-AMiddletonIDMeredithSinclair,CPC-ANampaIDGeoffreyKennedy,CPC-AArlingtonHeightsILBreinBrown,CPC-AChicagoILAmandaChen,CPC-AChicagoILMelissaAnnWilson,CPC-AChicagoILLovinaFarden,CPC-AEastPeoriaILVanessaBrooks,CPC-AFlossmoorILChristinaMariaSchultz,CPC-AMcClureILKathyBredbury,CPC-AO’FallonILSaraKirschbaum,CPC-AOttawaILStephenHa,CPC-APalatineILNataliyaBessonova,CPC-ARollingMeadowsILNikkiFreeman,CPC-ATonicaILSa’rahElaineWillham,CPC-ACharlestownINJamiKlitzman,CPC-A,CPC-H-AChurubuscoINKelliRollins,CPC-AChurubuscoINKathleenBorders,CPC-AGaryINRebeccaManning,CPC-AGreenwoodINCassandraLorraineJordan,CPC-AIndianapolisINJulieHall,CPC-ALaconiaINMariaDobbins,CPC-ANewSalisburyINJenniferHann,CPC-APeruINKaseyCrocker,CPC-ASheridanINCassidyMartin,CPC-ASheridanINYvonneKraemer,CPC-P-ATerreHauteINJaronKayneAsher,CPC-ALawrenceKSLoraAKorth,CPC-ALecomptonKSVictoriaPeterson,CPC-AOlatheKSRhondaWhitson,CPC-AEubankKYJudithNewberry,CPC-AFortThomasKYMargaretCoyle,CPC-AGoshenKYNatashaHaskins,CPC-ALexingtonKYNakeistaHays,CPC-ALexingtonKYAngieMurphy,CPC-ALexingtonKYJoAnnRiley,CPC-ALexingtonKYYvonneWisnicky,CPC-ALexingtonKYBrittianyJColey,CPC-A,CPC-H-ALouisvilleKYLaurenGreer,CPC-H-ALouisvilleKYDebraMiracle,CPC-ALouisvilleKYLatashaJWilliams,CPC-ALouisvilleKYDanaHolt,CPC-AMtWashingtonKYHeatherLynnAddison,CPC-ANewportKYSherryPadilla,CPC-AReedKYBonnieYork,CPC-AScottsvilleKYLauraSiler,CPC-AStanfordKYMaryJoSego,CPC-AWoodburnKYJeanMarieBarbaraCiotola,CPC-AGreenwoodLAKelliBrooks,CPC-ALafayetteLAElizabethBacon,CPC-APortAllenLASigridBrown,CPC-AFalmouthMALynnHitchings,CPC-AGraftonMAMarianneTeresaMadden,CPC-AMarlboroughMAHeatherMurphy,CPC-AMarstonsMillsMAMelissaMaglio,CPC-ANorthboroughMAElizabethJacobson,CPC-AShelburneFallsMAEllenAddy,CPC-AUptonMAScottBrennan,CPC-AWilbrahamMASandhyaNaik,CPC-AWorcesterMAGinaShulten,CPC-AWorcesterMA

VeritaUColkley,CPC-ABaltimoreMDYehudisZucker,CPC-ABaltimoreMDDebbieAnnRussell,CPC-ABurtonsvilleMDMoniqueWatkins,CPC-ACapitolHeightsMDMichaelLeeTaylor,CPC-AGlenBurnieMDRobbinALake,CPC-AGwynnOakMDLakiaSThompson,CPC-ANottinghamMDKimberleyLHubbard,CPC-APikesvilleMDSofiaGirma,CPC-ASilverSpringMDCatherineHeath,CPC-ABerwickMEDanielleBrewer,CPC-ALewistonMEMicheleBelanger,CPC-ARomeMEAngelaRTheriault,CPC-ASacoMEMaryLewis,CPC-ASanfordMEDebbieCoffin,CPC-AStandishMEGregorySamuelBarre,CPC-AWatervilleMEPamelaGPurgaric,CPC-AAlgonacMIJenniferPoppema,CPC-AAlleganMICaitlinSiembor,CPC-AAllenParkMIAudreyBinder,CPC-AArmadaMIJenniferFritz,CPC-ABloomfieldHillsMIMarthaHester,CPC-ABloomfieldHillsMIMichelleStoecker,CPC-AChinaMIJanetHart,CPC-AClarkstonMIRuthSzekely,CPC-AClayMIReneeParker-Appell,CPC-AClintonTownshipMICorinnePawlowski,CPC-AClintonTownshipMISusanneMMcGuire,CPC-AColumbusMILauraMcGuire,CPC-ACommerceTownshipMIMonicaSalvatore,CPC-ACroswellMINicoleShannon,CPC-H-ADearbornMISusanCrowley,CPC-AGrossePointeParkMIDeloresLohr,CPC-AJeddoMIChristineWelch,CPC-AJenisonMIJudithThomasma,CPC-AKentwoodMIJeanSpringberg,CPC-ALakeCityMILoriMiller,CPC-ALivoniaMIKayceeAnnMauer,CPC-ALudingtonMIJoyMcKay,CPC-AMantonMIMichaelJensen,CPC-AOrionMIPamelaReno,CPC-APlymouthMITriciaBehm,CPC-ARochesterHillsMILauraBethMuirhead,CPC-ARochesterHillsMIJaniceLoudenback,CPC-ARosevilleMIBarbaraWalkiewicz,CPC-ASanfordMIRasmeThirunavukarasu,CPC-ASouthfieldMIAnnaChorazyczewski,CPC-AStClairShoresMITammyRezny,CPC-AStClairShoresMIElizabethYDentry,CPC-ASterlingHeightsMILoDawnYoung,CPC-ATwinLakeMIKimKilander,CPC-AWarrenMIScottDenchfield,CPC-AWaterfordMIKarenBurmeister,CPC-AWhiteLakeMIJenniferHosler,CPC-AWyomingMISusanRader,CPC-AThiefRiverFallsMNKellyLeeEllsworth,CPC-ABernieMOTonyaMarieNoce,CPC-AFestusMODianeSartin,CPC-AFlorissantMODeborahLynnTatoian,CPC-AFlorissantMOCsillaPozos,CPC-AKansasCityMOLeighAnnKassinger,CPC-APerryvilleMOAmandaNunez,CPC-AStClairMOJalayneFoster,CPC-AStLouisMOShannonNicoleSlivinski,CPC-AStPetersMODeborahHarris,CPC-H-AUrichMOLisaKKnisley,CPC-AWillardMOTaniaMarieHughes,CPC-ABiloxiMSAllieRoberts,CPC-AMossPointMSJessicaMichelleJohnson,CPC-ARidgelandMSBrittanySuhl,CPC-AVancleaveMSSheriBagley,CPC-ABozemanMTJillFarley,CPC-ACaryNCShimicaLatia’Ager,CPC-ACharlotteNCJeanetteMiller,CPC-ADurhamNCJuliePeeleBreuer,CPC-ADurhamNCLynnRoberson,CPC-AFletcherNCMeganGutierrez,CPC-A,CPC-H-AGreensboroNCJerePilver,CPC-AHendersonvilleNCRebeccaKay,CPC-AHuntersvilleNCAndreaElizabethO’Rourke,CPC-ALelandNCKimTucker,CPC-AMarbleNCBarbaraSchlenker,CPC-APilotMountainNCCherylFredericks,CPC-AStatesvilleNCErinKearns,CPC-AWakeForestNCLaurenMcCabe,CPC-AWinstonSalemNC

