June Savannah. Shines. Plus: Unlisted Procedures E/M History EHRs Self Injection Modifiers 26 and TC

Transcription

1 June 2009 Savannah Shines Plus: Unlisted Procedures E/M History EHRs Self Injection Modifiers 26 and TC

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3 contents 32 [contents] June 2009 In Every Issue Letter From the President 7 Letter From Member Leadership 26 Letters to the Editor Features Extreme Coding 47 Coding News 10 Coding Consultations When Components or Time is a Factor AAPC Coding Communications Director G. John Verhovshek, MA, CPC, concludes his two-part consultation series with an explanation of how to apply consultation codes in the inpatient and outpatient settings. 14 Identify Binding Rules for Defensible Coding Medicare s way isn t always the right way. Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, tells us how reporting accurately, as defined by the billed carrier, will help you avoid substantial post payment liability. 22 Savannah Doubles, Taking the 2008 Chapter Award Savannah, Ga. sets exemplary standards in 2008 by having fun while learning, doubling in numbers, growing in closeness, and supporting and respecting each other. 28 Coders Hit the Jackpot in Vegas Attendees had a lot to say about this year s AAPC National Conference held in Las Vegas, Nev. Michelle A. Dick, senior editor, reports. 32 The Driving Components of E/M Level Selection AAPC Exam Director Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC, provides an indepth look at the history component in this first of a three-part series. 36 EHRs Pose Challenges, Provide Opportunities Electronic health records (EHRs) are an important part of a federal plan to improve the quality and cost effectiveness of health care. Michael Stearns, MD, CPC, CFPC, explains why it s important for coders to learn as much as they can about health information technology (HIT). On the Cover: The Savannah, Ga. Chapter radiates coding excellence and camaraderie. Together, they enjoy their day in the sun sharing coding tidbits at Forsyth Park. Cover photo taken by Matt Propst ( Education 50 Test Yourself People 31 Kudos 38 Newly Credentialed Members 48 Minute with a Member Coming Up ICD-10 Implementation Coding From Home Sentinel Node Imaging Compliance Plan Finger Tip Injuries Stimulus Package HIPAA Provisions June

4 Serving 78,000 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. June 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 Product Management Stephanie L. Jones, CPC, CEMC stephanie.jones@aapc.com Vice President of Marketing Bevan Erickson bevan.ericson@aapc.com Director of Business and Member Development Rhonda Buckholtz, CPC, CPC-I rhonda.buckholtz@aapc.com (814) Director of Coding Communications John Verhovshek, MA, CPC g.john.verhovshek@aapc.com Director of Member Services Danielle Fenochietti danielle.fenochietti@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, and CPC-P are registered trademarks of the American Academy of Professional Coders. Volume 20 Number 6 June 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 Half Way to 2010 and Growing Strong This month completes the first half of 2009, and the year s midpoint seems like a perfect occasion to pause to see where we ve been and to look ahead at rest of the year s goals. Mid-year Accomplishments to Celebrate in 2009 We redesigned and launched 19 new specialty credentials, including corresponding online practicums complete with audio lessons and interactive practice tests, providing examinees with rationales for answers. For students who prefer classroom learning, we created a 10-hour, face-to-face curriculum. Professional Medical Coding Curriculum (PMCC) instructors across the country can now access these to develop specialty exam classes. We made quality our clarion call. Whether we re talking about Coding Edge, AAPC staffs responsiveness to national office calls, or content quality in workshops, audio conferences, curriculum, or exams, AAPC has raised the bar, improving its offerings from month to month. We were instrumental in getting ICD-10 implementation delayed until Oct. 1, As an added benefit, your input on the proposed rule has provided us a much closer working relationship with the federal agencies that regulate health care in our country. We ve also brought past National Advisory Board (NAB) President Deborah Grider on board as an AAPC employee to lead our ICD-10 education efforts. We keep on growing. During the first half of 2009, we have grown another 9 percent. With almost 80,000 members, we continue to grow at a rate that outpaces all other health care organizations. Check the chart below to see how far we ve come. Exciting Plans for the Remainder of 2009 Our code book deals are the best value in our business. AAPC ICD-9-CM and HCPCS Level II code books are as good as any competitors. Exclusively for members, we sell them at a lower cost than any other vendor. With these books, we also provide a free resource that educates readers about code changes, using simple explanations in an easy to follow format. You ll be hardpressed to find a better deal anywhere. Regional conferences have quality curriculum with a slice of paradise. Oahu, Hawaii in September and Norfolk, Va. in October promise to feed your mind and your soul at the lower rates expected from AAPC regional events. Educational opportunities will expand. Previously, our PMCC instructor training program was limited to annual events tied to our national conference. Later this year, the instructor training program will expand its online format, making the curriculum available 24/7 to anyone with Internet access. If you ve ever thought about becoming a certified instructor (CPC-I ), but couldn t afford the time away from work or the travel costs, this will make your teaching dream more possible. Business is still as usual. We expect our growth trajectory to continue into 2010, and with it is the continued promise of quality products and communications, as well as legendary member service. Please let me know if we are meeting your needs by ing me. Just go to the Member Area on the AAPC Web site, and click on the Talk to Reed button in the lower-left corner. We continue to use the many ideas generated from this. Sincerely, Reed E. Pew CEO and President June

