November 2010 - Amazon Web Servicesaapcperfect.s3.amazonaws.com/5548A1AF-4C9F-49A2-BFE0-BFA......

Plus: Scribing • Biopsy • Signature Requirements • U.S. v. Stokes • PQRI

Kimberly Engel, CPC Atlanta, Ga.

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www.aapc.com November 2010 3

[contents] 7 Letter from the President and CEO

8 Coding News

10 Letters to the Editor

13 Letter from Member Leadership

In Every Issue

14 Scribing: A Very Old and Up-to-date Profession for Coders Jim Strafford, CEDC, MCS-P

16 Understand Medicare Physician Supervision Requirements G. John Verhovshek, MA, CPC

20 Why the New Signature Requirements Emphasis? Lynn S. Berry, PT, CPC

22 Report Transforaminal Epidural Injections With Precision G. John Verhovshek, MA, CPC

26 In the Journey Through Vessels - Code Destinations, Not Waypoints Kimberly Engel, CPC

28 Op Reports Show How to Code Selective Catheter Placement Nancy G. Higgins, CPC, CPC-I, CIRCC, CPMA, CEMC

30 Registries May Offer Advantages for PQRI Reporting Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC

34 U.S. v. Stokes: Compliance Implications for the Average Physician Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CHCC, CRA

43 Bundled or Separate Biopsy Depends on Circumstances Brad Ericson, CPC, COSC

48 Consult Your Payer for Consult Guidelines Lindsey H. Daly, MSHA, CPC

On the Cover: Kimberly Engel’s, CPC, travels start at the Cartersville Airport in Atlanta, Ga., and much like the selective catheter’s journey through blood vessels, it’s the destination, not the journey, that matters. Cover photo by Connie Locklear (www.locklearphotos.com).

Education

People

Coming Up

contents

November 201044

Online Test Yourself – Earn 1 CEU go to www.aapc.com/resources/

publications/coding-edge/archive.aspx

12 Synergize Your Local ChapterLynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC

44 Experience Is the Best TeacherKen Camilleis, CPC, CPC-I

46 Don’t Change the CodePam Brooks, CPC, PCS

25 KUDOS

38 Newly Credentialed Members

50 Minute With a Member

43

CPT® 2011

Vicarious Trauma

Springfield Regional Conference

Distinguish 78 from 58, 79

Customer Complaints

Features

26

22

CHANGES

COMING

JAN. 1

4 AAPC Coding Edge

Volume 21 Number 11 November 1, 2010Coding Edge (ISSN: 1941-5036) is published monthly by AAPC, 2480 South 3850 West, Suite B. Salt

Lake City, Utah, 84120, for its paid members. Periodical postage paid at the Salt Lake City mailing office and others. POSTMASTER: Send address changes to:

Coding Edge c/o AAPC, 2480 South 3850 West, Suite B, Salt Lake City, UT, 84120.

ChairmanReed E. Pew

[email protected]

President and CEODeborah Grider,

CPC, CPC-I, CPC-H, CPC-P, COBGC, CPMA, CEMC, CPCD, [email protected]

Vice President of MarketingBevan Erickson

[email protected]

Vice President, Business DevelopmentRhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTC

[email protected]

Directors, Pre-Certification Education and ExamsRaemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC

[email protected]

Katherine Abel, CPC, CPMA, CPC-I, [email protected]

Vice President, Post Certification EducationDavid Maxwell, MBA

[email protected]

Director of Editorial DevelopmentJohn Verhovshek, MA, CPC

[email protected]

Directors, Member ServicesBrad Ericson, MPC, CPC, COSC

[email protected] Montgomery

[email protected]

Senior Editors Michelle A. Dick, BS Renee Dustman, BS [email protected] [email protected]

Production ArtistTina M. Smith, AAS Graphics

[email protected]

Advertising/Exhibiting Sales ManagerJamie Zayach, BS

[email protected]

Address all inquires, contributions and change of address notices to:

Coding EdgePO Box 704004

Salt Lake City, UT 84170(800) 626-CODE (2633)

© 2010 AAPC, Coding Edge. All rights reserved. Reproduction in whole or in part, in any form, without written permission from the AAPC is prohibited. Contributions are welcome. Coding Edge is a publication for members of the AAPC. Statements of fact or opinion are the responsibility of the authors alone and do not represent an opinion of AAPC, or sponsoring organizations. Current Procedural Terminology (CPT®) is copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein.

CPC®, CPC-H®, CPC-P®, and CIRCC® are registered trademarks of AAPC.

Serving AAPC MembersThe membership of AAPC, and subsequently the readership of Coding Edge, is quite varied. To ensure we are providing education to each segment of our audience, in every issue we will publish at least one article on each of three levels: apprentice, professional and expert. The articles will be identified with a small bar denoting knowledge level:

APPRENTICE

PROFESSIONAL

EXPERT

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

More sophisticated issues including code sequencing, modifier use, and new technologies.

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

Serving 98,000 Members – Including You

November 2010

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letter from the president and CEO

Unlike family and friends, material posses-sions can often be replaced. Perhaps that is why we sometimes take them for granted. We forget that insurance only covers the face value of our assets, and much of what we possess holds far more value than the original price tag.

Can You Put a Price on Your AAPC Membership?Your AAPC membership, regardless of the credential(s) you hold, has tremendous value in the health care industry. AAPC creden-tials are the “gold standard” of our industry and AAPC education and services outmatch others in our field and can't be replaced.

There are three membership types: individ-ual, student, and corporate (which varies by number of members). Let’s look at what is included in your membership and the yearly value of these services:

Coding Edge magazine subscription 12 issues ($99.95)

Free ICD-10 resources including the implementation Benchmark Tracker (www.aapc.com/memberarea/ICD10/Default.aspx), the ICD-10 Code Translator (www.aapc.com/ICD-10/codes/index.aspx), articles, and other tools helpful for implementation ($500.00 value)

Member savings for code books ($122.90 and more on code book bundles)

ICD-10 Connect newsletter (www.aapc.com/resources/publications/icd-10-con-nect-subscribe.aspx ) ($25.00)

Billing Insider newsletter (www.aapc.com/resources/publications/billingin-sider-subscribe.aspx ) ($25.00)

Free continuing education units (CEUs) in Coding Edge ($120.00 per year)

Local chapter meetings/networking opportunities along with CEUs ($90.00)

National and regional conferences (sav-ings of approximately $200.00 more than conferences in the industry)

Low cost webinars and workshops ($50.00 savings over other organizations)

Here are some AAPC member benefits you cannot put a price on:

Lobbyist representation in Washington

AAPC representative on the CPT® Edi-torial Panel

AAPC EdgeBlast

AAPC News and Updates (news.aapc.com/)

Access to member forums

Access to Members Savings Benefits connection (www.aapc.com/resources/member-benefits.aspx ) (savings on name brand stores, items, and services from 5-20 percent)

Member savings on other resource materials, which varies by publication (10-20 percent)

Grocery coupons and more (savings vary)

AAPC membership is priceless. You can’t put a price on knowledge, networking, and building friendships. I hope you are as proud as I am to be a member of AAPC. We will continue to expand services to you in the coming years and hope you take advantage of what AAPC has to offer.

Let’s Give ThanksOn a final note, it’s the time of year to count your blessings and give thanks for all that is irreplaceable. Take time to be kind to those you hold most dear, and extend a helping hand to others. Set aside some quiet time and share it with a friend who brings you special joy.

Until next month, my friends.

Analyze Your AAPC Membership’s Value

Sincerely,

Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, COBGC, CPCD, CCS-P

AAPC President and CEO

8 AAPC Coding Edge

New ICD-9-CM Changes, Effective Oct. 1Additional changes have been made to ICD-9-CM that were not available at the time the Coding Edge article “ICD-9-CM for 2011 Aimed at Diagnostic Specificity” was written for the September issue.

The Centers for Disease Control and Pre-vention (CDC) discussed changing specific diagnosis codes at the March ICD-9-CM

Coordination and Maintenance Committee meeting, which only recently were finalized. The changes go into effect Oct. 1.

Here is a key to the changes:

= New = Revised Deleted

New text in revised codes is underlined

Deleted text in revised codes is crossed out

Neoplasms: Neoplasm of Uncertain Behavior of Endocrine Glands and Ner-vous System

237.79 Other neurofibromatosis

Rationale: This code joins 237.73 Schwannomatosis as a new code effective Oct. 1. Neurofibromatosis (NF) describes a set of distinct genetic disorders that cause tumors to grow along certain nerves. NF also can affect the development of non-nervous tis-sues such as bones and skin and is recog-nized in ICD-9-CM by subcategory 237.7 Neurofibromatosis. There is fifth digit speci-fication for type 1 (von Recklinghausen’s disease) and type 2 (acoustic neurofibroma-tosis). Schwannomatosis (237.73) recently was recognized as a distinct (although rare) form of NF, in which patients have multiple Schwannomas on cranial, spinal, and periph-eral nerves; however, they do not develop vestibular tumors and do not go deaf as in the type 2 NF.

The American Academy of Neurology rec-ommended the new code for “other” neu-rofibromatosis to be reported with 237.79 (NOT 237.78).

Special Symptoms or Syndromes, Not Elsewhere Classified

307.0 Stuttering Adult onset fluency disorder

Rationale: Code descriptors have been modified to distinguish adult onset fluency disorder, childhood onset fluency disorder (see new code 315.35), and fluency disorder subsequent to brain lesion or disease (such as neurologic disorders or late effects of trau-matic brain injury—see new code 784.52 below). Codes 307.0 and 315.35 include stut-tering and/or cluttering, as explained by new “includes” notes in the ICD-9-CM tabular

listing. Continue to report fluency disorder as a late effect of cerebrovascular accident with 438.14 Late effects of cerebrovascular disease, fluency disorder. These revisions, sup-ported by the American Speech-Language-Hearing Association (ASHA) and the American Psychiatric Association (APA), better capture the nature and description of fluency disorder.

Specific Delays in Development: Speech or Language Disorder

315.35 Childhood onset fluency disorder

Rationale: Code descriptors have been modified to distinguish adult onset fluency disorder (see revised code 307.0), childhood onset fluency disorder, and fluency disorder subsequent to brain lesion or disease (such as neurologic disorders or late effects of trau-matic brain injury—see new code 784.52 below). Codes 307.0 and 315.35 include stut-tering and/or cluttering, as explained by new “includes” notes in the ICD-9-CM tabular listing. Continue to report fluency disorder as a late effect of cerebrovascular accident with 438.14. These revisions, supported by the American Speech-Language-Hearing Associa-tion (ASHA) and the American Psychiatric Association (APA), better capture the nature and description of fluency disorder.

Influenza Due to Certain Identified Influenza Viruses

488.0 Influenza due to identified avian influenza virus

488.01 Influenza due to identified avian

influenza virus with pneumonia

488.02 Influenza due to identified avian influenza virus with other respiratory manifestations

488.09 Influenza due to identified avian influenza virus with other manifestations

488.1 Influenza due to identified novel H1N1

influenza virus

488.11 Influenza due to identified novel H1N1 influenza virus with pneumonia

488.12 Influenza due to identified novel H1N1 influenza virus with other respiratory manifestations

coding newscoding news


488.19 Influenza due to identified novel H1N1 influenza virus with other manifestations

Rationale: Codes 488.0 and 488.1 do not provide additional code specification under category 487 Influenza. Codes 488.0 and 488.1 were expanded to match the codes at 487. This allows for greater specificity and consistent coding of all forms of influenza with pneumonia. A review also has occurred for all ICD-9-CM tabular instructional notes related to categories 487 and 488.

Symptoms Involving Head and Neck: Other Speech Disturbance

784.52 Fluency disorder in conditions classified

elsewhere

Rationale: Code descriptors have been modified to distinguish adult onset fluency disorder (revised code 307.0), childhood onset fluency disorder (new code 315.35), and flu-ency disorder subsequent to brain lesion or

disease such as neurologic disorders or late effects of traumatic brain injury (784.52). Fluency disorder as a late effect of cerebro-vascular accident continues to be reported 438.14. These revisions, supported by the American Speech-Language-Hearing Associa-tion (ASHA) and the American Psychiatric Association (APA), better capture the nature and description of fluency disorder.

Need for Isolation and Other Prophylactic or Treatment Measures

V07.51 Prophylactic uUse of of selective estro-

gen receptor modulators (SERMs)

V07.52 Prophylactic uUse of aromatase inhibitors

V07.59 Prophylactic uUse of other agents affect-

ing estrogen receptors and estrogen levels

V07.8 Other specified prophylactic

or treatment measure

V07.9 Unspecified prophylactic or treatment

measure

Rationale: Descriptor wording has been modified to represent better the intent of the codes, to include treatment as well as prophylactic (preventive) measures.

You can find a summary of the March 9-10 ICD-9-CM Coordination and Maintenance Committee meeting agenda and discussion at: www.cdc.gov/nchs/data/icd9/TopicpacketforMarch2010.pdf.

Access the resulting ICD-9-CM tabular addenda effective Oct. 1 on the CDC website: www.cdc.gov/nchs/data/icd9/icdtab10add.pdf.

Find the resulting addenda list of ICD-9-CM Index to Diseases changes, effective Oct. 1, at: www.cdc.gov/nchs/data/icd9/icdidx10add.pdf.

Project1:CodingEdge Ads 8/13/10 12:03 PM Page 1

coding news

10 AAPC Coding Edge

letters to the editor

Cyclops Lesion: A Complication of Anterior Cruciate ReconstructionI have several comments and questions regarding the article “Arthroscopic Gems: Hints for Accurate Coding” (Coding Edge September 2010, pages 26-28):

In 2004, the American Academy of Orthopedic Sur-geons (AAOS) defined areas of the shoulder similar to compartments of the knee. AAOS defined those areas as glenohumeral, acromioclavicular, and subacromial. This information would have been a good addition to the refer-ence on shoulder arthroscopic procedures.

When referencing the open procedures 23410 Repair of rup-tured musculotendinous cuff (eg, rotator cuff) open; acute, 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic, and 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasy) versus arthroscopic 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair, I am not sure that 23420 should fall into this category because 23420 is a reconstruction, rather than a repair pro-cedure of the rotator cuff.

The author indicates that the open procedures “differentiate between whether the tear is acute or chronic or how many tendons are repaired.” I do not note the number of tendons in any of the listed codes. Code 23420 does state “com-plete;” however, I have never found a reference as to “com-plete” meaning all four tendons. If such a reference exists, where can I find it?

Lastly, when referencing debridement of a cyclops lesion, the author states that this lesion occurs after total knee replacement procedures. The cyclops lesion develops as a complication after anterior cruciate reconstruction, not com-monly after total knee replacement procedures.

Ruby O’Brochta-Woodward, BSN, CPC, CCS-P, ACS-OR

It is true that the AAOS Coding, Coverage, and Reimbursement Committee recognizes three “areas” or “regions” of the shoulder (the glenohumeral joint, the acromioclavicular joint, and the subacromial bursal space), and that these areas are clearly sepa-rate; procedures done in one area should not influence coding in a different area. I agree that the AAOS is a good reference; however, the article was not meant to be an exhaustive study of arthroscopy coding. My objective was to offer a general (i.e., applicable to private and federal payers) “hints and tips” article for newer coders; therefore, I decided to use only American Medical Association (AMA) references and those AAOS coding concepts the AMA has incorporated. Medicare recognizes the AMA as the source of information for correct use of CPT® codes for all providers except hospitals. The AMA receives input from the AAOS, but does not necessarily adopt all of their concepts—hence my inclusion of AMA endorsed concepts (knee compart-

ments) and omission of those not “ratified” by the AMA via publication (shoulder areas/regions).

I also took into consideration that excision of osteophytes and coplaning of the distal clavicle (i.e., involving the acromiocla-vicular joint) generally are considered as included in a procedure primarily aimed at the subacromial space (29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release). This scenario, on the surface, would seem to contradict the AAOS guidance cited above. I felt that a thorough explanation of why this sce-nario is not necessarily at odds with AAOS advice would take the article away from my objective. I decided to emphasize that the shoulder arthroscopy codes involve two separate joints.

As to the question on the number of tendons being a criterion for code selection for rotator cuff repair/reconstruction, please note this excerpt from the February 2002 CPT® Assistant: “Code 23420 describes a repair of a complete shoulder (rotator) cuff avulsion, referring to the repair of all three major muscles/ten-dons of the shoulder cuff.”

Your last statement is correct. Unfortunately, I noticed this error only after publication. A cyclops lesion is a complication of ante-rior cruciate ligament reconstruction. The article should read, “Debridement of cyclops lesion after anterior cruciate ligament repair/reconstruction and of adhesions after total knee replace-ment are common conditions for which arthroscopic lysis of adhesions is performed.”

Denis Rodriguez, CPC, CIRCC, CASCC, CCS

Are Skin Codes Appropriate for Surgical Reconstruction?The July 2010 Coding Edge offered conflicting advice as to whether it’s appropriate to use 15002-15431 when material such as acellular dermal allograft are used for abdominal wall recon-struction during compartment separations, hernia repairs, etc.

“Tie Up the Loose Ends of Surgical Wound Coding,” page 33, advises that skin replacement and skin substitution codes are not appropriate when the materials are used for closing the myo-fascial layers of a wound, and that an unlisted procedure code should be reported instead.

“Expose the Layers of Abdominal Wall Reconstruction,” page 45, employs 15330 Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children and +15331 Acellular dermal allograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and chil-dren, or part thereof (List separately in addition to code for primary procedure) to report the use of allograft materials overlaying and strengthening the closure of the rectus and/or fascia.

Which is correct?

Melissa Crabtree, CMA, CPC

Letters to the EditorPlease send your letters to the editor to:

[email protected].