MelvitaScott,CPC-AWinstonSalemNCKristalRansome,CPC-AWintervilleNCJeffreyNewhook,CPC-ADerryNHPatriciaElizabethBenjamin,CPC-ADoverNHGinaOliva,CPC-AManchesterNHOksanaRozhdestvenskaya,CPC-H-ADenvilleNJJessicaMcKay,CPC-AHackettstownNJArchanaKulkarni,CPC-ALawrencevilleNJMarisaRossano,CPC-ALittleFallsNJFrancesMTaylor,CPC-AMedfordNJLeilaniRick,CPC-AMilfordNJJenniferHubert,CPC-AMorrisPlainsNJKevinConway,CPC-ASpotswoodNJJacquelineKai,CPC-AWarrenNJJessicaBlakely,CPC-AAlbuquerqueNMBrigitteLeBronSeal,CPC-AAlbuquerqueNMKarrieSanchez,CPC-ALosLunasNMBlancaPrieto,CPC-ASunlandParkNMCrystalNMasset,CPC-ADaytonNVChadRichardDarre,CPC-ARenoNVSaraDelporto,CPC-ARenoNVCarlaAnnVaron,CPC-ARenoNVCherylMarieKline,CPC-ASparksNVTeriAnnPerez,CPC-ASparksNVNicoleSHarvey,CPC-AAlbanyNYColleenAKiernan,CPC-ABethpageNYVirginiaSturgis,CPC-ABronxNYChristineAPhippen,CPC-ACentralSquareNYTinaMarieHoffmeier,CPC-AChateaugauNYKerriCarmon,CPC-AChittenangoNYAmandaLMaxwell,CPC-AHastingsNYThomasNAcciavatti,CPC-ALathamNYJoanneMHarding,CPC-ALiverpoolNYEvieMaeHalley,CPC-AMaloneNYCassandraRAndriano,CPC-ASchenectadyNYPatriciaMGaudio,CPC-ASyracuseNYJenniferAnneMajkowycz,CPC-ASyracuseNYSusanLMotyka,CPC-ASyracuseNYAnitaMStanard,CPC-AWilliamstownNYMelisaBacon,CPC-AAmeliaOHNormaHamilton,CPC-ABereaOHAmyHayne,CPC-ABereaOHJeanniePheanis,CPC-ACamdenOHKathleenMAmendolea,CPC-ACanfieldOHPatriaCAndres,CPC-ACincinnatiOHJenniferMetcalf,CPC-ACincinnatiOHNicoleSmith,CPC-AClevelandOHCourtneyChicoine,CPC-AColumbusOHNicoleMiller,CPC-AColumbusOHTonjaLAllen,CPC-AFairfieldOHRachaelMcAllister,CPC-AFairfieldOHTamiWintrich,CPC-H-AGarfieldHeightsOHBarbaraWenger,CPC-AGlenfordOHJenniVardaman,CPC-AHicksvilleOHJosephJohnson,CPC-AKetteringOHMichelleGallagher,CPC-ALibertyTownshipOHMichelleBrick,CPC-AMedinaOHMaryJoWilliams,CPC-AMentorOHMichellePearson,CPC-AMiddletownOHVasilikiMichaels,CPC-ANewburghHeightsOHMelissaCatlett,CPC-ANorwalkOHHollyJayneFredericks,CPC-ARossfordOHToinetteBurton,CPC-AWilloughbyOHShirleyABanfield,CPC-AYoungstownOHMicheleAnnCresanto,CPC-AYoungstownOHPatriciaLynnJenkins,CPC-AYoungstownOHDeborahASchmitz,CPC-H-A,CIRCCCashionOKTamarraLigon,CPC-AWheatlandOKKevinKirschenmann,CPC-ABeavertonORRichardKing,CPC-AIndependenceORJenniferO’Brien,CPC-AKlamathFallsORLindaSims,CPC-AKlamathFallsORCherylTurner,CPC-AKlamathFallsORJarrodDyck,CPC-ALakeOswegoORSheilaGage,CPC-H-ALakeviewORMarshaRBenson,CPC-APowellButteORJLynnFinegan,CPC-ARoseburgORLisaColeman,CPC-AAllentownPAJoyLNixon,CPC-ACampHillPAAngelMarieScarpitti,CPC-AEriePASusanPaulsworth,CPC-AFairlessHillsPAAshleyColeman,CPC-AGlensidePAKristinCoffey,CPC-AIvylandPAMaryEllenCannon,CPC-AJamisonPALoriGordon,CPC-ALevittownPA