6 Want to Learn a Specialty and Earn 6 CEUs? Take a Specialty Practicum! 3 hours of audio lectures E/M Audit Tool 75-question practice exercise $ Each online practicum includes three (3) hours of streaming audio lectures to discuss trade-specific issues affecting coding for each respective specialty and three (3) hours of coding simulation with 75 coding scenarios linked to actual patient notes (matching the format of the actual specialty exam). Earn six (6) CEUs toward your CPC without leaving home Learn a specialty discipline Prepare to earn a Specialty Credential SPECIALTY CREDENTIAL SPECIALTY CREDENTIAL AMBULATORY SURGICAL CENTER CASCC GENERAL SURGERY CGSC ANESTHESIA CANPC INTERNAL MEDICINE CIMC CARDIOLOGY CCC OBSTETRICS/GYNECOLOGY COBGC CARDIOVASCULAR AND THORACIC CCVTC ORTHOPAEDICS COSC DERMATOLOGY CDERC OTOLARYNGOLOGY CENTC EMERGENCY DEPARTMENT CEDC PEDIATRICS CPEDC E/M AUDITOR CEMC PLASTICS AND RECONSTRUCTIVE CPRC FAMILY PRACTICE CFPC RHEUMATOLOGY CRHC GASTROENTEROLOGY CGIC UROLOGY CUC REGISTER TODAY! Call CODE (2633) or go to:

7 letter from member leadership National Conference Brings a Higher Standard to Las Vegas Perhaps it was the idea of four days of nonstop entertainment in the city that never sleeps. Maybe it was the desire for warm desert breezes and an azure sky. It could ve been the allure of hitting it big. I am reasonably certain, however, that what brought nearly 2,000 coders to Las Vegas April 5-8 was the AAPC s 17 th National Coding Conference. And I am absolutely positive about what made this year s conference a huge success. Oh, What a Night It all started with a Sunday night conference kick-off filled with laughter, dancing, reflection, and inspiration as the National Advisory Board (NAB) put on a comical skit an adaptation of the movie It s a Wonderful Life and the Charles Dickens story, A Christmas Carol. Johnny Biscuit, our resident comedian and AAPC friend, led NAB members through the ages, from the 1960s to the future to help them see how far they ve come and how far they have yet to go. For a grand finale, the entire audience performed a rousing rendition of YMCA, AAPC-style. Also Sunday evening, attendees visited and scored trinkets from chapter representatives who came from all parts of the country. Many thanks to participating chapters for bringing a part of home to conference, not to mention all the laughs and door prizes enjoyed by all. A Learning Experience The next three days were equally riveting filled with top notch educational classes led by outstanding speakers. General sessions included AAPC CEO and President Reed Pew giving a well-received talk addressing the issues regarding the future of health care. Attendees warmly received a motivational speaker who shared his fight and triumph with cancer at age 23. General session speakers addressed issues pertaining to the future of health care. And a multitude of breakout sessions covered an array of topics and specialties that surely met the individual needs of attendees. And a Side of Gravy At the awards luncheon, we said goodbye to the NAB, including President Deborah Grider who received well deserved accolades for her accomplishments over the past two years and welcomed into the fold the new NAB, including myself. Plaques and farewells were given to outgoing NAB members as well as the American Academy of Professional Coders Chapter Association (AAPCCA) Board members leaving their positions. The national winners for 2008 Networker of the Year, Coder of the Year, and Chapter of the Year were also recognized during the luncheon. These awards were well deserved by these folks. Set Your Sights Four days later after making new friends and spending time with old friends we rarely have an opportunity to see; after talking to vendors and comparing the most updated books and software of our trade; and after soaking our brains with the knowledge we thrive on parting was sweet sorrow. The conference, however, provided the professional boost of energy we all needed. We left rejuvenated and, for some, richer in more ways than one! I hope to see all of you at the Opryland Hotel, Nashville, Tenn., June 6-9, 2010, for the next AAPC National Conference. Regards, Terry Leone, CPC, CPC-P, CPC-I, CIRCC President, National Advisory Board June