A quick look at AAPC message forums will confirm that this is a much-debated topic (AAPC members may view an example at: www.aapc.com/memberarea/forums/showthread.php?t=121). The lack of clarity is not coincidental: Neither the AMA nor the Centers for Medicare & Medicaid Services (CMS) provide specific, direct coding advice for skin grafts and substitutes used in “non integumentary” circumstances (e.g., for abdominal reconstruction).

A conservative approach would advocate reporting an unlisted procedure code. As “Surgical Wound Coding” author Terri Brame, MBA, CPC, CPC-H, CPC-I, CGSC, CHC, notes: CPT® codes are procedure-based, not product-based, and apply-ing AlloDerm® (to cite one example) to the integument clearly is a different procedure than applying the same product to rectus and/or fascia. It may mean more time and work to submit the claim, but reporting an unlisted procedure code in this case most closely follows CPT® conventions.

Reporting 15002-15431 during surgical repair/reconstruction does have its advocates. To cite one example, Dr. Raymond Javenicus, an American Society of Plastic Surgeons representa-tive to the AMA CPT® Advisory Committee, published an article in the April 2006 Plastic Surgery News advocating 15330 for skin graft to close the abdominal cavity (www.lifecell.com/downloads/Ap06CPTCornerAbWallRecon.pdf).

“It almost always depends on the carrier and what rules they choose to follow,” explains John Bishop, PA-C, CPC, CGSC,

CPRC, author of the “Abdominal Wall Reconstruction” article, who also notes that many clinical and coding resources agree with Dr. Janevicius’ position.

The bottom line: Ask your payer for guidance, in writing. If the payer will allow 15002-15431 to report surgical reconstructions, be sure to do so. If you are absent such explicit payer consent, stick with an unlisted procedure code.

Sleep Apnea Coverage Receives PraiseI want you to know how much I appreciated the two-article format for sleep apnea in the August 2010 issue (“Sleep Apnea: The Not So Silent Bed Partner” and “Monitor Disturbances in Sleep Study Coding”). Presenting an entire article as a clinical piece with an entire article as a coding piece was great. I hope you’ll do this more in the future.

I also commend Dr. I. A. Barot for his candid assessment of the state of our medical environment, which he describes as physi-cians treating the numbers along with patient demands for instant resolution of symptoms. In his words, “The long-term result of this approach ... has included overzealous expenditure of health care dollars, increasing utility of already over-stretched resources.” Until Americans take responsibility for their health by eating a proper diet and exercising, we will continue to sink farther and farther into the health care abyss we’ve created.

Marti Bailey, MT (ASCP), CPC

letters to the editor

12 AAPC Coding Edge

AAPCCA

Local chapter officers are leaders working to synergize local chapters. Creating an inspiring vision for your local chapter is important; you must empower, inspire, and energize your members, building a team by encouraging initiative and involvement.

Giving your chapter direction, setting goals, and having confidence wins respect and trust from members. Always be enthusiastic and create a positive meeting environment. Delegate authority and be open to new ideas; believe in the creativity of others. Com-municate openly and honestly, giving the guidelines set out by AAPC and outlining what the next year will hold for members. Be willing to discuss, listen, and support.

Involve everyone to facilitate a team approach and create unity within the chap-ter. Coaching chapter members brings out the best. Having fun is a big element and should be a goal.

Tools to Boost Chapter EnthusiasmThere are many resources available on AAPC’s website (www.aapc.com) to assist you in handling next year’s challenges. Using these resources provides the energy you need to keep members excited and engaged:

Local Chapter Handbook

Forms

Meeting Ideas

Proctoring Information

CPC® Review Tools

May MAYnia Details

Best Practices

Local Chapter Code of Conduct

Coder of the Year

Request a Visitor

The local chapter handbook provides you with guidance on how to operate the local chapter efficiently and effectively. In the

forms section you can request AAPC Bucks, and download continuing education unit (CEU) certificates, seminar certificates, local chapter meeting attendance forms, quarterly meeting reports, and local chapter speaker agreements.

AAPC’s website helps you improve your meetings and attendance. This is where

other chapter officers share their ideas with AAPC and the AAPCCA Board of Direc-tors. There are an absentee ballot, ballot education request, meeting agenda, refresh-ment donation schedule, rewards points schedule, scholarship application, and a vote count sheet.

Mix It UpMake sure meetings are a good mix of edu-cation, networking, and fun:

Education—Organize the education sec-tion of the meeting to maintain your mem-bership and keep them involved.

Professional Medical Coding Curriculum (PMCC) instructors need to earn continu-ing teaching units (CTUs) to maintain instructor status and they can earn these by speaking at your meetings. AAPC has pre-sentations that can be given by local chap-ter officers. Some of these include “E/M Auditing;” “Communication or Bust;” and “Maximize Reimbursement.”

Proctoring examinations is a key role for local chapters. Administering exams cor-rectly protects the integrity of the certifica-tion process. The responsibility placed on officers as proctors is very serious. Provid-ing education to officers and members who assist ensures the process is done properly.

Networking—Have members network with physicians, compliance officers, and coding specialists presenting at your local meetings. Use other chapter officers as speaker resources.

Great resources for speakers are local medical carriers and other carriers. These meetings often have great attendance. The AAPC forum is another way to get ideas for chapter meeting speakers or roundtable discussions. Encourage members to bring their most difficult coding issues and work on them as a group.

You can even request a visit from AAPC, if it has been at least three years since the chapter has had a visit. Ask for this visit at least six months in advance of the meeting. The chapter can sponsor an AAPC seminar or conference.

Fun—Coding games are a great icebreaker for any meeting and a fun networking opportunity. AAPC’s website provides links to sites with games.

May MAYnia should be added to every chapter’s plans. Your educational speaker brings the membership and other health care professionals to your chapter. May is the month to spotlight on your chapter. AAPC awards prizes to the chapter with the most guests and to the chapter with the highest number of attendees.

The Rest Is Up to YouAs soon as elections are finalized, meet and brainstorm. Get organized, plan your meet-ings, speakers, exams, and post them on the AAPC website for all to view. Consider syn-ergizing your chapter and with the combined effort you’ll realize the sky is the limit.

SynergizeYour Local Chapter

Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC, a member of the AAPCCA Board of Direc-tors, is president of LCA Medical Consulting. Lynn has more than 25 years of experience in the health care industry. She provides PMCC training through Columbia State Community Col-lege and provides consulting services to Hick-man Community Health Services (part of Saint

Thomas Health Services). She has provided coding workshops for the Tennessee Medical Association. Lynn serves as president of the Professional Coders of Columbia, Tenn. and the Cahaba Physician Outreach and Education Committee for Tennessee.

Be a member of the AAPCCA Board of Directors. Applications are at www.aapc.com.

Bring your chapter together and activate success with these officer resources.

By Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC


I am passionate about coding. I get excited when I see how AAPC affects coders. The biggest thrill for me is when I train and hire coding professionals who beam with certification pride. They know the impor-tance of coding, hard work and dedication, setting goals, and the value of their coding education.

Find Your TalentsI started out as a radiology technologist. When I became involved in radiology coding, it was a natural transition for me. I was good at it and that was where my coding passion began. Since then, I have earned several AAPC credentials includ-ing the Certified Interventional Radiology Cardiovascular Coder (CIRCC™) credential. Currently, I own a physician billing com-pany and consult on radiology, interven-tional radiology, and orthopaedics. I also train coders, give presentations, and serve as president on the AAPC National Advisory Board (NAB).

I never dreamed my coding passion would take me to where I am today.

Find Your PassionYou may not be as enthusiastic about inter-ventional radiology coding as I am, but you may have expertise or enjoy working in another health care area. There are so many areas of coding that you can branch out into (interventional radiology cardiovascular coding pun intended). You can give your passion and expertise credibility in the med-ical industry by earning AAPC credentials for the particular area(s) that excites you:

Certified Professional Coder (CPC®)

Certified Professional Coder-Hospital (CPC-H®)

Certified Professional Coder-Payer (CPC-P®)

Certified Interventional Radiology Cardiovascular Coder (CIRCC®)

Certified Professional Medical Auditor (CPMA™)

Certified Ambulatory Surgical Center Coder (CASCC™)

Certified Anesthesia and Pain Management Coder (CANPC™)

Certified Cardiology Coder (CCC™)

Certified Cardiovascular and Thoracic Surgery Coder (CCVTC™)

Certified Dermatology Coder (CPCD™)

Certified Emergency Department Coder (CEDC™)

Certified Evaluation and Management Coder (CEMC™)

Certified Family Practice Coder (CFPC™)

Certified Gastroenterology Coder (CGIC™)

Certified General Surgery Coder (CGSC™)

Certified Hematology and Oncology Coder (CHONC™)

Certified Internal Medicine Coder (CIMC™)

Certified Obstetrics Gynecology Coder (COBGC™)

Certified Orthopaedic Surgery Coder (COSC™)

Certified Otolaryngology Coder (CENTC™)

Certified Pediatrics Coder (CPEDC™)

Certified Plastics and Reconstructive Surgery Coder (CPRC™)

Certified Rheumatology Coder (CRHC™)

Certified Urology Coder (CUC™)

Follow Your PassionSince I started my tenure, AAPC has focused on fostering each member’s profes-sional growth through AAPC local chapters. Local chapters are where you can talk about coding and help others in the coding com-munity. They provide an outlet to discuss the intricacies of coding and also provide a coding community to which you can relate. Chapters can help you develop your leader-ship skills by serving as an officer. Here is where your true passion for coding can develop into greater career possibilities.

Keep your coding passion alive by coding daily. Even if you aren’t an in-the-trenches coding professional, I encourage you to code for a few hours daily. I do.

letter from member leadership

Get Excited About Coding

Sincerely,

Terrance C. Leone, CPC, CPC-P, CPC-I, CIRCC

President, National Advisory Board

14 AAPC Coding Edge

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A health care profession that is booming and can stake a claim as being among the world’s oldest is scribing. Scribes appear frequently in the Bible

and ancient history as “record keepers” who transmitted legal texts and other documents. Four thousand years later, the modern scribe also transmits legal documents such as emer-gency department (ED) charts and documentation for other medical specialties.

Modern scribing has been around for several decades. In the late 1970s, a study by the “Annals of Emergency Medi-cine” found that scribes who “shadow physicians” and “act as human tape recorders” increased physician efficiency and improved chart documentation. Why, then, has the use of scribes only increased dramatically in the past five years (from a handful of practices to over 500 utilizing scribe ser-vices), particularly in ED practices?

“The implementation of electronic medical records [EMRs] in many emergency departments has required a physician learning curve,” suggests Dr. Luis Moreno, chief medical officer of Scribe America. “The systems often aren’t user friendly. As a result, EMRs actually increase chart documen-tation time. Interacting with a computer terminal instead of a patient is not an efficient use of a physician’s time; thus, the need for scribes.”

Advantages of ScribesSeveral additional factors have influenced the scribe boom. These include:

• ED overcrowding and patient throughput issues require more efficient use of physicians’ (and other medical pro-viders’) time.

• As all coders know, documentation guidelines require an emphasis on time-consuming documentation of his-tory/physical and medical decision making (MDM), plus all other chart elements.

• With recovery audit contractors (RACs) and other gov-ernment and payer oversight, the importance of com-plete, compliant, and medical necessity-supported charts has become critical.

“EDs must become more efficient from both a clinical and revenue-generation perspective,” Dr. Moreno notes. “A recent article from the Society of Academic Emergency Medicine demonstrated that the addition of a scribe collaborator results in an additional 24 RVUs [relative value units] during one 10-hour provider shift. Another article, written by Dr. Richard Bukata of Southern California, calculated that every minute spent on documentation and not seeing the next patient costs $18. Additional benefits, such as being able to task the scribe to hunt down labs or relatives and perform data entry, allow the physician to focus on higher levels of thought relating to patient care—as well as leave at the end of their shift instead of hours later.”

Dr. Craig Gronchewski, chairman of Princeton University Emergency Department, does not use scribes yet, but sees many advantages. “Burnout continues to be an issue for ED physicians,” he notes. “A less chaotic, more efficient work place improves the quality of work life for all providers in the ED.”

Scribe’s Role in MedicineThe scribe shadows the physician and records all of the chart elements that coders look for in determining evaluation and management (E/M) levels (and procedure codes). These include all elements of history, physical, and MDM. Scribe guidelines emphasize that scribes are recording these elements strictly from physician direction. Like coders, scribes cannot assume that something was done without clear direction from the physician. Scribes also document consults with other physi-cians, review old records, labs, ordered diagnostics, and find-

APPR

ENTI

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When physicians are free of hunting down labs and performing data entry, the focus is on patient care.

CRIBING:A Very Old and Up-to-date Profession for CodersBy Jim Strafford, CEDC, MCS-P


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ings. An effective scribe documents all of the elements for the all-important MDM element of documentation.

Scribes have begun to morph into a broader role in the ED. Scribes may visit the patient to record review of systems (ROS), family history, social history, and past medical his-tory. In the outpatient setting, these do not require physician presence—but do require documented physician review (phy-sician presence is required in the inpatient setting, according to the Centers for Medicare & Medicaid Services (CMS)). Overall, scribes provide a complete service to physicians, increasing physician efficiency and job satisfaction.

Scribe companies generally hire college students interested in a career in the medical field. “In the past, we have seen coders and scribes as having different skills,” Dr. Moreno admits. But he quickly adds, “We now are beginning to see the very close relationship between scribe and coder. We plan to increase coding training for our senior scribes. In fact, we have begun to discuss the concept of scribes working hand-in-hand with onsite coders. This could be an ideal situ-ation for assuring both documentation and coding is com-pleted in ‘real time,’ not several days later.”

Prospects for EmploymentIn a slow economy, there are plenty of openings for scribes. Scribes must be on-site, and many EDs are implement-

ing their own scribe services. Openings often are posted on scribe organizations’ websites. Scribe companies are recruit-ing prospects from local universities nationwide, especially among students with some medical or mid-level training. These companies provide classroom and on-line education—plus hands-on experience in the clinical setting, witnessing and recording actual patient encounters. Because turnover is expected as scribes graduate from school, there is a constant need for new scribes.

An effective scribe must not be squeamish at the sight of blood and other body fluids, have the fortitude and patience to stay on his or her feet and take constant direction from doctors and nurses, plus have people skills and the ability to deal with a high-intensity, chaotic environment. But for the right coder, scribing could be a perfect fit. “We recognize that a big change in how we view scribes may be in the cre-ation of the scribe who also codes,” Dr. Moreno says. “That is why we have begun to provide coding training and coding certification for our senior personnel and trainers.”

Jim Strafford, CEDC, MCS-P, principal of Strafford Consulting Inc., has over 30 years experience as a consultant, manager, and educator in all phases of medical coding, billing, compliance, and reim-bursement. Mr. Strafford is a published, nationally recognized expert on ED revenue cycle and coding issues. www.straffordconsulting.com. He can be reached at [email protected].

16 AAPC Coding Edge

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Medicare supervision requirements apply to out-patient services in both the hospital setting and the physician office. Following physician super-

vision requirements is crucial for compliance and reim-bursement. Services not meeting applicable guidelines are considered “not reasonable and necessary,” and are ineligible for Medicare payment; however, the rules differ depending on the type of service(s) provided.

Note: Medicare physician supervision requirements do not apply to hospital inpatient services. For inpatient services, the Centers for Medicare & Medicaid Services (CMS) defers to hospital policy and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards.

For Outpatient Diagnostic Services, a Physician Must SuperviseFor diagnostic services in an outpatient setting (hospital outpatient or physician office), only “a doctor of medicine or osteopathy legally authorized to practice medicine in his or her state of practice,” as defined by §1861(r) of the Social Security Act, may act as a supervisory physician.

The 2010 Hospital Outpatient Prospective Payment System (OPPS) Final Rule verifies, “Physician assistants, nurse practitioners, clinical nurse specialists, and certi-fied nurse midwives who do not meet the definition of ‘physician’ may not function as supervisory physicians for the purposes of diagnostic tests” (Federal Register, Nov. 20, 2009; view at http://edocket.access.gpo.gov/2009/pdf/E9-26499.pdf).

CMS recognizes three primary levels of physician super-vision. In the context of outpatient diagnostic services, these are defined as:

1. General supervision: The procedure is furnished under the physician’s overall direction and control. The physician must order the diagnostic test and is respon-sible for training staff performing the tests, as well as maintaining the testing equipment. He or she does not need to be present in the room during the procedure.

2. Direct supervision: The meaning of “direct supervi-sion” varies according to the precise location at which the service is provided:

In the physician office, the supervising physician must be present in the office suite and immedi-ately available to furnish assistance and direction throughout the procedure’s performance.

For hospital outpatient diagnostic services provided under arrangement in nonhospital locations (such as independent diagnostic testing facilities (IDTFs) and physicians’ offices), the supervising physician must be present in the office suite and immedi-ately available to furnish assistance and direction throughout the procedure’s performance.

For services furnished directly or under arrange-ment in the hospital or an on-campus provider-based department (PBD), the supervising physician must be present on the same campus and immedi-ately available to furnish assistance and direction throughout the procedure’s performance.

In any case, the physician does not need to be present in the room during the procedure, but must not be per-forming another procedure that cannot be interrupted, and must not be so far away that he or she could not pro-vide timely assistance.

3. Personal supervision: A physician must be in atten-dance in the room during the procedure’s performance.

Regardless of location, if a physician personally provides the entire service, supervision requirements are not a concern.

Note, as well, that supervision requirements apply only to the technical component (the actual test administra-tion) of a diagnostic service. A physician always must provide the professional component (reading/interpreting of results) for diagnostic services.

Resource: Medicare physician supervision requirements for outpatient diagnostic services are defined by CMS Program Memorandum B-01-28, change request (CR) 850 (April 19, 2001), and may be found in Medicare’s Internet Only Manual, 100-02 Medicare Benefit Policy Manual, chapter 15, § 80 (www.cms.gov/manuals/Downloads/bp102c15.pdf).