Newly Credentialed Members

40 AAPCCodingEdge

MaryAnnReday,CPC-ALevittownPAMaryfranRodgers,CPC-ALevittownPASydneyRomanof,CPC-ALititzPADorothyMcLaughlin,CPC-AMorrisvillePAScottAllenKuntz,CPC-ANewCumberlandPAKoreyRodgers,CPC-ANorthernCambriaPADeboraAGray,CPC-APalmyraPARachelSipling,CPC-APalmyraPAChristineFenimore,CPC-APhiladelphiaPAMelissaSanchez,CPC-APhiladelphiaPAMichelleWallace,CPC-APhiladelphiaPAChristineMZawierucha,CPC-APhiladelphiaPALorriJZawierucha,CPC-A,CPC-H-APhiladelphiaPAGinaKramer,CPC-APittsburghPALaurelMisko,CPC-APottstownPACynthiaBock,CPC-ASellersvillePAPamelaMeyer,CPC-AYorkPAJeffreyJFernandes,CPC-ACumberlandRIRachaelReynolds,CPC-APortsmouthRITaylorBlackwood,CPC-AWoodRiverJctRIBarryB’Rells,CPC-AColumbiaSCLorieMoore,CPC-AFlorenceSCDianeLMoreau,CPC-AFlorenceSCJohnPSenetto,CPC-AGooseCreekSCTonyaChappell,CPC-AGreenvilleSCSamanthaJParham,CPC-AGreerSCVentriceSimoneWilliams,CPC-AHollyHillSCKrystleFlowers,CPC-ALakeCitySCKarenEarley,CPC-AMoncksCornerSCCraigWalsh,CPC-AMyrtleBeachSCTracyDonahue,CPC-ASumterSCChristinaBuskol,CPC-ASiouxFallsSDJoletaJones,CPC-ASiouxFallsSDLaShondaAnternetteBond,CPC-AAntiochTNLindsayPerry,CPC-ABonAquaTNStarrNolan,CPC-ABrentwoodTNKarenCampell,CPC-AClarksvilleTNLatonyaWallace,CPC-ACordovaTNAmberWoodward,CPC-ADicksonTNRachelWard,CPC-AGrayTNSondraLPickett,CPC-AMemphisTNTiffanyDotson,CPC-ASpringfieldTNPamelaCohan,CPC-AAustinTXPamelaRumsey,CPC-ACedarHillTXLauraESheriff,CPC-ADallasTXSherryWilliams,CPC-ADeLeonTXRoseMarieMcDaniel,CPC-AElPasoTXKristinaSeracen,CPC-AFredericksburgTXJulieALinn,CPC-AFriscoTXLizyBabuKandoth,CPC-AGarlandTXSaraFernandez,CPC-AGrandPrairieTXCandaceAllen,CPC-AHoustonTXVivilynBarnes,CPC-H-AHoustonTXWilmaJones,CPC-H-AHoustonTXMargueriteMaddalino,CPC-AHoustonTXRodicaMoga,CPC-AHoustonTXLisaHenning,CPC-H-AIrvingTXTammyTipton,CPCO-ALeagueCityTXJenniferMoser,CPC-ALongviewTXMistiMorris,CPC-AMcKinneyTXLizanaJimenez,CPC-AMercedesTXSharonGreenwood,CPC-AMissouriCityTXSarahMichelleOtwell,CPC-APasadenaTXUroosaAnwar,CPC-APlanoTXAnnaAyala,CPC-APlanoTXMinhHo,CPC-APlanoTXIveauxGrant,CPC-ARedOakTXJanetPeyron-Smith,CPC-ARichardsonTXBethanySmith,CPC-ASaladoTXRubyMaeAdams,CPC-ASanAntonioTXLauraGarza,CPC-ASanAntonioTXYvetteRichardson,CPC-ASanAntonioTXKendraWatson,CPC-ASeguinTXChrisKates,CPC-ASpringTXElizabethForbes,CPC-ATempleTX

AmberPritchard,CPC-ATempleTXBethanyRodocker,CPC-ATempleTXShelleyRodocker,CPC-ATempleTXRonTeague,CPC-ATempleTXGregoryStevenCallahan,CPC-ATexasCityTXLoisMcCuan,CPC-ATroupTXKathleenFredericks,CPC-AVanAlstyneTXDavidLopez,CPC-AWeslacoTXDonnaJDelacruz,CPC-AWylieTXMariaHernandez,CPC-AOgdenUTHeatherMeikle,CPC-AOgdenUTHolliLamoreaux,CPC-AOremUTTheaMariePirmann,CPC-H-ASaltLakeCityUTCarrieDensley,CPC-ASouthJordanUTLaurelMiller,CPC-ASpanishForkUTLisaRoach,CPC-AWestPointUTJayRichards,CPC-ABroadwayVACarlaHollar,CPC-ACharlottesvilleVADianeLee,CPC-AColonialBeachVAKeishaBailey,CPC-AFranklinVAStanleyWillisBoothe,CPC-AFranklinVAToriRicks,CPC-AFranklinVAPennyRoberts,CPC-AGordonsvilleVAFlorenceDeniseJohnson,CPC-H-AHamptonVABrandeDSmith,CPC-H-AHamptonVALindaChicette,CPC-ALynchburgVANatashaPerry,CPC-H-ANewportNewsVACindySzejer,CPC-ARichmondsVAKimberlyButler,CPC-ASuffolkVAChristineLeaHatfield,CPC-AArlingtonWAChia-ChenChang,CPC-AKirklandWATammyToll,CPC-ASammamishWAKellyScott,CPC-ASeattleWALiliyaBigun,CPC-AVancouverWAMadhuGorur,CPC-ABrookfieldWIRachelWasmund,CPC-ABurlingtonWIAzucenaCalderon,CPC-AMilwaukeeWIJodeeKeleman,CPC-ARacineWIChristineLMetz,CPC-ASouthMilwaukeeWIElaineSchmay,CPC-AWestAllisWI

CherylMurto,CPC-AMorgantownWV

SpecialtiesJulieATanner,CPC,CPC-H,CPC-P,CANPC,COSCBellaVistaARLoraMarieCrawford,CPC,CHONCGilbertAZCyndiJMaas,CPC,COBGCTucsonAZLaShondaWhite,COBGCTucsonAZPrincessPadilla,CPC,CANPCGranadaHillsCAKrishnaVijayaRallabhandi,CPC-A,CHONCSanDimasCAJennyChavez-Sinks,CPC,CANPCSantaCruzCADeborahAnnSammons,CPC,CEMC,CIMC,CPRCWestSacramentoCAJodiGonzalez,CASCCWhittierCAWilliamJamieLujan,CPC,CENTCDenverCOTwilaMSmith,CPC,CEDC,CEMC,COBGCMonumentCOMariaRArizmendi,CPC,CHONCWestHavenCTTheresaLindenberger,CPC,CGICPuntaGordaFLDorisVBranker,CPC,CPC-I,CEMC

SunriseFLCharlotteJackson,CPC,CASCCTampaFLEmilyRuthMorton,CPC,CIMCAugustaGAJennieMelissaAnderson,CPC,CFPCDahlonegaGASylviaDennis,CPC,CFPCEvansGATinaMincey,CPC,CEMCGainesvilleGAGinaPatriciaHoldorff,CPC,CPC-H,CPC-P,CHONCHonoluluHITeresaWells,CASCC,COSCBettendorfIAValerieNussel,CPC,CEDCCantonILConnieWilson,CPC,CEDCOneidaILBridgetteMartin,CPC,CGICEvansvilleINTeresaThomas,CFPCRoachdaleINLizShepherd,CGICTecumsehKSRhondaLeeHill,CCCCorbinKYKimberlyLillis,CPC,CEMCLouisvilleKYGinaFTaylor,CPC,COBGCLudlowKYClaireDVanDeinse,CPC,CGICOldOrchardBeachMEEllenMorse-Simpson,CGICSPortlandMEAnnElizabethCampbell,CPC,CEMCJenisonMILisaSandusky,CPC,CANPCLincolnParkMIWendyLDutton,CPC,CEMCKalispellMTLeslieHagenow,CPC,CEMCBristolNHShirleyHolguin,CPC,CEMCLasCrucesNMBarbaraJeanO’Connor,CPC,CEMCLosLunasNMRobinMorris,CEMCRadiiumSpringsNMCherylMasterson,CPC,CEDCBereaOHKristiReneeFord,CPC-A,CEDCDaytonOHDebraArleneTaylor,CPC-A,CEDCVandaliaOHTammyShaffer,CPC,CEMCGuthrieOKMargaretBWeaver,CPC,CEMCEmmausPAMelanieHill,CPC,CASCCSumterSCKristyZimmerman,CPC,CASCCClarkvilleTNBarbaraMontemayor,CEMCFriendswoodTXCelesteZimicki,CASCCHarletonTXKimberlyHarrison,CPC,CEDCSanAntonioTXMistiWilson,CGICStaffordTXVictoriaLMayette,CPC,CENTCSouthBurlingtonVTAmyMcWilliams,CPC,CPMA,CEMC

