Immigrate to I-10. Plus: 2009 Salary Survey Robotic Assistance Five Documentation Dos Breast Reconstruction. October 2009

Transcription

1 October 2009 Immigrate to I-10 Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, COBGC, CEMC, CDERC, CCS-P Plus: 2009 Salary Survey Robotic Assistance Five Documentation Dos Breast Reconstruction

2 Better understand the context and meaning behind CPT code descriptions! Providing definitions of thousands of medical terms found with the CPT codebook, this must-have expanded, second edition now includes several definitions that are customized to define words in coding terms. Complete with new illustrations and updated appendixes listing detailed medical synonym, eponym, abbreviation and terminology information to help further aid medical understanding. Order #: OP300609DWL Enhance your coding efficiency and make Stedman s CPT Dictionary, second edition part of your everyday routine. Organized by CPT section for easy, side-by-side use with the Current Procedural Terminology (CPT ) codebook Go to or call (800) to order today!

3 contents 44 [contents] 9 24 October 2009 In Every Issue 5 Letter from the President 7 Letter from Member Leadership Features Five Documentation Dos Make the Most of Reimbursement Ensure improved documentation and reimbursement, as well as patient care, with five tips, provided by Dorothy D. Steed, CPC-H, CPC-I, CFPC, CEMC, CHCC, CPUM, CPUR, CPHM, CCS-P, ACS-OP, RCC, RMC, CPAR. 22 Use Op Report Details to Decide Breast Reconstruction Codes Choosing from among breast surgical modification or repair codes is easy if you pay attention to the code descriptors and the specifics of the surgeon s operative notes. Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC, explains. 26 Immigrate to I-10: AAPC Prepares for the New Land With the help of colleagues, our skilled captain, Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, COBGC, CEMC, CDERC, CCS-P, has developed an action plan for AAPC members and others who worry about disembarking on new ICD-10-CM territory. Brad Ericson, CPC, COSC, reports Salary Survey: Certification Protects Members from Recession This year s AAPC Salary Survey shows credentialed coders are weathering the economic storm and proving to be recession-proof. 44 Bundled E/M Services: A Global Perspective Learn how to determine when it is appropriate to separately bill a visit from the global surgical package with the help of Kelly Loya, CPC, CPC-I, CPhT. 48 Coder s Primer on the Anti-kickback Statute and Stark Law A clear understanding of federal fraud and abuse laws is your best defense against the government s arsenal: the anti-kickback statute and the Stark law. Christopher A. Parrella, JD, CHC, CPC, explains. On the Cover: Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, COBGC, CEMC, CDERC, CCS-P, waits to embark with us to new ICD-10 territory. Cover photo by Jennifer Driscoll Photography ( Photo manipulation by Tina M. Smith and Michelle A. Dick. 8 Letters to the Editor Education 12 Coding News Online Test Yourself Earn 1 CEU go to People 38 Newly Credentialed Members 41 Kudos Coming Up The Chief Complaint Legal Edge Gout OB Ultrasound Thermal Chondroplasty Chiropractic Coding October

4 Serving 82,000 Members Including You Targeting the AAPC Audience The 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. AAPC Code of Ethics Members of the American Academy of Professional Coders (AAPC) shall be dedicated to providing the highest standard of professional coding and billing services to employers, clients, and patients. Professional and personal behavior of AAPC members must be exemplary. z AAPC members shall maintain the highest standard of personal and professional conduct. Members shall respect the rights of patients, clients, employers, and all other colleagues. z Members shall use only legal and ethical means in all professional dealings, and shall refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive, or illegal acts. z Members shall respect and adhere to the laws and regulations of the land, and uphold the mission statement of the AAPC. z Members shall pursue excellence through continuing education in all areas applicable to their profession. z Members shall strive to maintain and enhance the dignity, status, competence, and standards of coding for professional services. z Members shall not exploit professional relationships with patients, employees, clients, or employers for personal gain. This code of ethical standards for members of the AAPC strives to promote and maintain the highest standard of professional service and conduct among its members. Adherence to these standards assures public confidence in the integrity and service of professional coders who are members of the AAPC. Failure to adhere to these standards, as determined by AAPC, will result in the loss of credentials and membership with the American Academy of Professional Coders. October 2009 CEO and President Reed E. Pew reed.pew@aapc.com Vice President of Clinical Coding Content Sheri Poe Bernard, CPC, CPC-H, CPC-P sheri.bernard@aapc.com Vice President of Strategic Development Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, COBGC, CEMC, CPCD, CCS-P deb.grider@aapc.com Vice President of Marketing Bevan Erickson bevan.erickson@aapc.com Vice President, Business and Member Relations Rhonda Buckholtz, CPC, CPC-I, CGSC, CPEDC, COBGC, CENTC rhonda.buckholtz@aapc.com Vice President of Product Management David Maxwell david.maxwell@aapc.com Director of Coding Communications John Verhovshek, MA, CPC g.john.verhovshek@aapc.com Director of Member Services Danielle Montgomery danielle.montgomery@aapc.com Director of Publications Brad Ericson, MPC, CPC, COSC brad.ericson@aapc.com Senior Editors Michelle A. Dick, BS Renee Dustman, BS michelle.dick@aapc.com renee.dustman@aapc.com Production Artist Tina M. Smith, AAS Graphics tina.smith@aapc.com Display Advertising Jamie Zayach, BS jamie.zayach@aapc.com Address all inquires, contributions and change of address notices to: Coding Edge PO Box Salt Lake City, UT (800) 626-CODE (2633) 2009 American Academy of Professional Coders, 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 American Academy of Professional Coders. Statements of fact or opinion are the responsibility of the authors alone and do not represent an opinion of the AAPC, or sponsoring organizations. Current Procedural Terminology (CPT ) is copyright 2008 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 the American Academy of Professional Coders. Volume 20 Number 10 October 1, 2009 Coding Edge (ISSN: ) is published monthly by the American Academy of Professional Coders, 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, AAPC Coding Edge

5 letter from the president Investment Research is Your Best EMR Defense Electronic medical records (EMRs) are on health care professionals minds with due cause. With mandates to adopt EMRs and stimulus bill money assistance, providers and hospitals might make hasty decisions, purchasing and implementing systems they may know little about. Physicians and providers who adopt an EMR in a meaningful way (to be officially defined in early 2010) by 2011 or 2012 will earn $18,000 their first year and qualify for the full $44,000 incentive by 2015 or Recipients must demonstrate at least 30 percent of patients are Medicare. The incentives for those who meet the threshold are shown in the table below. Incentive payments for late adopters start to phase out thereafter and are no longer offered after 2014, when EMR adoption is expected to be complete. Under Medicaid, providers would be eligible for reimbursement of 85 percent of allowable EMR costs, not to exceed a maximum over the four years of $63,750. Physicians and providers can be reimbursed based on Medicare or Medicaid, but not both. Hasty Decisions Result in Costly Mistakes You may have heard about the high rate of EMR deinstallations in Phoenix, Ariz. after a 2005 executive order by then Governor Janet Napolitano requiring all health care providers install an EMR by The Phoenix trend is due to an overly aggressive adoption of the mandated technology and to physician shortages making it difficult for doctors and staff to find time for EMR training. Year of Adoption Let the deinstallation trend in Arizona be a warning. Don t let the HITECH section of the stimulus bill influence your practice rashly to purchase a system that will not work well long term. Please don t plop in a system just to qualify for reimbursement payments. I recently spoke to several physicians and offices about EMR implementation and these were the problems encountered: A small physician practice (less than 10) spent $55,000-$65,000 on an EMR two years ago and the physicians still are seeing two fewer patients per day than before. A physician over 60 years-old in family practice said he did not use an EMR and never would. A 24-doctor residency program had no processes within the EMR to account for a teaching facility. Coder review can be cumbersome when you have first year interns who don t treat patients, let alone choose codes for surgeons, and generally have little interest in choosing correct codes. Some Windows based EMRs have numerous clicks to get through any note or billing screen. The number of screens to pull up and look through are too numerous to display on a computer screen. Another risk worth avoiding is purchasing an EMR before meaningful use is finalized; a physician or provider could unknowingly install a noncompliant system that doesn t qualify for reimbursement. Recommend to your physician he or she shop around, do research, and know what he or she is getting into before adopting an EMR. Find something that fits the practice or hospital s needs Total Incentive 2011 $18,000 $12,000 $8,000 $4,000 $2,000 $44, $18,000 $12,000 $8,000 $4,000 $2,000 $44, $15,000 $12,000 $8,000 $4,000 $39, $12,000 $8,000 $4,000 $24,000 Reed E. Pew CEO and President Streamline EMRs with Training Members have also written to me praising EMR adoption in their practices. Their success was due to ample education and training, and to keeping an open mind to a new way of working. To make sure they had a smooth transition from their old systems to new systems, they allowed themselves extra time for training. For example, a practice anticipated 14 days for the installation and training of an EMR system. When they realized they weren t ready to fully implement the new system, they purchased an additional 14 days of on-site training. This extra step to ensure proper education saved the practice money. The physicians said it changed the workflow pattern and increased the number of patients seen per day, but it also increased the staff required to help operate the practice. With no physical chart, they embraced a completely different way of working. The practice purchased its EMR system for $105,000 (paid in monthly installments) and has been using the system since The only downfall they ve experienced resulted from power outages. No power = No access to records. Another physician I talked to said he liked using EMRs because he could still dictate and have front office staff transcribe it into the EMR. He also loved that he can pull up previous patient history with ease and can quickly send prescriptions to a pharmacy. Long-term benefits of EMRs include fewer chart and file storage expenses, reduced transcription costs, and the potential for reduced premiums on malpractice insurance. For an EMR installation to be successful, it must increase physician productivity and be easy enough to use as not to cause physician or staff frustration. A mindset change within the office is your best defense against unsuccessful and costly results. Open your mind to ways you can make it work efficiently for your practice, rather than closing your mind by relishing the medical record system you no longer use. October

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7 letter from member leadership Are Your Physicians, Coders, and Billers Team Players? While consulting, speaking at local chapter meetings, or talking face-to-face with coders, I always ask: How many of you meet regularly as a team to discuss physician compliance, billing denials, or coding errors? I m amazed at how few meet regularly or have ever met at all. Are Your Physicians Approachable? A physician who makes his coding and billing staff feel they can t ask documentation questions exposes the practice to improper payments, potential compliance issues, and inevitable audits. Physician compliance should be monitored continuously. Working in radiology, I see documentation discrepancies all the time. I have a good working relationship with my physicians, however, and feel comfortable discussing documentation issues with them. They expect me to educate them about documentation changes, especially when new codes are implemented at the beginning of the year. Coders are an integral part of the team and should speak regularly with their physicians, which is why the coders office should be near the physician s office. That way, documentation questions can be addressed as they arise, rather than sending them through inter-office mail or leaving them on the physician s desk with a note. The last thing a physician wants to read at the end of the day is a note asking a question about a patient he saw days before. Try to build an open door working relationship with your physicians. They will soon see the enormous asset coders are to them and their office. Coding and billing staff should meet regularly. How often they meet should be decided by the documentation and reimbursement issues uncovered when the two departments speak openly. Coders don t know payerspecific requirements unless the billing staff brings them to their attention. Coders never see claim denials unless given the opportunity to correct them by the billers. Questions billers know, and coders should ask: Are the coders using correct modifiers? What are the payers policy requirements? Questions a physician or office manager should ask billers: How are billers fixing coding denials? Are billers fixing them regardless of whether the rules are known or are they just writing the claim off? Physicians who aren t team players should not point fingers at their staff, as documentation and compliance requirements are the backbone of a clean claim. With so many changes on the health care industry s horizon, physicians and their staff must master basic communication skills and work together as a team if they are to move forward. Good compliance, coding knowledge, and billing practices assure maximum reimbursement and a positive outcome when audited. A team approach is necessary as we move into ICD-10. Is your team ready? Sincerely, Terrance C. Leone, CPC, CPC-P, CPC-I, CIRCC President, National Advisory Board October

8 letters to the editor Please send your letters to the editor to: Letters to the Editor Consider This, Lab Coders It was with great interest that I read your article on professional service billing for clinical lab procedures [ Professional Services in the Clinical Lab: Billable or Not? July 2009, pages 48-49]. I work with hospital-based pathology groups in several states, and wanted to share additional information that non-laboratory coders may consider. Each hospital and managed care company treats reimbursement for the professional component on clinical lab differently. In one case I am familiar with, a pathology group receives a hospital fee to serve as laboratory medical director. These fees are based solely on Medicare admission rates because Medicare includes pathologists time in the calculation of DRG reimbursement. The pathology group, therefore, is allowed (according to hospital services contract) to bill the professional component separately for all lab services rendered to non-medicare patients. The hospital acknowledges the legitimacy of pathology medical director services, as well as the need for the pathologist to be paid for them. In the same facility, however, at least one managed care company has adopted the Medicare Standard by reimbursing clinical services on a global basis, with the payment being included in the amount paid to the hospital. The hospital, meanwhile, contends that it did not negotiate for professional clinical services as part of their reimbursement rate because the pathologist is not a hospital employee. As a result, the pathologist is not getting paid for professional services rendered to these managed care patients. I would caution: Even if the pathologist receives a salary for hospital directorship, further review is needed to determine whether separate professional services billing is acceptable in a particular case. Salaries do not always cover services for all payers. Brenda Cox, CPC, MT ASCP, FHFMA Pathology Resource Consultants If a managed care plan adopts the Medicare standard of a global payment, the supervising pathologist has to negotiate payment from the facility the managed care plan will not make separate payment to the pathologist (or allow the pathologist to bill the patient directly). As you note, this can cause problems if the facility does not know it must negotiate with the managed care plan for payment of professional services in the clinical laboratory, and in turn refuses separate payment to the pathologist. A supervising pathologist has a widely recognized claim to reimbursement for clinical lab services. If a facility salary accounts only for those patients enrolled in a particular plan, a supervising pathologist may seek payment for professional lab services to patients outside that plan, either by billing the insurer or patient (assuming the payer does not reimburse lab services with a global fee) or through separate arrangement with the facility. Coding Edge Word Mix-up Can Hobble Facility Coding In August s Coding Edge, p. 42, in the Part B E/M in a Part A Setting article, under the first subhead, 1. Undercoding, it reads: (such as inpatient, or outpatient) (for example inpatient or outpatient) In each case, it should say new patient and established patient rather than inpatient and outpatient. All the codes are for outpatient services. Coding Edge You are correct: A supervising pathologist s salary may cover only patients under a single managed care plan (such as Medicare). For patients of that plan, the supervising pathologist cannot both draw a salary and bill separately for professional services. For patients outside that plan, however, the supervising pathologist s professional services will require a separate payment arrangement. 8 AAPC Coding Edge

9 feature AAPCCA Harvests New Crop of Officers By Suzan Berman-Hvizdash, CPC, CEMC, CEDC Member AAPCCA Board of Directors I hear the doorbell ring and I open the door. It s a little fireman, a beautiful princess, a witch with a head full of green hair, a lion, and, of course, a ghost. I m prepared with a bowl filled with treats to share with the trick-or-treaters. There are, however, a few visitors I was hoping to see: the scarecrow, the tin man, a cowgirl, Superman, and, with visions of seasonal change on my mind, a mini local chapter officer. Yes, that s right! It s the time of year to think about and gather coders who are interested in becoming chapter officers. If you are unsure of the officer election process, we ll explain and help you get your foot in the door to leadership. Here s how you can become an officer, why you should become an officer, and who should be asked to become an officer. Look to AAPCCA for Leadership Guidance The local chapter is only as successful as its membership and leaders. The AAPC national office is always available to help with your day-to-day chapter issues. The American Academy of Professional Coders Chapter Association (AAPCCA) was formed to help you with issues, situations, and questions you have directly related to chapter business. The AAPCCA can t, however, assign officers nor can we pick officers. We can provide suggestions on becoming and finding an officer. We can also help train and groom new officers to become leaders and join the ranks of those before them those who have started their leadership careers as local chapter officers. Officer Status Can Open Doors Carry great pride in your certified coding credentials. You took the steps to advance your career, and becoming an officer can be the next step in your career path. Officer status can open doors for you by showing initiative and the ability to take on more responsibility. It means you can lead a group in accomplishing a goal. It provides extended networking, educational chapter activities, and career opportunities. If you ve thought about speaking at a local chapter meeting, now is the time to do so. Speakers become active members. Active members become officers. Officers become leaders. Leaders become mentors. Peruse Your Chapter for Potential Officers Any member of your chapter could potentially be the next treasurer, the next educational officer, or the next president. Some may just not know how to start this track. If you are a current officer, you can help potential officers. If you are a member, talk to your current officers and express your interest. Each officer position is important and is a vital piece to the continued success of the AAPC and its local chapters. If you re organized, ambitious, and want greater involvement, this is the perfect way to do it. Plus you d be helping out your local chapter and other members. A Season for Officer Changes With the changing color of leaves, the time to look for local chapter leadership change is upon us. A change in local chapter leadership is an important step in the continued growth and success of your chapter. AAPCCA representatives are here to give you advice. Each region has two representatives with addresses (firstname.lastname@aappca.org) for you to use often. Region 1-Northeast: Charla Prillaman, CPC, CPC-I, CEMC, CCC, CHCO, and Cynthia Trapp, CHFP, CME, CPC, CPC-I, CCS-P, CHC, PCA Region 2-Atlantic: Suzan Berman-Hvizdash, CPC, CEMC, CEDC, and Freda Brinson, CPC, CPC-H Region 3-Mid Atlantic: Janet Dunkerley, CPC, CPC-I, CMC, and Lynn Ring, CPC, CPC-I, CCS, CCS-P Region 4-Southeast: Reba Harrison, CPC, CEMC, CEDC, and Melissa Brown, RHI, CPC, CPC-I, CFPC Region 5-Southwest: Diana Yates, CPC, CPC-H, CPC-I, CPEDC, and Wendy Grant, CPC Region 6-Great Lakes: Jill Young, CPC, CEDC, CIMC, and Shelly Bauguss, CPC, CGSC, CANPC, CGIC Region 7-Mountain/Plains: Linda Hallstrom, CPC, CEMC, and Angela Jordan, CPC Region 8-West: Suzanne Fletcher-Petrich, CPC, CPC-I, CPC-P, and Jeri Leong, CPC, CPC-H, CPC-I When a member knocks on the door of coding opportunity, treat him or her to the chance to become a leader of your chapter. Officer status can open doors for you by showing initiative and the ability to take on more responsibility. October

10 feature Five Documentation Dos Make the Most of Reimbursement Proper payment means doctors can concentrate on patient care. By Dorothy D. Steed, CPC-H, CPC-I, CFPC, CEMC, CHCC, CPUM, CPUR, CPHM, CCS-P, ACS-OP, RCC, RMC, CPAR APPRENTICE Providers and coders must cooperate and work together to achieve a common goal of complete coding and positive reimbursement, supported by medical documentation. Providers should be in the habit of documenting services clearly and completely; and when a medical record falls short on sufficient information, coders should be comfortable asking providers for clarification or additional detail. Here are five tips to share with your physicians to ensure improved documentation and reimbursement as well as patient care. 1. Do Provide Full Diagnosis Detail Inpatient hospital claims are reimbursed solely on reporting ICD-9-CM codes. The Medicare severity diagnosisrelated groups (MS-DRGs) reimbursement methodology arranges medical conditions by severity to include coexisting complications and co-morbidities either requiring physician management or affecting the physician s management during the admission. Complications and co-morbidities (CC) are defined further as either standard or major. Greater severity equals a greater care level, which yields greater reimbursement. When the record is unclear as to the impairment degree, the coder may not be able to capture the code level that equates to a higher reimbursement for the hospital. Congestive heart failure is a common condition that provides a good example of how poorly-defined physician statements may reduce expected hospital reimbursement. Congestive heart failure without further definition does not equate to a CC for MS-DRG reimbursement. Further definition as chronic systolic and/or diastolic congestive heart failure equates to a standard CC, thereby increasing reimbursement. A complete descriptor of acute-on-chronic systolic and/or diastolic congestive heart failure equates to a major complication or co-morbidity (MCC), further increasing reimbursement. Clear, detailed documentation supports more than optimal reimbursement. Inpatient coders are expected to report all applicable codes describing the patient s conditions. The medical accuracy of the patient record is crucial to successful care. Hospitals use these codes to capture and report statistical data regarding the patients they treat. 2. Do Avoid EMR Shortcuts Electronic medical records (EMRs) have simplified documentation and record tracking. In some cases, the electronic record allows the physician to bring forward, or to cut-and-paste, previous patient information. Although physicians may view this feature as a wonderful timesaver, progress notes are critical to support successfully the reasons for continued hospitalization. Documentation shortcuts can create difficulty in supporting medical necessity for the patient s continued inpatient status. For example, if the patient s improvement or regression is not documented in a dedicated note each day, the payer may question whether services are medically necessary. If the notes do not indicate clearly the reason(s) for the patient s continued inpatient status, the payer may deny some of the days as medically unnecessary. 3. Do Document E/M Elements in Full Evaluation and management (E/M) services are often unsupported at the level billed. New patient visits, consultations, emergency services, observation services, and initial inpatient encounters require the provider to meet or exceed each of the history, examination, and medical decision-making (MDM) components for the chosen service level. Often, the review of systems (ROS) section is too weak to support the code level the provider desires to report. For example, to report a level 4 or 5 service, documentation must substantiate the review of 10 body systems. Or, the provider may discuss all positive findings and pertinent negative findings, finally stating that all other systems are negative. If between two to nine systems are reviewed during an outpatient consultation, service cannot exceed Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 10 AAPC Coding Edge

11 feature The medical accuracy of the patient record is crucial to successful care. Hospitals use these codes to capture and report statistical data regarding the patients they treat. The revenue difference between and Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family is approximately $60, based upon the current Medicare Physician Fee Schedule (MPFS). The difference between and Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-toface with the patient and/or family is approximately $100. The point is, medical necessity should always drive the service level, but consistently under-documenting the ROS can reduce revenue substantially. 4. Do Be Exact When Time s a Factor Time-based codes, such as critical care ( ), require the physician to document time precisely. Documentation may include face-to-face time, as well as floor time in the hospital. Floor time may include discussions with family and other providers involved in the patient s care and reviewing diagnostic tests. The time does not need to be continuous, but any time spent with other patients, or away from the unit on which the patient is admitted, must be deducted from the total time reported. 5. Do Give Procedure Specifics Surgical notes should identify clearly the approach, all procedures done at the surgical encounter, and unusual situations that occurred during the operative session. For instance, multiple spinal injections require the provider to identify whether the injections are bilateral in the same level or in several levels. If a procedure is stated as complicated, the provider should be precise as to how the determination was made. For example, when stating lesion measurements, the provider should specify whether margins were included and when the measurements were taken. If the coder must rely on the pathology report for the lesion size, the measurement will not be as accurate as it would be if taken before the tissue was removed from the blood supply. For instance, if documentation specified that a 3 cm, benign lesion was excised from the patient s face, you would report Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm. Had the documentation mentioned a margin of.4 cm on all sides, you could have reported Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm which pays approximately $50 more than Dorothy Steed, CPC-H, CPC-I, CFPC, CEMC, CHCC, CPUM, CPUR, CPHM, CCS-P, ACS-OP, RCC, RMC, CPAR a former Medicare specialist for a large hospital system, has 33 years of experience in health care and works as an independent health care consultant and educator in Atlanta, Ga. October