EXPE

RT

UnderstandMedicare Physician Supervision

RequirementsDx vs. Tx rules are critical to success.

By G. John Verhovshek, MA, CPC


Fee Schedule Lists Supervision Requirements per CodeThe National Physician Fee Schedule Relative Value File assigns a physician supervision level for all CPT® and HCPCS Level II codes. The column labeled “Physician Supervision of Diagnostic Procedures” contains a one- or two-character indicator. These apply specifically to out-patient diagnostic services.

The most common indicators are:

ɶ • 1– Procedure must be performed under general supervision

An example of such a procedure is the technical compo-nent of ambulatory electroencephalography (EEG), 95950 Monitoring for identification and lateralization of cerebral sei-zure focus, electroencephalographic (eg, 8 channel EEG) record-ing and interpretation, each 24 hours.

ɶ • 2 – Procedure must be performed under direct supervision

Included in this category is the technical component of many urinary studies, such as 51792 Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time).

ɶ • 3 – Procedure must be performed under personal supervision

Examples include the technical component of several X-ray studies, for instance 70370 Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique.

ɶ • 9 – Concept does not apply

For instance, the concept of physician supervision would not apply to surgical procedures such as 29806 Arthros-copy, shoulder, surgical; capsulorrhaphy.

A “0” indicator (procedure is not a diagnostic test, or procedure is a diagnostic test not subject to the physician supervision policy) currently is not assigned to any CPT® or HCPCS Level II code in the Relative Value File.

Resource: The Medicare National Physician Fee Schedule Relative Value File is available as a free download on the CMS website: www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4. Select the most recent (last-posted) file for download.

Provider Status May Affect Supervision LevelFor some services, supervision requirements depend on the training of the provider administering the service. Such services are identified in the Relative Value File with the following indicators:

ɶ • 4 – Physician supervision policy does not apply when the procedure is furnished by a quali-fied, independent psychologist or a clinical psychologist, or furnished under a clinical psychologist’s general supervision; otherwise must be performed under a physician’s gen-eral supervision.

Services assigned this indicator include all central nervous system assessments or tests in the range 96101-96125.

ɶ • 5 – Physician supervision policy does not apply when procedure is furnished by a qualified audiologist; otherwise must be performed under a physician’s general supervision.

An example of a service assigned this supervision require-ment is 92640 Diagnostic analysis with programming of auditory brainstem implant, per hour.

ɶ • 21 – Procedure must be performed by a tech-nician with certification under general supervision of a physician; otherwise must be performed under a physician’s direct supervision.

Included in this category are several evoked potential studies, including 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs and 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head.

A “22” indicator (procedure may be performed by a technician with on-line real-time contact with physician) currently is not assigned to any CPT® or HCPCS Level II code in the Relative Value File.

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If a mid-level provider administers the test without physician supervision, the medical record should document clearly that the service is within the provider’s scope of practice as allowed by state law.

18 AAPC Coding Edge

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Therapy Services Have Unique Supervision Requirements CMS designates several supervision categories specific to physical therapy services. These categories assign the required level of supervision based on the provider’s level of training:

• 6 – Procedure must be performed by a physician, or by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysi-ologic clinical specialist and is permitted to provide the procedure under state law.

• 66 – Procedure must be performed by a physician or by a PT with ABPTS certification and certifi-cation in this specific procedure.

• 6a – Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill.

• 77 – Procedure must be performed by a PT with ABPTS certification, or by a PT without certi-fication under direct supervision of a physician, or by a technician with certification under a physician’s general supervision.

• 7a – Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill.

Document for SuccessCMS guidelines specify, “Documentation maintained by the billing provider must be able to demonstrate that the required physician supervision is furnished.” The guidelines do not provide examples of appropriate docu-mentation; however, for those services requiring personal supervision, the physician should document, with a com-ment and signature, his or her presence during the test. For services requiring direct or general supervision, the provider performing the service should document the physician’s direction or presence in the office, as required by the level of supervision, and the physician should con-firm with a signature.

If a mid-level provider administers the test without phy-sician supervision, the medical record should document clearly that the service is within the provider’s scope of practice as allowed by state law.

Compliance tip: Diagnostic testing requirements for physician supervision are distinct from incident-to billing requirements for mid-level providers. Incident-to require-ments are not applicable to diagnostic testing in the office setting. The Medicare Benefit Policy Manual, chapter 15, § 80 states, “Diagnostic tests may be furnished under situations that meet the incident to requirements but this is not required.”

Mid-Level Providers May Supervise Outpatient Therapeutic ServicesAs outlined in the 2010 Hospital OPPS Final Rule, “All hospital outpatient services that are not diagnostic are services that aid the physician in the treatment of the patient, and are called therapeutic services.” Supervision requirements for outpatient hospital therapeutic services are different than those for outpatient diagnostic services.

Whereas only a physician may provide supervision for outpatient diagnostic services, nonphysician practitioners (NPPs) including “clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives, may directly supervise all hospital outpatient therapeutic services that they may perform themselves within their State scope of practice,” according to the 2010 Hospital OPPS Final Rule. The NPP must be privileged by the hospital to perform the services he or she supervises, and must abide by any applicable hospital physician-collab-oration or supervision requirements. An NPP may not supervise a service he or she cannot perform personally.

In other words, for therapeutic services in a hospital outpatient setting:

A physician may provide supervision at the required level (general, direct, or personal), or

An approved NPP may provide direct supervision for the service, as long as the NPP legitimately may perform the service him- or herself.

In this context, “direct supervision” may be defined:

For services provided in the hospital or on-campus PBD of the hospital, the physician or NPP must be present on the same campus and immedi-ately available to furnish assistance and direction throughout the procedure’s performance.

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


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“In the hospital or on-campus PBD” includes the main building(s) of a hospital or critical access hospital (CAH):

under the ownership, financial, and administrative control of the hospital or CAH;

operated as part of the hospital or CAH; and

for which the hospital or CAH bills the services furnished under the hospital’s or CAH’s CMS Certification Number.

For off-campus PBDs of hospitals or CAHs, the physi-cian or NPP must be present in the off-campus PBD, and immediately available to furnish assistance and direction throughout the procedure’s performance.

In either case, the supervising provider does not need to be present in the room during the procedure, but must not be performing another procedure that cannot be interrupted, and must not be so far away that he or she could not provide timely assistance.

There are some exceptions: Regardless of the NPP’s scope-of-practice or other qualifications, only a doctor of medicine or osteopathy may provide direct supervision for cardiac rehabilitation (CR), intensive cardiac rehabili-tation (ICR), and pulmonary rehabilitation (PR) thera-peutic services, as outlined in the 2010 Hospital OPPS Final Rule.

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G. John Verhovshek, MA, CPC, is director of editorial development/managing editor at AAPC.[ ]

20 AAPC Coding Edge

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Seemingly out of nowhere, providers have been barraged with material regarding Medicare signature require-ments. Why is there a new emphasis on something

that should be standard practice?

History in the MakingWhen the November 2009 Comprehensive Error Rate Testing (CERT) Improper Medicare Fee-For-Service (FFS) Payments Report was published, an astonishing result was noted. Although CERT errors had been falling steadily (from 10.1 percent in 2004 to 3.6 percent in 2008), there was a huge increase to 7.8 percent in 2009. Why?

Each year, the Office for Inspector General (OIG) conducts an audit of the CERT process and makes recommendations. Due to growing concern with Medicare fraud and abuse and a greater emphasis on government efforts to recover overpayments, the OIG performed a more extensive review in 2008 (especially of durable medical equipment (DME) payments) and, in 2009, conducted an independent review of 2008 CERT findings for all claim types. As a result of these audits, and based on the recommendations of the OIG, the Centers for Medicare & Medicaid Services (CMS) revised the error rate methodology for the 2009 report—instruct-ing CERT contractors, among others, to “strictly enforce the Medicare policies.”

The 2009 CERT report subsequently concluded, “a signifi-cant portion of the new errors found in FY 2009 were due to a strict adherence to policy documentation requirements, signature legibility requirements, the removal of claims history as a valid source for review information, and the determina-tion that medical record documentation received only from a supplier is, by definition, insufficient to substantiate a claim” [emphasis added].

Specifically, the following errors were found:

“Records from the treating physician not submitted or incomplete: In the past, CERT would review available documentation, including physician orders, supplier docu-mentation, and patient billing history and apply clinical

review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.”

“Missing evidence of the treating physician’s intent to order diagnostic tests: In the past, CERT would consider an unsigned requisition or physicians’ signatures on test results. Now, CERT requires evidence of the treating physi-cian’s intent to order tests, e.g., signed orders, progress notes.”

“Medical records from the treating physician did not substantiate what was billed: In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history and apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.”

“Missing or illegible signatures on medical record doc-umentation: In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures.”

Subsequent to the CERT report, CMS published March 16 Transmittal 327, Change Request (CR) 6698, and MLN Matters article MM6698 Revised (www.cms.gov/transmittals), which outline rules for signatures and clarify how Medicare claims review contractors review claims and medical docu-mentation. The transmittal identified contractors that must abide by the rules as Medicare claim review contractors (car-riers, fiscal intermediaries (FIs), affiliated contractors (ACs), Medicare administrative contractors (MACs), the comprehen-sive error rate testing (CERT) contractor, and recovery audit contractors (RACs)).

The Current Rule in EffectThe current rule, outlined in CR 6698, specifies that any services provided or ordered must be authenticated by the author either by a hand written or electronic signature. A current excep-tion to this is that orders for clinical diagnostic tests are not required to be signed; however, if not signed, there must be written evidence within the physician progress note or other

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Why the NewSignature Requirements Emphasis?Find out how it began and what holds true for 2011.By Lynn S. Berry, PT, CPC


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such documentation containing the provider’s intent for the clinical diagnostic test to be performed. This must be authenticated by a handwritten or electronic signature.

CR 6698 gives further guidance for e-prescribing signature requirements and signature dating requirements. It also pro-vides exceptions for hospice certifications and other require-ments as specified by local coverage determinations (LCDs), national coverage determinations (NCDs), or Medicare manuals.

CR 6698 is retroactive for the November 2010 CERT reporting period (which includes the prior year). If you find you have illegible signatures in any 2009 or 2010 records requested by any Medicare review contractor, make sure a recent signature log is attached; if you find missing signa-tures, make sure an attestation statement is attached (see the Program Integrity Manual (PIM), publication 100-08, chapter 3, section 3.4.1.1 and 3.4.1.2, www.cms.gov/manuals, for detailed instructions).

Proposed RulemakingPages 430-437 of the proposed rule (www.federalregister.gov/inspection.aspx#special) provide a history of government rulemaking regarding signatures for clinical diagnostic tests and their reasoning for changing the current rule. The pro-posal now requires a physician or non physician practitioner (NPP) to sign requisitions for clinical diagnostic laboratory tests paid on the basis of the Clinical Laboratory Fee Sched-ule (CLFS) as a part of the other signature requirements.

CMS believes this will eliminate any confusion because a physician’s signature would be required for all requisitions and orders, thereby eliminating any uncertainty:

Whether the documentation is a requisition or an order (a semantic issue)

Whether the type of test being ordered requires a sig-nature, or

Which payment system (the MPFS or CLFS) requires a physician or NPP signature.

CMS also says the proposed rule would make it easier for the

reference laboratory technicians to determine whether a test has been requested appropriately. Potential compliance issues would be eliminated during any subsequent Medicare audits because a signature would always be required.

What This Means for 2011If the proposed rule goes into effect, as of Jan. 1, 2011, every piece of documentation written by the physician or NPP, including any orders or prescriptions, must have an authen-ticated, legible signature. This includes any orders or requi-sitions for clinical diagnostic tests, as well as initial notes, progress notes, daily logs, or any other document in the medical record. You should include a printed name under the physician’s signature so it is clear who wrote the document or signed the order.

How does your physician signature appear on all documents?

This: _________ This: Or This:

John Whigg, MD

CR 6698 and the regulations in chapter 3, section 3.4.1.1 and 3.4.1.2 of the PIM clearly define a legible, authenticated signature for Medicare. It cannot be a stamped signature and or an electronic signature for prescribing narcotics (this last requirement may change). CR 6698 outlines how the pro-vider can appeal a ruling based on signature logs and attesta-tion statements.

Make sure your physician and/or NPP understands these regulations. This should help the CERT rate to go back down, reduce the possibility of fraud and abuse, eliminate any threats regarding this issue from MACs, CERT, or RACs, and reduce appeals on the part of the provider—thus improving your bottom line.

In the past, CERT would consider an unsigned requisi-tion or physicians’ signatures on test results. Now, CERT requires evidence of the treating physician’s intent to order tests, e.g., signed orders, progress notes.

Lynn Berry, PT, CPC, had over 35 years of clinical and management experience before beginning a new career as a coder and auditor and later becoming a provider representative for a Medicare carrier. She owns the con-sulting firm, LSB HealthCare Consultants, LLC, furnishing consulting and education to diverse provider types. She has held a variety of AAPC chapter offices and continues as one of the directors of the St. Louis West Chapter.

To discuss this article or topic, go to

www.aapc.com

22 AAPC Coding Edge

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A sharp rise in reporting transforaminal epidural injections in recent years has prompted the Office of Inspector

General (OIG) to scrutinize these services as part of its 2010 Work Plan (http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf). Keep yourself out of the OIG’s crosshairs with these seven coding tips.

1. Choose the Correct ApproachTransforaminal epidural injections (CPT® 64479-64484) are an interventional tech-nique to diagnose or treat pain, such as pain that starts in the back and radiates down the leg. A long-acting steroid is injected later-ally through the natural opening between the vertebrae (the neuroforamen) to place medication in the anterior epidural space and target a specific spinal nerve.

The translaminar epidural approach, by con-

trast, places the medicine inside the epidural space. Report these procedures using 62310-62311, depending on the targeted spine region (cervical/thoracic or lumbar/sacral).

2. Code by Spinal RegionCodes describing transforaminal epidural injections are specific to the targeted spine region (cervical/thoracic or lumbar/sacral):

64479 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level

+64480 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

64483 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level

+64484 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

3. Report per Level, Not per InjectionThe American Medical Association’s (AMA’s) CPT® Assistant (Feb. 2000) confirms that 64479-+64484 are to be reported once per level targeted, “regardless of the number of [unilateral] injections per-formed at a particular spinal level.” Report additional code units only when the physi-cian targets different levels.

Terminology alert: Although the code descriptors specify “levels,” these injec-tions target the area between the vertebrae (i.e., the spinal interspace), rather than an individual vertebra. For instance, two left side injections at C3/C4 and two left side injections at C4/C5 represent two levels (although they involve three vertebrae and, in this case, four separate injections), and are reported 64479-LT Left side for the ini-tial level and one unit of 64880-LT for the second level.

4. Apply Modifiers to Specify LocationCodes 64479-+64484 describe unilateral procedures; and because there are separate nerves on each side of the spine, these pro-cedures may be performed bilaterally at the same spinal level(s). “When a transforami-nal injection is performed on the opposite side, the work may involve redraping and positioning of the patient,” advises CPT® Assistant (Sept. 2005). “Therefore, when performing bilateral transforaminal epidu-ral injections at a single spinal level, modi-fier 50 [Bilateral procedure] is appended to the appropriate code(s).” As an example, the physician provides one right side injection

EXPERT

Report Transforaminal Epidural Injections With PrecisionWith OIG keeping a watchful eye on these interventions, be sure your coding is straight and narrow.By G. John Verhovshek, MA, CPC


and one left side injection at L1/L2. In this case, the appropriate coding is 64483-50.

The Medicare physician fee schedule rela-tive value file assigns 64479-+64484 a bilateral surgery indicator of 1, so most insurers will pay 150 percent of the stan-dard fee for bilateral injections.

As shown by example in our third tip, modifiers LT and RT Right side also may be used to designate location for unilateral injections.

5. Claim Guidance SeparatelyEpidural injections require imaging guid-ance to place the needle precisely. CPT® Assistant (Feb. 2000) explains, 64479-64484 “are performed under fluoroscopic guidance for precise anatomic localization to avoid potential injury to the vertebral artery or damage to the spinal cord or surrounding nerve roots.” CPT® further instructs, “For fluoroscopic guidance and localization for needle placement and injec-tion in conjunction with 64479-64484, use 77003 [Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarach-noid, or sacroiliac joint), including neurolytic agent destruction].”

Report a single level of 77003 per session, regardless of the number of levels/injections involved. Confirm in the documentation that guidance was used, and include a hard copy of the film in the patient record.

For example, documentation might state:

The lumbar spine was prepped and draped in a sterile manner. The C-arm was brought into view and the right side of the L2/L3, L3/L4, and L4/L5 transforaminal areas were visualized. Skin was marked and infiltrated with 1 percent Xylocaine. 22g, 3½ inch Quincke-type spinal needles were inserted into the transforaminal area and were advanced in the lateral view. In the AP view, 2 cc of Isovue were injected revealing adequate neurograms with medial spread. 20 mg of Kenalog with 1 cc of .25 percent bupivacaine at each level.

In this case, report:

• 64483-RTfortheinitialinjection

• 64484-RTforthesubsequentinjectionat L3/L4

• 64484-RTforthesubsequentinjectionat L4/L5

• 77003forfluoroscopicguidance(C-arm)

Beware of inappropriate bundling: Although some payers may attempt to bundle guidance into the injection proce-dure, the American Society of Anesthesiolo-gists (ASA) stresses, “Fluoroscopic guidance is reported and valued separately from spinal injection procedures. CPT® instruc-tions are clear and unequivocal. Medicare and other payers who use the CCI edits allow the reporting of 77003 along with codes.” For more information, view the ASA’s memorandum at: www.asahq.org/news/031907Fluoroupdate.pdf.