PlattevilleWI

Magna Cum LaudeMaryBethHurd,CPCAltadenaCAStephanieEaley,CPCCarsonCAAmySukhov,CPC-AElCerritoCAMatthewMSmith,CPC-AOaklandCAKristinaKaufmann,CPCRamonaCAMonaKaul,CPC,CPC-HSanDiegoCAJamesTam,CPC-ASanDiegoCATeresitaSorianoGuhit,CPCTorranceCAEdselHFeliciano,CPC-ATorrenceCAAngeliqueCook,CPCFirestoneCOShannonQuinn,CPCWilmingtonDEJessicaLee,CPC-AApopkaFLNancyVigeant,CPC-ACapeCoralFLMargaretLanier,CPC-AClearwaterFLJasonCavanaugh,CPCDaytonaBeachFLKatrinaGeneral,CPCJacksonvilleFLRachelAnnMatthews,CPCKeystoneHeightsFLGabrielaGomez,CPC-AKissimmeeFLToniJohnson,CPC-ANewPortRicheyFLEMischkaHylton-Maxwell,CPC-A,CPC-P-ASebastianFLHeatherColleenMitchell,CPC-A,CPC-P-AVeroBeachFLArielleElizabethCarey,CPC-AAcworthGAAshleaAmangoua,CPCCovingtonGANicoleBurnam,CPCDouglasGADanielHunter,CPC-ADouglasGAJoelMoorhead,CPCDunwoodyGAShaneBell,CPC-AWinderGAJenniferIseri,CPC-AHonoluluHITipsyMasaki,CPC-AHonoluluHIAnnRaymon,CPC-ABettendorfIAMaryMadsen,CPC-HRockvilleMDShannonLessard,CPC-AMinotMEGailBoettcher,CPC-ALivoniaMINicoleTereceWatkins,CPCTroyMOJenniferMouch,CPC-ABigforkMTMollyMcMurtrey,CPCClintonNCCarlaPhipps,CPCFleetwoodNC

LindseyBryant,CPC,CPC-HRaleighNCAmyStets,CPC-HRaleighNCAllisonMMarino,CPCSchenectadyNYPatriciaDePillo,CPC-HBergholzOHMichaelBower,CPC-ANewAlbanyOHColleenCaudle,CPCBensalemPABethSchalles,CPCHollidaysburgPADonnaHody,CPCJohnstownPATanyaHolzer,CPC-HAberdeenSDBhavaniPechimuthu,CPC,CPC-HChennaiTNMichelleSteen,CPC-AElPasoTXCoettaThompson,CPC-AFortWorthTXDanielleShort,CPC-ALaytonUTJaciCJohnson,CPC,CPC-H,CPMA,CPC-I,CEMCRichmondVAPattiLTempleton,CPC-AFortAtkinsonWIKimberlyBingen,CPCRubiconWI

Newly Credentialed Members


Expert

Begin Your Own CDI ProgramCapture conditions with clear, concise documentation to increase reimbursement and decrease risks.

A clinical documentation improvement (CDI) program is a great way to ensure your facil-ity is capturing all relevant details of a patient/provider encounter. This, in turn, boosts clinical and financial outcomes.

CDI programs began in the 1990s. Most were pilot projects to assess how such programs affect physician documentation. They have become more common since 2007, when the Centers for Medicare & Medicaid Services (CMS) implemented Medicare severity-diagnosis related groups (MS-DRGs). Accurate DRG reporting increases Medicare reimbursement and reduces compli-ance risks. CDI programs optimize DRGs by capturing conditions through clear, concise doc-umentation.

Use Queries to Prompt Complete DocumentationQueries are an essential component of any CDI program. A query is a communication and ed-ucation tool that prompts physicians to provide greater detail about under-reported conditions found in the medical record. For instance, if pneumonia is the primary diagnosis but the type is not noted, the query provides options to describe the condition as “viral,” “bacterial,” “commu-nity acquired,” or “hospital acquired.”

ExampleClarification for specificity of a diagnosis-patient admitted with productive cough, yellow sputum x 3 days-CXR reveals right lower lobe infiltrates/Dx: Pneumonia:Zosyn 3.375 g IV qd ordered/sputum cx sent;

QueryCan the origin/etiology of the patient’s pneumonia be further specified? Please type or dic-tate your response.

The resulting documentation better reflects co-morbidity/complication (CC) and major co-morbidity/complication (MCC) rates, which determine the case mix index. By contrast, non-specific documentation leads to nonspecific coding. The true severity of illness, mortality rate, and intensity of service are not captured and patient care, data integrity, compliance, and reim-bursement all suffer.Queries can address several areas, for example:

• to specify the severity of a condition;• to clarify the underlying cause of a presented symptom;• to substantiate present-on-admission issue; or,• to identify a potentially preventable complication.

The physician may answer the query verbally, in writing in the history or physical, in a progress note, or in the query form. Queries may be completed either concurrently (at the time of the phy-sician/patient encounter) or retrospectively.

Facility

By Karen Stanley, MBA, RN


42 AAPCCodingEdge

Facility

Ensure queries are clear, concise, and timely by developing clinical indicators to determine when the clinical picture suggests a particu-lar diagnosis. These clinical guidelines should be written in the que-ry template for each condition and updated appropriately. Several organizations offer example templates, or facilities can create their own guidelines based on medical literature (e.g., The New England Journal of Medicine).

Electronic vs. Paper QueriesAutomated queries as part of an electronic health record (EHR) pro-vide effective recording, tracking, and charting data from the medi-cal record, and are gaining popularity. There are drawbacks to auto-mated systems, however. If the query is in the queue with several oth-er documents for the physician’s signature, the physician may sign the document electronically without answering the query.Paper queries can be effective if automation is not an option. For ex-ample, at Civista Medical Center in Maryland, a clinical documen-tation specialist (CDS) attaches a color-coded query form the pa-tient’s medical record. The physician reviews the record, assesses the patient, and answers the query. The CDS records the information in the CDI database, and the query form becomes a permanent part of the medical record.

Build Physician SupportIn addition to well-executed queries, a successful CDI program re-quires the support of administration, ancillary staff members (such as case management), and—most of all—physicians. Physician re-sistance is high for two key reasons:1. Time: Physicians’ primary focus is patient care, and anything

that detracts from that immediate goal may be perceived as a distraction.

2. Education: To achieve accurate and concise documentation, physicians must be educated as to why it is important.

A clear, concise CDI plan must include physicians every step of the way. Here’s where your CDS and physician advisor come in.