8 extra Dunkerley Also Region 3 Networker of the Year Janet Dunkerley, CPC, CPC-I, CMC, was omitted from the May Coding Edge article side bar Regional Pick: 2008 Networker/Coder of the Year Awards. Having tied with Louise Hilliard, CPC, MT (AMT), for Region 3 Mid-Atlantic s Networker of the Year, Janet should have been included. We regret the omission. Janet is a senior medical consultant for QuadraMed and in 1995, founded Capital Coders, the Columbia, S.C. chapter. She enjoys 20 years of coding experience and has worked as a medical consultant, coder, auditor, instructor, and director of physician services. A certified PMCC instructor, Janet is an original member of the AAPC Chapter Association (AAPCCA) Board of Directors, where she serves as secretary. We congratulate her on being chosen. Coding Edge 8 AAPC Coding Edge

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10 feature Part 2 Selecting a Consultation Service Level? PROFESSIONAL By G. John Verhovshek, MA, CPC Part 1 of this feature ( Consult or Not? Here s How to Know for Sure, May 2009 Coding Edge) discussed how to differentiate a consultation service from other E/M services. This month, we conclude with an explanation of how to apply consultation codes in inpatient and outpatient settings. In addition to the usual medical necessity requirements, any consultation service must include a reason, request, and response. Having confirmed that these standards were met and documented, and having established that the intent of the service was to allow the requesting physician to continue to treat the patient with the advice of the consulting physician, you can get down to the business of selecting the appropriate consultation code for the service provided. We explained that in addition to the usual medical necessity requirements, any consultation service must include a reason, request, and response. After these standards are met and documented, and it is established that the service s intent was to allow the requesting physician to continue treating the patient with the help of the consulting physician s advice, you can get down to the business of selecting the appropriate consultation code for the service provided. This month, we ll conclude this two-part consultation series with an explanation of how to apply consultation codes in the inpatient and outpatient settings. Consultation codes do not distinguish between new and established patients. A physician may report a consultation for his or her own patient, as long as all the consultation requirements are met. CPT does, however, assign unique codes for outpatient and inpatient services. Select outpatient consultation codes for consultations provided in the physician s office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care or emergency department, according to CPT instructions. To report physician consultations provided to hospital inpatients, residents of nursing facilities or patients in a partial hospital setting, select from the inpatient consultation codes ( ), CPT continues. Three of Three Required to Support Service Level To report a given service level, coding guidelines require the consulting physician to meet all three key components: history, exam, and medical decision making (MDM). For example, to report a level III outpatient consult (99243 Office consultation for a new or established patient, which requires these three 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), the physician must document, at minimum, a detailed history, a detailed examination, and MDM of low complexity. If any one of the three components falls below the minimum requirement, you may not report In practice, the least or lowest of the three components will always dictate the appropriate service level when reporting a consultation. For example, if the physician documents an outpatient consultation with a comprehensive history, a comprehensive exam, and straightforward MDM, the code selection will default to Inpatient consultation for a new or established patient, which requires these three key components: An expanded prob- 10 AAPC Coding Edge

11 feature Consultation codes do not distinguish between new and established patients. A physician may report a consultation for his or her own patient as long as all the consultation requirements are met. lem focused history; An expanded problem focused examination; and Straightforward medical decision making. 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 low severity. Physicians typically spend 40 minutes at the bedside and on the patient s hospital floor or unit. Although the history and exam meet the requirements of a level IV visit (99254 Inpatient consultation for a new or established patient, which requires three 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 80 minutes at the bedside and on the patient s hospital floor or unit), the MDM component supports only a level II service. Keep in mind: Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted, according to the Medicare Claims Processing Manual, chapter 12, section A ( Time May Factor Into Code Selection If more than 50 percent of the total, documented time dedicated to a verifiable consultation service is spent in patient counseling or physician care coordination, you may determine an appropriate consultation service level using time (rather than history, exam, and MDM) as the key component. Each consultation code (inpatient and outpatient) includes a reference time to guide you when using time as the key component. For instance, CPT specifies for a level II outpatient service (99242 Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. 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 low severity. Physicians typically spend 30 minutes face-to-face with the patient and/ or family), Physicians typically spend 30 minutes face-to-face with the patient and/or family. For a typical 30-minute visit, the physician would have to document at least 16 minutes of face-to-face counseling or coordination of care to report using time as the key component. In the inpatient setting, physician time includes time spent at the patient s bedside (face-to-face time), as well as time on the patient s hospital floor or unit. Multiple Outpatient Consults Are Possible A physician may report more than one outpatient consult for the same patient. The subsequent visit, however, must meet all the consultation service criteria to bill it as such, according to the Medicare Claims Processing Manual, chapter 12, section C. Subsequent visits not meeting the consultation service requirements should be reported using the appropriate inpatient or established outpatient E/M service code. The Claims Processing Manual reiterates, If the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported by this physician or qualified NPP during his/her ongoing management of this condition. For example, a primary care physician (PCP) examines an established patient and diagnoses a breast mass. The PCP sends the patient to a general surgeon for advice. The general surgeon examines the patient and recommends a breast biopsy. The surgeon schedules the biopsy and sends a written report of his recommendations to the requesting physician. The general surgeon subsequently performs the biopsy, and continues to see the patient on a yearly basis for follow-up. Following the advice and intervention by the surgeon, the PCP resumes the patient s general medical care. In this case, the initial visit with the general surgeon meets all the requirements of an outpatient consultation, and may be reported as such (eg, 99242). Subsequent visits provided by the surgeon, however, should be billed as an established patient visit in the office or other outpatient setting ( ), as appropriate. In a second example, the patient from the previous example visits her PCP some months later with a new complaint of lower abdominal pain. The PCP requests a consult from the same general surgeon. In this case, as long as the visit for abdominal pain meets all the consultation requirements, the general surgeon may report another consultation service, as appropriate to the documented service level provided. June