6. Establish Medical NecessityTo establish medical necessity for spinal injections, the claim form must cite, and documentation must support, an appropri-ate diagnosis. Allowable diagnoses may vary by payer (Check with your particular payers for specifics.); however, commonly-allowable ICD-9-CM codes to establish medical necessity for 64479-64484 include intervertebral disc disorders (722.x), spinal stenosis (723.0 Spinal stenosis in cervical region, 724.0x), post-laminectomy syndrome (722.8x), and radiculitis (723.4 Brachial neuritis or radiculitis NOS, 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified), among others.

7. Observe Frequency GuidelinesMany payers will place limits on the number of levels a physician may inject during a single encounter, as well as the time between procedures and the maximum number of injections allowable over time.

As an example, the payer may state that if there is no documented pain relief after two injections, no further injection will be considered medically necessary at the same level. Or, the payer may limit reimburse-ment to no more than three injection series in a calendar year. Again, check with your individual payer for these guidelines.

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G. John Verhovshek, MA, CPC, is director of editorial development/managing editor at AAPC.[ ]

Transforaminal Epidurals With Ultrasound Call for Category III CodesTransforaminal epidural injections may be provided under ultrasound guidance as well as fluoroscopic guidance. When reporting these injections with ultra-sound, do not select 64479-+64484. Instead, rely on the following dedicated Category III codes:

0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level

0229T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guid-ance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)

0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guid-ance, lumbar or sacral; single level

0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guid-ance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

To discuss this article or topic, go to

www.aapc.com

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There was a tremendous feeling of southern hospitality at the second annual Louisiana Coding Workshop hosted by the New Orleans chapter, Aug. 21, at the Ochsner Brent House Confer-ence Center as blue shirted greeters donned ICD-9-CM codes and welcomed each of the 150 attendees. The ICD-9-CM code numbers were for a later coding quiz.

In the foyer of the meeting room were four decorated chapter tables (New Orleans, Covington, Baton Rouge, and Lafayette), reflecting each chapter’s uniqueness. Keynote speaker, Marti Johnson, director, local chapter support at AAPC, served as judge and awarded the Lafayette chapter the prize for their winning design.

Before getting down to serious coding business, chapter presidents broke the ice with the skit, “Coding Circus” which took a light-hearted look at some issues coders face daily. The audience favorite was “The Stressed-out Coder.” The Covington Chapter delighted the audience with a true Pepto Bismal™ version of the upset stomach.

Johnson brought participants up-to-date on “What’s Happening at AAPC?”

Dr. Angela Parise, an obstetrics/gynecology specialist at Och-sner, spoke on “Robotic Surgery.” Other presentations included: recovery audit contractors (RAC), Health Insurance Portability and Accountability Act (HIPAA), Medicare, incident-to, split/shared visits, and ICD-10-CM.

And what New Orleans party would be complete without music and food? Songs such as “Celebration” and “The New Orleans’ Saints’ Champion Song” were crowd pleasers as was the joyful “Second Line” celebration.

The day ended with a fun-filled and skill-testing round of “Quick Coding Challenge.” Contestants competed to win great prizes graciously donated by generous supporters.

What a wonderful way to keep up with coding changes, network with colleagues, and earn 7.5 continuing education units (CEUs) New Orleans-style! Kudos! New Orleans.

If you know anyone who deserves kudos, please email [email protected].

Laissez Les Bons Temps Rouler ("Let the Good Times Roll")

by George Dansker, CPC-A

Lafayette Chapter wins best table.

Covington Chapter performs the Pepto Bismal™ version of an upset stomach.

Hospitality greeters with Marti Johnson, AAPC National Office.

Coders compete to win Quick Coding Challenge prizes.

26 AAPC Coding Edge

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In the Journey Through Vessels, Code Destinations, Not WaypointsBy Kimberly Engel, CPC

Upper extremity arterial orders

Lower extremity arterial orders

Here’s how to report catheter placement from puncture to journey’s end.

When deciding the “order” of a vessel for catheter placement, first ask yourself, “Where did the provider access the

vessels for this catheter?” Femoral, brachial, jugular, and iliac are common access sites; other vessels also may be accessed.

For puncture only—that is, the provider stays in the access vessel and never travels to another—coding is fairly straightforward. Report either CPT® code 36000 Introduction of needle or intracatheter, vein for a vein or 36140 Introduction of needle or intracatheter; extremity artery for an artery.

It’s when the journey goes beyond the access point that one may wish there was a roadmap handy.


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Start at HomeThere are several orders of vessels past the access site. Zero order is the “home” or starting point. This almost always is the aorta (see illustration on preced-ing page). If the provider goes as far as the aorta and stops, report 36200 Introduction of catheter, aorta.

Note: Less frequently, the catheter is not advanced to the aorta, but is advanced directly from one vessel to another without passing through the aorta—for example, from the common femoral to the superficial femoral (in the same leg or ipsilateral), and perhaps to the popliteal or beyond. For more information on this topic, see the accompanying article “Op Reports Show How to Code Selective Catheter Placement.”

From the aorta, the ordered vessels branch outward like a network of streets, from highways (first order) to boulevards (second order) to side streets (third order) and down to alleys. The “streets” of the upper body (above the renals), including the neck, are coded with 36215-36218. The streets of the lower body (renals and below) are coded with 36245-36248.

Don’t Code Until You Reach the DestinationTo continue the street analogy, imagine that the cath-eter is a car. Once in the car (introduction of the cath-eter), if the provider wishes to travel any further, he always must check in at home (the aorta). If he contin-ues on from home, he is on a first-order street (vessel). If he turns again, he is on a second-order vessel, and so on. When coding this journey, report only the final destination; all stops along the way are included.

For example, the catheter enters the right common iliac artery. The physician drives the “car” (catheter) into the aorta (home) and over to the left common iliac. This would be a first order, lower body vessel, 36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family. You would not code the access (36140) or the zero order aorta code (36200) because they were along the path that had to be taken from the puncture to the final destination.

What if the physician needs to drive further, into

another vessel, from the aorta, such as the left super-ficial femoral? In that case, there would be three street names along the way. This would then be a third-order placement, and reported 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family.

As a final example, the provider documents: “Right common iliac access. Catheter advanced to the aorta. Imaging shows normal anatomy and no disease or defect. Catheter then advanced into the left external carotid artery … final placement in the left internal carotid.” The final code is 36216 Selective catheter place-ment, arterial system; initial second order thoracic or bra-chiocephalic branch, within a vascular family for a second order, upper body vessel.

Note: All examples are based on normal anatomy. There can be variations in the vascular anatomy that will change the order of vessels you code.

The same coding principles illustrated above apply to venous catheter placement outside the heart (36010-36012).

Keep reading: In future articles, look for more advanced concepts, such as how to determine vascular families, coding for second- and third-order vessel catheter placements beyond the initial placement, bypass vessels, and abnormal anatomy.

“From the aorta, the ordered vessels branch outward like a network of streets, from highways (first order) to boulevards (second order) to side streets (third order) and down to alleys.”

Kimberly J. Engel, CPC, is owner of Decision Medical Management Solutions, LLC, in Atlanta (www.decisionmedicalmanagementsolutions.com). She has been a Certified Professional Coder (CPC®) for nearly a decade for many specialties, and also is former coding manage-ment for Duke University Medical Center and Aurora-Advanced, among others.

DID YOU KNOW? On average there are 60,000 miles of vessels in the human body. That is 2.5 times around the equator.

Determining correct selec-tive catheter placement codes is an integral part of coding any interventional procedure. For a better understanding, code these two operative (op) reports demonstrating common coding scenarios.

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Op Reports Show How to Code Selective Catheter PlacementTo claim correctly consider the codes that should be assigned for these cases.

Example 1:PATIENT: John DoeSURGEON: John Smith, MDPROCEDURE: Abdominal and pelvic angiography with bilateral lower extremity runoff, selective runoff of left lower extremity.INDICATIONS: Mr. Doe is a 70-year-old gentleman who presents with worsening bilateral lower extremity claudication. CT angiogram had demonstrated severe atherosclerotic disease of the infrarenal aorta but there did not appear to be a focal high-grade stenosis. He had bilat-eral patent iliac stents and left SFA occlusion.DESCRIPTION OF PROCEDURE: The patient was brought to the angiography suite and placed on the table in supine position. We accessed the right femoral site with use of a SonoSite. A Magic Torque™ wire was advanced in a retrograde fashion under fluoroscopic guidance. A 5-French sheath was positioned over the wire and the wire and dilator were withdrawn. A pigtail catheter was then advanced up to the upper abdominal aorta over a wire and flush aortography was performed in an AP projection. The catheter was then brought down to the lower abdominal aorta and AP views of the pelvis were taken. Using a step-table technique, bilateral subtraction angiography of the lower extremity was performed. We then exchanged catheters for a uni-versal flush catheter, which was used with the Glidewire to select the left common iliac artery. A Glidewire was then advanced down to the superficial femoral artery and catheter exchange was performed over the wire for an angled taper catheter. Pressures in the left femoral artery distally were 80/40. There did not appear to be any focal high-grade stenosis proximal to that. The catheter was then utilized to perform selective angiography of the left lower extremity. FINDINGS OF THE DIAGNOSTIC EXAMINATION: There was atherosclerotic disease involving the entire infrarenal segment from the renal arteries to the bifurcation; however, this did not appear to result in a focal high-grade stenosis. There were duplicated renal arteries on the right. The left renal artery did not demonstrate any significant stenosis. Bilateral common iliac stents were patent. The left lower extremity runoff demonstrates a patent common femoral artery. The superficial femoral artery is occluded at its origin. Despite the fairly rapid filling of the profunda femoris, there was very poor distal runoff and very slow filling of the above-knee popliteal segment on that side. On the selective angiograms, we were able to identify three-vessel runoff. Distally, there is a short focal dissection in the proximal superfi-cial femoral artery that does not appear to be flow limiting. The super-ficial femoral artery appears patent down to the popliteal segment. He appears to have three-vessel runoff preserved on the right.

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


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This report indicates the catheter was introduced at the right femoral artery, advanced to the aorta, then to the left common iliac, and finally to the left superficial femoral artery. The correct catheter place-ment code is 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family because the superficial femoral artery is con-sidered a third-order branch and the code assignment is based on the final destination of the catheter.

To help with your coding, you may refer to the CPT® Appendix L , which shows the assignment of branches to first, second, and third order for vari-ous vascular families, assuming the starting point is the aorta. From this appendix, we can follow the progression from common iliac to superficial femo-ral. The appendix indicates that this is a third-order branch, confirming the correct catheter placement code is 36247.

Through various vendors, including Z Health Publishing (www.zhealthpublishing.com) and Medical Assets Management (www.medicalassetsmanagement.com), you can obtain color diagrams that show codes for various catheter placements by vessel. When using such a diagram, you also can determine, at a glance, 36247 is the appropriate code.

In example 2, the catheter is introduced at the left common femoral artery and advanced in an ante-grade fashion to the left superficial femoral artery. This case differs from the first one because the aorta was not crossed, and the catheter was moved down the leg from one branch to another.

Here, CPT® Appendix L is not as easy to use. Recall that Appendix L assumes the starting point for the catheterization is the aorta. In this case, the catheter was not moved to the aorta—so that assumption does not hold true. But you can still use the appendix if you are careful with your interpretation. The appendix indicates that if the catheter is in the common femoral and is moved to the superficial femoral, the catheter has moved from one branch to a different branch. If we consider the common femo-ral as the starting point, the superficial femoral artery would be a first-order branch. This scenario would support the use of 36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascu-lar family for the catheter placement.

Note: If you have access to color diagrams (as mentioned above), you will find them to be more intuitive when coding a case such as this.

To sum it up, you can determine the correct catheter placement code by always considering the location of the starting point, whether the catheter was advanced to the aorta, and the final destination of the catheter.

Keep reading: In future months, we will consider the other codes that should be assigned for these cases, and will look at other op reports and their coding.

Example 2:

PATIENT: Jane Doe

SURGEON: John Smith, MD

PROCEDURES PERFORMED: Left femoral angiogram by ante-grade access, left angioplasty and stent of superficial femoral artery.

DESCRIPTION OF PROCEDURE: The patient was brought to the angiography suite where both groins were prepped and draped in the usual manner. Skin overlying the left common femoral artery was infil-trated with 1 percent Xylocaine. Left common femoral artery was can-nulated with a 21-gauge perc needle in an antegrade manner. The wire was confirmed to be in the superficial femoral artery. The micropunc-ture sheath was then exchanged for a 5-French sheath. The 5-French sheath in place, angiographic images were acquired of the left superfi-cial femoral artery. She was noted to have a total occlusion at the level of the adductor canal as well as other multiple, relatively minor stenoses. The vessel was reconstituted at the level of the adductor canal. Popliteal artery is widely patent. Anterior tibial and posterior tibial arteries are patent, although there is some mild atherosclerotic disease at the tibio-peroneal trunk. A 5-French sheath was then exchanged for a 6-French sheath. With 6-French sheath in place, the lesion was crossed using a subintimal dissection technique. The superficial femoral artery was reentered well above the knee joint. The lesion was angioplastied with a 5 mm x 40 mm angioplasty balloon. Residual occlusion remained so a decision was made to place a stent. A 6 x 150 mm Viabahn stent was then deployed across the diseased segment. The stent was then angio-plastied with a 6 x 40 Powerflex balloon that did not adequately expand the stent through its proximal portion. A 6 x 40 Dorado balloon was then used to complete the angioplasty proximally. Follow-up angiogra-phy revealed some contour irregularities in the distal component of the stent deployment. This area was then covered with a 5 mm x 5 cm Via-bahn extension. Completion angiography showed the stent to be widely patent. I showed excellent flow through the stent. The angiogram shows the popliteal artery and proximal tibial vessels were unchanged from the preprocedure angiograms. The patient tolerated the procedure without difficulty and was returned to the holding area in satisfactory condition.

Nancy G. Higgins, CPC, CPC-I, CIRCC, CPMA, CEMC, is a senior compliance specialist with Carolinas Healthcare System. She has over 20 years of experience in the health care industry and is the immediate past president of AAPC’s Charlotte, N.C. Chapter. Nancy was recently named 2009 Coder of the Year by AAPC. She can be reached at: [email protected].

30 AAPC Coding Edge

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Eligible physicians (EPs) who wish to partici-pate in the Physician Quality Reporting Ini-tiative (PQRI) may use one of three methods

to report quality measures. They may report:

1. To the Centers for Medicare & Medicaid Services (CMS) on their Medicare Part B claims,

2. Through a qualified PQRI registry, or

3. To CMS via a qualified electronic health record (EHR) product.

Of these, the third option is the “easiest,” but works only if you already have a compliant EHR system up and running. As well, only a limited subset of measures may be reported via EHRs (10 in 2010, and up to 22 in 2011), leaving those EPs whose patient population isn’t described by the available measures subset out of luck.

EPs may pursue more than one reporting option during a reporting period, but of the remaining two options, certain EPs may find registry-based report-ing offers important advantages over claims-based reporting. In my experience, using a registry is a piece of cake, and not at all as complicated as work-ing with claims-based submissions.

For example, depending on the length of the reporting period the EP chooses (six or 12 months), registries offer more flexible (and potentially easier to achieve) reporting options. A well designed and supported registry also will alert you to potential reporting mistakes; whereas, claims-based report-ing requires you to “get it right the first time” (claims may not be resubmitted for the sole pur-pose of correcting PQRI reporting errors). Finally, registry-based reporting may occur retroactively: For instance, measures for 2010 may be entered into the registry anytime up to Jan. 31, 2011. In contrast, claims-based PQRI reporting and submis-sion of the actual claim must occur simultaneously.

Here’s the catch: Registry-based measures are dif-ferent from claims-based measures, and apply to a narrower patient population. As such, not all EPs can take advantage of registry-based reporting.

Registry-based vs. Claims-based ReportingClaims-based reporting encompasses 175 individual quality measures, plus four measures that together comprise the Back Pain measures group. The mea-sures are weighted toward primary care, but an EP of almost any specialty will find several measures that may apply to his or her patient population.

Registry-based reporting, in contrast, relies entirely on measures groups, of which there are only 13 in 2010 (one measures group will be added for 2011). A measures group is four or more individual measures related to a clinical topic having a common patient population defined by diagnosis and/or encounter codes. In 2010, these measures groups are:

Diabetes Mellitus

Chronic Kidney Disease (CKD)

Preventive Care

Coronary Artery Bypass Graft (CABG)

Rheumatoid Arthritis (RA)

Perioperative Care

Back Pain

Hepatitis C

Heart Failure (HF)

Coronary Artery Disease (CAD)

Ischemic Vascular Disease (IVD)

HIV/AIDS

Community-Acquired Pneumonia (CAP)

A complete list of measures groups, as well as qualifying CPT® patient encounter codes, ICD-9-CM codes, and measures group-specific intent HCPCS Level II G-codes may be found at:

EXPE

RT

Registries May Offer Advantages for PQRI Reporting

By Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC

Look at your reporting options and find out how your EP can benefit most.


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www.cms.gov/PQRI/15_MeasuresCodes.asp#TopOfPage. Select the link, “Getting Started with 2010 PQRI Reporting of Measures Groups,” near the bottom of the page.

These measures groups are skewed heavily in favor of primary care and cardiology, and EPs with these focus areas most easily would qualify for PQRI incentives under registry-based reporting. But an ear, nose, and throat specialist (ENT), to cite an example, likely would find that her patient popu-lation wouldn’t support registry-based reporting adequately—simply because the ENT would not be treating or tracking patients for the available mea-sures groups.