CDSThe CDS’ role is to support and enhance physicians’ documentation efforts. The CDS is involved in every facet of the CDI program. The CDS formulates query templates, leads the team that delivers (elec-tronic or paper) queries to physicians, records responses, and follows up on unanswered queries. The CDS formulates a working DRG and a target DRG, and evaluates the medical record for secondary diagnosis to increase the severity of illness. Coders review the DRG and secondary diagnosis. If this information helps to optimize the DRG, it is added to the final DRG for reimbursement. The CDS should provide feedback to various facility departments on the CDI program’s impact on quality, integrity, and reimbursement.A CDS must have clinical knowledge (including anatomy and phys-iology), a mastery of ICD-9-CM coding guidelines, expertise in health care regulatory compliance, and strong verbal and written communication skills. Having a doctorate, master’s, or bachelor’s degree in a related health care discipline is essential.

Physician AdvisorThe physician advisor is a liaison between the CDS, coders, and the medical staff. He or she is responsible for educating physicians on coding guidelines and new clinical terminology, and for optimiz-ing physicians’ documentation of condition severity, acuity, risk of mortality, and intensity of service. The advisor may present informa-tion at the monthly staff meetings, assist in the development of que-ries, address admission denials and DRG modifications, work with

MedicaldocumentationundertheMS-DRGsystemmustmeetfiverequirements

forquality,compliance,integrity,andreimbursement.

10TipsForCDIProgram

Success

1. Articulate a Vision State-ment. The“vision”oftheCDI program should re-flect the facility’s goalsanddesires,includingac-curateDRGassignment,quality monitoring, andoptimalreimbursement.

2. Look to successful pro-grams for guidance. Thereareseveralwell-es-tablished CDI programsinthehealthcareindus-try. Contact those CDIprograms in your areaandaskfortipsandguid-ance. Usually, they aremorethanhappytoshareinformation to help yougetstarted.

3. Don’t be shy. Establish-ing a CDI program is amultidisciplinaryteamef-fort,soyou’llhavetoen-courage open commu-nication throughout theteam.

4. Get face to face with your team. Electronicorpaper communication isacceptable,butespecial-ly during the setup andinitial phases, personalcontact emphasizes thecommitmenttoestablishaCDIprogram.

5. Accept both positive and negative feedback. A multidisciplinary teammayuncoverproblemar-easthatyouhadn’tcon-sidered.Be ready to lis-tenandlearn,aswellastocontributeyourideas.

6. Set short- and long-term goals for your CDI program. A short-term goal can be assimpleaspilotingyourCDIpro-gramwith one service in thehospital before going hospi-tal-wide.Along-termgoalcanbe broadening your outcomemeasurements. Goals shouldbe challenging but realistic.Don’tsetyourselfupforfailure.

7. Develop queries for physi-cians to improve documen-tation. Include coders andphysician advisors when cre-atingthetemplates.Makesurethequeryisclearandconciseanddoesnot“lead”thephysi-cian to document extraneousorincorrectinformation.Effec-tivequeriesmakeadifferenceinhowwellphysiciansrespond.

8. Adopt quality measures. Establish measurable out-comesthatcanbetrackedbyallstakeholders,includingad-ministrators, coders, physi-cians,andtheCDIteam.

9. Consider a CDI to help pre-pare you for ICD-10. ICD-10requiresagreaterlevelofdoc-umentationspecificitythanthecurrentICD-9-CMcodingsys-tem.PreparationstartsnowfortheOct.1,2013deadline.

10.The focus of the CDI program will dictate staffing. Theprogramcanbestaffedwithqual-ifiedprofessionalsincludingHIMcoders,nurs-es,physicians,oracombinationofeachdisci-pline.Ifqualityindicators,clinicaloutcomesaswellasDRGoptimizationareimportantissues,theprogrammayhaveacombinationofHIMcodersandnurses.Insomeprograms,physi-ciansconductreviewsandcommunicatewiththeirpeersondocumentationissues.

42 AAPCCodingEdge


Facility

5Documentation“MustHaves”Medical documentation under the MS-DRG system must meet five requirements for quality, compliance, integrity, and reimburse-ment:

1. Assign patient status (inpatient or observation)

2. Assess the risk in the assigned status (inpatient or observa-tion) to determine services ordered

3. Support medical necessity throughout the patient stay

4. Reflect that the nurse/attending physician frequently moni-tored/evaluated the patient

5. A discharge and transfer note must reflect a summary of care and a final diagnosis

For example, a patient is admitted to the ER with shortness of breath and dyspnea on exertion. During examination, the physi-cian notes that the patient has a wet cough. The patient’s lab work showed a bnp 20,485/dimer 6,000. CXR revealed pulmonary ede-ma/CHF. The patient diagnosis was congestive heart failure (CHF), and the patient was admitted as an inpatient with a Lasix 80 mg IV BID, 02 2L/NC; The CDS queried the physician for the type of CHF—which was not documented by the admitting physician.

The type of CHF (acute, acute-on-chronic, systolic, diastolic, com-bined systolic/diastolic, or decompensated) will drive the severity of illness and the DRG. Inadequate documentation of the sever-ity of the CHF will cause case mix complexity, underutilization of resources, inappropriate nurse-to-patient ratio, reduced profes-sional compensation, and incorrect perception of care provided.

health information management (HIM)/CDS personnel, and when necessary, approach physicians with unanswered queries. Together, the physician advisor and CDS should initiate a program to educate physicians about ICD-9-CM (and the forthcoming ICD-10).The physician advisor is nominated or appointed by his or her physi-cian peers (Physicians generally respond more favorably to a colleague than to administrators or support staff.). The qualified advisor can ac-curately analyze the health record, understands the complexity of the coding/prospective payment system, and provide in-services on med-ical conditions.

The Coder’s RoleYour role in the CDI program is paramount to its success. You will be using the query templates retrospectively if the physician does not an-swer the query concurrently. The CDS should meet with you routine-ly about documentation issues. You can offer insight on missed query opportunities and share your response rates to retrospective queries, and the effectiveness of the CDS concurrent reviews.

CDSCDI Resources:Association of Clinical Documentation Improvement Specialist (ACDIS) (www.ACDIS.ORG)CMS (www.cms.gov)

Karen Stanley, MBA, RN, is CDS for Civista Medical Center, Laplata, Md. Karen has 30 years experience in the health care industry. She received special recognition for outstanding perfor-mance as a case manager, appeals examiner, and claims auditor at Children’s National Medical Center in Washington, DC. She has been awarded Pediatric Screening Nurse of the Year and was featured in Nursing Spectrum magazine for Kaiser Permanente. Karen served as a medical surgical nurse for five years at King Fahad Hospital in Saudi Arabia. She can be reached at [email protected].

10TipsForCDIProgram

Success

1. Articulate a Vision State-ment. The“vision”oftheCDI program should re-flect the facility’s goalsanddesires,includingac-curateDRGassignment,quality monitoring, andoptimalreimbursement.

2. Look to successful pro-grams for guidance. Thereareseveralwell-es-tablished CDI programsinthehealthcareindus-try. Contact those CDIprograms in your areaandaskfortipsandguid-ance. Usually, they aremorethanhappytoshareinformation to help yougetstarted.

3. Don’t be shy. Establish-ing a CDI program is amultidisciplinaryteamef-fort,soyou’llhavetoen-courage open commu-nication throughout theteam.