12 coding news coding news By Michelle A. Dick MEDCAC Discusses Catheter Ablation for Atrial Fibrillation Coverage The Centers for Medicare & Medicaid Services (CMS) has called a Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) meeting for Oct. 21 to discuss the use of catheter ablative techniques to treat patients with atrial fibrillation. Medicare does not have a national policy for this and its coverage is left to the discretion of local Medicare Administrative Contractors (MACs). Atrial fibrillation is an abnormal cardiac rhythm triggered by aberrant electrical activity in cardiac tissue which is more prevalent with increased age. Treatment strategies focus on rate control or rhythm control. Thus far, action taken to help determine a national policy are: The term radiofrequency was deleted on Sept. 1 from the Issues section of the tracking sheet for MEDCAC to review all catheter ablation methods for the treatment of atrial fibrillation. Questions were posted to panel on Sept. 3. The Panel Voting Questions for discussion address Clinical Comparators, Population, Outcomes, and Device Characteristics and Physician Training and are posted at: asp?where=index&mid=50. Attention DMEPOS Consignment Closet Locations: Suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), physicians, and non-physician practitioners (NPPs) who maintain consignment closets and stock and bill arrangements for DMEPOS have updated standards to comply with and must verify them with the National Supplier Clearinghouse Medicare Administrative Contractor (NSC-MAC). Providers should inform billing staff of these billing and compliance standards. Those affected are DMEPOS suppliers who have inventory at a practice location owned by a physician or NPP for DMEPOS distribution purposes and who submit claims to the NSC-MAC. According to MLN Matters article MM6528, Medicare allows Medicare enrolled DMEPOS suppliers to maintain inventory at a practice location owned by a physician or NPP for DMEPOS distribution purposes when: The title to the DMEPOS is transferred to the enrolled physician or nonphysician practitioner s practice at the time the DMEPOS is furnished to the beneficiary. The physician or non-physician practitioner s practice is billed for the DMEPOS supplies and services using their own enrolled DMEPOS billing number. All services provided to a Medicare beneficiary concerning fitting or use of the DMEPOS is performed by individuals being paid by the physician or non-physician practitioner s practice, not by any other DMEPOS supplier. The beneficiary is advised that, if they have a problem or questions with the DMEPOS, they should contact the physician or non-physician practitioner s practice, not the DMEPOS supplier who placed the DMEPOS at the physician or non-physician practitioner s practice. DMEPOS suppliers should meet these conditions and verify them with the NSC- MAC. See CR 6528 for the official instructions. View it online at: Transmittals/downloads/R300PI.pdf. 12 AAPC Coding Edge

13 Complete 2010 ICD-9-CM Coding Updates AAPC 2009 Workshop Complete 2010 HCPCS Coding Updates AAPC 2009 Workshop Complete 2010 CPT Coding Updates Complete Coding Updates & Rationales Complete Coding Updates & Rationales Complete Coding Updates & Rationales Complete Coding Updates & Rationales Complete Coding Updates & Rationales Complete Coding Updates & Rationales Complete Coding Updates & Rationales Complete Coding Updates & Rationales AAPC Distance Learning Training Series: COMPLETE 2010 CODING UPDATES 6-Hour Webinar Series Up to 6 CEUs $ Rather than waiting until December for your coding updates and having to attend a live workshop, AAPC is making them available in a distance learning training series made available as the new codes are released. You ll spend a fraction of the amount charged elsewhere, get your 2010 code updates before anyone else and have the training multimedia and materials to review throughout Why you need these updates: * Learn which new, deleted and revised codes will affect your coding and reimbursement * All-encompassing 2010 details from three audio lectures and e-reference manuals * Prepare now to avoid claim errors in January * Identify the changes affecting YOUR specialty * Confirm your encoder or EMR system is accurate * Learn how to get buy-in to reduce under-coding, and keep a physician out of harm s way during an audit * Easily communicate changes with your team Best value and fastest access to code updates anywhere! Code Set Updates Webinar Slides emanual Bonus Recording Bonus Printed Manual Ships 2010 ICD-9-CM 2 Hours - September Shipping NOW! 2010 CPT 2010 HCPCS 2010 ICD-9-CM 2010 CPT 3 Hours - November November 2010 HCPCS 2010 CPT 2010 HCPS Level II 1 Hour - December December 2010 ICD-9-CM 2010 HCPCS 2010 CPT AAPC 2009 Workshop SHIPPED IN 3 PARTS * Current Procedural Terminology (CPT ) is copyright 2008 by the American Medical Association * No need to wait for a single event at the very end of the year Register Today! Membership Training Certification Employment Continuing Education

14 feature Seven Tips for Audiologist Billing Success Listen to what Medicare rules your provider should follow. By Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CHCC Medicare requirements for billing audiology services depend on the provider. What s good for an audiologist may not be good for a physician or non-physician, for example. Here are seven must-know tips for audiologists reporting services under Centers for Medicare & Medicaid Services (CMS) guidelines. 1. Audiologists Must Bill Medicare Directly Audiologists may no longer bill Medicare for services incident-to a physician s services. Medicare now requires an audiologist to bill under his or her own National Provider Identifier (NPI) for all claims for services rendered as of Oct. 1, 2008 (Medlearn Matters, 2008). Audiologists must register an NPI prior to billing Medicare. Resource tip: View Medlearn Matters July 18, 2008 article MM6061 at: www. cms.hhs.gov/mlnmattersarticles/downloads/mm6061.pdf. Note: Private payers may allow for billing of an audiologist s services incident-to physician services. The information throughout this article is specific for Medicare payers. Consult individual private payer policies and contracts for guidance. 2. Audiologists Must Be Qualified The Social Security Act (the Act) requires audiology services be provided by a qualified audiologist. Section 1861(ll)(3) of the Act provides that a qualified audiologist is an individual with a master s or doctoral degree in audiology, according to CMS (Transmittal 84, 2008). A Doctor of Audiology (AuD) 4th year student with a provisional license from a state does not qualify unless he or she also holds a master s or doctoral degree in audiology, reiterates CMS. Transmittal 84 (sec ) defines a qualified audiologist as an individual who: Is licensed as an audiologist by the state in which the individual furnishes such services, or In the case of an individual who furnishes services in a state not licensing audiologists has: completed successfully 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), and; performed not less than nine months of supervised full-time audiology services after obtaining a master s or doctoral degree in audiology or a related field, and; completed successfully a national examination in audiology approved by the secretary. Transmittal 84 provides payers with direction to validate qualifications, and allows that audiology services also may be performed, where it is allowed by state and local laws, by a physician or non-physician practitioner. Different billing and coding guidelines apply for audiological aides, assistants, technicians, or others who do not meet the above qualifications. Resource tip: View CMS Transmittal 84, issued Feb. 28, 2008 at: hhs.gov/transmittals/downloads/r84bp.pdf. 14 AAPC Coding Edge

15 feature 3. Audiology Services Must Be Diagnostic Chapter 15, section 80.3 of the Medicare Benefits Policy Manual, as updated by Transmittal 84, states, Diagnostic services performed by a qualified audiologist and meeting the requirements at section 1861(ll)(3)(B) are payable as other diagnostic tests. In contrast, There is no provision in the law for Medicare to pay audiologists for therapeutic services. The policy manual continues, For example, vestibular treatment, auditory rehabilitation and auditory processing treatment, while they are within the scope of practice of audiologists, are not diagnostic tests, and therefore, shall not be billed by audiologists to Medicare. In particular, audiologists may not bill Medicare for an Epley maneuver or canalith repositioning procedure (95992 Canalith, repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day). Note: Although CMS national policy does not allow Medicare payment to audiologists who perform therapeutic procedures, other payers may cover such services when performed by a qualified audiologist. Transmittal 84 identifies payable audiological diagnostic tests as tests of the audiological and vestibular systems, including hearing, balance, central auditory processing, tinnitus, and tests of certain prosthetic devices such as cochlear implants, osseointegrated auditory prosthetic devices and auditory brainstem implant devices, performed by qualified audiologists. More specifically, covered tests include: Vestibular function ( , 92548) Audiologic tests ( , , , 92596) Cochlear implant (re)programming ( ) Auditory processing, tinnitus ( , 92640) Watch for exceptions: According to the policy manual, Medicare payment for audiological diagnostic tests is not allowed when: The type and severity of the current hearing, tinnitus, or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or The test was ordered for the specific purpose of fitting or modifying a hearing aid. On the latter point, Transmittal 84 qualifies, It is appropriate to pay for audiological services for patients who have sensorineural hearing loss and who wear hearing aids if the reason for the test is anything other than evaluation of the hearing aid. As an example, a perceived change in hearing or tinnitus may be covered to rule out other causes (auditory nerve lesions, middle ear infections) and result in subsequent evaluation of the hearing aid (not covered) or aural rehabilitation by a speechlanguage pathologist. 4. Testing Must Be Ordered A physician must order audiologic testing for the purpose of obtaining information necessary for the physician s diagnostic medical evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem, according to the policy manual. The ordering physician would be identified in box 17 of the CMS-1500 claim form. A nonphysician practitioner (NPP) also may order testing when the nonphysician practitioner orders diagnostic tests within their scope of practice, state and local laws and any policies applicable to the setting. If a physician (or qualified NPP) orders a specific audiologic test, only that test may be provided on that order. An additional order is required if further testing is required. For example, an otolaryngologist may want all patients with ear problems to have audiologic function testing before the patient sees the physician. This standing order is not allowed; a specific order for diagnostic testing must be provided by the physician prior to the performance of any audiologic testing. When the physician orders diagnostic audiologic tests by an audiologist without naming specific tests, however, the audiologist may select the appropriate battery of tests, according to the policy manual, section If a beneficiary undergoes diagnostic testing performed by an audiologist without a physician (or qualified NPP) order, the tests are not covered, even if the audiologist discovers a pathologic condition. 5. Computer-administered Tests Don t Qualify Computer-administered hearing tests do not require the skilled services of an audiologist, physician, or NPP, and are not coded as diagnostic audiologic testing. Specifically, codes Comprehensive audiometry threshold evaluation and speech recognition (92553 and combined), Tympanometry (impedance testing), Acoustic reflex testing; threshold, and Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) have been valued to include professional delivery not present in automated tests. Examples of computer-administered tests include otograms and pure tone or immitance screening devices. The correct code to report computer-administered tests is Unlisted otorhinolaryngological service or procedure. October

16 feature 6. Provide Complete Service Documentation The policy manual makes clear, The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient s medical record. Reasons for testing may include evaluation of suspected change in hearing, tinnitus, or balance; evaluation of the cause of hearing, tinnitus, or balance disorders; determination of medication, surgery, or other treatment effects; and others. Ideally, documentation for audiologic testing explains why the procedure was done, the equipment and work involved, outcomes, and any benefit provided to the patient. CMS guidelines require the medical record identify the name and professional identity of the person who ordered and the person who actually performed the service. 7. Pay Attention to PC and TC Modifiers Some audiology test codes include both a technical and a professional component. Such codes are identified readily in the National Physician Fee Schedule Relative Value File by the separate line item listings for modifiers TC Technical component and 26 Professional component under the primary code entry. If the qualified audiologist performs the testing only using his or her own equipment, without interpreting the results, report the appropriate CPT code with modifier TC. For example, an independent audiologist performs a positional nystagmus test for which an otolaryngologist provides the interpretation. The audiologist would report TC Positional nystagmus test, minimum of 4 positions, with recording, while the otolaryngologist would report If the qualified audiologist both performs the testing and interprets the results using his or her own equipment, report the appropriate CPT code with no modifier for the audiologist s service. Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-I, CENTC, CHCC, is a nationally-recognized consultant in compliance, coding, and billing and president of CRN Healthcare Solutions. Barbara is a past member of the AAPC National Advisory Board and its executive board. She is also certified as a health care compliance consultant from Healthcare Compliance Resources. 16 AAPC Coding Edge

17 Think health insurance is light on coverage and heavy on price? For the cost of buying one latte every day, you may have the money it takes to pay for health insurance plan coverage for individuals.* AAPC and Aetna have teamed up to help you get coverage that s right for you and your family. Aetna Advantage Plans for individuals, families and the self-employed offer: A range of affordable plans, including child-only coverage A national network of health care providers No referrals required to see a specialist No waiting period for preventive health care Rates guaranteed in most states not to increase for 12 months from your effective date As an AAPC member, you can also receive these special services: Member Assistance Program Concierge Services *F o r illustrative purposes only. Rates vary based on health status, where you live, how old you are, how many dependents you seek to cover, and what type of benefits you choose. For a free quote call Priority Code 7936 or visit us online at Member Benefits Section Aetna Advantage Plans for individuals, families and the self-employed are underwritten by Aetna Life Insurance Company (Aetna) directly and/or through an out-of-state blanket trust. In some states, individuals may qualify as a business group of one and may be eligible for guaranteed issue, small group health plans. Aetna Advantage Plans are available in the following states: AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, IL, KS, LA, MD, MI, MO, MS, NC, NE, NV, OH, OK, PA, SC, TN, TX, VA, WV, WY. IN CT, THIS PLAN IS ISSUED ON AN INDIVIDUAL BASIS AND IS REGULATED AS AN INDIVIDUAL HEALTH INSURANCE PLAN. Health insurance plans contain exclusions and limitations. Plans may be subject to medical underwriting or other restrictions. These plans are medically underwritten and you may be declined coverage in accordance with your health condition. Rates and benefits vary by location. Plans are not available in all states. Investment services are independently offered through JPMorgan Institutional Investors, Inc., a subsidiary of JPMorgan Chase Bank. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Policy forms issued in Oklahoma include: Comprehensive PPO-GR (5/04), Limited-GR LME (5/04) and Dental Ed 9/ Aetna Inc.

18 feature Remove Unhealthy Decubitus Ulcer Coding Select excision or debridement codes with total accuracy. By G. John Verhovshek, MA, CPC PROFESSIONAL Surgeons may treat decubitus ulcers also known as bedsores, pressure sores, or pressure ulcers either by debridement or excision. Appropriate CPT code assignment depends on the coder s ability to differentiate these procedures by the operative report, and the physician s care in documenting the depth or extent of the wound. Depth Matters for Debridement Debridement codes describe surgical removal of nonviable tissue to aid the healing of surrounding healthy tissue. Rather than close the wound following debridement, the surgeon leaves the wound open, often to perform additional debridements over time as the wound heals. For smaller wounds, the surgeon may allow the wound to heal by secondary intention. To select an appropriate debridement code, consider the greatest depth of the tissue the surgeon removed, as follows: Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Debridement; skin, subcutaneous tissue, and muscle Debridement; skin, subcutaneous tissue, muscle, and bone. Careful physician documentation pays big dividends for debridement procedures. Under the 2009 Medicare Physician Fee Schedule (MPFS), the physician work value of partial thickness debridement (11040) is 0.5 relative value units (RVUs), while the physician work value for debridement to the level of bone (11044) is 4.11 RVUs a difference of over $130 at average Medicare payment rates. Because you can t code (or be paid for) what isn t documented, physicians should note the deepest level of tissue addressed. For instance, if debridement includes the bone, the operative note should specify, Debridement was carried out through the fascia, muscle, down to and including the bone. Tip: Clinicians classify pressure ulcers by stage, where stage 4 represents the most severe condition (reaching to the level of bone) and stage 1 represents the least severe condition (involving only pre-ulcer skin changes limited to persistent focal erythema). ICD-9-CM category 707.0x identifies pressure ulcers by location (eg, Pressure ulcer, hip), while a required secondary code from category 707.2x describes staging (eg, Pressure ulcer stage II). The stage of the pressure ulcer establishes medical necessity for treatment, but does not correlate directly to the depth of debridement. Rely on operative note documentation, not the severity of the ulcer as described by stage 1, stage 2, etc., to determine the extent of debridement. Look to 58 for Subsequent, Global Debridement If a surgeon performs a subsequent debridement of the wound during the global period, append modifier 58 Staged or related procedure or service by the same physician during the postoperative period to the appropriate, subsequent procedure code. Debridement codes and have a 10 day global period under the 2009 MPFS. Codes have a zero-day global period. For example, the surgeon debrides a pressure sore above the coccyx, also removing muscle and bone to clear infection (11044). Eight days later (within s global period), the surgeon must perform a subcutaneous debridement to remove additional diseased tissue, which is reported with In a second example, the surgeon performs a full-thickness debridement, followed six days later by a partialthickness debridement. Modifier 58 is not necessary in this case because the subsequent debridement (11040) does not occur within the (zero-day) global period of the initial debridement (11041). Excision Includes Closure A surgeon will perform an excision of a decubitus ulcer ( ) only if there are no signs of infection; and, unlike debridement, will close the wound. Documentation of closure provides a clue for coders that an excision is performed. 18 AAPC Coding Edge

19 feature Skin Fat Muscle Bone Stage 1 Stage 2 Stage 3 Stage 4 Selecting an appropriate decubitus ulcer excision code depends on three factors: 1. The ulcer s location; 2. The method of closure; and 3. Whether the surgeon also performs an ostectomy (removal of underlying bony structure) to remove infected bone under the ulcer. The main indication for ostectomy would be a diagnosis of ulcer with osteomyelitis (ICD-9-CM category 730.x). The CPT descriptors for provide you with all the necessary information to determine an appropriate code. For example, Excision, sacral pressure ulcer, with skin flap closure; with ostectomy indicates location (sacral), closure (with skin flap) and that ostectomy did occur. To simplify code selection for pressure ulcer excisions, refer to the Pressure Ulcer Excision Quick Selection Chart. Report Grafts With Excision Separately When the surgeon closes a sacral, ischial, or trochanteric ulcer excision using muscle flaps or skin grafts, CPT guidelines allow a separate code to describe the closure. The closure can be done either at the same time as the primary procedure, or as a staged procedure. For staged repairs that occur during the excision s global period, be sure to append modifier 58 to the appropriate muscle or skin graft repair code. For example, the surgeon excises an ischial pressure ulcer with ostectomy. She then closes the operative wound using a muscle flap. To report the excision, use Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure. Claim the muscle flap closure separately with Muscle, myocutaneous, or fasciocutaneous flap; trunk. For those flaps still attached to the donor site, such as the groin area to close an ischial pressure ulcer, include the flap in the appropriate excision with skin flap codes (eg, 15922, 15934/15935, 15944/15945, 15952/15953). G. John Verhovshek, MA, CPC, is AAPC s [ director of clinical coding communications. ] Pressure Ulcer Excision Quick Selection Chart Closure Methods: A = Primary Suture B = Skin Flap C = Muscle/Myocutaneous flap or Skin Graft Excision WITHOUT Ostectomy Location Closure Method A B C Coccygeal N/A N/A N/A Sacral Ischial Trochanteric Excision WITH Ostectomy Location Coccygeal Sacral Ischial Trochanteric All Unlisted Location * N/A * Closure Method A B C * N/A * * Documentation should describe ulcer location, whether excision included ostectomy, and type of closure. * For repair of defect using muscle or myocutaneous flap, use code(s) and/or in addition to the appropriate code for the pressure ulcer excision. For repair of defect using split skin graft, use codes and/or in addition to the appropriate code for the puressure ulcer excision. October

20 feature by Tom Criser American Society of Health Information Management Information Technology s Future: A Big HIT John Klimek, R.Ph, recently was appointed by the Department of Health and Human Services (HHS) to the Health IT Standards Committee, a federal advisory panel established by the American Recovery and Reinvestment Act (ARRA) of Klimek, has spent 33 years in the pharmacy industry and has seen the business go from paper prescriptions to eprescribing. In a recent American Society of Health Information Management (ASHIM) interview about the pending conversion to health information technology (HIT), which Klimek explains how the pharmacy industry s conversion can serve as a model for providers. Why is HIT so exciting to you? John Klimek: I started as a pharmacist years ago when everything was completed by paper. Then, we entered into an electronic age of transmitting prescription claims directly to the payer or processor. From there, pharmacies took the lead in eprescribing, which changed the industry completely. We now are able to process prescriptions electronically, increase patient safety, and receive approval from payers almost instantaneous. It takes an average of three seconds for us to get approval by a third party payer and payment follows shortly thereafter. To me, that is an exceptionally exciting example for the rest of the health care industry, because HIT does not have to reinvent the wheel. The small physician practices are the backbone of the health care industry and have seen their expenses climb, reimbursement reduced, and malpractice insurance go sky high. How do you see HIT solve some of these issues? JK: We discovered in our industry eprescribing is slowly being accepted by physicians and pharmacies. It took close to 10 years for the entire industry to get involved. Slowly but surely, physicians and pharmacists began to perceive the benefits of a paperless process. Also, we saw patient care improve, error margins go down, and administrative time shortened considerably. I see the same for physician practices in that they can obtain formulary information, drug history, and prevent drug to drug interactions and allergic reactions all using the eprescribing tools. As we move into an era of Electronic Health Records (EHR), physicians will find having complete patient information at their fingertips will help reduce and improve administration staff to be more cost efficient. More important is patient care. What if I m away from home and get sick or am in an accident? Also, let s say I can t communicate medications I m taking, allergies I may have, or any other medical history. Now, it takes hours of phone calls to try to get information and possibly many unnecessary time consuming tests. With HIT, the treating physician will have instant access to all the data he needs. This will not only reduce error margins, but increase the quality of care. Ever have to wait in an emergency room because the staff can t get information from your doctor s office? Well, that will be gone and more lives will be saved. Do you see HIT being readily accepted by physicians? JK: History would suggest no! Physicians are on a fast moving treadmill trying to run their business with a primary concern for patient care. Administration is a necessary evil one they would love to do without. To stop and implement HIT will take time away from patient care, which they, frankly, don t have. The Centers for Medicare & Medicaid Services (CMS) has an incentive program under Medicare which will increase payment to the physician if they eprescribe. This incentive most certainly is a positive approach. These same types of enticements will soon be enacted for physicians and hospitals to implement EHR. Time is not on the physician s side. HIT conversion is expected to start in 2011 with full implementation by How do you see physicians handling the change? JK: Physicians may have one of their staff members receive training in HIT or hire from outside. In either case, that will take time and money. Most IT people work for hospitals or super large practices and they, for the most part, are overloaded with work. That s why this field is so exciting and growing by leaps and bounds. I see small doctor practices scrambling for resources as deadlines are enacted. One encouraging aspect of a down economy is IT people in other industries, which are having a hard time and are reducing staff, will try to fill that need. We have some big industries right now that have IT people standing in unemployment lines, such as the auto and financial industries. However, they must quickly learn how to articulate with physicians and health care people in general not an easy task! You have been selected to serve on the ARRA HIT policy committee. What message will you be bringing them? JK: First, I want to say how honored I am to be selected to this committee. Health care is entering a time when demand for services will almost double because of aging Baby Boomers. This population is expected to take more medications and, unfortunately, suffer the highest proportion of medicationrelated problems (MRPs). Seniors often manage as many as five different medications for a variety of chronic ailments. According to a 2006 Institute of Medicine report titled, Preventing Medication Errors, adverse drug events account for more than 1.5 million preventable medication-related incidents. To prevent errors, technology will have to reinforce the circle of care between the primary physician, care environment, pharmacy, and the patient. My message will be that the pharmacy industry can be used as a great model of how IT can improve health care at all levels. It may take a while, but physicians will see improved care, reduced errors, and changes in their downward sliding profit margin. Sometimes you have to take a couple of steps backwards to advance 10 steps forward. 20 AAPC Coding Edge