12 feature Avoid Shared Visits When Reporting Consultations A non-physician practitioner (NPP) may perform a consultation service within the scope of practice and licensure requirements for NPPs in the state where he or she practices, and when the requirements for physician collaboration and physician supervision are met, according to the Medicare Claims Processing Manual, chapter 12, section A. State and payer guidelines vary, however, so research your particular state and payer requirements before reporting as a consultation any service provided by an NPP. The Claims Processing Manual states flatly that a consultation will not be performed as a split/shared E/M visit. A shared visit describes an E/M service during which a physician and an NPP each see a patient for a portion of the same visit. For example, if the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service, according to the Claims Processing Manual, section B. In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the incident to requirements are met, the physician reports the service. If the incident to requirements are not met, the service must be reported using the NPP s UPIN/PIN, the Manual continues. Report One Inpatient Consult per Stay A physician may report only a single inpatient consult per inpatient stay. CPT instructions state, Only one consultation should be reported by a consultant per admission. Subsequent services during the same admission are reported using Subsequent Hospital Care codes or Subsequent Nursing Facility Care codes , depending on the setting. For example, a hospital inpatient experiences a new onset of atrial fibrillation. The managing physician requests a consultation from a cardiologist for her advice on the patient s care and management. The cardiologist examines the patient, schedules a cardiac catheterization and other diagnostic tests, and sends a written report to the requesting physician. Following the advice and intervention by the cardiologist, the managing physician resumes the patient s general medical care. In this case, the cardiologist may report an inpatient consultation for her services at the level supported by documentation. If the cardiologist follows up with the patient during the same inpatient stay; however, she must report the visit(s) as subsequent inpatient care ( ), as appropriate to the documented service level. If the same physician provides a legitimate consult service during a different inpatient stay for the same patient (whether for the same or a different problem), the physician may report another inpatient consult code, as appropriate to the documented service level. For instance, the patient in the previous example has been discharged, only to be re-admitted several weeks later. If the same cardiologist who reported the previous consultation meets the requirements for a consultation service during the subsequent stay, she once again may report an inpatient consultation code ( ) for her services. For an excellent summary of Medicare rules regarding consultations, see MLN Matters article MM4215 on the CMS Web site at mm4215.pdf. Coding CMS Defines Pre- and Postoperative Consultations Rules The rules for reporting a consultation for preoperative clearance, as well as for postoperative care by the physician who provided a preoperative clearance consultation, are spelled out in the Medicare Claims Processing Manual, chapter 12, sections G and H, respectively. Specifically, preoperative consultations are payable for new or established patients when performed by a physician or qualified NPP at the surgeon s request as long as all of the requirements of a consultation are met and the service is medically necessary and not routine screening. Typically, a V code (for example, V72.81 Preoperative examination, cardiovascular) is linked to the appropriate consultation code to describe the service. A physician should not report a post-operative consultation if, following completion of a preoperative consultation (whether in the office or hospital), the consulting physician assumes responsibility for the management of a portion or the entire patient s condition(s) during the postoperative period. Rather, in an inpatient setting, the physician would report the appropriate Subsequent Hospital Care ( ) or Subsequent Nursing Facility Care ( ) code(s), depending on the setting. In the outpatient setting, the appropriate established patient visit codes ( ) should be used during the postoperative period. A physician (primary care or specialist) or qualified NPP who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code for evaluation and management services furnished during the postoperative period following surgery when all of the criteria for the use of the consultation codes are met and that same physician has not already performed a preoperative consultation, according to the Claims Processing Manual. G. John Verhovshek, MA, CPC, is AAPC s [ director of clinical coding communications. ] Edge sidebar 12 AAPC Coding Edge