4. Get face to face with your team. Electronicorpaper communication isacceptable,butespecial-ly during the setup andinitial phases, personalcontact emphasizes thecommitmenttoestablishaCDIprogram.

5. Accept both positive and negative feedback. A multidisciplinary teammayuncoverproblemar-easthatyouhadn’tcon-sidered.Be ready to lis-tenandlearn,aswellastocontributeyourideas.

6. Set short- and long-term goals for your CDI program. A short-term goal can be assimpleaspilotingyourCDIpro-gramwith one service in thehospital before going hospi-tal-wide.Along-termgoalcanbe broadening your outcomemeasurements. Goals shouldbe challenging but realistic.Don’tsetyourselfupforfailure.

7. Develop queries for physi-cians to improve documen-tation. Include coders andphysician advisors when cre-atingthetemplates.Makesurethequeryisclearandconciseanddoesnot“lead”thephysi-cian to document extraneousorincorrectinformation.Effec-tivequeriesmakeadifferenceinhowwellphysiciansrespond.

8. Adopt quality measures. Establish measurable out-comesthatcanbetrackedbyallstakeholders,includingad-ministrators, coders, physi-cians,andtheCDIteam.

9. Consider a CDI to help pre-pare you for ICD-10. ICD-10requiresagreaterlevelofdoc-umentationspecificitythanthecurrentICD-9-CMcodingsys-tem.PreparationstartsnowfortheOct.1,2013deadline.

10.The focus of the CDI program will dictate staffing. Theprogramcanbestaffedwithqual-ifiedprofessionalsincludingHIMcoders,nurs-es,physicians,oracombinationofeachdisci-pline.Ifqualityindicators,clinicaloutcomesaswellasDRGoptimizationareimportantissues,theprogrammayhaveacombinationofHIMcodersandnurses.Insomeprograms,physi-ciansconductreviewsandcommunicatewiththeirpeersondocumentationissues.


44 AAPCCodingEdge

In the federal criminal arena, you can be liable both for perform-ing an illegal act and for aiding and abetting a criminal act per-formed by superiors. You also may be liable for helping superiors to

avoid getting caught. Let’s explore the federal criminal laws regard-ing “aiding and abetting,” “accessory after the fact,” and “conspira-cy,” where you do not directly perpetrate the fraud, but perform some act that facilitates the fraud. As our first example, assume your employing physician comes to you and says, “Collections are down since you’ve been hired.” Then you explain to him that his evaluation and management (E/M) doc-umentation is insufficient to warrant what he has been marking on the charge ticket, and you have been re-coding the visits based on the E/M documentation he submitted. The physician advises that he, not you, will decide what code will be billed, and that you will code by the charge ticket, rather than on the documentation. To save your job, you agree.

Your Liability Under the LawThe federal criminal statute relating to aiding and abetting, 18 USC 2, states, “Whoever commits an offense against the United States or aids, abets, counsels, commands, induces, or procures its commis-sion, is punishable as a principal.” In other words, the helper is just as guilty as the mastermind of the scheme.The U. S. Department of Justice (DOJ) publishes a Criminal Re-source Manual for prosecutors. The manual states, the “defendant participates in the criminal activity if he has acted in some affir-mative manner designed to aid the venture. … Although the aider and abettor need not know the means by which the crime is carried out, he must share in the requisite intent. In order to show shared in-tent, the government must present evidence that the accomplice had knowledge he was furthering the crime.”This means that although you have to know your conduct will fa-

cilitate an illegal act, you do not have to come up with the idea, nor are you re-quired to have profited from the illegal act. The manual states, “It is unneces-sary to show that the aider and abettor re-ceived compensation or have any stake in the transaction to be convicted.” Mean-ing you do not have to participate in every phase of the illegal conduct. The manu-al instructs that the prosecutor “need not show the defendant participated in ev-ery phase of the venture.” You are not re-quired to have committed the act for a long time, or on more than one occasion. Finally, the fact that your job is threat-ened is not a defense to the illegal con-duct. Although legal coercion is a de-fense (e.g., a gun to your head), the threat of losing your job is not considered to be a type of legal coercion that allows you to escape criminal culpability.

Know Your Liability for Aiding and AbettingAs a coder, you are liable for more than you may think.

Coding Compass

By David M. Vaughn, JD, CPC


Not every act is considered aiding and abetting. For example, the manual states, “more than mere presence at the scene is required.” If you work at a physician’s office where improper coding occurs, it doesn’t automatically make you criminally responsible. And, “more is needed than simply knowledge that the crime was to be commit-ted.” For example, if you saw your neighbor shoot his wife, it doesn’t mean that you aided and abetted in her murder. “Participation” in the criminal act—not just knowledge of it—is required to show cul-pability. The DOJ manual defines participation as “the defendant engaged is some affirmative conduct designed to aid the venture.” As in the aforementioned example, “participation” would exist if your job was to handwrite the code on the charge sheet for data en-try to bill (and this is the case in many offices). If you knew the phy-sicians’ codes were upcoded, and you nevertheless wrote those codes on the charge ticket for data entry to enter into the billing system, you would be participating in the overcoding, and be an aider and abettor in violation 18 USC 2.

You Can Be Culpable “After the Fact”What if you do not know about the illegal billing at the time it oc-curred, but learn about it after the fact and help the physician to con-ceal it? Under this scenario, you cannot be prosecuted as an aider and abettor, but could be prosecuted as “an accessory after the fact.” According to federal statute 18 USC 3, “Whoever, knowing that an offense against the United States has been committed, receives, re-lieves, comforts, or assists the offender in order to hinder or prevent his apprehension, trial or punishment, is an accessory after the fact.” An accessory after the fact requires more than just knowledge—it re-quires an affirmative act. For example, in the hypothetical scenario of the physician who overcodes his E/M encounters, assume a zone program integrity contractor (ZPIC) is coming on site to conduct an audit of the overcoded E/M encounters. Your physician asks you to hide the original patient charts in the attic while he dictates new pa-tient charts, so his documentation will meet the code level billed. By agreeing to hide the original records, you have assisted in prevent-ing the ZPIC from catching the overcoding in the original patient charts. This would make you an accessory after the fact (and you

would have committed obstruction of justice, which is an addition-al criminal offense).

Conspiracy Can Ensnare You, Even If You Don’t ActIn addition to liability as an aider and abettor and an accessory after the fact, you can be prosecuted under the broadest criminal statute the government uses to prosecute medical office personnel: the con-spiracy statute, 18 USC 371. The conspiracy statute states that if two or more persons agree to defraud the United States, and if one of the persons commits an act to further the conspiracy, each is liable for the object of the conspiracy, even if only one person commits the act. Returning to our example, assume you refuse to rewrite the upcod-ed E/M codes on the charge ticket because you don’t want to com-mit any affirmative act associated with the upcoding, but you agree that your physician’s upcoded claims can be entered into the billing software by data entry. Your agreement, combined with your physi-cian’s act, allows the government to contend that you were a co-con-spirator to your physician’s conduct, even though only the physician wrote down the incorrect codes. The “take home message” is that if you participate in, agree to, or hide improper coding, knowing that it is improper coding, you have potential criminal exposure, even if you received no compensation, did not actually perform the improper coding, and feared for the loss of employment.