To cite another example: The perioperative care measures group seems tailor-made for general surgeons but you must be careful. The measures group applies only to specific CPT® codes (as listed in the aforementioned Getting Started with 2010 PQRI Reporting of Measures Groups document). If the surgeon is not performing procedures reported using the applicable CPT® codes, the perioperative care measures group will not apply.

Ideally, in future years, CMS will increase the number of measures groups to apply more broadly across specialties, thereby making it easier for more EPs to participate in PQRI. For a fair system, every specialty should be able to use a registry.

Using a RegistryTo become qualified, registries must meet certain technical and other requirements specified by CMS. A list of approved registries may be found on the CMS website www.cms.gov/PQRI/20_AlternativeReportingMechanisms.asp#TopOfPage: Select the “Qualified Registries for PQRI Reporting” link near the bottom of the page). Use only a CMS-approved registry. The registry will charge you a nominal fee per doctor to process and

submit your information to CMS. For instance, the registry with which I am most familiar, PQRI Wizard, charges $299 per doctor, and will negotiate reductions in the per-doctor charge for groups of 10 or more physicians.

Note: I use PQRI Wizard in my examples because I have used this system most often to assist cli-ents in submitting their PQRI data. Talk to your vendor: Any worthwhile registry should offer com-petitive pricing and functionality.

As an example of how a registry works, PQRI Wizard uses a questionnaire for each measure’s group that is available to their clients in Adobe PDF. The questionnaire mirrors the submis-sion that you must complete when entering each patient. The specific CPT® and ICD-9-CM codes applicable to each measures group is listed on the questionnaire for that measures group. The system automatically tracks patients by reported CPT® codes, constantly updates your PQRI reporting status, and lets you know when you have collected sufficient data for submission.

For instance, under the group measures report-ing guidelines (when submitting for a 12-month reporting period only), if the EP reports on all applicable measures within the selected measures group for a minimum sample of only 30 unique patients who meet patient sample criteria for the measures group, the EP is eligible for PQRI incen-tives (of the 30 unique patients, 28 may be non-Medicare Part B patients, ages 18 and above). A quality registry will monitor your progress to be sure you meet PQRI requirements (total number of patients and quality measures, etc.), and will alert you if there are missing or inconsistent data. This allows you to correct information so that informa-tion submitted to CMS is perfectly clean, thereby ensuring payment of your PQRI bonus.

Ideally, in future years, CMS will increase the number of measures groups to apply more broadly across specialties, thereby making it easier for more EPs to participate in PQRI.

32 AAPC Coding Edge

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For example, in one group that I worked with, there was a problem with the date the diagnosis first was made. PQRI Wizard contacted the client and asked them to go into the database and check the accuracy of the information. As such, both my client and the registry were making sure that the data submitted to CMS was appropriate, and a pay-able PQRI submission was made. Be sure your reg-istry provides similar audits and feedback, so that you can enjoy the same successes.

Although registry-based PQRI reporting may apply more narrowly than claims-based reporting, it also may be applied with a greater level of success. The ease of using a registry, and the high rate of suc-cess and payment, suggest that if you can find a measures group that applies, registry-based PQRI reporting may be to your benefit. You will find the cost per physician is absorbed in labor savings, the Medicare incentive, and the knowledge that you will be successful. Resource: CMS provides a “decision tree” to help you decide if registry-based (or claims-based) PQRI reporting is for you. Find it at: www.cms.gov/PQRI/Downloads/2010_GettingStartedwithPQRIReportingofMeasuresGroups_020510_FINAL_2.pdf

Learn PQRI BasicsIf you’re not already participating in PQRI, you probably should be. PQRI offers medical providers an opportunity to earn incentives of up to 2 percent of their total esti-mated Medicare Physician Fee Schedule-allowed charges for covered professional services within a reporting period. Although PQRI reporting is not mandatory, based on the trends we have seen with other CMS-sponsored programs (such as e-scribing and the adoption of EHRs), it’s safe to bet that providers who do not take part in PQRI will, at some time in the future, face reduced Medi-care payments.

It’s now too late to participate in PQRI for 2010, but you shouldn’t lose your opportunity for 2011. Information for PQRI eligibility may be found on the CMS website (www.cms.gov/pqri/). From this site, you can view a list of applicable quality measures, a list of frequently-asked questions (http://questions.cms.hhs.gov/app/answers/list: Type “PQRI” in the “search” box.), and additional information to help you get started with the program.

PQRI offers options for individual EPs and group report-ing. A list of individual Medicare EPs is available at www.cms.gov/PQRI/Downloads/EligibleProfessionals.pdf.

EPs are not just physicians (e.g., doctors of optometry and chiropractic), but also mid-level providers such as physician assistants (PAs), clinical psychologists, and more, as well as physical and occupational therapists (PTs and OTs). Individual EPs do not need to sign up or preregister to participate in the PQRI. Program require-ments and measure specifications differ from year to year, and EPs are responsible for ensuring they use the PQRI documents for the correct program year.

Requirements for group reporting differ from those for individual reporting. You may find specifics on the CMS webpage given above, or by going directly to www.cms.gov/PQRI/22_Group_Practice_Reporting_Option.asp#TopOfPage.

Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, is president of CRN Healthcare Solutions and senior coder and auditor for The Coding Network. She is con-sulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and health care-related topics nationally.

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

ICD-10 Will Change Everything.ICD-10 will be one of the largest changes health care has ever experienced. Systems, policies, procedures,payments, submissions and documentation will all change.

No matter your role in the process, we have a training solution for you:

• Implementation Training

• Fundamentals of ICD-10 • ICD-10 Summarized in a Series of 15-Minute Webinars

For more information, visit AAPC.com/ICD-10or call 1-800-626-2633

Have You Begun?

Another year has passed.

34 AAPC Coding Edge

coding compass

In a recent unpublished Sixth Circuit opinion, United States v. Stokes, 2010 WL 3245536 (6th Cir. 2010), the court affirmed the conviction

of a health care provider on 31 counts of health care fraud. Dr. Robert W. Stokes, a licensed, board certified dermatologist, became the target of a federal investigation in 2001. Federal agents looked at Stokes’ billing practices to determine whether he up-coded certain outpatient surgi-cal procedures. In particular, it was alleged that Stokes frequently billed shaved excisions as more costly full-thickness excisions, and billed less complex closure techniques as expensive adjacent tissue transfers. Stokes also was alleged to have billed for both an office visit and a surgical pro-cedure on the same day by indicating he treated surgical patients for impetigo. Stokes defended the charges on the basis of mistake; that is, he was unaware he did anything wrong and, in fact, believed his billing to be accurate.

Prior to trial, the government notified Stokes of its intention to use as evidence correspondence and audit notifications he received prior and subsequent to the start of the government’s investigation. This evidence fell into two general categories:

(1) letters from insurance providers addressing relevant billing rules and questioning Stokes’ above-average surgical billings; and

(2) documents and testimony concerning audit notifications that Blue Cross Blue Shield of Michigan (BCBSM) sent to Stokes in 2000 and 2002.

This evidence was meant to show Stokes was aware of relevant billing rules and, as such, his intent was to defraud.

Although Stokes attempted to exclude this evi-dence, the trial court rejected his motion by con-

cluding the “evidence of prior warnings is relevant to the defendant’s knowledge and intent.” The court, in affirming the conviction, determined the admission of this evidence (which normally would be excluded as hearsay) was proper because it was not presented as proof that his billing was wrong or fraudulent, but instead was offered to prove the physician had known about the false Medi-care claims at issue. The underlying assumption was the communications and audit notices from BCBSM contained sufficient information to notify Stokes that he was doing something wrong, that the carrier’s conclusions were accurate, and that the billing rules for BCBSM and Medicare were the same. It also assumed that Stokes actually saw these notices.

Be Aware of Carrier NotificationsIf the government’s theory about the case and the assumptions drawn above are accurate, this decision is significant to providers in the current post-pay-ment audit climate. Consider the following scenarios as a means of demonstrating how Stokes may affect the average physician:

Scenario No. 1You receive a request for records on a single patient or a small number of patients. The carrier con-cludes that services were miscoded. The services were coded correctly and the reason for the deter-mination was a misunderstanding about the con-tents of the documentation. Although you disagree with the result, the refund amount demanded is small, the decision is made that it is not worth arguing about, and the money is refunded. Because you are a mid-size physician group, the issue is handled through the compliance/billing depart-ment—the physicians don’t like to be bothered with these things, are not advised, and, therefore, have no knowledge of the issue.

U.S. v. Stokes: Compliance Implications for the Average PhysicianFailure to take corrective action can be perceived as admission of guilt.By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CHCC, CRA


coding compass

Scenario No. 2Your office receives written correspondence about use of a certain code. The correspondence includes coding policies that are unique to that carrier. They are reviewed by your billing/compliance staff. After review, the information is filed and the physician never sees it.

Scenario No. 3A carrier posts a provider alert on its website iden-tifying potential errors pertaining to a service you bill. According to the provider alert, you are billing incorrectly, but neither the provider nor the staff sees the alert.

Determine the RisksNow let’s apply the court’s reasoning in Stokes to determine what kind of risk is created in each scenario:

Compliance Risk No. 1Your acceptance of the audit result and its con-clusions without objection or appeal would be construed in a subsequent matter as agreement with the carrier’s conclusions. Even though the physician had no actual knowledge of the issue, the physician would be charged with knowledge of the error (the legal term is “constructive knowl-edge”). Based on the holding in Stokes, the govern-ment could then demonstrate knowledge of the error in a subsequent investigation, making the chances of being accused of similar, future fraud allegations more likely.

Compliance Risk No. 2There is an unfortunate presumption in the hold-ing of Stokes that coding and documentation rules are universal. Once again, because you did not respond to the correspondence, the conclu-sion would be that you agreed with the carrier’s concerns. Based on the outcome of Stokes, those

policies may be applied to billings to another carrier (even though that carrier may not have a similar coding policy). The failure to take correc-tive action could be construed as willful conduct from that point forward. The physician could be charged with knowledge of this correspondence, whether or not it was seen.

Compliance Risk No. 3The physician could be charged with knowledge of information in provider bulletins, in carrier e-newsletters, and in carrier medical policies even though they are only published on the carrier’s website. As an example, the government requires you to be familiar with the Centers for Medicare & Medicaid Services (CMS) Internet-only manuals and local coverage determinations (LCDs), which generally are available only on the web. Regardless of whether you saw or read these materials, you are responsible for doing so. The government need not prove actual knowledge of the contents of such documents. Constructive knowledge exists when you had an opportunity to know what these mate-rials contained.

Knowledge is a key element of demonstrat-ing fraudulent conduct and is often the most difficult element of fraud for the government to prove. Unfortunately, the holding in Stokes, as illustrated in the aforementioned scenarios, clearly demonstrates how knowledge can be attributed to you.

Providers, billing staff, and compliance personnel are encouraged to:

1. Pay attention to all carrier correspondence, provider bulletins, and medical policies addressing your services, especially for Medi-care and carriers with which you participate.

The underlying assumption was the communications and audit notices from BCBSM contained sufficient information to notify Stokes that he was doing something wrong, that the carrier’s conclusions were accurate, and that the bill-ing rules for BCBSM and Medicare were the same. It also assumed that Stokes actually saw these notices.

36 AAPC Coding Edge

2. Document receipt and review of the informa-tion, object in writing if you disagree, and identify and document any limitations to the instructions (i.e., only applicable to BCBSM).

3. Document the corrective steps taken to ensure future compliance.

4. Re-think refunding money where the amount is small and underlying assertion of error is believed to be inaccurate.

Take Action and Document Your EffortsSpecific to the scenarios presented, the following suggestions are provided to mitigate further risk:

Mitigation Technique No. 1Submit a written objection to the audit result, even if you agree to refund the money because it isn’t enough to fight over. Your objection should detail why, under the relevant contract, medical policy, etc., the carrier’s audit conclusion is inaccurate. Always discuss and evaluate the issue with the billing/compliance staff and the physician. If some-thing in the documentation led the carrier to the wrong conclusion, the physician is in the best posi-tion to correct and apply to future cases.

Mitigation Technique No. 2There are a number of ways to mitigate this prob-lem. Circulate the correspondence and require each staff member, including physicians, to initial when they have read and reviewed the material. A more effective approach is to have a staff member review the policy in detail and present during a periodic compliance meeting the issue, its impact, and rec-ommended solutions. Not only will everyone be apprised of the issue, but documenting compliance-oriented education will reduce your risk of being subject to fraud allegations.

Mitigation Technique No. 3Similar to the issue above, circulate the informa-

tion throughout the billing department and the physicians. For this to occur, the practice first must be aware there is information to circulate. Assign a member of the billing or compliance staff with the responsibility of periodically reviewing changes to your contracted and billed carriers’ websites/newsletters/medical policies. Raise any identi-fied changes during a staff meeting or compliance meeting, or circulate a copy of the notice or policy for individual review. If addressed in a meeting, record the identity of those attending and the issues addressed in your compliance binder. Be sure to follow up with any staff members who were absent from the meeting. When circulating a copy of the notice or policy, make sure each individual verifies by initials or other means that he or she reviewed the material, and place the returned copy in your compliance binder.

The holding in Stokes makes it clear that physicians can no longer remain aloof to billing policies or billing issues, especially when alleged coding and medical necessity errors are based on documenta-tion defects. Unfortunately, compliance plans and compliance personnel will not solve the problem entirely. At the end of the day, all providers must make a personal effort to understand and comply with carrier documentation and coding rules. To mitigate the potential of becoming a fraud target, providers must challenge inaccurate determinations when they occur, or take immediate corrective action when concerns are legitimate.

Providers should re-think refunding money where the amount is small and underlying assertion of error is believed to be inaccurate.

coding compass

Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, is president of Practice Masters, Inc. and the founding partner of Miscoe Health Law, LLC, a member of the AAPC Legal Advisory Board (LAB) and a past member of National Advisory Board (NAB). He is admitted to the Bar in the state of California and to practice law before the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. Mr.

Miscoe has nearly 20 years of experience in health care coding and over 14 years as a compliance expert testifying in civil and criminal cases.


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Apprentices


Shelton Ray Welch, CPC-A Fremont CALucelmina Araneta, CPC-A Fullerton CAMa.Elenita Vargas, CPC-A Gardena CAKristen Fan, CPC-A Glendora CACarol A Ballard, CPC-A Huntington Beach CASteven Herbert, CPC-A Huntington Beach CALoujean Kapinus, CPC-A Irvine CAKuangChin Yang, CPC-A Irvine CAJohn V Rigor, CPC-A La Palma CAHonorio Santos, CPC-A Laguna Niguel CATyler A Youderian, CPC-A Lakewood CABridgette Lopez, CPC-A Lomita CAMelissa Shumsky, CPC-A Lomita CAMary Walsh, CPC-A Lomita CAGregory Brown, CPC-A Los Angeles CAMarvin Gomez, CPC-A Los Angeles CAOneika Denise Parker, CPC-A Los Angeles CAMichelle Bustos, CPC-A Norwalk CAAileen A Llave, CPC-A Norwalk CAApril M Thomas, CPC-A Norwalk CAKarina Autz, CPC-A Oakland CADavid Bliss, CPC-A Oakland CAGina Sandler, CPC-A Oakland CAWarren Taylor, CPC-A Oakland CAMaggie Vashel, CPC-A Oakland CAKevin Watkins, CPC-A Oakland CALisa Woll, CPC-A Oakland CATina Muela, CPC-A Oakley CAHenry James Robicheaux, CPC-A Oceanside CAValerie Nicole Cortez, CPC-A Ontario CABetty Laughlin, CPC-A Orange CATheresa Mayer, CPC-A Orange CAGrace Ann Rebuck, CPC-A Pinole CACristina Batugal, CPC-A Pittsburg CAGrace Kim, CPC-A Rancho Palos Verdes CAJayne M Groen, CPC-A Rancho Santa Margarita CAMarie Negron, CPC-A Rolling Hills Estates CAErna Doctora Cruz, CPC-A San Diego CAMichael Tyrone Ingram, CPC-A San Diego CAStephanie K Lean, CPC-A San Diego CAVirginia Cordova West, CPC-A San Diego CAMigdalia Herrera, CPC-A San Pablo CAThan Aung, CPC-A San Pedro CAJane I Wang, CPC-A Sierra Madre CABamidele (Dele) Olufunmilola Grillo, CPC-A South San Francisco CATeresita Almeda, CPC-A Torrance CAYaeko Mihara, CPC-A Torrance CAAngelica Oreta, CPC-A Torrance CAKristy Payne, CPC-A Torrance CAElizabeth Smith, CPC-A Torrance CAChara Perez, CPC-A Turlock CAMarsha Diy, CPC-A Tustin CAElpidio Javier, CPC-A Valencia CALynn Ledesma, CPC-A Valencia CADonna Marie Peters, CPC-A Yorba Linda CAVicki L Boisen, CPC-A Loveland CODenise Dawn Kelley, CPC-A Loveland COElizabeth Rebaleati, CPC-A Loveland CODavid Scott Russell, CPC-A Loveland COChristine Ann Webb, CPC-A Loveland COCarrie B Giesler, CPC-A Windsor COBonita Camire, CPC-A Beacon Falls CTDaisy Tali Martinez, CPC-A Bridgeport CTRobyn Chase, CPC-A Bristol CTTheo W Pawlowski, CPC-A Broadbrook CTElissa Genereux, CPC-A Brookfield CTLaura V LaPointe, CPC-A Coventry CTCatherine C Wood, CPC-A Coventry CTEileen Pendl, CPC-A Cromwell CTCarolanne Rowe, CPC-A Danielson CTJacqueline Doris Cormier, CPC-A East Hartford CTMegan Hope Obrero, CPC-A East Hartford CTDeborah A Parlos, CPC-A East Windsor CTNicole Desiree Laymon, CPC-A Glastonbury CTMichael Stein, CPC-A Glastonbury CTKristen Tobias, CPC-A Griswold CTKasy A Reyes, CPC-A Hartford CTTracey LaForge, CPC-A Manchester CTSusan Levine, CPC-A Manchester CT