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14 coding compass Identify Binding Rules for Defensible Coding Medicare s way isn t always the right way. By Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC EXPERT There is an old adage that if you are right with Medicare, you are right with the rest of the (payer) world. Although such a universal truth would make both coders and auditors jobs much easier, it simply isn t true. In 1996, the federal government established the Administrative Simplification Act (the Act), which required the Department of Health and Human Services (HHS) to develop regulations standardizing the codes used by all entities covered by the Act. Covered entities included all insurance carriers and nearly all health care providers reporting services to third-party payers and/or federal government benefit programs. Regulations implementing this statutory mandate are commonly known as the Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code set standards (the formal title is 45 CFR Parts 160 and 162, Health Insurance Reform: Standards for Electronic Transactions, 65 FR , 2000 WL ). A Matter of Interpretation The key to understanding the mandated rules significance is that only the codes and descriptions, including modifiers and their descriptions, are incorporated in the mandated code set. Although these rules eliminated local codes, the code set rules purposely did not eliminate local rules pertaining to standard codes usage or even what they mean beyond the description. The rules for how codes are used are reserved to the payer. Because payers determine code utilization rules, there is no single answer to any coding question. When the payer is someone other than the local Medicare contractor, using Centers for Medicare & Medicaid Services (CMS) guidance to report a service may lead to an inaccurate result. There are examples where a controlling standard has you report services in a grossly different way than you might when following guidance published by CMS. Following the CMS guidance, particularly use of National Correct Coding Initiative (CCI) bundling rules, may result in less reimbursement than you are entitled to. Why bundle according to CCI if you do not have to? Because coding is about correctly representing a service so the billed carrier can make the correct payment determination. Importantly, consider how a carrier will interpret the codes you report and how they want you to use the existing codes for a particular situation. Speak their Language If coding is a language, think of each carrier having its own dialect. While the words (codes) are the same, they potentially mean something different to each carrier. Some may not allow you to use certain codes in combination, some will. Some may recognize modifiers in certain circumstances, some may not. The lack of standardization in what codes mean and how they should be used presents an interesting dilemma, as well as a unique challenge to coders. The better you understand individual carrier policies and rules pertaining to coding, the more valuable you are to your organization. Proving your value establishes job security and also helps you progress within your organization and the profession of coding. Caution: Applying the appropriate rules isn t necessarily about getting paid. Sometimes, reporting a service accurately means the carrier is not obligated to pay for the service. In such cases, the payment burden usually falls on the patient. Coding to avoid such a result is often the genesis of many False Claims Act (FCA) cases. Coders must describe procedures and services so the carrier can understand what was done and can make an appropriate payment determination. When the selected code causes the carrier to misinterpret what was done under the carrier s coding policy, and an improper payment is made based on that misinterpretation; the provider may get paid, but will usually be forced to return the money and potentially more in the form of penalties at some point in the future. When coders report accurately as defined by the billed carrier, it is unlikely the provider will be exposed to any substantial post payment liability. With the number of post-payment audits on the rise, this should be particularly concerning to all. 14 AAPC Coding Edge