David M. Vaughn, JD, CPC, is the founding member of Vaughn & Associates, LLC. He graduated from Mississippi College with Special Distinction (Magna Cum Laude) in 1974, graduated from LSU Law School in 1977, and has been a certified coder since 1999. David is the author of several coding and compliance books, and is the editor of a coding newsletter. He is a national speaker for health care associations and facilities. His practice consists of representing providers in fed-eral and state prosecutions, qui tam cases, and Medicare and third-party payer audits. He also conducts audits and provides education to providers.

Coding Compass

Althoughlegalcoercion(e.g.,aguntoyourhead)isadefense,the

threatoflosingyourjobisnotconsideredtobeatypeoflegalcoercion

thatallowsyoutoescapecriminalculpability.

46 AAPCCodingEdge

Added Edge

Align Your Credentials with Current Health Care TrendsAAPC offers CPC-H®, CPMA®, and CPCO™

credentials to meet today’s coding needs.

A Certified Professional Coder (CPC®) is the base creden-tial offered at AAPC. It signifies expertise in coding of services, procedures, and diagnosis of medical claims. It demonstrates the professional is proficient in coding rules and regulations, is current on new changes, and is com-mitted to following a code of ethics. In short, a CPC® rais-es the bar for the medical coding industry.To achieve this level of professionalism, a CPC® must pass a coding certification examination administered by AAPC and have at least two years of hands-on coding experience. Examinations test knowl-edge of CPT®, HCPCS Level II procedure and supply, and ICD-9-CM diagnosis codes used for billing professional medical services to insurance companies. In exchange for this level of dedication, most employers recognize and prefer hiring CPCs®. The average salary is 20 percent higher for a CPC® than for a non-certified coder, according to AAPC’s annual salary surveys.Although earning core certification opens the door into the coding world, it doesn’t always mean your coding education is complete. Be-cause many credentialed coders have an ongoing thirst for coding ex-cellence, AAPC has developed additional credentials which allow cod-ers to stay current with today’s coding trends. And with today’s regu-latory changes, additional credentials are attractive to employers, and sometimes even necessary.

Coding Changes Call for Specialized ExpertiseFreda Brinson, CPC, CPC-H, CEMC, compliance auditor for cor-porate compliance at St. Joseph’s/Candler Health System, obtained her second credential, Certified Professional Coder - Hospital Out-patient (CPC-H®), in 1998. At the time, multiple certifications were uncommon. “I do not think there was any industry trend,” Brinson said. “As a matter of fact, I was the only double certified coder in the area.” Times have changed, though, and multiple certifications are more common.

“Not only does certification show you care about your job, it also shows you are serious about your profession and continuing education. Health care has never changed as fast and as of-ten as it is now. Being certified and involved with an organization such as AAPC proves your commitment,” Brinson said.

Today’s health care trends show a need for greater expertise in:• outpatient vs. inpatient coding, as private practices merge with

hospitals to cut costs• auditing electronic health records (EHRs), as paper claims

decrease and electronic transactions increase• fraud and waste in health care, as the government increases

regulatory enforcement The credentials CPC-H®, Certified Professional Medical Auditor (CPMA®), and Certified Professional Compliance Officer (CPCO™) can prove your worth in these emerging health care areas.

Coding Moves to More Outpatient Services In this ever-changing world of health care, physicians are looking for cost-effective solutions that will allow them to continue practicing medicine. One solution many physicians have found to be advanta-geous is working under a hospital’s umbrella. Physicians receive the administrative and financial support of the larger organization, and the hospital, in turn, gains direct access to the physicians and their pa-tients. For these reasons, hospital acquisitions of physician practices have been rapidly increasing in the last three years. The CPC-H® cre-dential prepares a coder for this growing trend.

CPC-H® Prepares You for Hospital CodingDorothy Steed, CPC-H, CPC-I, CEMC, CFPC, CPMA, CPUM, CPUR, CPHM, CCS-P, CHCC, ACS-OP, RCC, RMC, PCS, FCS, CPAR, an independent consultant and educator, earned her CPC-H® to demonstrate her expertise in the hospital side of coding and to keep up with the increased number of physician practice acquisitions.

By Michelle A. Dick

“Therearealwaysnewchallengesintheindustry…,”accordingtoDebbie L. Senarighi, CPC, CPC-H, CPC-P, CPMA, physiciancoder.“Iwanttobethelastonestanding,orthefirstonehired.”

Apprentice


To discuss this article or topic, go to www.aapc.com Added Edge

“With the current trend of hospi-tals purchasing physician practic-es, my experience has been invalu-able in working with both entities as well as assisting physician coders who may need to prepare for the hospital world,” Steed said.

For Brinson, too, “being certified in the hospital outpatient side was important because I felt the credential carried merit when discuss-ing hospital coding issues with various departments, CMS, and oth-er payers.”Coding compliance analyst/auditor Kevin B. Shields, CPC, CPC-H, CPC-P, CCS, CCS-P, also obtained his CPC-H® because he felt “a hospital certification through AAPC was integral and very rele-vant” to his job duties.

“There are very few academic pro-grams focused on producing hospital coders,” Shields said. “My first stride in combating that was to gain the cer-tification.”

Since then, he has been an advocate for the CPC-H® by promoting classes, holding review sessions, and becoming an “ad hoc spokesper-son for the certification and its importance to career and skill devel-opment.”

Coders’ Role Changes with EHR AdoptionThe EHR is revolutionizing documentation and reporting in the med-ical profession; and with recent government support initiatives, EHRs will become more prevalent. The eventual goal of the Obama admin-istration is EHR use in every physician’s office, with data sharing be-tween all—the theory being widespread adoption will cut governmen-tal spending and improve quality of care. While EHRs do hold promise, there are also well-documented poten-tial problems with EHR use involving templated records, wrong code assignments, and inadequate documentation. As a result, coders will need to verify whether EHR systems are assigning the correct codes to documentation and that Medicare guidelines and other governmen-tal regulations are being met.According to AAPC’s 2010 quarterly workshop “EMRs—What You

Need to Know NOW!” by James M. Taylor, MD, CPC, medical di-rector revenue cycle, Kaiser Permanente, Colo., after an EMR instal-lation, coders transition to a “new paradigm: educator/auditor vs. res-cue recovery coders.” “Using coders in an upstream auditing and educational role was cru-cial to the success of attaining 95 percent accuracy in coding and claims accuracy in Kaiser Permanente Colorado,” Taylor said.

CPMA Prepares You for an Auditing RoleThe CPMA® credential prepares a coder to move into a coder/auditor role. Cindy Cox, CPC, CPMA, a behavioral health and HIV med-ical coder, realized obtaining the CPMA™ would further her coding education.