Lisa Nisula, CPC-A Manchester CTCarol Lynn Phillips, CPC-A Manchester CTLaura Kristin Gulliksen, CPC-A Marlborough CTPatrice C Smart, CPC-A Marlborough CTMaureen Gradzewicz, CPC-A Meriden CTGail VanDerLinden, CPC-A Middletown CTShannon Santos, CPC-A Naugatuck CTDee-Anna Sybal, CPC-A New Britain CTMeg Jane Scarneo, CPC-A New Fairfield CTBrenda Wilson, CPC-A New Haven CTRajmonda Xhaxho, CPC-A Newington CTMadeline Medina, CPC-A South Windsor CTKristin Ruthen, CPC-A South Windsor CTJohanna Lawry, CPC-A Tariffville CTDawn Seitz, CPC-A Terryville CTJune Cameron, CPC-A Thomaston CTShawn Murowsky, CPC-A Thomaston CTDebra Ann Anderson, CPC-A Tolland CTNancy Randall, CPC-A Uncasville CTMarsha A Alexson, CPC-A Vernon CTLisa C Gardiner, CPC-A Vernon CTAmy Wessell, CPC-A Vernon CTSarah Femia, CPC-A Wallingford CTPadmaja Seshadri, CPC-A Weatogue CTAshlie Hernandez, CPC-A West Hartford CTCrystal Marie Antolini, CPC-A Willington CTLaurie Ann Caetano, CPC-A Windsor CTDoreen Tracey Hicks, CPC-A Windsor CTLaurie A Sheahan, CPC-A Wolcott CTAllison Melchiorre, CPC-A Claymont DEJennifer Sutton, CPC-A Wilmington DEMelanie Taylor, CPC-A Apopka FLLuisa E Hassen, CPC-A Brandon FLChristy A Torres, CPC-A Brandon FLChristina Zibers, CPC-A Cape Coral FLRenee Moore, CPC-A Clermont FLWalda Gonzalez, CPC-A Coral Springs FLKimberly Cunningham, CPC-A Hernando Beach FLAnnette White, CPC-A Hobe Sound FLKaren L Felix, CPC-A Hollywood FLBonita A Bope, CPC-A Homestead FLIsbelys C De Armas, CPC-A Homestead FLRaquel Leal, CPC-A Homestead FLTammy Roessner, CPC-A Houdson FLBhavna Jobanputra, CPC-A Jacksonville FLSelesia Lujuana McClendon, CPC-A Jacksonville FLSandra Nichols, CPC-A Jacksonville FLNadine Bignall, CPC-A Kissimmee FLKeysha Clemente, CPC-A Kissimmee FLAdalgisa Fernandes, CPC-A Kissimmee FLVirgen Galarza, CPC-A Kissimmee FLPhillipa McFarlane, CPC-A Kissimmee FLKrystal Melendez, CPC-A Kissimmee FLAlma I Santiago, CPC-A Kissimmee FLBetsy Santiago, CPC-A Kissimmee FLNeha Vinay Shukla, CPC-A Lake Mary FLTiffiny Leshon Smith, CPC-A Lake Wales FLArica Ann McGraw, CPC-A Lakeland FLFlorence Hoadley, CPC-A Land-O-Lakes FLRachel D Moore, CPC-A Largo FLLeandra Samuel, CPC-A Lauderhill FLJennifer Rebecca Perry, CPC-A Longwood FLRobert E Fields, CPC-A Lutz FLMarianne Fraser, CPC-A Melbourne FLMarley Gagliardi, CPC-A Merritt Island FLMaxine Kelly, CPC-A Miami FLDawn Greaves, CPC-A Miramar FLAnita Gatlin, CPC-H-A Mount Dora FLRuth Nuss, CPC-A New Port Richey FLAnthea J Lewis, CPC-A North Lauderdale FLDonna Morgan, CPC-A North Miami FLAinalem Almonte, CPC-A Orlando FLKelly Chase, CPC-A Orlando FLAundrea Melvin, CPC-A Orlando FLHeloisa Tarnan Pereira, CPC-A Orlando FLBeatrice Vazquez, CPC-A Orlando FLYareliz Vazquez, CPC-A Orlando FLNorma Young, CPC-A Orlando FLEvelyn Zimmerman, CPC-A Orlando FLZeenat Lalani, CPC-A Ormond Beach FL

Julie N Adams, CPC-A Palm Bay FLAnn Schnitzer, CPC-A Palm Bay FLKimberly Hollins, CPC-A Palm Coast FLAnna Lojewski, CPC-A Palm Coast FLOlga Hollmann, CPC-A Pembroke Pines FLMonika Rose, CPC-A Plantation FLCarol Harvison, CPC-A Riverview FLCourtney Flores, CPC-A Saint Cloud FLChandra Howton-Riley, CPC-A San Antonio FLTammy Lynn Valko, CPC-A Sebastian FLBrian Geary, CPC-A Spring Hill FLKandi Middleton, CPC-A Spring Hill FLChristine Mondo, CPC-A Spring Hill FLAngela Sancenito, CPC-A Spring Hill FLSamantha Sancenito, CPC-A Spring Hill FLDouglas Szymanski, CPC-A Spring Hill FLStephen Taylor, CPC-A Spring Hill FLMelissa Arnold, CPC-A St Augustine FLAimee Powell, CPC-A St Cloud FLJohn Toomer, CPC-A St Cloud FLHector Roxas Aguilar, CPC-A Tampa FLKritsia Figueroa, CPC-A Tampa FLGregory S Gitlitz, CPC-A Tampa FLDemetria S Green, CPC-A Tampa FLDebbie Perham, CPC-A Tampa FLTracy Shamonsky, CPC-A Tampa FLKelly-Noelle Wells, CPC-A West Melbourne FLMartha Franklin Van Hoose, CPC-A Winter Park FLAshley Hollars, CPC-A Acworth GAJennifer Jo Gartrelle, CPC-A Braselton GAKay Walters, CPC-A, CPC-H-A Canton GAKatie Simmons, CPC-A Cartersville GAErin Blair, CPC-A Cleveland GARegina Joan Lee, CPC-A Cumming GATracy Wolfe, CPC-H-A Cumming GAPatricia E Dixon, CPC-A Dacula GAKelly Massaro, CPC-A Flowery Branch GAJulie Lowe, CPC-A Gainesville GAWanda Bridges, CPC-A Gray GATikisha Genea Winbush, CPC-A Lithonia GAAmy Michelle Ross, CPC-A Marietta GAAlia Natasha Naffouj, CPC-A Martinez GALeslie Sargent, CPC-A McDonough GAJohn Bennett, CPC-A, CPMA Milton GAVirgil Jones, CPC-A Powder Springs GAHeather Ebright, CPC-A Meridian IDIsabel M Cowley, CPC-A Aurora ILDipty Amit Maharaj, CPC-A Aurora ILAmy Jo Webb, CPC-A Charleston ILZenaida Ramos, CPC-A Chicago ILHannah MK Zimmerman, CPC-A, CPC-H-A Dakota ILCasey Henry, CPC-A De Land ILRachel A Eichorn, CPC-A Decatur ILMelissa M Stowell, CPC-A, CPC-H-A Dixon ILPatti K Susan, CPC-A, CPC-H-A Dixon ILJanice Louise Wagner, CPC-A, CPC-H-A Dixon ILLaTreece M Nelson, CPC-A Evergreen Park ILDionis R Fleischer, CPC-A, CPC-H-A Freeport ILSusan M Paonessa, CPC-H-A Freeport ILJessica Gail Robertson, CPC-A, CPC-H-A Freeport ILJeannine C Frye, CPC-A, CPC-H-A German Valley ILLindsey Broyles, CPC-A Hoffman Estates ILLori A Meyers, CPC-A, CPC-H-A Lena ILKenna Rene'e Robinson, CPC-A Lewiston ILJennifer Jeanne Thomas, CPC-A Mackinaw ILCindy Hall, CPC-A Mattoon ILPamela Jo Hoelscher, CPC-A Mattoon ILMarlena A Kerr, CPC-A, CPC-H-A Mt Carroll ILTerri L Raisbeck, CPC-A, CPC-H-A Mt Carroll ILKameke Lashae Johnson, CPC-A Peoria ILLajava Alise Wade, CPC-A Peoria ILShawn V Morales, CPC-A Riverton ILMelissa Marie Booker, CPC-A, CPC-H-A Rockford ILLynn McKee, CPC-A Rockton ILJulie Ann Brigham, CPC-A, CPC-H-A Savanna ILKate A Gillespie, CPC-A, CPC-H-A Sterling ILAngie Rae Shimon, CPC-A, CPC-H-A Sterling ILSamantha Jo Brunner, CPC-A, CPC-H-A Stockton ILAlicia Kay Dever, CPC-A Sullivan ILDawn M Bailey, CPC-A Tremont IL

Michelle Lynn Eatherton, CPC-A Waterloo ILEsther Schoen, CPC-A Corydon INLaura Ausderan, CPC-A Fort Wayne INLisa Barker, CPC-A Fort Wayne INAmanda Hughes, CPC-A Fort Wayne INTracy Knipstein, CPC-A Hoagland INDonielle Y Martin, CPC-A Indianapolis INJosh Vinson, CPC-A Indianapolis INJo Anne Kuc, CPC-H-A Schererville INJean Marie Dworniczek, CPC-H-A Valparaiso INSandy Proud, CPC-A Waterloo INMark Brocker, CPC-A Kansas City KSCarol M Thurston, CPC-A Lawrence KSChris Schelp, CPC-A Lenexa KSCourtney Ann Cunningham, CPC-A Manhattan KSKaren K Gilliland, CPC-A Topeka KSChristina Leigh Knutson, CPC-A Topeka KSAntuan Karion Kyles, CPC-A Topeka KSTonya Brandenburg, CPC-A Berea KYSue Curtis, CPC-A Bowling Green KYSusan Lynn Gardner, CPC-A Bowling Green KYPeggy Aleshire, CPC-A Clinton KYAmy Lynn Perkins, CPC-A Cynthiana KYVeronica Decker, CPC-A Edmonton KYTracy Faul, CPC-A Georgetown KYDeborah Jones, CPC-A Georgetown KYMelissa Baldridge, CPC-A Lexington KYAdam Cook, CPC-A Lexington KYLori Cooper, CPC-A Lexington KYDanny J Elmore, CPC-A Lexington KYNoelle K Evans, CPC-A Lexington KYSabrina Hall, CPC-A Lexington KYWendy Hightower, CPC-A Lexington KYDenise Megge, CPC-A Lexington KYJudy Riddell, CPC-A Lexington KYBen Rollins, CPC-A Lexington KYTeresa Smith, CPC-A Lexington KYHattie Stonecipher, CPC-A Lexington KYTheresa Rae Griffiths, CPC-A, CPC-H-A Louisville KYMelissa Williams, CPC-A Louisville KYChad Buckley, CPC-A Midway KYElinor Grimes, CPC-A Nicholasville KYJennifer Smith, CPC-A Shelbyville KYTracey Amis, CPC-A West Paducah KYSandra Castle, CPC-A Winchester KYAlicia Danos, CPC-A Baton Rouge LAKim Freeman, CPC-A Bogalusa LAPaige Pertuis, CPC-A Bush LAMissy Fitzpatrick, CPC-A Destrehan LACarl Dexter Hurst, CPC-A New Orleans LAAlison Morse, CPC-A Ayer MAAudrey Sowell, CPC-A Granby MAJulia Fabian, CPC-A Lawrence MARose Bednar, CPC-A Millbury MADiane Rollins, CPC-A Northborough MADeborah Stanley, CPC-A Rutland MALorna Christiansen, CPC-A Webster MARonda J Burns, CPC-A West Boylston MAMark Laserte, CPC-A Worcester MARon Cicio, CPC-A Baltimore MDColleen Rhine, CPC-A Baltimore MDAnnellen Moore, CPC-A Bowie MDJaneice Gail Kelly, CPC-A Carl Junction MDKristen Trombero, CPC-A Chuchville MDKassia Jamison, CPC-A Columbia MDLisa Moore, CPC-A Crofton MDLinda Tolliver, CPC-A Easton MDMaria Stabosz, CPC-A Glen Burnie MDMarian Tucker, CPC-A Laurel MDLeandra Osei, CPC-A Silver Spring MDBeth Anders, CPC-A Street MDCeleste Mariano-Perrigo, CPC-A Berwick MEKymberly York, CPC-A Carmel MECarol E Hill, CPC-A Denmark MECarmen C Gagnon, CPC-A Kennebunk MEHeather Barnes Adams, CPC-A Limington MECatherine Elizabeth Hanson, CPC-A Livermore MEMichelle Poulin, CPC-A Saco MEJoseph Duclos, CPC-A Shapleigh MEErin Thurlow, CPC-A Unity ME

Mandy L Brydges, CPC-A Grand Rapids MICatherine Ann Heatley, CPC-A Grand Rapids MIPlereah Charmell Mayfield, CPC-A Grand Rapids MIDorothy Kay Popma, CPC-A Grand Rapids MIKoyya Brandie Taylor, CPC-A Grand Rapids MIKari Kaye Lohman, CPC-A Jenison MIGabrielle Davida Mae Vanstedum, CPC-A Lake Odessa MIMary Garrett, CPC-A Livonia MIDavid Nichols, CPC-A Livonia MITammy Lynn Kolean, CPC-A Middleville MISharey J Goerke, CPC-A Newaygo MIMary Roussey, CPC-A Novi MIDeTreda Buford, CPC-A Romulus MIHeather Martz, CPC-A Roseville MIDawn Findley, CPC-A Traverse City MIDebra Kraus, CPC-A Westland MIBrenda McGee, CPC-A White Lake MIShawn C Simons, CPC-A Wyoming MIConnie Louise Nielsen, CPC-A Brownville MNKristin Ann Jeanette Campbell, CPC-A Houston MNKiva Stevens, CPC-A Rochester MNChristina Marie Staige, CPC-A Winona MNMary L Nestor, CPC-A Ballwin MODiane M Lane, CPC-A Cape Girardeau MOStephanie Nicole Robertson, CPC-A Chesterfield MOJackie Zellmer, CPC-A Creighton MOCynthia Michele Hooker, CPC-A Desoto MOSandra Lynn Shepherd, CPC-A Florissant MOElan Wright, CPC-A Raytown MOLaDora L Erickson, CPC-A Senaca MOPortia Blaser, CPC-A St Charles MOAmy Lynn King, CPC-A St Louis MOApril Evelyn Piilani Wilkerson, CPC-A St Louis MOIleana Stewart, CPC-A St Peters MOJamie Elizabeth Green, CPC-A Sunset Hills MOEdna Blasingame, CPC-A Ackerman MSRobin L Rakestraw, CPC-A Blue Springs MSJennifer L Renfroe, CPC-A Hernando MSMelissa J Bates, CPC-A Horn Lake MSKimberley G Green, CPC-A Horn Lake MSVicci D McCreary, CPC-A Southaven MSKatie Elizabeth Worden, CPC-A Southaven MSSanda Campbell, CPC-A Aberdeen NCChetan Deshmukh, CPC-A Cary NCStephanie Bays, CPC-A Charlotte NCPaula Chapman, CPC-A Charlotte NCVarsha Evans, CPC-A Charlotte NCGeorge Holton, CPC-A Charlotte NCHugh Christopher Polland, CPC-A Charlotte NCPamela Wyatt, CPC-A Clemmons NCLinda Jurgensen, CPC-A Durham NCAnita E Jones, CPC-A Evergreen NCBriana Davis, CPC-A Goldsboro NCAmelia Perry, CPC-A Hampstead NCMonica Brett, CPC-A Hubert NCAleasha Michelle Humphrey, CPC-A Jacksonville NCCindy Hardin, CPC-A Kannapolis NCJennifer Graham Burleson, CPC-A Locust NCJennifer Pickett Lee, CPC-A Maysville NCMelanie Underwood, CPC-A Monroe NCBobbie Brown, CPC-A Mooresville NCRobin Morrison, CPC-A Mooresville NCTammy Greene, CPC-A Mt Pleasant NCRebecca Evans, CPC-A Princeton NCWendy Reed Archible, CPC-A Raleigh NCAmy O'Connor, CPC-A Richlands NCYvaughn Mullis, CPC-A Salisbury NCThomas Angel, CPC-A Statesville NCSherry Blevins Kilby, CPC-A Statesville NCLois Pelto, CPC-A Statesville NCSandra Wright, CPC-A Statesville NCScottie Mays, CPC-A Taylorsville NCBonni Staples, CPC-A Waxhaw NCConnie Crissman, CPC-A Youngsville NCJoy C Doll, CPC-A Mandan NDJennifer Lynn Brinegar, CPC-A Lincoln NEMeghan Lowry, CPC-A Manchester NHCathy Trombetta, CPC-A Meredith NHAshley Margaret Yahrling, CPC-A Blackwood NJ