15 coding compass The lack of standardization in what codes mean and how they should be used presents an interesting dilemma, as well as a unique challenge to coders. The better you understand individual carrier policies and rules pertaining to coding, the more valuable you are to your organization. Get the Right Answer When billing carriers, there are questions that should come to mind to help you determine appropriate codes: Who is the carrier? Is there a statutory code utilization rule that applies? If yes, does the statute provide guidance as to what code utilization standards should be applied? Are you contracted with that carrier? If yes, does the contract provide guidance as to what code utilization standards should be applied? Does the contract bind the carrier s medical policies? When there isn t a contract or the policies aren t incorporated into the contract, is there guidance available in the carrier s medical policies to assist in correctly reporting the services at issue? In the absence of a specific carrier rule, what generally accepted guidance will you use persuasively to guide your coding decisions? Obtaining an accurate (or at least defensible) answer in any situation requires sorting out controlling guidance from persuasive guidance. For example, some may think a newsletter from a national organization is considered controlling guidance. I have seen similar cases where an auditor found guidance in the CPT Assistant and terminated the analysis. In these cases, both individuals failed to look for the authority making either reference binding with respect to payment. In reality, both were incorrect and the guidance was merely persuasive. Controlling Guidance vs. Persuasive Guidance Controlling guidance can arise either by statute/regulation or by contractual agreement with the carrier (most commonly the beneficiary contract and, in some cases, a provider contract). Controlling guidance establishes must do rules. By contrast, persuasive guidance can be anything, including CPT Assistant, association coding advice, and articles such as this one. The value of persuasive authority pieces vary based on the source s credibility and accuracy. Never assume that coding advice, even from a respectable source, is accurate for your particular circumstance. Failure to follow persuasive advice can never establish a payment error. Identifying controlling guidance requires an objective analytical process. The most critical element of this process is what the HHS, Office of Inspector General (OIG), and Office of Audit Services (OAS) auditing guide calls criteria analysis. Criteria analysis is nothing more than identifying and understanding the binding rules that apply in your specific coding situation. Binding Beneficiary Rules Take Legal Precedence The OAS Audit Process Manual defines criteria as the standards against which the audit team measures the activity or performance of the auditee Criteria can come in many forms, including Federal laws and regulations, state plans, contract provisions and program guidelines. (HHS, OIG, OAS, The Audit Process, 2nd ed., 2005) The OAS manual provides additional guidance with respect to criteria hierarchy: It is important to determine a criteria hierarchy. In other words, if laws, regulations and guidelines on the same program appear to contradict each other, the audit team must decide which criterion takes precedence. In cases where the criteria are not clear, or when laws and regulations are significant to the audit objectives, the audit team should seek a legal opinion. The first rule in our criteria hierarchy, regardless of the case, is the HIPAA code set rule identified earlier. When applying this rule, remember that your code set is nothing more than the CPT, HCPCS Level II, and ICD-9-CM codes with their descriptions. The instructions contained within these manuals detailing the publishers guidance for how to use the codes are not part of the code set. As a result, these instructions are not controlling (binding) unless the carrier formally adopts these instructions in a binding policy. After isolating your codes and descriptions, coders must identify and list all possible code choices that fairly and accurately describe the service performed. Refining this list to a single code requires more analysis. The next level in our rule hierarchy is a statutory or regulatory rule pertaining to the case being billed. Some states, for example, have adopted the published code guidance of the CPT Editorial Panel; otherwise known as the CPT manual. It is probably relevant to point out that this does not include the CPT Assistant, which is published by a separate division of the American Medical Association (AMA). Where such statutory guidance doesn t exist, you must turn to the beneficiary contract. Because the beneficiary contract is the document that spells out the payment obligation of the carrier, it is available to the enrollee (patient) but you, as a provider, may have difficulty getting a copy of it. When beneficiary contract guidance exists, it must be applied to the possible correct code choices list you identified after description matching under the code set rules. June

16 coding compass Beyond the beneficiary contract, you are usually entering persuasive guidance. Even when you are a participating provider, most standard provider contracts establish conditions of participation, not conditions of payment. Nonetheless, some contracts, usually in larger specialty physician groups, may establish binding coding and payment standards so be alert! Without Controlling Guidance, Turn to Persuasive Guidance Where statutory/regulatory or binding contractual guidance does not exist, you are forced to resolve your coding issues with persuasive guidance, which also has a hierarchy. Start with carrier guidance before going out to other standards. When looking at any persuasive standard, evaluate the standard s credibility by looking at the review process the guidance was subjected to prior to publication. Beyond the provider contract, you can usually find carrier guidance published in medical policies or billing guides. Lower on the carrier totem pole are carrier newsletters. Although these are useful information sources, they are rarely controlling. Noncontracted providers should also consider this guidance when making coding decisions because such guidance alerts the provider either to what the carrier expects to see, or how they will interpret the codes you report. The remaining problem is the situation where there is no controlling statutory, regulatory, or contractual guidance nor is there carrier generated persuasive guidance. At this point, you must turn to other persuasive guidance. In such a circumstance, following CMS, AMA, or other national association guidance would provide a reasonable basis for your coding decisions. When there is no controlling or carrier generated persuasive guidance, selecting the external standard that provides the best reimbursement result is proper. Before doing so, however, make sure there is no controlling criterion requiring you to report differently. Substantiate Code Choices Never make coding decisions based on the unsubstantiated advice of others, and absolutely never rely on payment to establish the validity of your code choice ( They paid it so it must be okay. ). Research the criteria applying to each coding situation. Although this is time consuming initially, when you identify relevant controlling criteria, and credible persuasive criteria where no controlling criteria exists, your ability to apply these rules and code correctly will not only make you a more competent professional coder, but also an invaluable asset to your employer. Michael D. Miscoe JD, CPC, CASCC, CUC, CHCC, is president of Practice Masters, Inc., a past member of the AAPC National Advisory Board (NAB) and current member of the Legal Advisory Board (LAB). He is admitted to the Bar in the state of California as well as to the practice of law before the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. Mr. Miscoe has nearly 20 years of experience in health care coding and over 12 years as a compliance expert testifying in civil and criminal cases. Need CEUs? Over 50 Courses Available From $30: Annual CEU Coding Scenarios Evaluation and Management Specialty Coding Medical Billing and Reimbursement Medical Terminology and Anatomy Other Healthcare Related Topics...and more CodingWebU.com Providing Quality Education at Affordable Prices (484) Audio Conferences: Monthly Series Starting May 2009 $ Group Price Includes S&H and Taxes All Book Titles Available