21 Are you our fan on... ASHIM American Society of Health Information Managers

22 featured coder Use Op Report Details to Decide Breast Reconstruction Codes Piece together the correct descriptor with the services rendered. By Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC APPRENTICE CPT contains nearly two dozen codes ( ) to describe breast surgical modification or repair, including breast augmentation with or without prosthetics. Choosing from among these codes is not difficult, if you pay attention to the code descriptors and the specifics of the surgeon s operative notes. Breast Lifts, Reductions, Stand Alone A single code, Mastopexy, describes a breast lift procedure. These procedures do not include the use of prosthetics. Rather, the surgeon relocates the nipple and areola to a higher position while removing excess skin below the nipple and above the lower breast crease. Mastopexy is generally cosmetic, but insurers may cover mastopexy if the surgeon performs a full reconstruction on one breast (for example, following cancer), and then performs mastopexy on the healthy breast to make it look like the reconstructed breast. Similarly, just one code, Reduction mammaplasty, describes breast reduction. Insurers may deem a payable service for medically-necessity reasons, such as for those patients with a history of back pain, neck pain, shoulder grooving, or when the surgeon must remove more than 500 grams from the breast. Coverage requirements differ from payer to payer, and as more patients request breast reductions, payers are enacting stricter prior-approval policies. Documentation must support medical necessity for the procedure. Common diagnosis codes for a breast reduction include Hypertrophy Quick Tip Vital information: All CPT codes from series describe unilateral procedures. When any of the procedures are performed bilaterally, you may append modifier 50 Bilateral procedure to the appropriate code. of breast; Pain in joint, shoulder region; Cervicalgia; Pain in thoracic spine; and Other specified erythematous conditions. Some patients with excessive breast tissue undergo reduction mammaplasty and a nipple reconstruction (19350 Nipple/areola reconstruction) in the same operative session. In these cases, report separately and in addition to With or Without Prosthetic Distinguishes Augmentation Breast augmentation can occur either with (19325 Mammaplasty, augmentation; with prosthetic implant) or without (19324 Mammaplasty, augmentation; without prosthetic implant) prosthetic implant(s). When coding for augmentation with implants, report also the prosthetic. For those payers who accept HCPCS Level II, apply L8600 Implantable breast prosthesis, silicone or equal. Otherwise, select CPT Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or material provided), and provide an attached report to explain the details. Select Reconstruction by Method Breast reconstructions may be described as belonging to any of three broad categories. 1. A saline-filled tissue expander may be used, following mastectomy, to stretch surrounding skin in preparation for a prosthetic implant to be inserted at a later date. This is reported Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion. The implant is reported separately (see below). Some surgeons may make a conservative recommendation for the patient to wait at least six months before undergoing reconstruction following excision, to heal sufficiently prior to tissue expansion and implant placement. Note: The descriptor for says, includes subsequent expansion. Do not bill return visits for gradual expansion separately. Surgeons usually fill the expander until the size is suitable for an implant insertion. 22 AAPC Coding Edge

23 featured coder 2. Flaps may be used on the skin surgically to support or create a new breast. Coding depends on the specific flap used: A latissimus dorsi flap uses tissue from the patient s back, positioned into a mound, to support a reconstructed breast. This is reported Breast reconstruction with latissimus dorsi flap, without prosthetic implant. Note: This procedure does not include prosthetic implant, which may be reported separately (see below). A free flap technique uses tissue transplanted from the patient s thighs or buttocks to support or create the new breast. Blood vessels within the transplanted tissue are connected to those in the chest to maintain a blood supply (anastomosis). The procedure typically requires a surgeon with both plastic surgery and microvascular surgical skills, and is reported Breast reconstruction with free flap. A transverse rectus abdominis myocutaneous flap (TRAM) transplants muscle, fat, and skin from the patient s abdominal area, tunneled to form the new breast mound. The flap may single pedicle, without anastomosis (19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site), or with anastomosis (19368 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)). A single pedicle TRAM means one side of the abdominal wall is used to reconstruct the breast. If both sides of the abdominal wall are used, code for a double pedicle TRAM (19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site). To improve blood supply, and improve the chances for a successful procedure, the surgeon may perform a delay of flap (15600 Delay of flap or sectioning of flap (division and inset); at trunk) prior to TRAM. In such a case, watch your global days: Code carries a 90-day global period. If the TRAM occurs within the 90-day global period of 15600, append modifier 58 Staged or related procedure or service by the same physician during the postoperative period to the appropriate TRAM procedure code. TRAM requires nipple/areola reconstruction (19350) to create an areola and nipple. The surgeon usually takes skin from the inner thigh or from behind the ear to form the nipple. The donor site repairs are generally considered separate repairs, as in the case of grafting. When the donor site requires separate repair, you can report it separately. 3. For breast reconstruction by method other than those described above, select Breast reconstruction with other technique. When reporting this code, have a copy of the operative notes on hand to describe the procedure/method precisely. Once again, breast implants are reported separately. Any time the surgeon revises a previously-reconstructed breast, the appropriate code is Revision of reconstructed breast. This is done when there is something not quite right with the reconstructed breast. In some cases, the surgeon needs to remove excess skin from the reconstruction site, or the surgeon needs to reposition an implant. Post-reconstruction Implants May Be Immediate or Delayed Implants may be placed either immediately following reconstruction procedures as described earlier, or at a later time. For prosthetics following breast reconstruction, do not report Instead, call on Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction or Delayed insertion for breast prosthesis following mastopexy, mastectomy or in reconstruction, depending on the circumstances. In addition to prosthetic insertion, code for the implant supply itself, as described earlier. For example, a patient is diagnosed with cancer in her right breast. Following removal of the cancer, she is ready to proceed with reconstruction. The patient decides to have an implant on the right side, with an equalizing augmentation on the left for symmetry. The proper coding is for the right breast and for the left breast. Supporting diagnosis would be V10.3 Personal history of malignant neoplasm; breast and V45.71 Acquired absence of breast and nipple. Capsule Procedures, Removals, Call on Dedicated Codes Following breast augmentation, the patient may develop a painful or distorting tissue capsule surrounding the implant. An open capsulotomy (19370 Open periprosthetic capsulotomy, breast) involves making numerous incisions in the tissue capsule to release the implant. To report complete removal (excision) of the capsule and implant, claim Periprosthetic capsulectomy, breast. If the surgeon inserts a new implant following the capsulectomy, report separately. Surgeons usually don t perform capsulectomy and implant reinsertion through the same incision; although the surgeon treats the same breast, he has to dissect a new pocket, often in a different place. Because of the separate sites, correct coding demands you report both and For removal of an implant alone, consider either Removal of intact mammary implant or Removal of mammary implant material, depending on whether the implant is intact or must be removed piece by piece. Do not report removal separately with capsulectomy (19370, 19371). Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC, has 20 years of coding and billing experience. She works for a reconstructive plastic surgeon in Phoenix, Ariz. She is an approved PMCC instructor, AAPC Workshop presenter, past president of her local AAPC chapter, and was a member of the AAPC National Advisory Board. October

24 facility Robotic Surgery: Standard Coding Describes High-tech Approach By Brad Ericson, CPC, COSC and G. John Verhovshek, MA, CPC The Food and Drug Administration (FDA) approved the first fully-robotic surgery device, the da Vinci surgical system, in early In recent years, robotic surgery technically called laparoscopic robotic-assisted surgery has revolutionized minimally invasive surgery (MIS). Robotic-assistance has been adopted by several surgical specialties for complex procedures, such as mitral valve repair, Roux-en-Y, prostectomy, hysterectomy, sacral colpopexies, coronary anastomosis, nephrectomy, and others. Standard Procedure The da Vinci surgical system, manufactured by Intuitive Surgical, Inc., allows a surgeon to operate while seated at a console. The surgeon views the surgical field through a 3-D eyepiece while his fingers grasp the instrument controls below the display, which in turn direct a robotically-controlled laparoscope. The surgeon s movements are translated, precisely and in real time (but minus hand tremor, according to the device manufacturer), to the articulating laparoscopic robotic instruments. The device cannot be programmed, and remains under the surgeon s direct control at all times. The da Vinci sports four praying mantis-like arms projecting from a unit at the head of the table. A surgeon and operation room (OR) technicians attach special surgical instruments, cameras, tubes, and other items to the arms. While an anesthesiologist monitors the patient, the primary surgeon sits at a console near the OR table. An assistant surgeon stands at the OR table next to the patient. Hand and foot controls allow the primary surgeon to move the robotic arms and attachments through tiny incisions. The surgical field is visible via a 3-D view from the cameras on the arms. According to Intuitive Surgical, Operating images are enhanced, refined and optimized using image synchronizers, high-intensity illuminators and camera control units. Although expensive (in excess of $1 million for the device alone, not including maintenance, surgeon training, and other costs), the da Vinci offers numerous technical advantages to surgeons and patients, alike. Surgeons may benefit from improved precision and less fatigue, while patients can experience lower risks, improved outcomes, and faster recovery especially when compared to open surgical techniques. Proponents say the da Vinci system expands the breadth of laparoscopic procedures, which are restricted by conventional rigid laparoscopic instruments that only offer two-dimensional views and are hampered by the surgeon s hand tremor during delicate maneuvers with straight non-rotating instruments. More complex procedures requiring delicate fine-tissue manipulation, lymph node retrieval, maneuverability in tight pelvic spaces, extensive dissection and critical suturing can be done by the surgeon with robotic laparoscopic instruments. The manufacturer of the system says it is the fastest growing treatment for prostate cancer and told Coding Edge there are 1,242 da Vinci systems installed, of which 916 of those are in the United States. The technology is proving successful and popular; and it, in the same way the laptop computer changed our lives, may change how surgery is done. Straightforward Coverage The procedure may sound exotic, but coding laparoscopic robotic-assisted surgery claims isn t. The primary surgical procedure is laparoscopic and is covered by routine and customary laparoscopic CPT and ICD-9-CM coding practices. There is no need for unlisted procedure codes or modifier 22 Increased procedural services for robotic assistance (unless, of course, there is no existing laparoscopic code to describe a procedure). Note: Many leading payers have specific medical policies about robotics. Rates are influenced by the hospitals contract terms that preceded acquisition of the robot. However, hospitals have been successful with updating contract terms. Any insurance covering MIS (including Medicare) generally covers robotic surgery. But many leading payers do not permit an additional payment allowance for the robotic surgical technique. For instance, if the surgeon uses robotic-assist to perform a laparoscopic myomectomy of two myomas 24 AAPC Coding Edge

25 facility weighing a combined 100 grams, the appropriate code is Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas. The payment for the robotic component is considered part of the global surgical service. In a second example, if the surgeon performs a laparoscopic radical, nerve sparing prostatectomy with robotic assistance, the appropriate code is Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing. If your payer accepts HCPCS Level II S codes, you may report S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure) in addition to the primary procedure code, to identify the procedure as robotic-assisted. Note that S codes are not payable under Medicare, and likely won t result in additional payment from leading insurers, such as CIGNA and United Healthcare. (For consideration, CIGNA and United Healthcare have robotic surgery reimbursement policies). In the institutional setting, a series of ICD-9-CM procedure codes to identify robotic-assisted procedures became effective Oct. 1, 2008: Open robotic assisted procedure Laparoscopic robotic assisted procedure Percutaneous robotic assisted procedure Endoscopic robotic assisted procedure Thoracoscopic robotic assisted procedure Other and unspecified robotic assisted procedure These codes are used in addition to the appropriate code to describe the primary procedure. For instance, to report a laparoscopic total abdominal hysterectomy with robotic-assistance, assign Laparoscopic total abdominal hysterectomy, cholecystectomy followed by Brad Ericson, MPC, CPC, COSC, [ is AAPC s director of publications. ] G. John Verhovshek, MA, CPC, is AAPC s [ director of clinical coding communications. ] Don t forget to get your CEUs! Our CD-ROM course line-up: E/M from A to Z (18 CEUs) Demystifying the Modifiers (16 CEUs) Medical Coding Strategies (15 CEUs) Time Based Coding (8 CEUs) HealthcareBusinessOffice LLC: info@healthcarebusinessoffice.com Web site: (Some courses also have CEU approval from AHIMA and PMI. See our Web site.) Make it as easy as child s play. Need to earn CEUs to renew your CPC? Use our CD-ROM courses anywhere, any time, any place. You don t even need the Internet. Completely at your own pace Use your office, home, or any other PC: nothing to install No Internet connection needed You could finish a CD in just a few hours, or on a schedule that works best for you it s really all up to you. So visit our Web site and learn more about earning your CEUs in the most convenient and cost-effective way! Years of Excellence Continuing education. Any time. Any place. October

26 cover PROFESSIONAL IMMIGRATE to I-10: AAPC Prepares for the New Land By Brad Ericson, CPC, COSC A Skilled Captain And A Detailed Map Set The Course For Smooth Sailing. When you open the October 2013 Coding Edge, we ll be using ICD-10-CM. After more than a decade of false starts and revisions, we are all finally packing for destination ICD-10, which features a new language of an enormous but elegant code set. For a profession whose members weather weekly reimbursement rules and quarterly code changes, implementation seems both reassuringly far away and uncomfortably close. And frankly, after experiences like the Correct Coding Initiative (CCI) Black Box Edits and various audit programs, it s hard to get excited about embarking for yet another federal initiative. That s why when AAPC leaders looked at the journey ahead, they searched for the right approach, the right curriculum, the right timing, and the right cost, said Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, COBGC, CEMC, CDERC, CCS-P. As AAPC vice president of strategic development and former National Advisory Board (NAB) president, she ll guide us through the transition. Grider is a long-time Coding Edge ICD-10 contributor and author of such coding standards as AMA Press Coding with Modifiers, with a new book, Preparing for ICD-10-CM: Make the Transition Manageable, released by the AMA Press this month. With the help of colleagues, she has developed an action plan for AAPC members and others who worry about what ICD-10-CM will be like after disembarking. The Right Approach, Timing, and Curriculum Coders won t be abandoned on the shore. Expert trainers have been recruited and will be educated in general and specific topics for training throughout the country, Grider said. To make it 26 AAPC Coding Edge

27 cover To discuss this article or topic, go to member easier, we re taking advantage of new technologies to reach every member. Training via the Internet and smart phone will supplement, and in many cases, replace traditional workshops. New technologies make training more convenient for members, she said, but traditional workshops and other techniques will also be used. Webinars for both providers and payers are already available. These audiovisual presentations are available via the Internet for free, and offer an overview of ICD-10 implementation to help set the scope for the transition. They can be viewed at your leisure from home or the office. Continuing education units (CEUs) can be earned for these for an additional $29.95 by taking post presentation tests. Proper planning now forestalls panic later, Grider said. Most of the overall training through 2010 is aimed at large organizations, she said. They need to start earlier because they have more to do to coordinate than smaller practices. We don t want people to panic and feel they have to learn everything now or fail. We have four years to do this so that we can make the transition smooth and effective. Right now, the emphasis is on what needs to be done to get ready. Beginning next year, training is on proper code structure, information technology requirements, crosswalking, and how implementation alters the reimbursement cycle. Training will include a three-to-five day session for large facilities and physicians offices, presented by a cadre of elite, well-prepared coding instructors. For individuals besides Webinars and what pops up on your Blackberry there will be presentations at national conferences, Internetbased distance learning modules, and more Coding Edge articles to allow education outside of the office. Onsite and distance learning will continue well into And in 2013, as we get closer to implementation, there will be eight regional conferences all on ICD-10 to help members and others before things change. Here is what curriculum is tentatively planned: Implementation Distance Learning Modules A series of around a dozen Webinars focusing on implementation begins this month. Cost for the Webinars is still being determined Onsite Provider Training Begins February, 15-Minute Webinars for Physicians & Admin. A series of 15 Webinars specifically geared for the physician or nonphysician practitioner. These modules will be approximately 15 minutes long and cover issues applicable to practitioners (for example, how to make sure your documentation will support ICD-10, how to set your budgets, etc.) These brief Webinars are for doctors and practice administrators who are not deeply involved in coding, but need to be prepared because they may have some involvement in implementation. ($ for all 15 or $29.95 each). Beginning in April, Onsite Three-Day Implementation Training Available Particularly geared toward larger practices, this onsite program will cover implementation training and guidance, featuring intensive instruction on ICD-10-CM, structure and guidelines, and crosswalking and mapping, along with hands-on exercises using the ICD-10-CM code set. The curriculum will also include an introduction into ICD-10-PCS, which will be beneficial for the facility coder. This will enable any provider location to systematically and cleanly make the switch to ICD-10. Onsite training is for large providers. National Conference: Five Education Sessions Don t miss these sessions, which will help you adopt ICD-10-CM, while you re attending the annual AAPC conference in Nashville, Tenn Onsite Provider Training Continues One Half-Day Workshop Throughout the Country This workshop will be held in 65 locations across the country and will help you progress through implementation benchmarks and to become knowledgeable about the new ICD-10-CM codes and structure. The half-day workshops will cover guidelines, structure of ICD-10-CM, crosswalks and mapping, as well as hands-on exercises, and an introduction to ICD-10-PCS. This workshop is for all coders. March, Specialty-specific Distance Learning Webinars, and Audio Conference Courses Become Available These courses will cover new specialty-specific ICD-10 codes (for example, obstetrics/gynecology (OB/GYN), cardiology, orthopaedics, family practice, internal medicine, and general surgery ICD-10-CM codes), addressing the common procedure codes each specialty will use. How the current coding method might be impacted such as the superbill versus the electronic medical record (EMR) along with crosswalking and mapping from ICD-9-CM to ICD-10-CM will be addressed. These courses will contain three modules: ICD-10-CM guidelines (based on the specialty) Commonly used codes (based on the specialty) Crosswalking and mapping There will be a quiz at the end of each module and a final exam at the end of the course. The Webinars and audio conference series will occur in one-hour segments. National Conference: 10 Education Sessions We go to Long Beach, Calif. in 2011, where you can learn how to implement and use ICD-10-CM without gambling your reimbursement Proficiency Validation Begins Two Half-day Workshops Throughout the Country An update on the 2011 workshop, these workshops will be held in 65 locations across the country and help you progress through implementation benchmarks and become knowledgeable about the new ICD-10-CM codes and structure. The half-day workshops will cover ICD-10-CM guidelines, structure, and crosswalks and mapping, as well as provide hands-on exercises and an introduction to ICD-10-PCS. This workshop is for all coders. Specialty-specific Distance Learning (E-learning), Webinars, and Audio Conference Courses Continue. National Conference: 20 Education Sessions All eyes will be on ICD-10 implementation at the AAPC national conference when half of the presentations address the new coding system. Proficiency Validation Available Proficiency validation begins October

28 cover Oct. 1, 2012 and can be taken online within the AAPC Member Area at The validation will be composed of 75 questions timed, and open book. All certified coders are required to pass the validation by Sept. 30, 2014 to maintain certification. The proficiency validation may be taken twice for $ Regional Conferences Eight Regional Conferences (January May) Conferences will be held in locations across the country. General, payer, and specialty ICD-10 tracks will be available to further help implementation. National Conference: 20 Education Sessions General, payer and specialty ICD-10 sessions will help you as we near the end of the journey and implementation begins. Specialty-specific Distance Learning (E-learning), Webinars, and Audio Conference Course Continue. Set the Proper Pace For years, coders have been told it is important to learn ICD-10-CM and ICD-10-PCS details as soon as possible, but Grider disagrees. Planning is the first step to successful implementation, she maintains, and the details are best left until later in the process after each practice and payer determines how to manage reimbursement under ICD-10. She doesn t advise immersing yourself in ICD-10 just yet, either. You ll forget a lot of it; you probably already have. And, the Centers for Medicare & Medicaid Services (CMS) and payer policies and procedures still to be written may change the details of using ICD-10-CM and ICD-10-PCS. Grider recommends a timeline and course preparation for both provider and payer. Recommended Provider Preparation Timeline September 2009 October 2009 May 2010 August 2010 August 2010 August 2010 September 2010 December 2010 September 2011 August 2012 September 2012 October 2012 May 2013 July 2013 September 2013 Oct. 1, 2013 Organize the Implementation Effort Develop a Communication Plan Conducting an Impact Analysis Organize Cross Functional Efforts (for medium to large practices) Estimate Budget Begin Internal System Design and Development (for medium to large practices) Development of Education and Training Plan Contact System Vendors Implementation Planning Business Process Analysis Phase I Education and Training Begin Education and Training, Phase II Deployment of Code by Vendors to Customers Policy Change Development Outcomes Measurement Implementation Compliance Recommended Payer-specific Preparation Timeline July 2009 October 2009 April 2010 July 2010 November 2010 November 2010 December 2010 December 2010 December 2011 October 2012 October 2012 May 2013 Oct. 1, 2013 ICD-10 Awareness Organizing the Implementation Effort Impact Assessment Budget for the Change Development of Education Plan Business Area Strategy Formulation Application Systems Strategies Vendor Strategies System Design and Development Begin Phase II ICD-10-CM and ICD-10-PCS Training Internal Testing Deployment of Code Begin Monitoring and Support You can track your progress in the Members Area on the AAPC Web site: Empowering Credentials at the Right Cost Going to a new system can be expensive, but Grider said the plan is to keep prices low, so coders can learn what is necessary to make the transition. For example, the Overview Webinars available now are free of cost. Naturally, said Grider, with the AAPC CPC and other credentials being the accepted standard for coders among employers, it will be necessary to update current credentials to reflect the new code set. Coders will have two years to take an online, open book, 75-question Proficiency Evaluation on ICD-10 beginning Oct. 1, There will only be a $60 administration fee and the exam can be taken twice in the comfort of your home or office. Coders need not re-take their CPC, CPC-H, CPC-P, or CIRCC exams when ICD-10-CM and ICD-10-PCS arrive. Nothing Ventured, Nothing Gained Fear and anxiety about venturing to the new land of ICD-10 is natural. You may experience some bumps in the road; however, Grider thinks you will love the detailed coding the new land brings. Like the immigrants stepping off at Ellis Island a century ago, we encounter huge possibilities. The reward for accuracy and ease are tremendous if we re all prepared. Brad Ericson, MPC, CPC, COSC, [ is AAPC s director of publications. ] 28 AAPC Coding Edge