40 AAPC Coding Edge


Joanne Havlicek, CPC-A Deptford NJWayne Toscano, CPC-A Egg Harbor Township NJBarbara Goszka, CPC-A Flemington NJCarolyn Joyce-Goodwin, CPC-A Flemington NJDevi Chidambaram, CPC-A Hillsborough NJMandvi Tandon, CPC-A Jersey City NJAndrea Bobb, CPC-A Pennsville NJDaniel J Long, CPC-A Swedesboro NJJanet M Hall, CPC-A West Deptford NJNicholas Michael Reyes, CPC-A Woodbury NJTomrita Naomi Andy, CPC-A Albuquerque NMDianne M Crozier, CPC-A Magdalena NMCynthia Judge, CPC-A Amherst NYLinda Anne Newell, CPC-A Amherst NYNadeen Daniel, CPC-A Brooklyn NYCecilia Ferrera, CPC-A Brooklyn NYPatricia Hamilton, CPC-A Brooklyn NYJoanna DeJesus, CPC-A Carmel NYSusan Gonzalez, CPC-A Elmira NYKelly A Haynes, CPC-A Elmira NYKathleen R Rhodes-Riker, CPC-A Horseheads NYHazel Best, CPC-A Jamaica NYDebra A Fisher, CPC-A Kingston NYLaShonda Donetta Corey, CPC-A Liverpool NYAlina Majewski, CPC-A Maspeth NYKristen E Spickerman, CPC-A Middleburgh NYCassandra Marie Vallee, CPC-A Niagara Falls NYEileen G Blair, CPC-A North Syracuse NYMatthew Graham, CPC-A North Syracuse NYMary F DoKuchitz, CPC-A Oneonta NYJon Shobin, CPC-A Smithtown NYJudith Giammarino, CPC-A Staten Island NYPatricia Hewston, CPC-A Swan Lake NYMartina Marie Delfuoco, CPC-A Syracuse NYKathryn Elizabeth Castaldo, CPC-A Walden NYKimberly Gayle Pacenza, CPC-A Walden NYCheryl Lynn Veith, CPC-A Walden NYMaryann Graziadio, CPC-A Warwick NYCourtney Lutz, CPC-A Waterloo NYKatherine M Sears, CPC-A Webster NYDenise A Nagode, CPC-A West Seneca NYAmy L Ramadhan, CPC-A West Valley NYAmy F Janke, CPC-A Akron OHMarlena Rudd, CPC-A Batavia OHPatricia A Sirna, CPC-A Bedford OHLori Dawn Sanders, CPC-A Chesapeake OHSusan Jerge, CPC-A Columbus OHPaddy Lyons, CPC-A Edison OHLadelle V Small, CPC-A Euclid OHElizabeth C Rothacker, CPC-A Fairview Park OHJo Anne Davies, CPC-H-A Gahanna OHJairia C Caldwell, CPC-A Garfield Heights OHAmanda Thompson, CPC-A Grafton OHAutumn Marie Bourgeois, CPC-A Hubbard OHKim Corron, CPC-A Jefferson OHTina M Leasure, CPC-A Lexington OHLaura Ann Rice, CPC-A Lexington OHHelen Elaine Bailey, CPC-A Mansfield OHTricia Ann Carroll, CPC-A Mansfield OHJennifer Circosta, CPC-A Mansfield OHGerald F Krupar, CPC-A Mantua OHPamela J Sobieski, CPC-A Mentor OHPaula J Jablonski, CPC-A Mosury OHChristina Louise Moody-Roudebush, CPC-A Newton Falls OHChristina M Spung, CPC-A Olmsted Falls OHApril Bucci, CPC-A Parma OHBarbara Ann Messinger, CPC-A Proctorville OHAdrienne Prince, CPC-A Richmond Heights OHDebra Arlene Taylor, CPC-A Vandalia OHKathy Stevenson, CPC-A Wellington OHMichael Hellyar, CPC-A Westlake OHHeather Siders, CPC-A Willoughby OHTricia Ann Terlesky, CPC-A Youngstown OHFelicia Jones, CPC-A Oklahoma City OKCherice Taylor, CPC-A Oklahoma City OKTina M Collins, CPC-A Aloha ORMaureen Beatty, CPC-A Beaverton ORKaren E Frost, CPC-A Clackamas ORGina Washington, CPC-A Gresham ORTerry Keeler, CPC-A Junction City ORClaudia Leigh, CPC-A McMinnville ORNancy Cummings, CPC-A Milwaukie ORAlicia A Henson, CPC-A Milwaukie ORCatherine Moore, CPC-A Newberg ORDonna Lavonne Dyal, CPC-A Portland ORKaye Killgore, CPC-A Portland ORHeather Kramer, CPC-A Portland OR

Sarah Ysasaga, CPC-A Portland ORAumbria Caspers, CPC-A Salem ORVirginia McEntee, CPC-A Bensalem PAAngela Bunch, CPC-A Burnham PAJuanita K Lehman, CPC-A Carlisle PAMichele Savoie-Shevlin, CPC-A Carlisle PAMarlene Stank, CPC-A Catawissa PAJennifer Lynn Britton, CPC-A Corry PABrenda Lee Jacobs, CPC-A East Springfield PAMichaelyn R Orlando, CPC-A Erie PATheresa Ann Schaeffer, CPC-A Erie PACurtis Daniel Space, CPC-A Erie PADenise Tousey, CPC-A Erie PASharon Irene Toy, CPC-A Erie PASylvia Musser, CPC-A Hanover PABert Baker, CPC-A Lancaster PAKori McDaniel, CPC-A Linfield PAMelinda Dressler, CPC-A McAlisterville PABill Gerry, CPC-A Norristown PAHolly Vanvolkenburg, CPC-A North East PAKelly Kennelly, CPC-A Palmyra PAAmy Renee Cross, CPC-A Saegertown PAJoyce M Schittler, CPC-A Sinking Spring PAApril Lynn Winnies, CPC-A Spring City PAPeggy Shaw, CPC-A Springfield PAMary Tucker, CPC-A Warren PAShannon Marie Shaffer, CPC-A York PALisa L Verdi, CPC-A Westerly RINellie Wade, CPC-A Campobello SCTammy W Bauknight, CPC-A Chapin SCJane Mcmanus, CPC-A Florence SCBregma Barrera, CPC-A Fort Mill SCAnn Myers, CPC-A Greer SCVicki Carnes, CPC-A Lancaster SCKimberly Nicole Hopkins, CPC-A Ware Shoals SCNicole Siobhan Buchanan, CPC-A Waterloo SCCarol Hansen, CPC-A Irene SDLyndsie Leigh Clark, CPC-A Antioch TNToni Wellman, CPC-A Antioch TNMonica Homonnay, CPC-A Brentwood TNLaurie Daugherty, CPC-A Burns TNShelia Monroe Flatt, CPC-A Cane Ridge TNDeanna Suzanne Jarrell, CPC-A Chapel Hill TNChristel Felts, CPC-A Clarksville TNJulie Gallacher, CPC-A Clarksville TNFelecia Ann Armstrong, CPC-A Columbia TNShanika Clyburn, CPC-A Columbia TNVickie Fuller, CPC-A Columbia TNDebra Grate, CPC-A Columbia TNKathy Hodge, CPC-A Columbia TNDiane E Jones, CPC-A Columbia TNEdna (Nell) Lassiter, CPC-A Columbia TNWilliam Lorz, CPC-A Columbia TNSandra Simmons, CPC-A Columbia TNPierman Peggy, CPC-A Cornersville TNJames R Hendricks, CPC-A Gallatin TNApril Young, CPC-A Greenbrier TNAngela Michael, CPC-A Hartsville TNJohannson D Lynn, CPC-A Hendersonville TNHaley McLaughlin, CPC-A Jackson TNCarol J Carmichael, CPC-A Knoxville TNCamille Hanggi, CPC-A Knoxville TNLeslie Nation, CPC-A Lebanon TNLaurie Longchamps, CPC-A Lewisburg TNTina Kunkelman, CPC-A Manchester TNTraci Michele King, CPC-A Murfreesboro TNMaima J Massaquoi, CPC-A Murfreesboro TNJana Beth Rich, CPC-A Murfreesboro TNBrandon Spangler, CPC-A Murfreesboro TNRoline Hodge, CPC-A Nashville TNSarah Temkin, CPC-A Nashville TNMichelle Renee Walls, CPC-A Pulaski TNCathleen M Barry, CPC-A Rutledge TNMelissa Cozze, CPC-A Spring Hill TNKristina Johnson, CPC-A Springfield TNSandra Kay Fournerat, CPC-A Thompsons Station TNMeagan Smith, CPC-A Watertown TNWilliam Edward Pridgeon, CPC-A Ben Wheeler TXCathy Gardner, CPC-A Dallas TXTigist Gebreyesus, CPC-A Dallas TXBecky Hernandez, CPC-A Dallas TXYvonne Sanchez, CPC-A Dallas TXSabine M Comstock, CPC-A Fischer TXJanet Lee Phillips, CPC-A Ft Worth TXVickie Pursley, CPC-A Ft Worth TXKaren Darden, CPC-A Garland TXDiem Nguyen, CPC-A Grand Prairie TXTramekia Shondel Luster, CPC-A Jefferson TX

Linda Morgan, CPC-H-A Lampasas TXP Kaye Marr, CPC-A Lipan TXSandy Ramirez, CPC-A Lubbock TXKalli Tidwell, CPC-A Lubbock TXBeverly Mardis, CPC-A Mesquite TXJennifer Russell, CPC-A North Richland Hills TXVic Holmes, CPC-A Plano TXCarissa Messenger, CPC-A Rockwall TXAngela De Hoyos, CPC-A San Antonio TXVirginia Leath, CPC-A Springtown TXCecilia Barrett, CPC-A Weatherford TXJami McClendon Burns, CPC-A Weatherford TXSusan Machelle Hicks, CPC-A Weatherford TXTambra N Korson, CPC-A Weatherford TXJoyce Ann Prentice, CPC-A Weatherford TXDeborah Roller, CPC-A Wolfforth TXTamera Livesey, CPC-A Clearfield UTPatricia Shermeister, CPC-A Clearfield UTNathan Ludwig, CPC-A Kearns UTLanae Peterson, CPC-A Magna UTAshley Griffith, CPC-A Midvale UTMariellen Higgins, CPC-A Murray UTMalynda Boyle, CPC-A Ogden UTTraci Pehler, CPC-A Price UTLeslie M Hollingsworth, CPC-A Salt Lake City UTJackie Reed, CPC-A Salt Lake City UTRachel Roy, CPC-A Salt Lake City UTMegan Weber, CPC-A Salt Lake City UTElizabeth M Weist, CPC-A Salt Lake City UTShrina Baumann, CPC-A Sandy UTDebbie Johnson, CPC-A Sandy UTKaren Goddard, CPC-A South Weber UTCheryl Webb, CPC-A Chesterfield VAKelly Dixon, CPC-A Hampton VASushma Raghu, CPC-A Newport News VAVicki Hastings, CPC-A Norfolk VAJenna Marie Neff, CPC-A Petersburg VAJo Schilling, CPC-A Edmonds WAJoan K Soelter, CPC-A Lynnwood WATamra Vandyke, CPC-A Malden WATambra L Hobbs, CPC-A Morton WAKate Kurfess, CPC-A Mountlake Terrace WABrenda Feitler, CPC-A Seattle WAHarmony Nelson, CPC-A Spanaway WAVanessa Crisp, CPC-A Vancouver WAKathy Ackerson, CPC-A Vancouver, WATeri Dove, CPC-A Yakima WATambra Maples, CPC-A Yakima WAKris M Schwier, CPC-A Bangor WITamera Yoghourtjian, CPC-A Bayside WILonnie S Simplot, CPC-A Black River Falls WIMichelle Lee Butterfield, CPC-A Galesville WIKathy Ann Flahive, CPC-A LaCrosse WIErika Lyn George, CPC-A LaCrosse WICheryl Jean Ihle, CPC-A LaCrosse WIShari L Bockenhauer, CPC-A Mindoro WIJoan L McNulty, CPC-A Nashotah WINancy Figon, CPC-A New Berlin WIRhyne C Roberts, CPC-A Onalaska WIJennifer Joy Glynn, CPC-A Onalaska WIAndrea C Jeffers, CPC-A Onalaska WIJennifer Lynn Kaatz, CPC-A Onalaska WITina Millard, CPC-A Oshkosh WISheila Lynn Cavadini, CPC-A Rockland WIJennifer Marie Dols, CPC-A Sparta WILinda Lee Ingenthron, CPC-A Tomah WIBrenda A Boe, CPC-A Trempealeau WIMelanie Vonne Creamer, CPC-A Huntington WVBeverley Ann Kimbler, CPC-A Huntington WVStephanie Ann Klinger, CPC-A Huntington WVCrystal Leigh Miller, CPC-A Huntington WV

David Nance, CPC, CPC-H, CEDC, CEMC Ceres CA

Nicole L Kauffmann, CEMC, CFPC Santa Maria CA

Linda Hinkle, COBGC Vista CA

Kate Lamont, CENTC Ft Myers FL

Theresa Karlene, CHONC Titusville FL

Brenda L Goodrich, CPC, CEDC Churubusco IN

Heather D Dombrowski, CPC, CEDC Ft Wayne IN

Lena Gail Holbrook, CPC, CCVTC Brodhead KY

Belinda Keeling, CPC, CANPC Lafayette LA

Heather D Marean, CPC, CPC-H, COBGC Holden MA

Lauri Williams, CPC, CUC Shrewsbury MA

Stephanie Ann Thebarge, CPC, CEMC New Gloucester ME

Harland Bruce Redmond, CPC, COSC Old Orchard Beach ME

Jessica Smith, CPCD Peru ME

Judy A Roy, CPC, CANPC Turner ME

Melodie Alery, COSC Grass Lake MI

Sally Wilkins, CPC, CHONC Hickory Corners MI

Tressa M McGuire, COBGC Pinckney MI

Christine M Bonn, CPC, CHONC Arden Hills MN

Sue Jordan, CPC, CGSC, CHONC Blaine MN

Rebecca Kramer, CPC, CHONC Bloomington MN

Kimberly Dahlberg, CHONC St Paul MN

Nancy A Frescas, CHONC St Paul MN

Fay Arnold, CPC, CHONC St Paul MN

Kerrie Amos, CPC, CPEDC Blue Springs MO

Dawn Pruitt, CPEDC Cabool MO

Hannah Rowland, CPC, CANPC Mt Pleasant NC

Sharon M Casto, CPC, CEDC Oakboro NC

Delores Roberson Everette, CPC, COBGC Tarboro NC

Angie R Mangum, CPC, CEMC Las Cruces NM

Rachel Keith, CPC, CGSC Voorheesville NY

Desiree Easterwood, CPC, CPRC Akron OH

Wendy Ryder, CPC, CPC-H, CPC-I, CPEDC Hilliard OH

Rhonda Wagner-Shank, CPC, CEMC Middletown PA

Linda Benner, CPC, CPMA, COBGC New Cumberland PA

Karen Marie Goering, CPC, CEMC York PA

Judy A Yauk, CPC, CCC Ashland City TN

Susan Smith, CGIC Chattanooga TN

Rhonda G Crouch, CHONC Cookeville TN

Paul R Wickline, CPC, CPC-H, CEMC Franklin TN

Kristi Terrell, CRHC Hixson TN

Gail A Edmondson, CPC, CEMC Pulaski TN

Crystal Tamara Hunnicutt, CPC, CPMA, CEMC Spring Hill TN

Caroline Tuck, CPEDC Tullahoma TN

Heather E Neal, CPC, CGIC, CGSC, COBGC Mansfield TX

Tammie Newton, CPC, CEDC Mansfield TX

Peggy C Anderson, CPC, CPMA, CEMC Castle Dale UT

Kimberly C Cook, CPC, CEMC Danville VA

Lori Ann Buchanan, CPC, CHONC Mathews VA

Lia M Lisiecki, CPC, CCC, CEMC Oak Creek WI

Sarah Wechselberger, CPC Mountain Home AR

Ann Wooten, CPC Mountain Home AR

Lisa Rosellen Vincent, CPC Tucson AZ

Teresa D Walsh, CPC Tucson AZ

John Paul Mashikian, CPC San Diego CA

Yodchai Lapakulchai, CPC-A Torrance CA

Agnieszka Piasecka-Senior, CPC-A Hartford CT

Rebecca Jane Brewer, CPC Cocoa FL

Lisa O'day, CPC-A Hobe Sound FL

Janet Leclerc, CPC-H Miami FL

Jay Norton, CPC-A Alto GA

Avrom Simon, CPC Chicago IL

Elizabeth Duncan Rich, CPC Carmel IN

Christian J Black, CPC Franklin IN

Debra L Hudak, CPC South Bend IN

Tracy Linette Leslie, CPC-A Oronago MO

Jaime Kristen O'Brien, CPC-A Nashua NH

Denise I Schmidt-Simon, CPC-A Mickleton NJ

Christina A Sweeten, CPC-A Vineland NJ

Nancy Janak, CPC West Seneca NY

Sara LeFever, CPC-A Westfield NY

Nikki Lynn Palmer, CPC Moore OK

Elaine Garczynski, CPC-A Gilbertsville PA

Lisa Ludwig, CPC-A Hanover PA

Danita Dameron, CPC-A McKenzie TN

Cayce Gibson, CPC-A Murfreesboro TN

Michelle M Vollmer, CPC-A Oconomowoc WI

Specialties

Magna Cum Laude

Official CMS Information forMedicare Fee-For-Service Providers

R

Questions AboutMedicare Billing?

http://www.cms.gov/MLNGenInfo

The Medicare Learning Network® (MLN) is the destination for official Centers for Medicare & Medicaid Services (CMS) information for Medicare Fee-For-Service Providers. Get nationally consistent, accurate, timely and free information that will help providers

correctly submit claims the first time. Please visit our website today.

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MLN Coding Edge.Nov.10 FINAL.pdf 1 9/9/10 6:06 PM


A biopsy performed on the same date of service as a more extensive procedure—such as an excision,

destruction, or removal—generally is bundled into that more extensive procedure. But, under two-specific conditions for Medicare and most other payers, a same-day biopsy and more extensive procedure may be reported independently. The qualifying circumstances are outlined specifically in chapter 1 of the National Correct Coding Initiative (NCCI) “General Correct Coding Policies.”

1. “If the biopsy is performed on a sepa-rate lesion, it is separately reportable. This situation may be reported with anatomic modifiers or modifier 59.”