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 PROFESSIONAL Avoid Prolonged Services Pitfalls Knowing which guidelines to follow ensures successful E/M reporting. By G. John Verhovshek, MA, CPC 18 AAPC Coding Edge

19 feature Before reporting prolonged service codes , consider that American Medical Association (AMA) and the Center for Medicare & Medicaid Services (CMS) coding requirements may differ. For CPT 2009, AMA revised the descriptors of inpatient critical care codes Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient Evaluation and Management service) and Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged physician service) to eliminate the phrase direct (face-to-face) patient contact and replace it with unit/floor time. For instance, physicians may bill unit/floor time for reviewing medical records, documenting, and discussing the case with other providers. The descriptor change brings consistency with other inpatient service codes (such as inpatient consults ) that also measure unit/floor time, rather than face-to-face time. Medicare, however, still requires direct face-to-face time for all inpatient prolonged services. Medlearn Matters number MM5972 ( effective July 1, 2008, specifies, You cannot bill as prolonged services In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient s condition, for end of a therapy, or for use of facilities. This means, when reporting inpatient prolonged services codes to Medicare or any payer that follows CMS guidelines, count only the time the provider spends in direct contact with the patient. Outpatient Service Requirements Match CMS and CPT requirements for outpatient prolonged services both require you to count only time spent in direct contact with the patient. The descriptors for Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service) and Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged physician service) specify face-to-face. As well, Medlearn Matters MM5972 stresses, You may count only the duration of direct face-to-face contact with the patient. Document Time with Precision You must appropriately and sufficiently document in the medical record that [the provider] personally furnished the direct face-to-face time with the patient specified in the CPT code definitions, according to Medlearn Matters MM5972. For all payers (even those not requiring face-toface time for inpatient services), document the start and end times of the visit, along with the date of service. The time counted toward prolonged services need not be continuous, but must occur on the same date of service. CPT specifies that prolonged service codes should be used only once per date, even if the time spent by the physician is not continuous on that date. For instance, the physician may consult with a patient in the hospital, spend 30 minutes discussing his condition, leave to perform regular rounds, and return later in the day to that patient for another 40 minutes of counseling. The time spent with the patient both before and after the physician made rounds can contribute toward prolonged services. Finally, documentation must explain why the physician provided prolonged services. Medlearn Matters MM5972 states, Documentation is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill. For instance, simply noting the physician spent an extra 60 minutes with the patient is not adequate to support a claim. The medical record must show the medical necessity for the extra time spent. Unless you have been selected for medical review, you do not need to send the medical record documentation with the bill for prolonged services. The message is clear: Payers may not want full documentation upon initial claims submission, but it had better be available on request. Add-on Prolonged Services with Approved E/M Codes You may report prolonged service add-on codes only in addition to E/M codes including a reference time. As such, you would report outpatient services and with: June

20 feature Generally, you will select an E/M service using the key components of history, exam, and medical decision making (MDM) using the prolonged services codes, as appropriate, to account for physician time over and above the reference time for that service Office or other outpatient visit Office or other outpatient consultation Domiciliary, rest home, or custodial care services Home services Similarly, you must apply and only in addition to: Initial hospital care Subsequent hospital care Inpatient consultation , Nursing facility services Document at Least 30 Additional Minutes To report an initial prolonged services code (99354 outpatient or inpatient), the physician must document at least an additional 30 minutes beyond the reference time of the chosen E/M service level, according to CPT guidelines. CMS requirements also stress, You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the evaluation & management (E/M) codes. You may use (outpatient) or (inpatient) to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately, according to Medlearn Matters MM5972. See Charts A and B for a complete list of threshold times (that is, minimum total documented time for the service) for reporting prolonged services. Generally, you will select an E/M service using the key components of history, exam, and medical decision making (MDM), using the prolonged services codes, as appropriate, to account for physician time over and above the reference time for that service. For example, a physician performs an expanded problemfocused history, an expanded problem-focused exam, and MDM of low complexity for an established outpatient. By these criteria, the visit meets the requirements of: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and 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 low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. The total visit time is 65 minutes, or 50 minutes greater than the reference time for 99213, so you may report with one unit of When counseling and/or coordination of care comprise more than 50 percent of the total time with the patient, you may use time as the determining factor when selecting an E/M service level. In such a case, however, you may only report prolonged services with the highest code level in that code family as the companion code. For example, a physician performs an office visit with an established patient. Of a total visit time of 75 minutes, 60 minutes was spent on face-to-face counseling and coordination of care with the patient. Based on time alone, the physician may report a level V established outpatient visit (99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; 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 40 minutes face-to-face with the patient and/or family), which has a 40 minute reference time. Based on the additional 35 minutes over and above this reference time, the physician may also report a single unit of AAPC Coding Edge