29 Start now. The earlier you familiarize yourself with the ICD-10-CM code set, the easier the transition will be! New! Be ready when the next generation of codes comes rely on this helpful resource to make the transition between the ICD-9-CM and ICD-10-CM code sets easier. Designed to help you prepare for the switch, Preparing for ICD-10-CM, includes Easy-to-understand explanations of how the change to ICD-10-CM will effect your medical practice Explanations describing the differences between the ICD-9-CM and ICD-10-CM code sets Detailed code set overview with helpful Q&A sections by chapter, ICD-10-CM conventions and resourceful tables and guidelines throughout Available October 2009, softbound, 8½" x 11" Order #: OP Price: $72.95 AMA member price: $54.95 Order your copy today! Call (800) or go to:

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31 We like staying on top of things. Physician practices rank Navicure #1 clearinghouse service in 2008 KLAS report. Our clients like us on top of things, too. On top of leading technology. On top of resolving problems. On top of constant industry changes like NPI, ICD-10, and ANSI In the 2008 Top 20 Best in KLAS Awards report, practices rated Navicure tops in client satisfaction, resolving their problems, and getting their money s worth. Navicure would like to thank our clients for their business and their trust. We re happy to keep you on top with us. OUR PARTNERS The #1 rated clearinghouse service by physician practices* Established in 1996, KLAS provides the healthcare information technology (HIT) industry with unbiased factual information on HIT vendor performance. The Top 20 Best in KLAS Awards reflects the summary of HIT product performance data collected for healthcare executives over a 13-month period. www. research.com

32 added edge 2009 Salary Survey: Certification Protects Members from Recession RECOGNIZED AS PROFESSIONALS, CODERS WEATHER ECONOMIC STORM By Brad Ericson, CPC, COSC, and Jennifer Rothlisberger Credentialed coders prove recession-proof in this year s AAPC Salary Survey, which shows your salaries rose 4 percent to an average of $44,750. And even non-certified coders benefited from their affiliation with AAPC, with a 2 percent average salary gain to $37,290. And this, mind you, in the midst of bank failures, foreclosures, layoffs, and a housing bust. $70K $68,593 It appears certified coders are more recession proof than others, that multiple specialty credentials improve your career, and that education, of course, adds to that benefit, Reed Pew, AAPC president/ CEO, told Coding Edge. The type of credential makes a difference, too, when paired with work venue. Those who work in the insurance industry or facilities are naturally more likely to make more than those in a smaller physician practices. But the results of this and another study are encouraging not only for those who are certified but for all those who are AAPC members. More than 10,000 members responded to the annual salary survey, which was conducted this summer over the Internet. $60K $50K $55,172 $53,725 $52,777 $51,980 $45,253 $44,740 $40K $30K $20K $10K CPC-I CPC-P Specialty Multiple Specialties CPC-H CPC Certified Non-certified $37,290 CPC-A $34,699 $0K Average by Credential 32 AAPC Coding Edge

33 added edge $30,323 $33,584 $39,770 $44,949 $49,949 $50,350 $54,477 (years) yrs $10K $20K $30K $40K $50K $60K $70K Technical School 5 yrs High School Graduate Associates Degree Some College Bachelor s Degree Master s Degree 10 yrs $38,129 $40,746 $42,304 $42,787 Experience also determines the average salary of members. $51,820 Average by Experience 15 yrs Average by Education $66, yrs 21+ Being certified adds more than $7,000 to the average salary over being noncertified. CPC-As, many of whom are just entering the workforce, have a lower average income, and there is no underestimating the effect experience has on one s career. Coders with more than 21 years of experience averaged $54,477 this year. Education is the other part of the equation: This year, more of us report having been to college: 73.5 percent compared to 69 percent last year. There are 17.5 percent of the respondents who completed their bachelor s degrees. Your education level, not surprisingly, has a significant impact on salary level. This is the second survey of coders this year indicating we are being recognized for our professional skills and that our coding community is relatively immune to downturns. Not only do certified coders show a jump in salary and opportunity in this data, but paired with an earlier study published in the March 25 journal For the Record, we find coders with an AAPC certification fared positively while those with other credentials suffered during the downturn, Pew said. In the earlier study, 17 percent more CPCs than CCSs said they had not been negatively impacted by the economy. Coders who work for physicians, groups, ambulatory surgery centers (ASC), outpatient departments, and payers are seeing their careers blossom, according to the For the Record study. The bottom line for AAPC coders at a time when bottom lines are looking pretty bleak is simple, Pew said. It is clear we are increasingly recognized for who we are and how our skills add value to our employers. This is especially true of those who have specialty certification. While it s difficult to accurately determine what specialty credentials are most financially advantageous, we can look at the salaries of those who indicated they work in a specialty for a hint. Those who work in radiology, cardiovascular and thoracic, plastic and reconstructive, and rheumatology specialties report the highest average salaries this year. While little has changed this year in the order of specialties, we note that last year s highest paid specialty, neurology, fell off the list because too few responded to the survey. October

34 added edge Salary by Specialty Specialty Avg. Salary Responses Anesthesia and Pain Management $43, Cardiology $41, Cardiovascular and Thoracic $48, Dermatology $45, Emergency Medicine $41, Family Practice $39,900 1,069 Gastrointestinal $42, General Surgery $41, Internal Medicine $42, Obstetrics/Gynecology $42, Orthopedic $42, Otolaryngology $43, Pediatrics $41, Plastic and Reconstructive $46, Rheumatology $48, Urology $44, Radiology $49, Salary by Work Place Where We Work Avg. Salary Responses Consultant $75, Payer $54, Insurance Company $49, Government Facility $46, Hospital $44,895 1,865 ASC $44, Coding-Related Vendor $43, Large Group Practice (11+ Physicians) $43,187 2,384 Medium Group Practice (6-10 Physicians $40, Billing Company $40, Small Group Practice (3-5 Physicians) $40, Individual Practice (1-2 Physicians) $39, DME/Pharmacy Company $38, Rehab Center $37, Coders have a lot of roles, carry a lot of titles, and present a number of responsibilities founded on our professional skills. This data is interesting enough that we present it in two ways: by salary and by title. Those whose professional titles are consultants, managers, and administrators do better, not surprisingly. Consultants historically are at the top of the list, but we see those working in physician groups and practices moving up. By Title, Alphabetized Salary by Title By Salary, Highest to Lowest 10+ Practice Manager $63,148 Consultant-Owner $83, Practice Manager $46,705 Consultant-Employed $66, Practice Manager $54,742 Administrator $64,482 Administrator $64,482 Compliance Manager $63,251 Apprentice $30, Practice Manager $63,148 Audit Specialist $49,185 Reimbursement Manager $58,946 Billing Coordinator $35,804 Coding Manager $57,258 Billing Manager $49, Practice Manager $54,742 Billing Supervisor $42,010 Insurance Manager $54,079 Coding Manager $57,258 Educator-workplace $52,980 Coding Supervisor $49,958 Coding Supervisor $49,958 Compliance Manager $63,251 Billing Manager $49,722 Consultant-Employed $66,762 Audit Specialist $49,185 Consultant-Owner $83,802 Educator-school $47,618 Denials/Appeals Specialist $37, Practice Manager $46,705 Educator-school $47,618 Payer Coder $42,388 Educator-workplace $52,980 Medical Records Supervisor $42,273 Hospital Coder $39,280 Billing Supervisor $42,010 Insurance Manager $54,079 Hospital Coder $39,280 Insurance Rep $36,920 Denials/Appeals Specialist $37,757 Medical Records Supervisor $42,273 Physician Coder $37,564 Payer Coder $42,388 Insurance Rep $36,920 Physician Coder $37,564 Billing Coordinator $35,804 Reimbursement Manager $58,946 Apprentice $30, AAPC Coding Edge

35 added edge More Interesting Tidbits Our survey shows 58 percent of coders work an average of hours per week. Those reporting they worked an average of 41 to 71 hours per week amount to 38 percent. Those who are part-time, working 30 or fewer hours, amounted to only 5 percent. Coders work hard for their employers. A significant 81 percent don t have productivity standards in your offices and work at the office each day. A third may work from home some days of the week. Half of the respondents say they work flex-time schedules. More than 91 percent of you receive health insurance, 89 percent receive paid holidays, 82 percent receive paid sick time, and 78 percent receive dental insurance as benefits. Slightly over half who do have health insurance as a benefit said their employer help pay for coverage. Almost 9 percent work with physicians who have coder certification. New information, this is something we look forward to watching in subsequent studies. Who s doing the coding and how? Are they using documentation and electronic medical records (EMRs)? Here s a breakdown directly from the study: The majority of coders code all procedures from the documentation. The next largest group codes all procedures from a paper billing form. Only 8 percent code only a part of the claim on an EMR program. $35-40,000 $35-40,000 This map details the regions and their average salaries New England & NY $48,066 Atlantic $49,208 Mid-Atlantic $40,713 South $41,950 Southwest $41,690 Great Lakes $41,510 Mountain/Plain $42,848 Pacific $50,143 October

36 added edge How do you fare compared to your state average? Again, you ll notice that location affects the salary, considering cost of living, urban vs. rural setting, and regional economic pressures. State Avg. Salary Alabama $39,278 Alaska $49,667 Arizona $45,222 Arkansas $38,791 California (Northern) (Southern) $53,346 ($54,175) ($52,783) Colorado $45,969 Connecticut $50,420 Delaware $48,000 Florida $42,530 Georgia $42,017 Hawaii $49,323 Idaho $42,787 Illinois (Chicagoland) (Downstate) $40,991 ($48,020) ($35,947) Indiana $41,552 Iowa $39,238 Kansas $40,264 Kentucky $37,830 Louisiana $38,750 Maine $40,428 Maryland $53,060 Massachusetts $52,650 Michigan $42,306 State Avg. Salary Minnesota $46,536 Mississippi $40,184 Missouri $40,397 Montana $35,933 Nebraska $40,240 Nevada $45,739 New Hampshire $47,184 New Jersey $52,369 New Mexico $43,703 New York (New York City) (Outside NYC) $48,107 ($59,093) ($44,721) North Carolina $42,709 North Dakota $36,301 Ohio $40,163 Oklahoma $39,556 Oregon $44,960 Pennsylvania $46,093 Rhode Island $51,142 South Carolina $39,992 South Dakota $37,580 Tennessee $42,212 Texas $44,839 Utah $45,000 Vermont $41,030 Virginia $41,967 Where is Key, Too Location, location, location makes a difference in how much respondents say they are paid. Here is the breakdown of those who work in the cities, suburbs, and in rural areas: Urban $45,631 Suburban $44,551 Rural $38,930 While salaries in the New England, Southwest, and Mountain regions grew by at least 4 percent, it appears cost of living helps mould average salaries. The economy, no doubt, had an impact this year as downturns in other industries impacted coders in the Great Lakes and Mid-Atlantic region. The Good News It appears we are being recognized for our professional skills and our certifications not only helped protect us from the economic downturn, they are helping us in addition to our titles, roles, and locations. Paired with results from an earlier survey, we find being a coder is a pretty good gig with possibilities and opportunities, and that your CPC credential gives you a pretty beneficial professional and personal network with which to be associated. More results of the survey can be found on Brad Ericson, CPC, COSC, is [ AAPC s director of publications. ] Jennifer Rothlisberger is a marketing communications specialist and statistician for the AAPC. [ ] 36 AAPC Coding Edge