“I know, in my career, I have worn multiple ‘hats’ while working for the same organization … and having the additional CPMA® credential is a real plus,” Cox said. “I felt the CPMA® was a necessary credential for me because I do both coding and auditing in my organization.”

In addition to obtaining the CPC-H® credential to achieve accurate claim capture for hospital billing, Steed felt it important to earn the CPMA™ credential, as well. “As health care became business focused, I decided it would be advan-tageous to gain as much knowledge as I could about both entities,” Steed said. “The CPMA has been an added advantage in assisting phy-sicians and hospital staff about industry standards and requirement.”

Government Increases Fraud and Waste ScrutinyThe government sees reducing fraud and waste as the “low-hanging fruit” in reducing health care costs. To tackle these areas of excessive government spending, a proliferation of federally-funded entities has been tasked to scrutinize claims, uncover fraud, and recoup overpay-ment. As a coder, you should be able to demonstrate an understand-ing of the key requirements needed to effectively develop, implement, and monitor a health care compliance program for your practice, or to help others in their compliance efforts, based on governmental regu-latory guidelines.

CPCO™ Prepares You for Regulatory MandatesAAPC has developed the CPCO™ credential to take your career and practices to the next level in compliance. Health care compliance cer-tification addresses the growing requirements, laws, regulations, rules, and guidelines; it shows an exceptional understanding of how to im-plement a compliance program.

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What’s the difference between earning a CPC® credential and a CPCO™?

Christopher Parrella, JD, CHC, CPC, CPCO, of The Health Law Of-fices of Anthony C. Vitale, says “The CPC deals in a very hyper-technical detailed world of specificity, both clin-ical and otherwise. A CPCO is tasked with big thinking, risk management in the dynamic world of health care fraud and abuse.”

In other words, the CPCO™ credential prepares a coder to manage an office compliance program, protecting the physician and the practice.“The CPCO shows the individual is acutely adept at spotting fraud and abuse issues in terms of a detailed unbundling or CCI violations to much more broad matters such as false claims or payment relation-ships which could implicate the federal anti-kickback law or Stark law,” said Parrella. “In this enforcement initiative-driven industry of today, a CPC/CPCO speaks from a level of heightened knowledge and hopefully heightened vigilance.”

Credentials Set You Apart from Other CandidatesCredentials are valuable even if they are not requested in the job post-ings for which you apply. Most auditing and compliance job listings found on the AAPC job board do not specify an auditing or compli-

ance credential. They specify a core coding credential (CPC®, CPC-H®, etc.). With the job market and economy the way it is, taking the initiative to obtain the CPMA® or CPCO™ credential gives any candi-date a clear advantage over other applicants with the same work expe-rience and core credential.Shields said, “It is more important than ever for coders to embrace how the job market has changed and adapt to those alterations.” This re-quires “reaching into a variety of settings and work environments to optimize qualifications and broaden labor opportunity.”“There are always new challenges in the industry, whether it be medi-cal billing and coding challenges, technology, compliance, health care advances, government regulations, and even corporation downsizing, layoffs, reorganizing, and hiring, etc.,” according to Debbie L. Se-narighi, CPC, CPC-H, CPC-P, CPMA, physician coder. To prepare herself career-wise for whatever challenge lies ahead, she said, “I want to be the last one standing, or the first one hired. Obtaining AAPC coding credentials paid off for me in all of the above.”

With Credentials, the Sky’s the LimitWith major forces shaping and changing health care, the best way to advance your career is to acquire the skills that will be in demand in the near future through credentialing. As credentials expand, creden-tial holders will demonstrate their specialized capabilities, and specif-ic credentials will become required for positions (similar to the histo-ry of the CPC® credential).

Michelle A. Dick is executive editor at AAPC.

More doctors are teaming up with hospitals and outpatient facilities because of rising costs and regulations for private practices. Plus, with the latest medical advancements, an increasing number of inpatient procedures are now being performed outpatient.

With outpatient services on the rise, there’s never been a better time to consider the CPC-H® credential.

Learn more at www.aapc.com/cpc-h

Be InDEMAND

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MinutewithaMember

Linda A. Poulos, CPC, CPC-H, CPC-ICoder/Auditor for Scripps Health, San Diego, Calif.

Tell us a little bit about your career—how you got into coding, what you’ve done during your coding career, what you’re do-ing now, etc.I came into the medical field by way of Blue Cross as a claims exam-iner and then a patient service representative. After I left the insur-ance side, I worked as a medical assistant and then a medical biller for several specialties. Eventually, I became a medical records manager for a skilled nursing facility. I then went on to work as a biller/cod-er at an ambulatory surgical center. It was at this point in my career that I decided I was more interested in pursuing coding. I tracked down an instructor, rounded up some colleagues, and we had a class.After taking the class and passing the Certified Professional Coder (CPC®) exam, I followed up with the Certified Professional Coder – Hospital (CPC-H®) credential and later rounded out my creden-tials as a Certified Professional Coder – Instructor (CPC-I®). Now, I am employed as a coder/auditor for a major medical institution in San Diego. I also participate with community and career colleges on their advisory boards. What’s next? … Let’s chat!

What is your involvement with your local AAPC chapter?I am recycling through the chapter board process. I ran the San Di-ego AAPC local chapter for many years and was very effective thanks to my supportive coder buddies. We all pitched in to make the chap-ter grow and become a respected part of the San Diego medical com-munity. I now serve as the president-elect under Michael Reynolds, CPC, and look forward to another excellent experience in 2012. Supporting every level of education is very important for our chap-ter and we always respond to our members’ needs.

What AAPC benefits do you like the most?The on-demand webinars are probably the best thing since cell phones. All kidding aside, they are convenient, informative, and well thought out. Thank you to those who brought us this educa-tion opportunity.

What has been your biggest challenge as a coder?Understanding that billing and coding go hand in hand is crucial, but coding in itself is a challenge. When it’s done correctly, it can be influential in meeting the contractual guidelines and compliance statutes.

How is your organization preparing for ICD-10?I’m not involved in the organizational roll out, but I understand there is a steering committee and a consultant involved. My coder buddies have come together to practice ICD-10 and it’s been fun for all of us. I can’t wait to see the final product, as scary as it all seems. It’s a very exciting time for coders and another education and career development opportunity.

If you could do any other job, what would it be?I plan to be a consultant and teach office staffers the importance of coding and billing accountability. I also consulted for a book on cod-ing outcomes and we’re discussing a sequel. That was quite an inter-esting project for me—it’s a good thing I’m an avid researcher!

How do you spend your spare time? Tell us about your hob-bies, family, etc.My entire family lives in the western suburbs of Chicago. I live in California by myself, which is OK. I have two small dogs occupying a lot of my spare time.I enjoy socializing over a meal with fellow coders and stimulating my brain with conversations about coding. I also enjoy shopping a little too much! I love rodeos and going to the Las Vegas finals whenever I can. I like watching television, especially Discovery, National Geo-graphic, Food Network, and other educational networks.

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