For example, the physician biopsies a lesion on the left breast, and excises a lesion of the right breast. Depending on payer preference (check with your payer), you may report the appropriate biopsy code with modifier LT Left side and the appropriate excision code

with modifier RT Right side; or, you may report the excision code (the “most exten-sive” procedure) without a modifier, and append modifier 59 Distinct procedural service to the biopsy code.

2. “If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the patho-logic examination.”

In other words, if the results of the biopsy prompt the physician to perform a more extensive procedure, both the more extensive procedure and the biopsy may be reported.

As an example, consider a patient with a suspicious lesion on the forearm: If the physician excises the lesion and sends it to pathology, we know that the biopsy is

not reported separately because, as NCCI explains, “If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more exten-sive procedure.”

Suppose, however, that the physician sends a portion of the suspicious lesion for examina-tion, and pathology confirms a malignancy. The physician proceeds to excise the entire lesion. In this case, because the biopsy led to the decision to perform the more extensive procedure, both the excision (e.g., 11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm) and the biopsy (11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion) may be reported separately. NCCI instructs you to append modifier 58 Staged or related procedure or service by the same physician during the postoperative period to the excision code (11603), “to indicate that the biopsy and the more extensive procedure were planned or staged procedures.”

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B008621300

CFHA

CODING EDGE

1/4 PAGE

08-31-2010

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Brad Ericson, MPC, CPC, COSC, is director of membership and publishing at AAPC.[ ]

feature

Bundled or Separate BiopsyDepends on CircumstancesLook to NCCI policy for the two-specific conditions that call for unbundling. By Brad Ericson, CPC, COSC

44 AAPC Coding Edge

a coder’s viewP

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AL I was very impressed by Beverly Haynes’ article in the June issue entitled “Become a Successful Coder in the Class-room.” As an educational consultant and billing/coding

instructor, I share many of Ms. Haynes’ sentiments. I bring to the table more than 20 years’ experience in medical practice management, and, before I became a professional coder, my primary focus had been on billing and reimbursement.

Like Ms. Haynes, I have never actually worked as a coder in a physician’s office; however, I did observe firsthand the types of issues with which an “in-the-trenches” coder may be faced, especially regarding quality of physician documenta-tion and proper communication of information that impacts the cash flow cycle. Authorizations for surgeries, primary care physician (PCP) referrals, Health Insurance Portability and

Accountability Act (HIPAA) compliance and up-to-date demographic data were often an issue. Being the

senior manager of an off-site billing company

made my staff and I further removed from information sources because the medical records were not readily acces-sible to us to determine whether an encounter form was coded properly.

Although we were familiar with the structure of ICD-9-CM and CPT® manuals in terms of what services practitioners and specialists were likely to perform for conditions, the function of our business was essentially reduced to being a processing house based on the “garbage in, garbage out” (GIGO) prin-ciple. We had access to Medicare bulletins and other periodic payer publications, and we would inform the providers as we learned of new coding regulations, deleted or changed CPT® codes, or new reporting guidelines, and we managed our cli-ents’ ongoing accounts receivable. Beyond that, our job, plain and simple, was to process piles of superbills every day for a multitude of specialties, most of which were prepared by hand and delivered by postal mail or courier. Although we submit-ted the bulk of our claims electronically through a clearing-house, it was too much bother and expense for most of our clients to hook up with us for electronic charge capture.

Start at the BottomMy career took a major twist in May 2006 when a “golden opportunity” fell right in my lap. I received an unsolicited call from the regional director of a career school chain. She was looking for a billing and coding instructor. After 18 years as a billing manager, I was getting more and more frustrated deal-ing with countless denials, delays, and underpayments because of poor practitioner documentation and communication. I welcomed this opportunity to bring my knowledge into the classroom. I subsequently shut down the billing business to become a spinoff coder and educational coding consultant. Four years ago I didn’t know how to read a chart note, but I went through intense training, took online courses running the gamut from medical terminology, anatomy (hearing terms I hadn’t studied since my eighth-grade biology class), HIPAA, coding guidelines, and other subjects germane to coding. I joined AAPC in the summer of 2008 and took a Professional Medical Coding Curriculum (PMCC) course that fall. I passed my Certified Professional Coder (CPC®) exam on Dec. 13, 2008, and I haven’t looked back.

ExperienceIs the Best TeacherPMCC instructor offers coding and billing students a taste of the real world.By Ken Camilleis, CPC, CPC-I


a coder’s view

Work Your Way UpIn the past four years, I’ve taught coding to individuals of all ages, from numerous walks of life, with diverse careers, and with different learning capacity. I especially enjoy teaching new students who have no prior knowledge of medical coding, such as a typical audience where the PMCC program begins with the Step-By-Step book.

To grab the attention of students and make learning enjoy-able, I start the first class by:

Breaking the ice with a ‘tell us about yourself and your career goals’ to help students feel comfortable in the classroom.

Illustrating a ‘bird’s eye view of the life cycle of a medi-cal claim’ with an interactive demonstration involving four to six multicolored markers, where each student plays an integral role in the cycle, explaining the process of the life cycle from the time the patient schedules the appointment to when the claim gets paid and posted into the practice management system.

Explaining how lay words like “office visit” and “low back pain” are translated into codes like 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key com-ponents: A problem focused history; A problem focused examina-tion; Straightforward decision making and 724.2 Lumbago.

Bask in the GloryIt really gives me a great feeling when one of my students in this capacity says she wants to move on and pursue a career as a coder. My mentoring has given her that impetus to move forward. While I won’t reach everyone, I feel that each new AAPC member especially every new CPC® or other creden-tialed member I’ve helped and encouraged to continue in the coding field is a feather in my cap.

Kenneth Camilleis has over 20 years’ experi-ence in health care, mostly as a billing spe-cialist. For the last five years, Mr. Camilleis’ primary focus has been coding education, mostly at local career schools. He is the education officer for a Boston-area AAPC chapter, and is preparing education programs related to ICD-10.

join us at the beachwww.aapc.com/longbeach

AAPC NATIONAL CONFERENCE

46 AAPC Coding Edge

added edgeAP

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Take a stand when patients are told you can code differently.

I was very interested to read the article, “Just Change the Code” by Simone Tessitore, CPC, COBGC, in the May 2010 Coding Edge.

Our facility owns multiple primary and specialty care practices, and recently this issue has come to the forefront after several of our practice managers and customer service staff reported patients were calling with angry demands to change codes. When we learned patients had been told by the payers that claims will be paid only if they are coded in a certain or differ-ent way, we knew we had to take a stand.

Inform PatientsFirst, we met with the president of our local medical man-agement association. We asked him to bring this concern to their next meeting and address it with the third-party rep-resentatives who also attend these meetings. At the meeting, the association requested that payers caution their customer service representatives to not suggest to patients that a claim was denied due to the way it was coded, or insinuate that a physician’s office simply could make a change in the code sets to satisfy coverage limitations because, in doing so, they were potentially requesting we commit fraud.

Second, we drafted a disclaimer to present to our patients prior to their receiving services. (See the disclaimer above.)

Patients are expected to sign this disclaimer annually with hope of educating them regarding our commitment to compli-ance, and to protect us from any potential improper billing. For Medicare recipients, this disclaimer is also presented with an Advance Beneficiary Notice (ABN), if appropriate.

Review Claim DenialsErrors occasionally are made with the selection of ICD-9-CM or CPT® codes, particularly in the electronic medical record (EMR) world, where physicians often submit these choices without a pre-billing audit. All patient requests for claim denial review should be performed by a certified coder to determine if an administrative error was made, or if a claim was denied for coverage reasons.

If an error is identified, the original documentation must always support the correct code, and it should be noted the cor-rected claim was resubmitted due to an administrative error—not specifically to meet a payer’s specific coverage guidelines. Appending a record to support an additional diagnosis exclu-sively for payment reasons is inappropriate, but additions may be made to clarify a legitimate ICD-9-CM or CPT® issue.

Discourage physicians from submitting or changing codes specif-ically to meet the demands of patients. It is our responsibility as certified coders to educate our physicians on this risky practice.

Sample DisclaimerAs a courtesy, we will submit your claim for all

services to your insurance company. Please remember your individual health insurance policy is a contract

between you and your insurance company, and we are not a party to that contract. Be aware that some of our

services may not be covered by your insurance policy. By presenting for care, you agree that you are responsible

for all services and charges, regardless of your insurance status. Should any provided services not be covered by your insurance, we will not alter your claim, change

your diagnosis, or report a different service than what was performed in order that your insurance will cover

the charge. You will be responsible for the balance.

Pam Brooks, CPC, PCS, is physician services coding supervisor at Wentworth-Douglass Hospital in Dover, N.H. She has a bachelor of science in Adult Education/Workplace Training, from Granite State College (Con-cord, N.H.) and is enrolled in the MHA program at St. Joseph’s College of Maine. She is experienced in billing, coding, and practice management and is secretary of the Seacoast-Dover, N.H. local chapter.

Don’tChange the CodeBy Pam Brooks, CPC, PCS

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48 AAPC Coding Edge

featured coder

As I write this, it has been over six months since the Centers for Medicare & Medicaid Services (CMS) stopped accepting CPT® consultation codes 99241-99245 (out-patient) and 99251-99255 (inpatient); however, not all payers have followed suit. Many non-Medicare payers still recognize consult codes for appropriately documented services. If you have not done so already, you would be wise to identify your payer consultation guidelines and code accordingly.

Recently, I surveyed payers in my area (Colorado) and most of them distributed a formal policy. You might locate this information in either bulletin or online news-letter format. Often the information is difficult to locate, however, and I’ve found contacting the payer directly is the best way to determine the policy. Locating the appro-priate contact can be tricky as well, but by calling pro-vider relations you should be directed to the right person.

To simplify your request, be prepared to ask the contact what the payer’s status regarding consultation code reim-bursement is by referring to the CMS policy (available at www.cms.gov/MLNMattersArticles/downloads/MM6740.pdf). Often the provider relations contact will direct you to the online policy for your reference. If possible, e-mail the contact so you have additional documented infor-mation supporting the policy. Sometimes the provider relations contact does not respond to email, and docu-menting the details of the phone conversation is adequate (if not preferable).

After collecting the data, list each payer and its policy on consultation codes. For example:

PR

OFE

SSIO

NAL

Consult Your Payer for Consult GuidelinesMedicare no longer accepts 99241-99255, but other payers may.By Lindsey H. Daly, MSHA, CPC

Health Plans No Longer Recognizing Consultation Codes Physicians’ Ally, Inc. has phone or e-mail confirmation that the following health plans no longer recognize con-sultation codes:

ɶ Anthem—MedicareFor Medicare products that Anthem administers only, Anthem follows Medicare guidelines and no longer recog-nizes consultation codes.

ɶ Colorado MedicaidAs of April 1, 2010, Colorado Medicaid no longer accepts consultation services. This affects CPT® consultation inpatient CPT® codes 99251-99255 and office/outpatient consultation CPT® codes 99241-99245.

Health Plans Continuing to Recognize Consultation CodesPhysicians’ Ally, Inc. has phone or e-mail confirmation that the following health plans continue to recognize consultation codes:

ɶ AetnaSince the American Medical Association (AMA) still lists “consult” codes as active in CPT® 2010, Aetna and Cofin-ity continue to accept and price these codes as valid after Jan. 1, 2010. This is subject to future change, however. ɶ Anthem—Commercial

Anthem is not following Medicare’s lead on the consult codes for commercial reimbursement. However, Anthem is discussing a new fee schedule update for Jan. 1, 2011.

Locating the appropriate contact can be tricky as well, but by calling provider relations you should be directed to the right person.


featured coder

For easy reference, refer to Table 1 for a quick-view summary of each payer’s guidelines.

Table 1: Payer Reimbursement—Summary

Payer Status Effective

Aetna Accepts Consultation Codes

Anthem—Commercial Accepts Consultation Codes

Anthem—Medicare Does NOT Accept Consultation Codes 01/01/10

CHP+ Under Review

CIGNA Accepts Consultation Codes

Colorado Access Does NOT Accept Consultation Codes 03/05/10

Colorado Medicaid Does NOT Accept Consultation Codes 04/01/10

Denver Health Accepts Consultation Codes

Humana—Commercial Accepts Consultation Codes

Humana Medicare (MCHMO and MCPPO) Does NOT Accept Consultation Codes 01/01/10

Rocky Mountain Health Plans Does NOT Accept Consultation Codes 04/01/10

UnitedHealthcare—Medicare Solutions Does NOT Accept Consultation Codes 01/01/10

UnitedHealthcare Commercial Accepts Consultation Codes

This is the most recent information available for these payers in Colorado. Be sure to research your specific payer guidelines; and be aware that rules change. It is important to look for notifications to determine when or if health plans will no longer recognize con-sultation codes. Resources:Revisions to Consultation Services Payment Policy(www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf)Revisions to Consultation Services Payment Policy(www.cms.hhs.gov/Transmittals/downloads/R615OTN.pdf)Colorado Medicaid Provider Bulletin, Reference: B1000281, March 2010UnitedHealthcare Consultation Code Update(www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStatic-Files/ProviderStaticFilesPdf/News/2010/ConsultationCode_Update.pdf)

Lindsey H. Daly, MSHA, CPC, is a health care consul-tant with Physicians’ Ally, Inc., where she coordinates projects for physician group practices and practice administrators such as practice analysis and strategic planning, managed care contracting, government insur-ance contracting, and coding/chart auditing reviews. Her experience includes administrative and financial management and process improvement for health care

facilities in Colorado and California. She holds a Bachelor of Science in Finance from the University of Colorado at Boulder and a Master of Sci-ence in Health Administration from the University of Colorado at Denver and Health Sciences Center.

50 AAPC Coding Edge

minute with a member

Coding Edge (CE): Tell us a little bit about your career—how you got into coding, what you’ve done during your coding career, what you’re doing now, etc.Susan: In 1999, I received a Registered Health Information Technician (RHIT) degree. My teachers told me to get more cre-dentials as my career advanced. I took their advice, and have since earned Certified Pro-fessional Coder (CPC®) and Certified Profes-sional Coder-Hospital (CPC-H®) credentials.

I began working for the University of Mis-sissippi Medical Center (UMMC)—a large pediatric department associated with the Blair E. Batson Hospital, and the only chil-dren’s hospital in Mississippi. I focused on evaluation and management (E/M) coding, and training residents and attending physi-cians on those guidelines. After 18 months

with pediatrics and becoming involved with my local chapter, I was offered a job with Renal Care Group at a local chapter meet-ing. At Renal Care Group I was the health information manager (HIM) for 51 facilities throughout the state. I worked closely with Medicare and Medicaid to ensure requested records were received and claims were paid. After four years, they merged with another company and I moved on to work at Mis-sissippi Methodist Rehabilitation Hospital where I was responsible for coding out-patient services for the hospital and their outlying clinics. I began appropriate coding of E/Ms and ambulatory payment classifica-tions (APCs).

My career path eventually led to insurance company Humana, Inc., as a Medicare risk assessment analyst for Mississippi. I visit our providers and review medical records for chronic conditions, and discuss coding issues and health care environment changes. I am a social person so I really enjoy becoming friends with providers and staff. I also enjoy traveling to give seminars to AAPC mem-bers who cannot travel. You may remember the 1957-1963 television series “Have Gun Will Travel.” Well, I feel like “Have coding seminar will travel.”

CE: What is your involvement level with your local AAPC chapter?Susan: I am active in the Jackson, Miss. chapter and have been president-elect and president twice. Now I am a new member development officer. This year the Jackson and Biloxi chapters sponsored a seminar in Hattiesburg to assist those needing continu-ing education units (CEUs).

I really enjoy networking. After all, I did get a job opportunity from one meeting. I ask all my providers’ staff: “Are you credentialed?” If the answer is “No,” I ask, “When are you taking the test?” Several ask for assistance and I give them coding training to refresh anatomy, disease process, and coding.

CE: What has been your biggest challenge as a coder?Susan: Working for Renal Care Group as a liaison between them and Medicare and Medicaid was a wonderful learning experi-ence but most challenging. Health care is ever evolving and I have to keep up, train-ing is a constant challenge in my life. My first seminar was tense, but after I got to know the members, I relaxed and laughed at myself.

CE: How are you and/or your organization preparing for ICD-10?Susan: Humana has always supported their coders with weekly AAPC coding conference calls and monthly, in-house coding calls, and it’s my understanding that all coders will be trained by AAPC’s ICD-10 semi-nar. Humana sends coders to each annual conference. At the conference in Orlando, Fla., I met more Humana coders because we were all taking the same break-out sessions. Great networking!

CE: If you could have any other job, what would it be?Susan: I’m at the end of my career. I love working for Humana and want to retire with this company. If I do anything else, it would be working with medical record documentation, reviews, and external audits.

CE: How do you spend your spare time? Tell us about your hobbies, family, etc.Susan: I live on six acres and have lots of cats and one dog. I support my son, Jeff, while he pursues a bachelor’s degree in com-puter security. My daughter, Sherry, is my accountant since my husband passed away. The two of them keep me exercising and bowling with Wii. Sherry hosts a monthly “girls’ night out” where we play all sorts of games and just have fun.

I enjoy painting; although, I’m not very good as of yet. That learning curve really makes it interesting.

Susan Curtis, RHIT, CPC, CPC-HMedicare Risk Assessment Coder, Humana, Inc. Jackson, Miss.

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SPEAKERSDeborah Grider, AAPC President & CEO, Key Note Speaker

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Shannon Smith (DeConda), Founder of NAMAS/ Coding & Auditing Dept. Director

Rhonda Burkholtz, AAPC Vice President, Business Development

Kevin Townsend, NAMAS Instructor/ Consultant

Melody Irvine, NAMAS Instructor/ Consultant

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*Credentials of speakers along with their biographies may be found on our website.

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