37

38 newly credentialed members newly credentialed members Michelle Hasting, CPC Athens AL Vanessa Moore, CPC Harvest AL Wendy Stuckey, CPC Mobile AL Linda C Carter, CPC Montgomery AL Albert Wilson Ivey, CPC Montgomery AL Jonathan Jason Ware, CPC Montgomery AL Tara M Paul, CPC Salem AL Jasmine Saunders, CPC Samson AL Tarra Elizabeth Shelton, CPC Austin AR Stefanie Ballard, CPC Benton AR Lori Michelle Lemley, CPC Bryant AR Jonathan Brett Tracy, CPC Bryant AR Cynthia (Cindy) Dianne Sindle, CPC Conway AR Lisa V Bradley, CPC, CPC-H Fort Smith AR Kevin Daniel Robbins, CPC Greenbrier AR Katerra Leann Westfall, CPC Greenbrier AR Janette McCready, CPC Jacksonville AR Amanda Michelle Wylie, CPC Jacksonville AR Nicholas Paul Blanchard, CPC Little Rock AR Stacy Lynn Misenheimer, CPC Little Rock AR Latosha Shanice Perkins, CPC Little Rock AR Mary Weaver, CPC-H Lowell AR Leanna Jelain Chamberlain, CPC Mabelvale AR Amy Nicole Knight, CPC Maumelle AR Charles Jeffrey White, CPC Maumelle AR Stephania M Finch, CPC N. Little Rock AR Rozan R Loveday, CPC Ozark AR Tammy Gale Bishop, CPC Plumerville AR Shannon Layne Wise, CPC Sherwood AR Julieann Marble, CPC Avondale AZ Theresa A Warren, CPC Mesa AZ Aleshia Flynn, CPC Phoenix AZ Bryan Donald Gilpin, CPC Phoenix AZ Cheryl Foley, CPC Scottsdale AZ Deborah A Herrera, CPC Tucson AZ Kellie L Kuhn, CPC Tucson AZ Jacqueline Steele, CPC Tucson AZ Cindy Odett Hernandez, CPC Yuma AZ Misty Leamons, CPC Yuma AZ Kimberly Thomson, CPC Adelanto CA Anita R Williams, CPC Aylett CA Michelle Ann Benson, CPC Bishop CA Kristen Roxanne Bernasconi, CPC Bishop CA Amy Danielle Roberts, CPC Bishop CA Heidi Christine Nelson, CPC Bridgeport CA Teresa Gonzalez, CPC Burbank CA Dorothy Jean Williams, CPC, CPC-H Carson CA Esther Kim, CPC Cypress CA Mandeep Singh Japra, CPC Elk Grove CA Nataliya Kis, CPC Elk Grove CA Christina J Baker, CPC Fairfield CA Jennifer L E DeWitte, CPC Fullerton CA Linda Dadian, CPC Glendale CA Beverly Ann Lacy, CPC, CPC-H Hawthorne CA Cheyri Pouncil, CPC, CPC-H Hawthorne CA Evelyn Estrada, CIRCC Lakewood CA Alison Clement, CPC Los Angeles CA Cynthia Del Rosario, CPC, CPC-H Los Angeles CA Kimberly Dillard-Bethel, CPC Los Angeles CA Debra Lockhart, CPC, CPC-H Los Angeles CA Laura B Hidy, CPC Mammoth Lakes CA Donna Kathryn Sheckter, CPC Mammoth Lakes CA Bianca Yvette Rodriguez, CPC Merced CA Dwipa Kumar, CPC Mission Viejo CA Andrea Dominique Klein, CPC Modesto CA Thelma Moya, CPC Norwalk CA Ginger S Reding, CPC Oakland CA Phylliss L Williams, CPC Oakland CA Jessica Sarah LaBenne, CPC Oceanside CA Annabelle M Aquino, CPC, CIRCC Rancho Cucamonga CA Romeo K Aquino, CPC, CIRCC Rancho Cucamonga CA Margarita Sanchez, CPC Riverside CA Jennifer J Beardsley, CPC Roseville CA Adelaida J Barrios, CPC San Diego CA Michele D Summers, CPC San Diego CA Angelina Caunca, CPC Santa Clarita CA Teofisto Arnel Manese Paran, CPC Sunland CA Evelyn Carolina Claros, CPC Sylmar CA Virgilio Castillo, CIRCC Torrance CA Abelardo Sanchez, CIRCC Torrance CA Laura Trinca, CPC Visalia CA Daniel Keys, CPC Aurora CO Sharyl Ann Ostwald, CPC Brush CO Johnna M Nichols, CPC-H Fort Collins CO Ronda Joy Daniel, CPC Granby CO Darlene A Egloff, CPC Greeley CO Jennifer Ridell, CPC Henderson CO Kay L Carroll, CPC Longmont CO Tina Lillard, CPC Longmont CO Teresa D Burlingham, CPC Loveland CO Wanda L Eberhard, CPC Loveland CO Kimberly S Hammond, CPC Loveland CO Constance Hansen, CPC Loveland CO Tammy H Spurgeon, CPC Peyton CO Jennie Marie Kawata, CPC Platteville CO Andrea Duplesys, CPC Silt CO Machaelle M Diaz, CPC Wheat Ridge CO Mary Beth Bangs, CPC Bethel CT Patricia A Parry, CPC Bethel CT Darlene Rose Foshay, CPC Danbury CT Nicole A Lopez, CPC Danbury CT Cheryl E Cwik, CPC Guilford CT Anita Fraser, CPC Guilford CT Krishna Gopal, CPC Milford CT Lisa Longo, CPC New London CT Kelley Fisher, CPC New Milford CT Mary Kitchens, CPC New Milford CT Cindy E Kisselburgh, CPC, CIRCC South Windsor CT Jonvieve Whitmire, CPC South Windsor CT Karen N Cacace, CPC Southbury CT Melissa S Matthews, CPC Woodbury CT Jason Bodden, CPC Belleair Bluffs FL Kristin Terry, CPC Brooksville FL Yamile Yanes, CPC, CPC-H Coconut Grove FL June Ann Davis, CPC Crystal River FL Colleen Floyd, CIRCC Crystal River FL Beth Ann Gibb, CPC Daytona Beach FL Ashley Schurger, CPC Fernandina Beach FL Jeffery Helble, CPC Gainesville FL Yamel Santana, CPC, CPC-H Hialeah Gardens FL Kawanda Brazil, CPC Jacksonville FL Monique Ellis, CPC Jacksonville FL Wendy G Melton, CPC Jacksonville FL Lorraine E Scheurer, CPC Jacksonville FL Diana Barriss, CPC Lakeland FL Kathryn Bean, CPC Lakeland FL Faith Oliver, CPC Lakeland FL Kent Williston, CPC Lakeland FL Peggy S Hickman, CPC Melbourne FL Diana C Richardson, CPC Melbourne FL Luz M Arce, CPC, CPC-H Miami FL Lourdes Lucila Artiz, CPC, CPC-H Miami FL Yosley Carballosa, CPC, CPC-H Miami FL Sarah Castro, CPC Miami FL Susana Doval, CPC, CPC-H Miami FL Deborah Johnson, CPC Miami FL Yanexis Montero, CPC Miami FL Maria Guadalupe Navarro, CPC Miami FL Yamila Prendes, CPC, CPC-H Miami FL Barbara Regalado, CPC, CPC-H Miami FL Moi Stone, CPC Miami FL Michele E David, CPC New Port Richey FL Donna Robichaud, CPC North Port FL Shanika Johnson, CPC-H Opa Locka FL Anastasia Powers, CPC Orange City FL Cecelia Ellen Shipp, CPC Orange Park FL Leah Carter, CPC Port St Joe FL Claire C Patten, CPC Port St John FL Jeanine Mulvey, CPC Punta Gorda FL Marvalet A Donald, CPC Sarasota FL Donna Wolaver, CPC Satellite Beach FL Arlene Cotton, CPC-P Tallahassee FL Joyce B Anderson, CPC Tampa FL Cherie R Resmondo-Williams, CPC Tampa FL Marilyn L Koerner, CPC Vero Beach FL Stephen Panczak, CPC West Palm Beach FL Anthony Cheney, CPC-P Weston FL Karen Davis, CPC Armuchee GA Matthew J Genzy, CPC Atlanta GA Kimberly C Hartley, CPC Atlanta GA Sarah Beth James-Bentz, CPC Atlanta GA Josefina Moseley, CPC Atlanta GA Janice Willis, CPC Augusta GA Carol Wells, CPC Buena Vista GA Susan Williams, CPC Columbus GA Gladys L James, CPC Covington GA Jeanestal Barnes, CPC Douglas GA Chaney Holland, CPC Duluth GA Keyona Ward, CPC Fairburn GA Melissa Claudine LaPompe, CPC Hampton GA Tamera Peace, CPC Kingston GA Wendy G Gottlieb, CPC Lilburn GA Remelle C Pendergrass-Shane, CPC Lithonia GA Kathleen Fitzwater, CPC Marietta GA Terri Drummond, CPC Milledgeville GA Mara Blackard, CPC Newnan GA Vontressa Flournoy, CPC Newnan GA Northa Collier, CPC Norcross GA Cheryl Fullick, CPC Pine Mountain GA Deborah Farrow, CPC Ringgold GA Dorothy Malone, CPC Snellville GA Tamara Telise Lipscomb, CPC Stockbridge GA Darlene Marshall, CPC Stockbridge GA Maliakah Ward, CPC Stone Mountain GA Robin Wood, CPC Winder GA Sheryl A Thayer, CPC Woodstock GA Teresa Brandt, CPC Altoona IA Kelly Ann Eckstein, CPC Indianola IA Aimee Lee Deets, CPC Kanawha IA Cynthia Balmer, CPC Newton IA Nancy L Gallivan, CPC Boise ID Connie Kniefel, CPC Boise ID Judith Ann Walker, CPC Boise ID Cristina Lea Briolet, CPC Meridian ID Stacie A Toombs, CPC Meridian ID Whitney Marie Haun, CPC Nampa ID Lori Ann Jeffs, CPC Nampa ID Danielle J Kingston, CPC Nampa ID Carol Lynn Mierisch, CPC Nampa ID Valerie J Munoz, CPC Nampa ID Fayetta Cain, CPC Chicago IL Keith Joel Crutchfield, CPC Chicago IL Ellen M Young, CPC Chicago IL Kenyatta Adams, CPC Collinsville IL Leonora Martin, CPC Forrest Park IL Jackie Micek, CPC Glen Ellyn IL Ann P Quick, CPC Harvey IL Leticia Cervantes, CPC Lansing IL Theresa Almeroth, CPC Lisle IL Julie M Gehn, CPC Moline IL Steluta Stroie, CPC Naperville IL Janet Westberry-Davis, CPC Park Forest IL Sandra Ressler, CPC South Elgin IL Robin Skratsky, CPC Streamwood IL Diane T Brzezinski, CPC Tinley Park IL Tina Jerden, CPC Crawfordsville IN Patricia Shaw, CPC Elwood IN Lea Ellis, CPC Evansville IN Andrea Cly Morris, CPC Fishers IN George Wright, CPC, CPC Fishers IN Rosalyn Christina Paisley, CPC Gary IN Chris K Moore, CPC, CIRCC Greenfield IN Janet M Fields, CPC Indianapolis IN Karrie V Hinkle, CPC Indianapolis IN Traci Lynn Snider, CPC Indianapolis IN Jo Ann Lynch Wilson, CPC Indianapolis IN Sandra J Browning, CPC Lebanon IN Lori Ann Tabor, CPC Middletown IN Karen Bizzell, CPC New Albany IN Cynthia L Dornick, CPC Noblesville IN Karen V Strbjak, CPC Portage IN Lauren Anne Nowocin, CPC St John IN Libby Gengelbach, CPC-H Tell City IN Patricia Lynn Mordacq, CPC Westfield IN Kelly Johnson, CPC Manhattan KS Linda Kay Schweers, CPC Milton KS Kendra Reynolds, CPC Wichita KS Magdalena Blicharska, CPC Alexandria KY Joyce Turner, CPC Berea KY Nicola M Boyers, CPC Burlington KY Jessica Dixon, CPC Butler KY Pamela Jean Martinez, CPC Cynthiana KY Angela D Lane, CPC Danville KY Pamela Jean Turner, CPC Dry Ridge KY Susan T Chaney, CPC Independence KY Christine Ann Brown, CPC Lexington KY Jenny C Carey, CPC Lexington KY Nicole Lee Harris, CPC Lexington KY Gomana M Nashnoush, CPC Lexington KY Laura Jean Brown, CPC Louisville KY Dawn Gast, CPC Louisville KY Jackie James, CPC Louisville KY Oneida Kay Mills, CPC Louisville KY Terri Prater, CPC Louisville KY Patricia Ann Hays, CPC Versailles KY Charla Foster, CPC Winchester KY Jackie M Osborne, CPC Winchester KY Susan D Small, CPC Attleboro MA Bai Margolin, CPC Boston MA Jeanne S Thompson, CPC Brockton MA Jill Janko, CPC Chelmsford MA Denise Ann Pomeroy, CPC Chicopee MA Elissa M Allessio, CPC Dalton MA Dawn Philbrook, CPC Dudley MA Angela M Dias, CPC Fall River MA Renee Levasseur, CPC Fall River MA Celia M Martins, CPC Fall River MA Ellen Russell, CPC Fall River MA Robert Bruce Coit, CPC Harvard MA Irina Veron, CPC Hopkinton MA Brenda J Ozimek, CPC, CPC-H Hyannis MA Heather A Picard, CPC Jefferson MA Ilona Kalisky, CPC Lincoln MA Helen Marie Bullock, CPC Lowell MA Stephanie M Charette, CPC Ludlow MA Minnie Lamburn, CPC Marlborough MA Jennifer Lee Assetta, CPC Medford MA Denise Marie Binari, CPC Melrose MA Catherine V McGovern, CPC Melrose MA Shing Pik Katherine Yung, CPC Needham MA Julie Kuconis, CPC Peabody MA Robyn E Chojnowski, CPC Pittsfield MA Marci A Giardina, CPC Pittsfield MA Deborah J Kirchner, CPC Pittsfield MA Elizabeth T McCarty, CPC Pittsfield MA Darla J Soldato, CPC Pittsfield MA Jodi A Vallone, CPC Pittsfield MA Faye Hogeland, CPC Plymouth MA Ann Sheehan, CPC Plymouth MA Donna Bell, CPC Rehoboth MA Patricia A Quitadamo, CPC Rochdale MA Christine Marifiote, CPC Saugus MA Heather L Gaspar, CPC Seekonk MA Ann Dawidczyk, CPC Shresbury MA Patti P Wood, CPC Southwick MA Melissa A Mercon, CPC Spencer MA Anna Maria Kelleher, CPC Springfield MA Sheila M Stillings, CPC, CPC-H Wareham MA Kristy Johnston, CPC West Field MA David Iserman, CPC Westfield MA Jane Tuttle, CPC, CPC-H, CPC-I Westford MA Debra A Robitaille, CPC Windsor MA LaTonya Felicia Felder, CPC Baltimore MD Karen Johnson, CPC Boyds MD Kathleen Jillson, CPC Catonsville MD Karen Webster, CPC Columbia MD JoAnn Smith, CPC Elkton MD Quinn Anthony Burwell, CPC, CPC-H Fort Washington MD Elizabeth R Wilson, CPC Glen Burnie MD Brandi Nicole Cain, CPC Newburg MD Kerry Elayne Smith, CPC-P Owings Mills MD Pamela Drgos, CPC Severn MD Maria Sekar, CPC Sparks MD Linda Casey, CPC Takoma Park MD Barbara L Glass, CPC Ellsworth ME Judith A Slote, CPC Brownstown MI Ellen Marie Paxson, CPC Clawson MI Laurie Marchese, CPC Clinton Township MI Melissa Weintraub, CPC Commerce Township MI Jim Pawloski, CIRCC Commerce Township MI Tammy Calderon, CPC Dearborn MI Deborah McNeilance, CPC Farmington Hills MI Nicola Honyoust, CPC Garden City MI Carrie Ann Rivera, CPC Garden City MI Kimberly Wiater, CPC Garden City MI Candace Darlene Carver, CPC Grosse Ile MI Rebecca Leigeb, CPC Kingsley MI Beverly Vines, CPC Livonia MI Queenie Geralda Evans, CPC Niles MI Amy Frady, CPC Novi MI Sumathi Raja, CPC Novi MI Nancy Toutant, CPC Riley MI Kerri Elizabeth Kowalski, CPC Royal Oak MI Diana Jean Gentry, CPC South Lyon MI Denise Johnston, CPC Troy MI Marcianna M Davis, CPC Whitmore Lake MI Lisa Marie Sellman, CPC Andover MN Yvette Aubineau, CPC Blaine MN Megan K Piffer, CPC Blaine MN Janelle Kephart, CPC Bloomington MN Samantha Jo Borgen, CPC Brooklyn Center MN Christie Dixon, CPC-H Clearwater MN Karen Irons, CPC Elmore MN Kathy Roering, CPC North St Paul MN Heidi J Wintheiser, CPC Prior Lake MN Carol Januschka, CPC St Paul MN Melanie Lea, CPC St Paul MN Krista M Backstrom, CPC Woodbury MN Melissa Ruediger, CPC Jefferson City MO Brandy Williams, CPC Jefferson City MO Erin Lyon, CPC Moberly MO Vivian Wilson, CPC-H Greenville MS Mara Amy Mitchell, CPC Big Sky MT Regina I Gunderson, CPC Billings MT Amber Sark, CPC Helena MT Sandra Absalonson, CPC Kalispell MT Teresa L Garner, CPC Kalispell MT Marla J Sisco, CPC Malta MT Kathleen M Leahy, CPC Whitefish MT K Adonyah Balfour, CPC Charlotte NC Veronica Olivia Hodges, CPC Charlotte NC Tiffany McCluney, CPC Charlotte NC Kari Slade, CPC China Grove NC Michele Maria Thomas, CPC Cornellus NC Kathryn D White, CPC Creedmoor NC Anna Holland, CPC Durham NC Emily S Hudson, CPC Gastonia NC Tarshia Brady, CPC Greensboro NC Crystal Gallagher Robinson, CPC Mebane NC Dawn Wesley, CPC Monroe NC Gwen Brown, CPC Pinehurst NC Judith Arnold, CIRCC Pittsboro NC Denis O Connell, CPC Raleigh NC Michelle Uhl, CPC Raleigh NC Lee Rowell Hall, CPC Rocky Point NC Diane Oldfield, CPC-A, CPC-P-A Shelby NC Paula Fritz-Russell, CPC Waxhaw NC Michelle Elaine Woodruff, CPC Winston Salem NC Nancy Irmen, CPC Coleharbor ND Cindy JoAnn Schuster, CPC Elgin ND Jennifer Ruth Guderjahn, CPC Minot ND Penny King, CPC Minot ND Katerri Florence Rodriguez, CPC Minot ND Renae Weatherspoon, CPC Minot ND Rebecca B Licking, CPC Norfolk NE Connie Majer, CPC North Platte NE Heather M Rogers, CPC Waverly NE Renee Lacasse, CPC Hudson NH Gail Drouin, CPC-H Laconia NH Karen P Cross, CPC Litchfield NH Beth Brown, CPC-H Manchester NH Michael Shortell, CPC Carteret NJ Debbie Keil, CPC Howell NJ Carol Ann Churchill, CPC Iselin NJ Nancy B Bustos, CPC Lodi NJ Grace Belo, CPC Morganville NJ Elisa C Arbeeny, CPC Oakhurst NJ Roxanne Bucknavage, CPC Perth Amboy NJ Teresa Christensen, CPC Reno NV Lourdes-Gina Louis, CPC Brooklyn NY Silvia Ronda, CPC Chestnut Ridge NY Sandra Anderson, CPC Elmont NY Katy Suk-Wah Li, CPC, CPC-P Flushing NY Tashani F Frater, CPC Jamaica NY Jill Jennings, CPC Lincolndale NY Crystal Mayer, CPC Mahopac NY Kathryn Ralph, CPC New York NY Claudia A Rivera, CPC New York NY Merill Ann Weinstein, CPC New York City NY Kim Gordon, CPC Philadelphia NY Lesley Ann Olive, CPC Rodman NY Barbara K Gerow, CPC Sherrill NY Tonya Monique Cook, CPC Valley Stream NY Jeannine A Chassey, CPC Wingdale NY Daniel Lefkowitz, CPC York Town Heights NY Rebecca L Wilson, CPC Akron OH Dianne Elizabeth Garrison, CPC Avon OH Angela Marsiglia, CPC Avon OH Mary P Muller, CPC Avon Lake OH Jane Elizabeth Hamilton, CPC Bellville OH Cheryl Russo, CPC Brook Park OH Kelly Bing, CPC Canton OH Melissa Langfitt, CPC Canton OH Elaine Fehring, CPC Cincinnati OH Andrea Juanita Humphrey, CPC Cleveland OH Jenifer Danielle Arnold, CPC Columbus OH Lisa Brewster, CPC Columbus OH Stacy Garcia, CPC Columbus OH Amy Spengler, CPC Columbus OH Kara Marie Wohlwend, CPC Columbus OH Marcia J Boyd, CPC Crestline OH Angela K Barnett, CPC Eastlake OH Teresa Demarco, CPC Elyria OH Tonya Kessler, CPC Elyria OH Kathleen Ross, CPC Elyria OH Terri Zunis, CPC Elyria OH Mariann Dalton, CPC Franklin Furnace OH Tonia L Zochowski, CPC Gahanna OH Lauren Young, CPC Grafton OH Jodie Baga, CPC Hamilton OH Corrinne Robin Ball, CPC Hillsboro OH Kimberly Wilson, CPC Lagrange OH Lori Jones, CPC Laura OH Marilyn Hastings, CPC Lorain OH Heidi Tucker, CPC Lorain OH Tracy Nutter, CPC Marion OH Brandi Taddeo, CPC Oberlin OH Angela Flores, CPC-H Oregom OH Sandra Delane Bergman, CPC Orient OH Gina Denise Dedo, CPC Parma OH Carol Long, CPC Parma OH Myra Maria Zochowski, CPC Pataskala OH Roxanne Lynn Glick, CPC Plain City OH Karen S Lopez, CPC Springfield OH Colleen Ellen Arebaugh, CPC Toledo OH Zandra Lee Boepple, CPC Vermilion OH Melissa Cassidy, CPC Vermilion OH Katherine Jones, CPC Vermilion OH Rebecca Gill, CPC Westfield Center OH 38 AAPC Coding Edge

39 newly credentialed members Christopher E Gatchel, CPC Worthington OH Sherry Davis, CPC Youngstown OH Susan J Britton, CPC Oklahoma City OK Glenda M Stever, CPC Shawnee OK Sarah Fox, CPC Tulsa OK Patricia M Kidd, CPC Albany OR Theodore John Colombo, CPC Beaverton OR Catrina M Thomas, CPC Eugene OR Julie Ann Jensen, CPC Florence OR Jill Woodward, CPC Grants Pass OR Chanda Arscott, CPC-H Oakland OR Kathy Strawn, CPC Salem OR Janine Margiotta, CPC Veneta OR Phyllis Ann Bender, CPC, CPC-H Bethlehem PA Katherine Sciecinski, CPC Boothwyn PA Carol F Flory, CPC Chambersburg PA Ann L Underkoffler, CPC Chambersburg PA William J Cameron, CPC Dover PA Tammy S Wise, CPC Dover PA Karen Lynn Hunt, CPC Fayetteville PA Amy Ann Gumm, CPC Gettysburg PA Elizabeth W Hayes, CPC Greencastle PA Dawn Gerrish, CPC Greenville PA Barbara-Ellen Young, CPC Hughesville PA Melissa Groff, CPC Langhorne PA Beverly Slemmer, CPC Levittown PA Megan Beth Price, CPC, CPC-H Luzerne PA Amy C Hobbs, CPC Marion PA Crissty Marie Johns, CPC Marion PA Misty Jo Mowery, CPC McConnellsburg PA Susan Trapuzzano, CPC Mckees Rocks PA Carrie R Baughman, CPC Mercersberg PA Melissa S Clayton, CPC Muncy PA Charlene A Foresman, CPC Parkesburg PA Cynthia Errigo, CPC Scott Township PA Brenda K Line, CPC Shippensburg PA Ruth Ann Wonders, CPC Shippensburg PA Mandy L Bakner, CPC Waynesboro PA Kathleen McKula, CPC Waynesboro PA Kathryn M Barbera, CPC Williamsport PA Kimberly Ann Bush, CPC Windber PA Karen Marie Goering, CPC York PA Jennifer L Izzi, CPC Cranston RI Patti J Santilli, CPC Cranston RI Beverly King, CPC Columbia SC Patti E Norris, CPC Florence SC Cathy Turner Watts, CPC Florence SC Jacqueline Miller, CPC Fort Mill SC Lisa Michelle Grimsley, CPC Goose Creek SC Paula Russell Smith, CPC Greenville SC Gloria P Wise, CPC Johnsonville SC Gwendolyn Geneva Johnson, CPC Latta SC Lisa Storey, CPC Lexington SC Lori DeMello, CPC North Charleston SC Tamesha Denise Greene-Simmons, CPC North Charleston SC Maggie Rowe, CPC North Charleston SC Susan Renee Hayes, CPC Pamplico SC Sheila Shepherd, CPC Pelzer SC Connie D Coward, CPC Scranton SC Carla Howard, CPC Summerville SC Janel Rae Nielsen, CPC Sumter SC Erika Nivens, CPC Sumter SC Linda Henderson, CPC Walterboro SC Trina Church, CPC Antioch TN Amelia Mickles, CPC Antioch TN Penny Harper, CPC Blountville TN Annette Gentry, CPC Cleveland TN Kimberly Dawn Cooper, CPC Columbia TN Deanna Huff, CPC Dandridge TN Linda Kay Payne, CPC Kingsport TN Donna M Henry, CPC LaVergne TN Kim Elaine Webb, CPC Mt Juliet TN Jillian K Hansen, CPC Murfreesboro TN Rosezella Kindall, CPC Murfreesboro TN Heather Nobles, CPC Murfreesboro TN Jennifer P Allen, CPC Nashville TN Candace Bivens, CPC Old Fort TN Kelly Hall, CPC Smyrna TN Cassandra W McKibben, CPC Smyrna TN Sandy Logan, CPC Amarillo TX Jodi Burchett, CPC Athens TX Salima Merchant, CPC Carrollton TX Gladys Whittington, CPC Carrollton TX Robin M Black, CPC Eastland TX Kelly Skinner, CPC Eastland TX Jorge Ruiz, CPC Edinburg TX Felipa Wood, CPC El Paso TX Cynthia Cramer, CPC Flower Mound TX Mayra E Ramirez, CPC Flower Mound TX Susan M Montford, CPC Houston TX Jenifer Scallan, CPC Houston TX Deanna Solomon, CPC Houston TX Patricia Buchanan, CPC Kyle TX Barbara Walker, CPC-H La Grange TX Jessica Camille Adair, CPC Lancaster TX Jessica L Jones, CPC Lavon TX Lorena Rodriguez, CPC Round Rock TX Barbara Dell Guerra, CPC San Antonio TX Diane Pitre Stevens, CPC, CPC-H San Antonio TX Amber Marie Wilson, CPC San Antonio TX Nancy R Kennedy, CPC Wylie TX Kathleen Rodriguez, CPC Basye VA Christina Michelle Taylor, CPC Bristol VA Stacey Jane McCoy, CPC Chester VA Terri Anne Carpenter, CPC Chesterfield VA Kristin Monique Jones, CPC Chesterfield VA Crystal Gordon, CPC Fredericksburg VA Melissa Brown, CPC Hampton VA Carolyn Wilson, CPC-H Harrisonburg VA Natalie A Gibbs, CPC Hopewell VA Lynn J Woods, CPC Machanicsville VA Diane E Royston, CPC Marshall VA Arden Aylesworth, CPC Midlothian VA Ashley Pearman Carvana, CPC Midlothian VA Amy Winfree Shelton, CPC, CIRCC Midlothian VA Phyllis W Berkle, CPC Richmond VA Charlotte Brooks, CPC Richmond VA Dellene DePlata, CPC Richmond VA Natasha Nicolle Williams, CPC Richmond VA Michelle Ivanchukov, CPC Sterling VA Sherry M Tuttle, CPC Swoope VA Charlene Phillips, CPC Williamsburg VA Judy Walters, CPC Winchester VA Danielle Lynn Dragon, CPC Burlington VT Tracey Collins, CPC Bremerton WA Jennifer Olmstead, CPC Bremerton WA Brenda K Strowger, CPC Bremerton WA Bonnie M Swanson, CPC Bremerton WA Laronda Durrant, CPC Everett WA Sarah Neely, CPC-H Ferndale WA Nicole Barnett, CPC Kent WA Dara Barnes, CPC, CPC-H La Center WA Debbie Hart, CPC Mount Vernon WA Gena L Rooney, CPC Mountlake Terrace WA Jennifer Jorge, CPC Port Orchard WA Angela M Wilson, CPC Renton WA Dawn Pomeroy, CIRCC Seattle WA Skye Summers, CPC Seattle WA Laurie Whitney, CPC Silverdale WA Sunni M Hearin, CPC University Place WA Barbara A DeRosier, CPC Caledinia WI Brenda Brookens, CPC Edgerton WI Janet Mahnke, CPC Franklin WI Mary M VanBiljouw, CPC Greenfield WI Dena M Wrobel, CPC Greenfield WI Mary E Mahoney, CPC Hubertus WI Lisa Rhodes, CPC Janesville WI Debra J Elfering-Haney, CPC Kansasville WI Joanne Ruth Kramer, CPC Kenosha WI Lynne Marie LaScola, CPC Kenosha WI Tina Marie Richer, CPC Kenosha WI Tina M Bartus, CPC Madison WI Kathy L Skeels, CPC Madison WI Lynn A Bremer, CPC Milwaukee WI Heather Galaszewski, CPC Milwaukee WI Ronn Gilbert, CPC Milwaukee WI Doreen M Karpinski, CPC Milwaukee WI Linda Lee Koch, CPC Milwaukee WI Danielle Marie Pursley, CPC Milwaukee WI Heather Rivera, CPC Milwaukee WI Michelle Lyn Bruns, CPC Mukwonago WI Laura A Gomez, CPC New Berlin WI Anuradha Kalyani, CPC New Berlin WI Sharon Ann Woodman, CPC Oconomowoc WI Jodi Pierce, CPC Tomah WI Tamara Ann Hoffman, CPC Waukesha WI Jean Marie Dorscher, CPC Wauwatosa WI Breanna Suskey, CPC Wauwatosa WI Cheryl Anne Krueger, CPC West Allis WI Cheryl Nugen, CPC Glenwood WV Angie Dickerson, CPC Lavalette WV Judi Brost, CPC Cody WY Sharon Holifield, CPC Sheridan WY Apprentices Amanda Perrizo, CPC-A North Pole AK Laura Thornton, CPC-A Huntsville AL Tammy Doss, CPC-A Indianapolis AL Kelli Sutter Morgan, CPC-A Montgomery AL Robert Lapatrick Crawford, CPC-A Phenix City AL Katalin Szuts, CPC-A Spanish Fort AL Christy Michele Harbison, CPC-A Benton AR Janet S Hicks, CPC-A Cabot AR Tawny S Flores, CPC-A England AR Jean Anne Dawson, CPC-A Fayetteville AR Anne M Elliott, CPC-A Fayetteville AR Emily Cain, CPC-A Fort Smith AR Patricia Patterson, CPC-A Fort Smith AR Katherine Alexander, CPC-A Hot Springs AR Judith Lynn Millard, CPC-A Little Rock AR Cora Smith, CPC-A Springdale AR Victoria Rodriguez, CPC-A Avondale AZ Theresa Krejci, CPC-A Gilbert AZ Beth Timms, CPC-A Goodyear AZ Christiane Antone, CPC-A Mesa AZ Shannon B Davis, CPC-A Mesa AZ Cheryl Miles, CPC-A Mesa AZ Donavon Lee Stewart, CPC-A Phoenix AZ Aileen Sanders, CPC-A Queen Creek AZ Lisa Bosworth, CPC-A Scottsdale AZ Samantha Ayers, CPC-A Surprise AZ Christopher Camia, CPC-A Buena Park CA Stella E Cha, CPC-A Buena Park CA Nelli Semerjian, CPC-A Canoga Park CA Russell Francis Clark, CPC-A Carlsbad CA Clarice Ann Hood, CPC-A Carlsbad CA Marylou Veneracion, CPC-A Carson CA Patricia Castro Clavano, CPC-A Chula Vista CA Alexander Vitmer, CPC-A Citrus Heights CA Jennifer Leal, CPC-A Downey CA Tajinder Singh Japra, CPC-A Elk Grove CA Mark Mathew Quail, CPC-A Fountain Valley CA Brandy Minvielle, CPC-A Grass Valley CA Jessica E Amezcua, CPC-A, CPC-H-A Hacienda Heights CA Jenny Day, CPC-A Irvine CA Mee Rhang Won, CPC-A Irvine CA Glenn Degraaff, CPC-A La Mirada CA Josephine Anne Lucero, CPC-A La Mirada CA Jeffrey Ho, CPC-A Long Beach CA Jocelyn Ho, CPC-A Long Beach CA Becky C Brady, CPC-A Los Angeles CA Alex Argote Chua, CPC-A Los Angeles CA Candace Farran, CPC-A Los Angeles CA Eunice Nam, CPC-A Newport Beach CA Selina Safari, CPC-A Northridge CA Alyssa Avila, CPC-A Norwalk CA Gloria Coria, CPC-A Norwalk CA Ramiro Garcia, CPC-A Norwalk CA Nora Vasquez, CPC-A Norwalk CA Carmelita Harker, CPC-A Oakland CA Rachel A Lim, CPC-A Orange CA Nickolai Ed Altoveros, CPC-A Panorama City CA Rainier Amigable, CPC-A Pasadena CA Robert Edwards, CPC-A Porter Ranch CA Valerie B Bates, CPC-A Ramona CA Eileen Fontanoza, CPC-A Rancho Cucamonga CA Irene Nugent, CPC-A Redwood City CA Rebecca Lynn Johnson, CPC-A Riverbank CA Rochelle Ann Shaw Sharma, CPC-A Sacramento CA Pamela Cale, CPC-A San Diego CA Yvonne M O Leary, CPC-A San Diego CA John G Robinson, CPC-A San Diego CA Lisa J Talamantez-Galego, CPC-A San Diego CA Kim Ellen Turner, CPC-A San Diego CA Phouthong Voravong, CPC-A San Diego CA Joyee Hoiyee Zhu, CPC-A San Diego CA Maria Lourdes Santos Cabuang, CPC-A San Marcos CA Catherine Frost, CPC-A San Ysidro CA Oleg Korsakov, CPC-A Tarzana CA Jennie Ho, CPC-A Vallejo CA Huong Tran, CPC-A Westminster CA Jackie Adeline Gallegos, CPC-A Arvada CO Diane Neal-Ault, CPC-A Broomfield CO Nancy Festa, CPC-A Carbondale CO Willow Kauffman, CPC-A Castle Rock CO Tammy Lou Schroeder, CPC-A Castle Rock CO William Howard, CPC-A Colorado Springs CO Kerstin Stout, CPC-A Colorado Springs CO Patricia Yagielski, CPC-A Colorado Springs CO LeeAnn Marie Camp, CPC-A Denver CO Robyn J Maxwell, CPC-A Denver CO Mary J Carver, CPC-A Lakewood CO Malinda Erin Ard, CPC-A Loveland CO Teresa J Brown, CPC-A Morrison CO Nicole Renee Holley, CPC-A New Castle CO Rex E Helmsing, CPC-A Pueblo CO Janele Watson, CPC-A Pueblo West CO Tia Loera, CPC-A Thornton CO Michele M McPartland, CPC-A Branford CT Shiela A Milne, CPC-A Branford CT Judith L Robertson, CPC-A Brookfield CT Jesse Bey-Wagner, CPC-A Danbury CT Valerie Olivet, CPC-A Danbury CT Maureen A Duffy, CPC-A Durham CT Wendy Kinkade, CPC-A East Windsor CT Cindy L Underhill, CPC-A Ellington CT CarriAnn Backus, CPC-A Enfield CT Jennifer Justine Graham, CPC-A Enfield CT Ellen Kelting, CPC-A Enfield CT Tricia A Donovan, CPC-A Hamden CT Jasmine Hong Cao, CPC-A Hartfort CT Luz M Cruz, CPC-P-A Meriden CT Kim L Seman, CPC-A Middlebury CT Heather A McKeon, CPC-A Naugatuck CT Melissa Louise Murray, CPC-A New Britain CT Marianne D Vesey, CPC-A New Fairfield CT Debbra Marie Rizzo, CPC-A N Branford CT Cheryl A Landry, CPC-A North Haven CT Denise L Wentworth, CPC-A Northford CT Valerie Dondero, CPC-A Stafford Springs CT Sherry L. Fantoli, CPC-A Stafford Springs CT Debra L Turcotte, CPC-A West Haven CT Gail A Rodriguez, CPC-A West Haven CT Lynn Busby, CPC-A Bridgeville DE Teresa Van Dyck, CPC-A Clayton DE Patricia Wiggins, CPC-A Middletown DE Danielle Zucker, CPC-A Brandon FL Amanda Arteaga, CPC-A Clearwater FL Marilyn Bates, CPC-A Clearwater FL Lauren Daniel, CPC-A Cocoa FL Desiree Sama, CPC-A Deerfield Beach FL Rabecca Elaine Vallejo, CPC-H-A Ft Walton Beach FL Virginia Leighton Vance-Carter, CPC-H-A Ft Walton Beach FL Pamela Canedy, CPC-A Ft Myers Beach FL Patria A Davis, CPC-A Gainesville FL Frank Bordenga, CPC-A Greenacres FL Lissette L Unzueta, CPC-A Hialeah FL Rayshelle Aparicio, CPC-A Hollywood FL Bianca Maura, CPC-A Homosassa FL Annette Pope, CPC-A Jacksonville FL Dolores Puttbach, CPC-A Jacksonville FL Gerlinde Dancy, CPC-A Lakeland FL Lourdes Bernal, CPC-A Miami FL Tania Estevez, CPC-A Miami FL Milvia M Keeling, CPC-A Miami FL Marta Menendez-Veliz, CPC-A Miami FL Roxana Molleda, CPC-A Miami FL Estrella Matheu Morales, CPC-A Miami FL Doreen Marjorie Watson, CPC-A Miami FL Sheila Yvonne Cudd, CPC-A New Port Richey FL Melissa May, CPC-A New Port Richey FL Mary M Presson, CPC-A Orange Park FL Catrina Lloyd, CPC-H-A Palm Bay FL Terry Heidemann, CPC-A Palm Harbor FL Katherine Dietle, CPC-A Panama City FL Angela Walton, CPC-A Royal Palm Beach FL Zoe T Pine, CPC-A Seminole FL Joshua Anthony Coggins, CPC-A Spring Hill FL Theresa M Cook, CPC-A Spring Hill FL Dolores G Morris, CPC-A St Petersburg FL Jeffrey Eckmann, CPC-A, CPC-P-A Tampa FL Adam Maingot, CPC-A Tampa FL Carla Ivan Jimenez, CPC-A Weston FL Marina S Perez, CPC-A Weston FL Anna Keeton, CPC-A Yulee FL Angie Caldwell, CPC-A Adairsville GA Ashley Louetta Keaton, CPC-A Alpharetta GA Vickey Lawson, CPC-A Augusta GA Charmaine Lisha Walker, CPC-A Augusta GA Sara Michelle Johnson, CPC-A Commerce GA Lucy Reyes, CPC-A Douglasville GA Rosalind Passmore, CPC-A Ellenwood GA Ashley Obrien, CPC-A Fayetteville GA Rebecca Grates, CPC-A Grovetown GA Susan Brunner, CPC-A Harlem GA Michelle Riggleman, CPC-A Mcdonough GA Tracey White, CPC-A Rock Spring GA Mary Evans, CPC-A Stockbridge GA Henry M Castillo, CPC-A Honolulu HI Aileen Mae C Porras, CPC-A Honolulu HI Shannon Lee Ann Patrick, CPC-A Kapaa HI Vicky L Muller, CPC-A Anamosa IA Crystal Estabrook, CPC-A Des Moines IA Amanda Dawn Richter, CPC-A Boise ID Suzanne Hutchison Schwinger, CPC-A Boise ID Lisa Smith, CPC-A Caldwell ID Candice D Richter, CPC-A Twin Falls ID Shannon Sheley, CPC-A Wilder ID Merlene S Booker, CPC-A Bloomington IL Joshua Galvan, CPC-A Burbank IL Vaibhavi Sheth, CPC-A Carol Stream IL Kimberly Davis- Mayers, CPC, CPC-A Chicago IL Princess Williford, CPC-A Chicago IL Donisha Dunagan, CPC-A Glen Ellyn IL Lori Ann Allison, CPC-A Highland IL Jennifer Anderson, CPC-A Loves Park IL Antwon A Freeman, CPC-A Matteson IL Cora Nicole Whited, CPC-A Mount Olive IL Amanda Sinkey, CPC-A New Baden IL Kaeron Demetrius Haywood, CPC-A Park Forest IL Melinda S Bachman, CPC-A Peoria IL Mia S White, CPC-A Rockford IL Gina M Coletta-Stien, CPC-A Rockton IL Tamie L Smith, CPC-A Smithboro IL Susanne B Miller, CPC-A Troy IL Eleanora Reeves, CPC-A Urbana IL Camille Buncak, CPC-A Willow Springs IL Rebecca Jerabek, CPC-A Yorkville IL Tiffany Depinet, CPC-A Cicero IN Elizabeth Joan Walmoth, CPC-A Clayton IN Theresa Pioth, CPC-A Dyer IN Angela Banet, CPC-A Floyds Knobs IN Patricia Melton, CPC-A Georgetown IN Sharon Bair, CPC-A Greenwood IN Shelby Louise Edinger, CPC-A Indianapolis IN Monica Elston, CPC-A Indianapolis IN Darcy Ann Brummett, CPC-A Lafayette IN Jeanell Barnes, CPC-A Merrillville IN Susan Burke, CPC-A Munster IN James Harvey, CPC-A New Albany IN Jody Zapata, CPC-A New Albany IN Heather Mull, CPC-A Pekin IN Hilary Pritchard, CPC-A Rockport IN Jana Elliott, CPC-A Salem IN Barbara Langton, CPC-H-A Schererville IN Dora Thomas, CPC-A Scottsburg IN Stacy Shireman, CPC-A Sellersburg IN Deborah Vietzke, CPC-A Sellersburg IN Sheila Marie Welsh, CPC-A South Bend IN Cindy R Brunes, CPC-A Westfield IN Kimberly Turpin, CPC-A Westfield IN Christy Lynn Richards, CPC-A Hutchinson KS Felicia Ann Brown, CPC-A Lawrence KS Tasha Lower, CPC-A Lawrence KS Melissa Haller, CPC-A Louisburg KS Tiffany L Simeta, CPC-A Manhattan KS Rebecca Hamilton, CPC-A Olathe KS Lana Lee, CPC-A Olathe KS Trudy L Bilimoria, CPC-A Overland Park KS Jana Rupp, CPC-A Paola KS Antheron Bailey, CPC-A Wichita KS Amanda Marie Boyd, CPC-A Wichita KS Monique Renee Buchanan, CPC-A Wichita KS Elizabeth Craig, CPC-A Wichita KS Megan Harris, CPC-A Wichita KS Tamara Jean Moore, CPC-A Wichita KS Nina Simone Ross, CPC-A Wichita KS Tina Williams, CPC-A Wichita KS Carrie Jarrell, CPC-A Ashland KY Evelyn Sue Clemons, CPC-A Burlington KY Kimberly Renee Fins, CPC-A Crab Orchard KY Lois Runden, CPC-A Crestview Hills KY Dora D Justice, CPC-A Georgetown KY Delorah Wheeler, CPC-A Inez KY Ripal K Bodiwala, CPC-A Lexington KY Patricia Ann Coe, CPC-A Lexington KY Madeline Flynn, CPC-A Lexington KY Tracy Alise Sarver, CPC-A Lexington KY Rita Gunta Bole, CPC-A Louisville KY Rachael Boone, CPC-A Louisville KY Brittney Cappel, CPC-A Louisville KY Casie Duvall, CPC-A Louisville KY Charles Hammond, Jr, CPC-A Louisville KY Kimberly Erin Land, CPC-A Louisville KY Connie Elaine Mefford, CPC-A Louisville KY Laura Stocker, CPC-A Louisville KY Penny Thielmeier, CPC-A Louisville KY Diana Gentry, CPC-A Middleburg KY Shannon Haag, CPC-A Mt Washington KY Mary Marcus Elam, CPC-A Pans KY Dory Smith, CPC-A Shepherdsville KY Kimberly Mayfield, CPC-A Somerset KY Melanie Thacker, CPC-A Waco KY Robert Marks, CPC-A Covington LA Susan Hillard, CPC-A Fort Polk LA Alison Andrus, CPC-A Lake Charles LA Nicole Nichols, CPC-A Madisonville LA Lauren Loughlin, CPC-A Beverly MA Donna Stevens, CPC-A Billerica MA Allison Blythe, CPC-A Boston MA Frances Cioffi, CPC-A Burlington MA Abigail Bond, CPC-A Charlestown MA Yesenia Alvarado, CPC-A Dorchester MA Karen Lennon, CPC-A Franklin MA Rhonda Janeczko, CPC-A Lowell MA Pamela Rourke, CPC-A Methuen MA Jason Czernich, CPC-A Millers Falls MA David Ward, CPC-A Monson MA Cynthia Jones, CPC-A Northborough MA Mary Camyre, CPC-A Pittsfield MA Jennifer M Hall, CPC-A Pittsfield MA Joann M Squires, CPC-A Pittsfield MA Marsha S Gerber, CPC-A Salem MA October

40 newly credentialed members Christine Norton, CPC-A Shrewsbury MA Julie Augello, CPC-A Stoneham MA Joan Mendieta, CPC-A Tewksbury MA Sandra L Adams, CPC-A Westwood MA Elvira A Pentella, CPC-A Wilmington MA Sumit Dhall, CPC-A Baltimore MD Fatima Rode, CPC-A Baltimore MD Carol Kelliher, CPC-A Bel Air MD Maria Victoria Rogers, CPC-A Brooklyn Park MD Nancy P Judge, CPC-A Columbia MD Laurie Tierney, CPC-A Columbia MD Shehla Ahmed, CPC-A Ellicott City MD Leigh Giannandrea, CPC-A Ellicott City MD Joy-Jasmin A Brunnelson, CPC-A Frederick MD Mary Stanton, CPC-A Laurel MD Cecilia Queen, CPC-A Lothian MD Aprile Murphy, CPC-A Pasadena MD Grace Lalonde, CPC-A Poolesville MD Ericka Kamya, CPC-A Potomac MD Charles Carnagey, CPC-A Severna Park MD Jenny Nguyen, CPC-A Silver Spring MD Julie Hill, CPC-A Allendale MI Karl Ecklund, CPC-A Ann Arbor MI Andrea Graef, CPC-A Ann Arbor MI Linda Kathleen Trujillo-Duris, CPC-A Ann Arbor MI Therese Marie Badalament, CPC-A Bloomfield Hills MI Kristine Bauman, CPC-A Canton MI Laura Hodges, CPC-A Canton MI Tracy Bunge, CPC-A Chesterfield MI Jennifer Andrews, CPC-A Clare MI Nicole Janos, CPC-A Clio MI Mary Kathryn Wilding, CPC-A Commerce Township MI Denise Renee Biondo, CPC-A Commerce Township MI Sharon M Brouillard, CPC-A Commerce Township MI Margaret G Dunteman, CPC-A Dearborn MI Monica L Cooper, CPC-A Detroit MI John Korthals, CPC-A Kingston MI Nancy Granke, CPC-A Lenox Township MI Sean C Scott, CPC-A Levering MI Bernice Grove, CPC-A Livonia MI Teena Jakowinicz, CPC-A Livonia MI Cynthia Rose Reynolds, CPC-A Livonia MI Aaron Sawicky, CPC-A Livonia MI Daniela Simoski, CPC-A Macomb MI Susan Mccambridge, CPC-A Northville MI Maureen Skupny, CPC-A Novi MI Edith Gold, CPC-A Oak Park MI Linda R Ross, CPC-A Oak Park MI Carol S Spencer, CPC-A Ortonville MI Katherine Fitzgerald, CPC-A Plymouth MI Karyn L Sherman, CPC-A Redford MI Karen Dawkins, CPC-A Rochester Hills MI Genevieve Kelpin, CPC-A Shelby Township MI Elisheva M Snow, CPC-A Southfield MI Suzanne Ankawi, CPC-A Sterling Heights MI Sarah Decaussin, CPC-A Sterling Heights MI Jacqueline L Allison, CPC-A Waterford MI Shera Baker, CPC-A Columbia MO Brandi Chick, CPC-A Columbia MO Sonya Fogle, CPC-A Columbia MO Misty Woods, CPC-A Higbee MO Terri Peters, CPC-A Jefferson City MO Anne Rehagen, CPC-A Jefferson City MO Colleen Fitzgibbons, CPC-A Kansas City MO Diana Smith, CPC-A Kansas City MO Sandra McCoy, CPC-A Leadwood MO Cathryn Sumpter, CPC-A Sturgeon MO Mary Kay Murphy, CPC-A Biloxi MS Karla Nitchmann, CPC-A Biloxi MS Ann G Stevens, CPC-A Florence MS Connie Elliott, CPC-A Ocean Springs MS Ralph Purdy, CPC-A Southaven MS Christopher Field, CPC-A Billings MT Keri Kiesser, CPC-A Billings MT Jill McPherson, CPC-A Billings MT Zara Dawn Ryder, CPC-A Billings MT Sonja Spencer, CPC-A Billings MT Kasey M Thorne, CPC-A Billings MT Lindsey Nadine Burns, CPC-A Colstrip MT Garnet M Jones, CPC-A Great Falls MT Nancy Brosten, CPC-A Helena MT Daniel Gagnon, CPC-A Charlotte NC Auretha Gregory, CPC-A Charlotte NC Elizabeth Jackson, CPC-A Charlotte NC Denise Harvey, CPC-A Concord NC Julie Martin, CPC-A Concord NC Lisa Cannon, CPC-A Denver NC Maria Millsaps, CPC-A Denver NC Darleine Bolch, CPC-A Gastonia NC Liz Gartman, CPC-A Graham NC Linda P Hargrove, CPC-A Graham NC Ann Brown, CPC-A Hickory NC Robin R Huffman, CPC-A Hickory NC Arlene Soblotney, CPC-A Hickory NC Kelly Marie Kuehn, CPC-A Indian Trail NC Jessica Taylor, CPC-A Matthews NC Kristyn Martin, CPC-A Monroe NC Sandra Drye, CPC-A Polkton NC Jane Gault, CPC-A Raleigh NC Holly Ridge, CPC-A Raleigh NC Sandie Gail Ellis, CPC-A Statesville NC Adair Jackson, CPC-A Wilmington NC Marisa Folstad, CPC-A Glenburn ND Michelle L Metschke, CPC-A Elkhorn NE Barbara Ann Steele, CPC-A Omaha NE Joel Christopher Wane, CPC-A Omaha NE Katelyn Griggs, CPC-A Barrington NH Suci Reeves, CPC-A Concord NH Dana Jeanne Stewart, CPC-A Deerfield NH Corrine Elizabeth Voisine, CPC-A Dunbarton NH Britt E O Donnell, CPC-A Epping NH Joanne Murawski, CPC-A Loudon NH Susan Kelley, CPC-A Merrimack NH Amanda L Jordan, CPC-A Salem NH Kim Bevel, CPC-A Allenhurst NJ Joseph Lamantia, CPC-A Barnegat NJ Susan Buckman, CPC-A Belford NJ Jiji John Kuchentang, CPC-A, CPC-H-A Bergenfield NJ Dena Failla, CPC-A Florham Park NJ Ana Tan Simon, CPC-A Jersey City NJ Gina Della Rovere, CPC-A Kinnelon NJ Heather Schnitzer, CPC-A Marlton NJ Aaron Lucas, CPC-A Mt Laurel NJ Deborah Scheller-Collier, CPC-A Mt Laurel NJ Marianne Paolise, CPC-A Oceanport NJ Samuel Deutscher, CPC-A Robbinsville NJ Jessica Martinez, CPC-A Westwood NJ Shelby Cooper, CPC-A Williamstown NJ Patricia Murphy-Wright, CPC-A Fallon NV Evelyn S Gilbert, CPC-A Sparks NV Amanda P Fenn, CPC-A Addison NY Caroline Ann Twarog, CPC-A Albany NY Patrica F Antonelli, CPC-A Ballston Spa NY Loretta A Ruckle, CPC-A Brewster NY Lynda C Faustin, CPC-A Brooklyn NY Jodie L Freedman, CPC-A Clifton Park NY Pattsy Briones, CPC-A Corona NY Vishnupriya Anilkumar Desai, CPC-A Flushing NY Stella Garabedian, CPC-A Forest Hills NY Ajish K Abraham, CPC-A Garnerville NY Denise M Darling, CPC-A Gloversville NY Donata Megaro-Parker, CPC-A Hicksville NY Roy E Franks, CPC-A Jamaica NY Cynthia A Casazza, CPC-A Katonah NY Tara McKeever, CPC-A Lake Ronkonkoma NY Diane Hoffman-Jones, CPC-A Latham NY Gisele M Busone, CPC-A Mechanicville NY Ruth Ann Bombard, CPC-A Nassau NY Linda S Akin, CPC-A Patterson NY Bridgette E Dodge, CPC-A Petersburgh NY Claire Elizabeth Schlemme, CPC-A Poughkeepsie NY Grace Mon Kuriakose, CPC-A Queens Village NY Prabhawatie Devi Shionarain, CPC-A Richmond Hill NY Sara J Smithers, CPC-A Sandy Creek NY Barbara M Brown, CPC-A Schuylerville NY Emily Michelle Horgan, CPC-A Scotia NY Sharon Ann Nicpon, CPC-A Schenectady NY Indira Gaitree Bacchus, CPC-A South Ozone Park NY Hilary Zavaski, CPC-A Spencer NY Tammy J Carbino, CPC-A Winthrop NY Nicole Denise Coleman, CPC-A Akron OH Karen Christine Osborne, CPC-A Akron OH Terrie Pfeil, CPC-A Akron OH Marilyn M Seaman, CPC-A Akron OH Melissa Camp, CPC-A Amherst OH Jacki Adams, CPC-A Canton OH Tracy E Angelo, CPC-A Canton OH Kimberley Michelle Cheatwood, CPC-A Canton OH Wendy Marie Cole, CPC-A Canton OH Jennifer Michelle Karcher, CPC-A Canton OH Tracey LaDonna Lenzy, CPC-A Canton OH Brenna Kathleen Murphy, CPC-A Canton OH Rebecca P Walker, CPC-A Canton OH Stephanie Lorraine Zegers, CPC-A Canton OH Brittany Panek, CPC-A Chesterland OH Michelle Alexander, CPC-A Cincinnati OH Lynn A Swanson, CPC-A Cleveland OH Heather Folick, CPC-A Cleveland Heights OH Amanda Fauvette Corbin, CPC-A Clinton OH Tiffany Fischer, CPC-A Coshocton OH Erika Mahoney, CPC-A Cuyahoga Falls OH Kate Singleton, CPC-A Elyria OH Kristie Garfield, CPC-A Grafton OH Peggy Jo Murphy, CPC-A Hartville OH Cynthia O Mhanna, CPC-A Highland Hts OH Erin Jayne Mshar, CPC-A Hubbard OH Leslie Willhoite, CPC-A Kettring OH Ruth Cordy, CPC-A Lagrange OH Ashley Brentlinger, CPC-A Lakeview OH Laura L Spreng, CPC-A Loudonville OH Donna J Balg, CPC-A Mansfield OH Tennelle S Bauman, CPC-A Mansfield OH Kristy R Owens, CPC-A Mansfield OH Tammy L Partridge, CPC-A Mansfield OH Sheri L Persinger, CPC-A Mansfield OH Cheryl Lynn Swanson, CPC-A Mansfield OH Latonda M Warren, CPC-A Maple Hts OH Debra J Norris, CPC-A Massillon OH Angelina Drake, CPC-A Maumee OH Julie D Funk, CPC-A Mogadore OH Karen F Froman, CPC-A Monroe OH Elizabeth J Glover, CPC-A North Royalton OH Lynette R Tuikka, CPC-A Painesville OH Billie D Yannayon, CPC-A Peninsula OH Bradley James Hickman, CPC-A Port Clinton OH Elaine Linette Ward, CPC-A Proctorville OH Elena L Mitchell, CPC-A Ravenna OH Jennifer Lynn Smith, CPC-A South Point OH Karen Cristina Ricci, CPC-A Strongsville OH Julie Fockler, CPC-A Wadsworth OH Nitra L Cunningham, CPC-A Warren OH Ciara Unique Milton, CPC-A Warrensville Heights OH Jessica Ball, CPC-A Waterville OH Lora A Copley, CPC-A Wooster OH Ruth L Lemon, CPC-A Wooster OH Lisa A Swartz, CPC-A Wooster OH Jennifer S Todd, CPC-A Wooster OH Tina Marie Mannion, CPC-A Youngstown OH Lorrie Newman, CPC-A Broken Arrow OK Deborah Kay Lankford, CPC-A Collinsville OK Christy Dees, CPC-A Geronimo OK Carrie Knight, CPC-A Albany OR Cindy Marcum, CPC-A Albany OR Lexa Nichole McConnell, CPC-A Albany OR Erin Terwilliger, CPC-A Corvallis OR Dustin Tescher, CPC-A Corvallis OR Joyce Vomocil, CPC-A Corvallis OR Erin Rae, CPC-A Florence OR Amber Briggs, CPC-A Forest Grove OR Elaina Waller, CPC-A Gresham OR Rustie Chapple, CPC-A Lake Oswego OR Janet Derfler, CPC-A, CPC-H-A Lake Oswego OR Serena Smith, CPC-H-A Roseburg OR Tammy Antonelli, CPC-A Aldan PA Kimberly Gizzio, CPC-A Aston PA Lynn A Funk, CPC-A Bangor PA Brianne Marie Brenneman, CPC-A Carlisle PA Dianne Svopa, CPC-A East Stroudsburg PA Angela Gilmore, CPC-A Erie PA Summer Kraatz, CPC-A Erie PA Aletha Norconk, CPC-A Gillett PA Jami D Angelo, CPC-A Harbocreek PA Maria Mcdonald, CPC-A Kingston PA Roseanne Sondermeyer, CPC-A Langhonre PA Jennifer Cooper, CPC-A Marysville PA Gretchen L Schuman, CPC-A Mechanicsburg PA Crystal Ann Bennett, CPC-A North East PA Sheryl Hopkins, CPC-A North East PA Kristy Schugsta, CPC-A Pottstown PA Jane Belcher, CPC-A Saylorsburg PA Lisa Harkins, CPC-A Springfield PA Tu Pham, CPC-A Upper Darby PA Kimberly L Hall, CPC-A York PA Holly A Lobb, CPC-A York PA Sonia Leigh Conner, CPC-A Clover SC Helen Marie Keene, CPC-A Lake Wylie SC Crystal Holbrook, CPC-A Brandon SD Patricia K Person, CPC-A Pierre SD Cindy Hagle, CPC-A Sioux Falls SD Penny Morton, CPC-A Antioch TN Margaret Joines, CPC-A Athens TN Keira A Conner, CPC-A Chattanooga TN Alan Foster, CPC-A Cleveland TN Elena Legg, CPC-A Cleveland TN Debbie Sue Martin, CPC-A Dayton TN Nadine Yvonne Neale, CPC-A Dayton TN Brandy Hewitt, CPC-A Dixon Springs TN Tracey Culberson, CPC-A Etowah TN Brittany Johnson, CPC-A Gainesboro TN Tamara W Kolditz, CPC-A Germantown TN Jeannie Turner, CPC-A Hendersonville TN Ellen Coode McWhirter, CPC-A Knoxville TN Timothy Dale Ferguson, CPC-A Lebanon TN Jonnie Grissom, CPC-H-A Mc Minnville TN Rebecca Holland, CPC-A Murfreesboro TN Maquania Bentley, CPC-A Nashville TN Sara Davidson, CPC-A Orlinda TN Josh Tunkel, CPC-A Philadelphia TN Tabitha Leigh Dishman, CPC-A Rickman TN Christy Buchanan, CPC-A Smyrna TN Kristine L Kennedy, CPC-A Smyrna TN Brande Ross, CPC-A Smyrna TN Jessica Sue Martin, CPC-A Watertown TN Crystal Russell, CPC-A Burleson TX Christina Ann Kearney, CPC-A Cypress TX Sally Kreimborg, CPC-A Dallas TX Priscilla E. Anderson, CPC-A El Paso TX Tracy Levins, CPC-A El Paso TX Rachael Doss, CPC-A Fort Worth TX Muriel Howard, CPC-A Fort Worth TX Susan Stephenson, CPC-A Fort Worth TX Aimen Mobeen, CPC-A Frisco TX Samuel M Glenn, CPC-A Greenville TX Pamela Kathleen Menapace, CPC-A Houston TX William Rutledge, CPC-A Houston TX Susan Shipper, CPC-A Midlothian TX Joyce Rice, CPC-A Plano TX Patricia Kalley, CPC-A Quinlan TX Lindsey Vitez, CPC-A Richardson TX Angela D Chandler, CPC-A San Antonio TX Arely Rodriguez, CPC-A San Antonio TX Claudia Thames, CPC-A San Antonio TX Crystal Ivette Lawson, CPC-A Bluefield VA Rosa L Roush, CPC-A Caret VA Karen Grenadier, CPC-A Earlysville VA Karin Smith, CPC-A Forest VA Carol Jeanette Robinson, CPC-A Glen Allen VA Diane Valerie Grebe, CPC-A Goochland VA Kerri Lynn Parker, CPC-A Gordonsville VA Joanne L Hinson, CPC-A Kilmarnock VA Kelley Desiree Ruffner, CPC-A Manassas VA Mary A Slaughenhaupt, CPC-A Midlothian VA Keena Dan-yel Andrews, CPC-A Newport News VA Pamela J Finchum, CPC-A Palmyra VA Sherri Dawn Quiroga, CPC-A Penn Laird VA Barbie Haley, CPC-A Richmond VA Felicia Johnetta Harris, CPC-A Richmond VA Lisa Johnita Harris, CPC-A Richmond VA Ann Glenn Taylor, CPC-A Richmond VA Shereen Merricks, CPC-A Roanoke VA Sarah Mullen, CPC-A, CPC-H-A Roanoke VA Amber Madison, CPC-A Ruckersville VA Denise Brackett, CPC-A Spotsylvania VA Rhonda A Johnson, CPC-A Spotsylvania VA Dianna Lyne Davis, CPC-A Stafford VA Ray Johnston, CPC-H-A Stafford VA Patricia Dale Atcheson, CPC-A Virginia Beach VA Kimberly Jackson, CPC-A Woodbridge VA Puishan Denise Cleary, CPC-A Burlington VT Donna Jean Bevins, CPC-A Colchester VT Cecile Goodwin, CPC-A Colchester VT Linda Blades, CPC-A Jeffersonville VT Renee Michelle Corbett, CPC-A Richmond VT Myla Zamora, CPC-P-A Arlington WA Nidhi Ritolia, CPC-A Bothell WA Robbin Victoria Harris, CPC-A Everett WA Omega Renne, CPC-A Kent WA Sharon Gilliland, CPC-A Monroe WA Georgeanne L Granner, CPC-A Bristol WI Margaret H Janiszewski, CPC-A Cudahy WI Lisa A Linsley, CPC-A Janesville WI Tina R Buchanan, CPC-A Lodi WI Jennifer M Correia, CPC-A Madison WI Stephania Brown, CPC-A Milwaukee WI Jennifer Ione Maniscalco, CPC-A Milwaukee WI Stephanie Ulrich, CPC-A Neosho WI Janice D Larson, CPC-A Oak Creek WI Teresa M Torok, CPC-A Racine WI Elin Bjorkman, CPC-A Wauwatosa WI Rebecca Berger, CPC-A Wauwatosa WI LaShaune Nicole Hardin, CPC-A W. Allis WI Whitney Marie Andrew, CPC-A Bridgeport WV Donna Rae Jones, CPC-A Fairmont WV Jennifer S Wood, CPC-A Huntington WV Kimberly J Jones, CPC-A Huntington WV Stacey Michelle Anderson, CPC-A Kenova WV Patricia Ann Amsler, CPC-A Lumberport WV Specialties Christopher West, COSC Decatur AL Madelyn Myhuong Nguyen, CPC, CASCC Garden Grove CA Nana A Pianim, CPC, CGSC Harbor City CA David Davis, CPC, CPC-H, CCC Highlands Ranch CO Rita Miller, CPC, CUC Enfield CT David Hernandez, CPC, CIMC Miramar FL Charla Velez, CPC, CASCC Palmetto FL Cynthia A Swanson, CPC, CEMC Adel IA Julie Lee Bolles, CPC, CPC-I, CEDC, CEMC, CFPC, CIMC, CPEDC Fishers IN Beverly A Strube, CPC, CPC-H, CPC-I, CEMC, COBGC Indianapolis IN Leah Rachel Christy, CPC, COSC New Bedford MA Deborah M Shih, CPC, CPC-H, CANPC Revere MA Lana Powell, CPC, CASCC Hughesville MD Sandra A Steele, CPC, CEDC Fraser MI Tracy Gildner-Brindley, CASCC, CASCC Saginaw MI Cathy Galloway Hartman, CPC, CCC Gastonia NC Robin Ingalls-Fitzgerald, CPC, CEDC, CEMC Bristol NH Barbara M Suse, CPC, CEMC, CIMC Claremont NH Donna Reamer, CPC, CPC-H, CEDC, CEMC Barrington NJ Lynn Nobes, CPC, CPC-I, CEMC Grafton NY Carrie Joann Palmateer, CPC, CASCC Highland NY Astara N Crews, CPEDC White Plains NY Faith Ann Hawthorne, CPC, CEDC Chesapeake OH Karen Christner, CANPC Columbus OH Vickie Bargo, CPC, COBGC Heath OH Nancy E Gard, CPC, COBGC Pomeroy OH Michael Gamel, CPC, COSC Bethany OK Brenda Taylor, COSC Oklahoma City OK Amy Flanagan, CEDC Clearfield PA Melissa Stern, CASCC Dover PA Lisa Broomall, CCVTC Reynoldsville PA Michele R Hayes, CPC, CGIC Anderson SC Cassandra Ann Vadas-Rehoric, CPC, CPRC Piedmont SC Martha Nel, CPC, COSC Germantown TN Bevan Erickson, CPC, CPC-I, COBGC Hyrum UT Christine M Chaffin, CPC, COBGC Yorktown VA Christie A Hewson, CPC, CEMC South Burlington VT Betsie D Wilson Ortiz, CPC, CUC Bothell WA Penka Dringova, CPC, CEMC, CIMC Renton WA Shelly V Reed, CPC, CEMC, CPEDC Tacoma WA 40 AAPC Coding Edge

41 Enthusiasm Keeps Member Going and Going Kudos go to Diane Phelps, CPC, CPC-I, who began her career in the early 1980s, processing Medi-Cal forms in the pediatric department of Loma Linda University, Loma Linda, Calif. Her expertise led to a billing supervisor promotion, a later job in orthopedics, a coding certificate, and the team leader coding position at the Faculty Patient Business Office. She earned the CPC credential in 1998; became a Professional Medical Coding Curriculum (PMCC) instructor in 1999; and earned the CPC-I credential in After 27 years with Loma Linda University Medical Center, Phelps retired last year but remains an active participant by teaching coding and PMCC classes, among other things. In 1999, Phelps played a key role in the creation of the Loma Linda AAPC Local Chapter and continues to work to increase membership with meeting topics and speakers, providing members with opportunities to network and earn CEUs. Exams are scheduled every three to four months, bringing new members to the chapter. She also plays an important role in a number of special projects, including extensive coding training and special presentations, and is known as a productive and popular instructor at chapter meetings and seminars. Each month it is such a joy to see students at the AAPC meeting and to see how much we have grown in our area, Phelps said. She says she even looks forward to learning opportunities and challenges of ICD-10-CM implementation! If you or a colleague deserve kudos, please kudos@aapc.com. Anotherday, another Reason First full-service hospital in New York City to earn Magnet re-designation - a distinction held by only 2% of hospitals in the nation Ranked among the Best Hospitals by US News & World Report Compliance Resource Specialist Hospital Compliance Department Unique opportunity for a NYS licensed RN with broad knowledge and understanding of billing compliance as it relates to Federal and State regulations.. Requires knowledge of CPT and ICD 9/Medicare/Medicaid rules and current professional certification in Hospital Coding. Responsibilities include clinical documentation monitoring, reviews, education and training as it relates to Part A billing and reimbursement compliance. 3 Easy Ways to Apply EOE Online: Call: (212) /(866) SinaiRN (outside NYC) Fax: (212) Be a leader...pursue your career at Mount Sinai kudos New Medicare E-Prescribing Incentive Program - Critical Care - CMS extends IPPE coverage - Proper Incident-To Billing - Modifier 22 - Identified Compliance Risks, Investigations and Development of Corrective Action Plans Includes access to 12 AAPC approved CEUs October

42 feature PROFESSIONAL Does Established Patient + New Doctor = New Problem? Most providers and payers say, Yes! By G. John Verhovshek, MA, CPC Stacy Henning, CPC, CEMC, recently wrote to Coding Edge: The article The Driving Parts of E/M Level Selection [Coding Edge August 2009, page 32] states, A new problem (new to the patient or new to the provider) without any additional workup is worth three points. A consulting group advised me that even if a provider is seeing the patient for the first time, a problem is not truly new if another provider in the same group practice has seen the patient previously for the same problem. For example, one month after provider A sees a patient for trauma at the hospital, provider B (a member of the same group practice, billed out under the same tax ID) sees the patient for the first time in the clinic for the same problem. I have reviewed the Medicare Audit Tool, as well as the 1995 and 1997 E/M documentation guidelines, the Specialty Study Guide for E/M and Management Auditor, and the Auditing Guide by Decision Health, but I could not find anything to support this line of thinking. Is this correct? If yes, where can I find this in writing? The rules to determine a new vs. established patient are clearly stated in CPT and supported by the Centers for Medicare & Medicaid Services (CMS) guidelines (for more information, see Establish Patient Status at a New Location, Coding Edge, September 2009, page 44), but do not necessarily affect the status of an individual patient s problem. For most payers, a problem is new if it is new to the individual provider not to the patient or the practice. Or, as the American College of Rheumatology explains in the Coding FAQ portion of its Web site ( emfaq.asp?aud=mem), Problem status is relative to provider and not relative to the patient. Highmark Medicare Services (Medicare carrier for several Mid-Atlantic States and the District of Columbia), among other Medicare payers, supports this interpretation, stating on its Web site (www. highmarkmedicare services.com/partb/em/new-vsestablished-problem.html) that what matters is whether the problem is new or established to the examiner. Both Highmark and First Coast Service Options (Medicare provider in Florida and several U.S. territories) offer evaluation and management (E/M) documentation worksheets using the phrase new problem to examiner in the medical decision-making (MDM) portion. E/M service levels are really about giving credit to the physician for his or her cognitive work in evaluating the patient, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. If a physician is encountering a problem for the first time, even if the patient is established with the practice, more cognitive work is required of the physician. Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians, agrees generally, but notes that in her facility they do things a bit differently. 42 AAPC Coding Edge

43 feature E/M service levels are really about giving credit to the physician for his or her cognitive work in evaluating the patient... If a physician is encountering a problem for the first time, even if the patient is established with the practice, more cognitive work is required of the physician. If a patient sees a different physician in the group as a matter of convenience, we don t count the problem as new. For instance, if a patient who usually sees Dr. Jones on Tuesday comes in on Thursday when Dr. Smith is working, or if Dr. Smith is covering for Dr. Jones on Tuesday, we wouldn t say that the problem is new if it was previously established with Dr. Jones. If there s a medically-necessary reason why a patient is seeing a different physician in the practice, however, the problem may be considered new. Let s say that the patient is referred to a sub-specialist for evaluation, Bucknam continues. This isn t just a convenience for the facility or the physician, it s a medically-necessary visit. We ll count as new any problems the sub-specialist has not seen in that patient previously. At least one payer gives its official support to the approach Bucknam describes. Palmetto GBA, Medicare Part B carrier in Ohio, features this FAQ on its Web site: Q: Must a problem be new to the patient or new to the provider in order for it to be considered a new problem when scoring diagnosis/management options for an Evaluation and Management Service (E/M)? A: In most instances, a new problem is one that is new to the provider and being addressed at that visit. There are two exceptions to this general rule: The initial visit of an established beneficiary in a single specialty group practice setting with a new provider A visit by an on call or covering provider. In these instances, the established problems are treated as if the beneficiary was seen by the unavailable provider. Caveat: The definition of a new problem as new to the examining physician has been credited to former Health Care Financing Administration (HCFA) executive medical officer Dr. Bart McCann, but is not an official definition currently embraced by national CMS policy. Although many payers follow the rule, some may not and some may offer more nuanced interpretations, as evidenced by Palmetto GBA s aforementioned instructions. To repeat the advice offered by the American Academy of Family Physician Web site ( We suggest you ask your regional Medicare carrier s medical director how reviewers evaluate the complexity of decision making. Considering whether a problem is new or established may not weigh very heavily in your final code choice. A new problem is only one consideration among the number of diagnosis and management options, which is only one of the three elements that figure into the level of medical decision-making. And, medical decision-making is only one of three components along with history and exam that determine the overall E/M service level, Hammer notes. It s a small piece of the puzzle that in many cases will not be the deciding factor between two levels of service. G. John Verhovshek, MA, CPC, is AAPC s [ director of clinical coding communications. ] October

44 hot topic Bundled E/M Services: A Global Perspective APPRENTICE Determine whether the visit is billed separately from the global surgical package. By Kelly Loya, CPC, CPC-I, CPhT Whether you are in a surgical office, noninvasive specialty, or primary care, understanding the surgical package concept is essential in determining which patient visits requiring procedural services are separately payable. The Surgical Package: What s Included? Surgical CPT codes include not only the procedure performed, but a variety of services known as the surgical package. As explained by the Office of Inspector General s (OIG s) fiscal year 2009 Work Plan ( workplan/2009/workplanfy2009.pdf), Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure and related E&M services provided during the global surgery period. These included components, as noted in the Surgery Guidelines outlined in the CPT manual, are not reported separately because they are an inherent part of the surgical service. In addition to the operation, the surgical package as defined by CPT 2009 includes: Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia; Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical); Immediate postoperative care, including dictating operative notes, talking with the family and other physicians; Writing orders; Evaluating the patient in the postanesthesia recovery area; and Typical postoperative follow-up care. The national Correct Coding Initiative (CCI) provider manual addresses the surgical package in chapter 1, section C. The Medicare Claims Processing Manual, pub , chap. 12, sec. 40, provides interpretive guidance to further explain what is and is not considered part of the global surgical payment. Centers for Medicare & Medicaid Services (CMS) guidelines are intended to provide guidance and consistent payment policy parameters for all Medicare carriers to avoid Medicare Administrative Contractor (MAC) or local Medicare carrier reimbursement levels that are more (or less) comprehensive than intended. Billing for services to seek reimbursement outside of published guidelines would constitute a compliance concern. Global Period May Vary First, to determine whether the visit may be billed separately from the global surgical package, know if a surgical package indicator applies. A list of procedures by CPT /HCPCS Level II codes can be found on the CMS Web site ( PfsLookup) using the Physician Fee Schedule lookup feature. These payment rules apply to all codes with a designation of 0 and 10 days for minor procedures, 90 days for major procedures, and sometimes YYY. A YYY global period designates carrier priced procedures; in which case, the carrier determines, during claim processing, the applicable global period. 44 AAPC Coding Edge

45 hot topic To determine whether the visit may be billed separately from the global surgical package, know if a surgical package indicator applies. A list of procedures by CPT /HCPCS Level II codes can be found on the CMS Web site ( Although the global periods are indicated as 0, 10, and 90 days, the actual length of the global period is 1, 11, and 92 days, as follows: For a 0 global indicator, the service includes the date of service (DOS) only. Total = 1 day (eg, surgery on Jan. 3 - includes Jan. 3 only) For a 10 day global indicator, the service includes the DOS and 10 days postoperative. Total = = 11 days (eg, surgery on Jan. 3 - includes Jan. 3 Jan. 13) For a 90 day global indicator, the service includes the day before the procedure, the day of the procedure, and 90 days post operative. Total = = 92 days (eg, major surgery on Jan. 3 includes: Jan. 2 April 3) The following examples highlight the evaluation and management (E/M) services provided routinely for a wide variety of surgical patients. For compliant billing of all services, documentation is paramount, and must support the service rendered. Where circumstances allow for separate reimbursement, documentation clearly should support the course of care and the medical necessity. For illustrative purposes, we will assume the documentation supports the visit s medical necessity in all of the following examples: Visit No. 1 (March 1): A patient presents to a surgeon s office for evaluation of a lump she found during a self breast exam. The physician schedules an outpatient breast biopsy (19101 Biopsy of breast; open, incisional: 10 day global indicator) for the following day. Bill the E/M: Assuming this patient had not been seen by a provider of the same specialty within the same group on that day, this initial visit is a new patient visit ( ). Code has a 10-day global period, which does not include the day before the procedure. The E/M is billable and no modifier is required. Visit No. 2 (March 2): On the day of the procedure, the patient is examined. A brief interval history is recorded. The surgeon decides to proceed with the biopsy, as planned. There is no separately billable E/M. On the day of the minor procedure, the surgeon may not bill for an E/M visit. The purpose of the encounter and brief workup described is preoperative in nature. The problem was known and this was a planned service. Visit No. 3 (March 5): Three days after the biopsy (with a 10-day global), the patient returns to the office to discuss the pathology results. The biopsy specimen reveals malignancy. The physician plans the treatment course due to the pathology finding, including a plan discussion with the patient. The plan includes risks and benefits of a medication regimen vs. partial or radical mastectomy of the right breast. The patient is unsure of her decision and is told to consider her options, discuss it with her family, and return to the office in one week. The visit is billable as an established patient visit ( ) and reported with modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period to indicate the visit was unrelated to postoperative care within the global period (Medicare Claims Processing Manual, pub , chap. 12, sec B) The purpose of the E/M was to provide care and counseling for the underlying condition (malignancy) and is not part of the normal recovery phase of the procedure. Visit No. 4 (March 7): Two days after the last visit, (postoperative day No. 5) the patient is seen again due to local warmth and irritation at the incisional site. The physician determines the wound is infected, redresses the surgical site, and prescribes antibiotics. This visit is reported only as a follow-up postoperative visit (99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure), and is not separately reimbursable. The purpose of the visit was due to a minor complication resulting from the procedure. Both the visit and dressing change are included in the surgical package (Medicare Claims Processing Manual, pub , chap. 12, sec B). Visit No. 5 (March 14): One week after the above visit (biopsy postoperative day No. 12), the patient returns for a postoperative check of the incisional site. The wound has healed and her antibiotic course is complete. No sign of infection remains. During the visit the patient informs the physician she wishes to proceed with a par- October

46 hot topic tial mastectomy (19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy: 90 days global) as her course of treatment. The physician agrees and schedules surgery the following day. The E/M is billable and reported with a modifier 57 Decision for surgery. The purpose of the visit was to re-evaluate the healing and infection status of the operative site provided outside of the 10-day global of the biopsy. Although the visit is within the global package of the partial mastectomy scheduled the following day, it also became the physician s initial decision for the surgery. Visit No. 6 (March 15): On the following day the procedure is performed. The surgeon speaks with the patient prior to the surgery. He discusses risks, benefits, and possible complications and performs a problem focused exam. This visit is not billable. The E/M is preoperative in nature and considered within the confines and payment for the surgical package. Visits No. 7 and 8 (March 16 and 17): The surgeon makes daily visits to the patient in the hospital on postoperative days No. 1 and 2. These visits are included in the surgical package and reported as CPT code without fee. The purpose of the hospital daily visits and discharge day management is considered routine postoperative care. Visit No. 9 (March 22): The patient returns to the office in one week (postoperative day No. 7) for routine postoperative care. At the visit, the patient notices a small mass in her left breast. The surgeon determines after physical examination and subsequent ultrasound that the lump is cystic in nature and presents no concern at this time. He performs an incision and drainage (I&D) on the cyst (10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) that has a 10-day global period. During the visit, he also provides follow up and counseling related to the partial mastectomy postoperatively. In addition to the I&D, an established patient E/M ( ) is separately billable with modifiers 24 and 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Modifier 24 indicates the service provided was unrelated to the surgery within the postoperative period. Modifier 25 indicates the E/M was also separately identifiable from the I&D which was performed on the same day. The documentation to support the service level includes only the portion to which the evaluation and subsequent I&D of the cyst on the left breast applies, as indicated by appending modifiers 24 and 25. The ultrasound and I&D are also billable services with the appropriate anatomical modifiers. These services were provided on a separate site for an unrelated condition to the prior major procedure. Visit No. 10 (March 29): One week later (postoperative day No. 14), the operative site of the right breast is warm and swollen where a seroma is identified. The surgeon performs I&D of the seroma and prescribes antibiotics to help fight infection. Report the visit with The purpose of the visit is to treat minor complications as a part of the recovery phase from the major surgery and is included in the surgical package. For Medicare, don t bill the performed I&D: It did not require a return trip to the operating room (OR), nor was it planned or staged for treatment purposes due to the disease process according to CMS policy. For non-medicare payers, the procedure may be billable with modifier 78 Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period (check with your individual payer for guidelines). The definition for modifier 78 was changed to include a return to a procedure room by the same physician within the postoperative period. CMS policy restricts the use of modifier 78 as a return trip to the OR only. Visits No. 11 and 12 (April 12 and May 10): The patient returns again four weeks (postoperative day No. 28) and eight weeks (postoperative day No. 56) after the surgery for routine surgical follow-up care. These visits are considered normal postoperative care. Report both visits with code with no fee. Not every patient has all aspects of the examples described above; however, these are common scenarios that may occur routinely in multiple patients. Our coding determinations were presented using published CMS guidelines. Non-Medicare carriers policies vary in both components included and in the length of time considered part of the global period. The CPT manual instructs the presence of surgical complications at any level including exacerbations and reoccurrences are not part of normal recovery and can be reported separately with lesser restriction. Refer to your individual Medicaid and other non- Medicare carrier manuals for the global surgical payment policies, and report all provided services according to the specific carrier s guideline to avoid both missed reimbursable E/M visits and other services and compliance problems. Kelly Loya, CPC, CPC-I, is a senior consultant with Sinaiko Healthcare Consulting. Loya is responsible for coding audits and, staff, and physician training, in addition to reimbursement consulting with specific focus on revenue cycle and compliance related projects. 46 AAPC Coding Edge

47 CODING CERTIFICATION TRAINING CAMP 212 NEW Locations Now, preparing for the AAPC s CPC Exam is just a driving distance away. Our AAPC approved instructors are coming to YOUR hometown ready to provide you with exam-taking tips and preparation you won t find anywhere else. Best of all, 3 days are all it takes to prepare for the exam! How? With CodingCert.com s 3-Day CPC Training Camps! CPC Training Camp Course Overview: - Exam-taking tips guaranteed to boost your confidence and prepare you for the real thing! - Tricks of the trade that make the most of the open-book format - Time management tactics that will help you get through the full exam - Intimate classroom setting to maximize interaction with your trainer - Checklists and study guides you won t find anywhere else - Advice for tackling ALL areas of CPT, and much more! CodingCert.com Get Certified. Get Ahead! For additional information please contact CodingCert.com at (866) and mention code VCPCEO09 or visit us online at Coding Update & Reimbursement Conference All ICD-9, CPT and HCPCS code changes for your specialty plus your guide to the dramatic reimbursement changes ahead! Join us on Dec. 6-8, 2009 in sunny Orlando, FL. This 2-1/2 day conference will arm you with all the tools necessary to help you select the correct codes from the start, avoid claim denials, maximize your productivity, and increase your practice's bottom-line. Best of all - You can jump between any of the specialty tracks below FREE of charge! Ambulatory Surgery Center Anesthesia Billing & Collections Track Ob-Gyn Oncology & Hematology Pain Management Pathology & Clinical Lab Pediatric SAVE $100 NOW! Earn up to 17 CEUs! Register Today! Call and mention code VCEDGO09 or at CODING CONFERENCES The Coding Institute Live Conference Division

48 coding compass Coder s Primer on the Anti-kickback Statute and Stark Law Understanding government fraud and abuse laws is your best defense. By Christopher A. Parrella, J.D., CHC, CPC As the Obama administration further reinforces its federal and state health care fraud and abuse enforcement budgets, it is essential that you, the coder, have a basic understanding of two of the biggest fraud and abuse tools within the government s arsenal: the anti-kickback statute (AKS) and the Stark law. The Federal Anti-kickback Statute The anti-kickback statute (42 U.S.C. 1320a- 7b(b)(1-3)) prohibits the offer, solicitation, payment, or receipt of any remuneration, in cash or in kind, in return for, or to introduce, the referral of a patient for any service that is covered by a federal health care program (most notably, Medicare and Medicaid). Remuneration in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item reimbursed under a federal health care program is also prohibited conduct. Examples of potential kickback violations include: A physician who offers a patient recruiter $100 per patient. A manufacturer of medical devices offering gifts and educational programs in exotic locales to physicians who prescribe its products. A pharmacy who pays for a patient s groceries and cleaning service in return for the patient s continued loyalty. Whether the remuneration actually results in a referral is immaterial as it s sufficient that the remuneration may induce someone to refer or recommend. Under Greber (United States v. Greber, 760 F.2nd 68, 71 (3rd Cir.), cert. denied, 474 U.S. 988 (1985)), it is also irrelevant if there are other legitimate reasons for the remuneration. If one purpose is to induce referrals, then the AKS may be violated. The AKS contains exceptions protecting parties from criminal liability for conduct that would otherwise violate the statute. Similarly, the AKS permits the Department of Health and Human Services (HHS) secretary to promulgate safe harbors, which identify referral arrangements that do not violate the anti-kickback statute (see 42 CFR ). If the requirements of the safe harbor are strictly complied with, individuals and entities can insulate themselves from prosecution under the AKS for conduct that would otherwise violate the statute. There are 25 exceptions and nine safe harbors. A violation of the AKS constitutes a felony criminal offense. Sanctions include imprisonment of up to five years, criminal fines of up to $25,000, civil money penalties of $50,000 per act, and/or exclusion from all federal and/or state health care programs. Sanctions apply to all parties to the transaction he who offers/pays and solicits/receives. Patient Referral Act Ethics Stark law (42 U.S.C. 1395nn), effective for referrals made after Dec. 31, 1994, states that if a physician (or an immediate family member of such physician) has a financial relationship with an entity, the physician may not make a referral to that entity for the furnishing of designated health services for which payment is sought under Medicare or Medicaid. Nor may 48 AAPC Coding Edge

49 coding compass A violation of the AKS constitutes a felony criminal offense. Sanctions include imprisonment of up to five years, criminal fines of up to $25,000, civil money penalties of $50,000 per act, and/or exclusion from all federal and/or state health care programs. the entity present a claim or bill to any individual, third party payer, or other entity for designated health services. The following services/ items are currently defined as designated health services (enumerated by CPT codes): Clinical laboratory services; Physical therapy services, speech-language pathology services; Occupational therapy services; Radiology or other diagnostic services, including magnetic resonance imaging (MRI), computed tomography (CT) scans, and ultrasound services; Radiation therapy services and supplies; Durable medical equipment and supplies; Parenteral and enteral nutrients, equipment, and supplies; Prosthetics, orthotics, and prosthetic devices and supplies; Home health services; Outpatient prescription drugs; Inpatient and outpatient hospital services; and Nuclear medicine services and supplies. All six elements of Stark must be present to implicate the statute. If all six elements are present, the referral will be protected only if an applicable exception applies. There are four general exceptions, two ownership/investment exceptions, and seven compensation exceptions. Potential self-referral violations include: A physician refers all blood specimens to a clinical laboratory in which he has an ownership interest. A physician has a compensation arrangement (without a written agreement) with a diagnostic facility to which she refers her radiation therapy patients. In cases where the physician or a group practice has billed and collected for designated health services in violation of the Stark law, the physician or group is required to refund such amounts on a timely basis. The Office of Inspector General (OIG) also may impose upon any person a civil penalty of up to $15,000 for each improper service provided by the person who knew, or should have known, the service was rendered in violation of the Stark law; and up to $100,000 for each scheme to circumvent the Stark law. Any physician or entity entering into an arrangement or scheme in violation of the self-referral ban may also be subject to an assessment of not more than twice the amount claimed for each designated health service rendered in violation of the ban, and may also be excluded from participation in all state and federal health care programs. With the increased likelihood that an enforcement agency may send a request for records or perform a site visit at your facility, being able to identify a potential issue that gives rise to one of the statutes discussed above is an enormous benefit. Christopher A. Parrella, J.D., CHC, CPC, is with The Health Law Offices of Anthony C. Vitale in Miami, Fla. He can be reached at (305) or at cparrella@vitalehealthlaw.com. October

50 feature PROFESSIONAL Four separate modifiers help you make the right choice. By Sarah Sebikari, MHA, CPC Circumstances Designate Assistant at Surgery When coding for an assistant at surgery, you may choose from among four modifiers. Which one you select depends on who performed the assistance, the extent of assistance, and the payer billed: Modifier 80 Assistant surgeon Modifier 81 Minimum assistant surgeon Modifier 82 Assistant surgeon (when qualified resident surgeon is not available) Modifier AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant The Centers for Medicare & Medicaid Services (CMS) designates which codes are applicable for the assistant at surgery modifier. Most commercial carriers have adopted CMS guidelines for assistant at surgery, but always check with your private payers for individualized instruction. For Medicare, services rendered by an assistant at surgery are eligible for reimbursement only when national claims data indicate the procedure requires an assistant in at least five percent of claims, based on a national average. CMS assigns a payment policy indicator to each CPT procedure code to describe whether an assistant at surgery modifier may be reasonable and necessary. Assistant at surgery payment policy indicators for all CPT codes are found in CMS Medicare Physician Fee Schedule Database (MPFSDB), which is updated annually. Modifiers 0 Assistant surgeon may be paid with documentation 1 Assistant surgeon cannot be paid 2 Assistant surgeon can be paid 9 Assistant surgeon concept does not apply Resource tip: Download the MPFSDB at no cost from the CMS Web site: asp?listpage=4. Medicare reimburses 16 percent of the allowed amount/fee schedule amount for an assistant surgeon; for non-physician assistants, reimbursement is 85 percent of 16 percent of the allowed/fee schedule amount. Reimbursement may differ for other payers, depending on the modifier used, but generally ranges from percent of the maximum allowable, or billed, charges (whichever is less). Document the Necessity To append an assistant at surgery modifier to a surgical procedure, the operative report must substantiate that an assistant surgeon s services were needed due to a patient s condition or detail/complexity of procedure. It is not enough for the physician just to mention the assistant surgeon s name in the subject line of the operative report. Language to justify the use of an assistant at surgery could include: Due to the complexity of the procedure, I requested the services of Dr. X to assist. 50 AAPC Coding Edge

51 feature Modifier 81 is not used widely because there are no guidelines as to what may be considered minimal. When reporting this modifier, however, the physician must document which portion of the procedure required minimal assistance. Procedure was potentially risky because of patient s age. I, therefore, requested Dr. X to assist with the procedure. As a result of the patient s deteriorating condition, Dr. X assisted with the procedure. Due to the lack of a qualifying resident, I asked Dr. X to assist. For example, a patient with a history of morbid obesity is taken to the operating room for a laparoscopic, gastric restrictive procedure with bypass and Roux-en-Y gastroenterostomy. The patient also has had abdominal pain for the past week, and the patient s appendix is inflamed. A laparoscopic appendectomy is performed. The primary surgeon s documentation states, Due to the patient s condition of morbid obesity and complexity of procedure, Dr. X assisted with the entire procedure. In this case, Dr. X bills Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) and Laparoscopy, surgical, appendectomy. If, however, the primary surgeon documented, Dr. X assisted with the entire procedure due to lack of a qualifying resident, the assistant surgeon, Dr. X, would bill and Modifier 82 applies specifically to teaching facilities. Documentation guidelines for modifier 82 are the same as for the other assistant at surgery modifiers. In certain circumstances, a resident may not assist even when available. Such situations include: Exceptional medical circumstances (emergency, life threatening situations such as multiple traumatic injuries), which require immediate treatment; Exceptional medical circumstances where the medical staff can justify the services of a physician or non-physician provider to assist at surgery even though a qualified resident is available; or If the primary surgeon has an across-theboard policy of never involving residents in the preoperative, operative, or postoperative care of his or her patients (see Social Security Act XVIII section 1842(D)(i)). Modifier 81 may be appended when an assisting surgeon performs a simple task, or assists with part of the procedure. Physicians providing minimal assistance are reimbursed at 10 percent of the fee schedule or maximum allowable fee. Modifier 81 is not used widely because there are no guidelines as to what may be considered minimal. When reporting this modifier, however, the physician must document which portion of the procedure required minimal assistance. For example, Dr. A documents, Given the complexity of the procedure, I requested Dr. W to assist with retraction of surgical site, making it easy for me to make an incision and proceed with the wedge biopsy of the liver. Retraction of the surgical site performed by Dr. X is considered minimal assistance, and Dr. W would bill Biopsy of liver, wedge. October

52 feature To discuss this article or topic, go to member Some commercial payers require modifier 81 in lieu of modifier AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery (as I ll explain next) for non-physician practitioners (NPPs). If this is your payer s policy, get direction in writing; such use does not fit the CPT description of modifier 81. Check Reimbursement for Mid-level Providers Over the years, we have seen a paradigm shift from medical doctors to NPPs, mainly because of NPPs impact on health care cost management. The number of assistant at surgery services paid under the physician fee schedule and provided by non-physician health professionals increased more than 200 percent from 1997 through 2002, while the number of services provided by physicians serving as assistants declined about 23 percent ( items/d0497.pdf). Modifier AS is a HCPCS Level II modifier, and represents a non-physician assistant at surgery. Physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists are recognized by Medicare as NPPs, and must bill with their own provider numbers. Medicare national policy requires modifier AS on all NPP claims (claims submitted with modifier 80 are denied). Modifier AS is specific to Medicare, but is accepted by some commercial carriers. Check with commercial payers to verify which clinicians are considered NPPs, the claim format, and appropriate modifier for NPPs. Medicare reimburses at 85 percent of the 16 percent of the allowed/fee schedule amount for a non-physician assistant at surgery. Reimbursement from other insurers is payer-specific. Order Multiple Modifiers Correctly When using more than one modifier for a service, modifier placement is crucial. The modifier affecting reimbursement should be primary. For example, Dr. X performs a partial colectomy with ilececectomy with colostomy (44205 Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy). Dr. X performs a proctoplexy for prolapsed using perineal approach (45541 Proctopexy (eg, for prolapse); perineal approach). Dr. X documents, Given the complexity of the procedures and the fact that the patient has a recurrence of colon cancer, I requested Dr. Y, a colorectal surgeon, to assist with both procedures. Both applicable procedure codes have a payment policy indicator of 2, which means payment restriction does not apply for these procedures. Dr. Y, as the assistant surgeon, would bill and Distinct Procedural Service. A Tricky Case of Assistant at Surgery Coding According to the American Academy of Family Physicians, if a consultant is called to perform a cesarean delivery and the family physician assists with the delivery, the consultant bills Cesarean delivery only and appends the appropriate modifier (80, 81, 82, or AS). The family physician bills Routine obstetric care including antepartum care, cesarean delivery, and postpartum care. Sarah W. Sebikari, MHA, CPC, (sarasebikari@ yahoo.com) is a health care fraud and abuse analyst with Premier Health Care Exchange, a health care cost management company. She has been in the health care field for eight years, and has been a certified coder for six years, with experience spanning from multiple-specialty physician to outpatient coding and reimbursement. 52 AAPC Coding Edge

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54 feature Winning Members Drive Us to 100K As part of our Drive to 100K initiative, the AAPC challenged members to invite coders to join. We are proud to announce those who helped the most colleagues join our organization. Lori Hendrix, CPC, CPC-H, CIRCC, CPC-I, Dallas, Ga. referred 16 new members. For doing so, she is our 2009 Networker of the Year and receives the following: Nashville Conference Registration $795 Membership Dues Waived (next 2 years) $ Coding Books (Physician Bundle 1) $ Audio Subscription $795 Total Value: $2,000+ How did Hendrix do it? She just talked to everyone, she said. Lashel Denise Church, CPC, Selah, Wash. referred 11 new members and receives the following: 2010 Coding Updates $ Membership Dues Waived $ Coding Books (Physician Bundle 1) $ Audio Subscription $795 Any product in the Logo Products section of online store Total Value: $1,260 Gaynell Vaccaro, CPC, Prairieville, La. referred nine new members. Sandra Puka, CPC, CPC-H, Wilmington, Del. and Mandy Nicole Flagg, CPC, Toledo, Ohio referred seven new members. All three win the following: 2010 Coding Updates $ Membership Dues Waived $ Coding Books (Physician Bundle 1) $ Total Value: $ Vaccaro helped so many join by mainly working through internal resources in the company and my colleagues, she told Coding Edge. It s all about networking and reaching out to non-aapc folks in the community. Others excelled, as well. One person recruited five new members and received $ in prizes. Two members referred four people, and six current members introduced three new members, all receiving prizes totaling $ An enthusiastic 23 brought two new members and receive free membership for a year, and 59 members brought in one person, allowing them to choose an AAPC logo item from the AAPC Web site. AAPC s Audit Credential Will validate expertise in: 54 AAPC Coding Edge COMING EARLY 2010

55 Presented by: a division of Access Intelligence CPT Changes 2010 Workshops Early Bird Special $445 Register before Oct. 16, 2009 Four Reasons to Attend 1. Learn about critical coding changes from the trusted source the AMA 2. Receive both a CPT 2010 Professional Edition and CPT Changes 2010 books for FREE (a $ value) 3. Earn 7 CEUs from AAPC, ACMCS, AHIMA and ARHCP 4. Master a clinical understanding of the changes Can t Attend the Live Event? We now also offer elearning. You ll receive the same information, materials and CEUs. Call to register or visit Live elearning 4 LOCATIONS Dallas, TX Dec. 8, 2009 Newark, NJ Dec. 8, 2009 Baltimore, MD Dec. 9, 2009 Atlanta, GA Dec. 10, 2009 CEUs available from: CPT is a registered trademark of the American Medical Association 16290

56 Coding resources as specialized as you are because one size does not fit all. AAPC Members: Save 20% on coding resources designed exclusively for your specialty. Imagine how much time you could save if you could get to the code information you needed, faster. Our resources are designed exclusively for your specialty so you can work smarter, not harder. And as an AAPC member, you can enjoy special discounts on these valuable resources tailored to meet your specific needs. Coding Companions Simplify the coding process with CPT and ICD-9-CM code sets in an illustrated, one-page format. New and Improved for 2010! Coding and Payment Guides Streamline your workflow with this essential coding, billing, and documentation guide. Cross Coders Simplify and speed coding with the one-stop, cross-coding resources developed for those who work for physicians, hospitals, or payers. Fast Finders Code it faster with these double-sided, laminated sheets with approximately 300 of the most commonly reported codes and descriptions for each specialty. Billing Companions Find essential rules and instructions for billing professional services. NEW! Coders Desk References for Specialties Understand the clinical background of diseases, medical procedures, and anatomy from the coders perspective. Here s what your fellow coders are saying about Ingenix specialty books: We are a multi-specialty clinic and the Coding Companions help us so much the diagrams, coding tips, and clinical definitions give us a clearer picture on how to code. Suzette E. Riley, CPC Visalia Medical Center Having descriptions of procedures, as well as a list of covered diagnoses at my fingertips, saves a tremendous amount of time and has improved efficiency. D. Polk, Simon-Williamson Clinic Coding resources available for the following specialties: AAPC Members: SAVE 20% on coding resources designed exclusively for your specialty. Go to and enter source code or call (800) INGENIX ( ), option 1.