21 feature Chart A: Threshold Time for Prolonged Visit Codes Billed With Office/Outpatient and Consultation Codes Code Typical Time for Code Threshold Time to Bill Code Threshold Time to Bill Codes and Chart B: Threshold Time for Prolonged Visit Codes and/or Billed with Inpatient Setting Codes Code Typical Time for Code Threshold Time to Bill Code Threshold Time to Bill Codes and G. John Verhovshek, MA, CPC, is AAPC s [ director of clinical coding communications. ] June

22 cover 22 AAPC Coding Edge Most of the members of Savannah chapter pose in front of one of the city s famous fountains. Savannah Doubles, Taking the 2008 Chapter Award By Michelle A. Dick, senior editor The Savannah, Ga. chapter works hard to promote the coding profession and this dedication won them the 2008 Chapter of the Year Award. Freda Brinson, CPC, CPC-H, 2008 chapter president, said she set high standards for Savannah When I became president, there were so many things I wanted for our chapter. I was very ambitious and eager to bring Savannah into the running for Chapter of the Year. When Coding Edge asked AAPC Director of Local Chapter Support Marti Johnson why she thought the chapter won 2008 Chapter of the Year award, she said, These guys are full of enthusiasm and they try to do everything perfectly by the book. They make sure they follow all the rules. They met all the qualifications plus held an extra exam and two review classes. Linda Litster, local chapter member relations, feels the Savannah chapter sets exemplary standards. Because they are a chapter that is truly committed to Upholding a Higher Standard, they are committed to excellence, she said. In 2008, they doubled their size from attending members to attending members. Chapter member Mary C. Figuereo, CPC, said, Over the past year our local chapter has more than doubled. In December 2007 we had 11 members and as of December 2008 we had reached 25 members. That is awesome! The Savannah chapter now has a total of 164 members assigned to it. Brinson made chapter information easily accessible for members who couldn t attend meetings. I received s from members who couldn t attend our chapter meetings but would respond to the information provided in our monthly newsletter and our monthly meeting summaries, said Brinson. All members know what s going on in and with the chapter and that s important to me. Every time I receive an from a member or see each member walking into our chapter meeting, I know our chapter is growing.

23 cover The Savannah chapter also earned the honor through the following: Reviewing the Chapter of the Year requirement list in the handbook and thinking We can do some of this. Fulfilling member requests. When a member made a request, they did it. Starting the Coders Teaching Coders seminar. When a member asked for a class where experienced coders could share their knowledge and experiences with new coders, Savannah started the Coders Teaching Coders seminar, which was on the Chapter of the Year list. Offering a CPC review class upon a student s request. Deciding to offer a review classes prior to every exam Savannah proctored because of the first review class success. Totaling four review classes. Creating a chapter newsletter. This offered better communication to all chapter members providing up-to-date chapter news to all. More than doubling chapter attendance. Getting chapter members involved in the chapter meetings. Making meetings both professional and fun. What Makes the Savannah Chapter Special? When Savannah members were asked, why do you think Savannah won the 2008 Local chapter of the Year Award? Debbie Tober, 2008 secretary/treasurer, said, That is obvious we had an outstanding president. She worked hard to make the Savannah Chapter what it is today number 1. Brinson disagrees with Tober s assessment. She said, It s because of our members who actively participate in chapter meetings. That s why we won. It wasn t the president it was the members. I told our members back in January 2008 in our newsletter and at the first meeting that I wanted us to win. I honestly never thought we had a chance. Everything we did during that year was because a member asked about it. We would NEVER have just decided to do four review classes or a seminar. But as president, I thought it was my duty to try and provide anything a member asked for. The Savannah chapter has Great speakers. You actually feel that if you miss a meeting, you will miss out on some very useful information, Faye Grile, CPC, said. She tries not to miss a meeting because she puts that information to real-world use. There is no such thing as too much good information! Grile said. We offer exams four times a year. We also offer Coders Teaching Coders. This allows training and education for many different specialties. It is so easy for coders to get into only one specialty, feel comfortable, and not expand their knowledge. This [Coders Teaching Coders] can really open a door with some great information. In larger facilities, this can also open the door for opportunities President Tamara M. Gentry, RHIT, CPAR, CPC, said, With any efforts I put into the chapter I receive back tenfold in the form of information I can directly use in my career, cohesive relationships with other members, and as part of the AAPC. Gentry thanks the Savannah chapter for what they have given her. She is proud as a peacock of her chapter. She told Coding Edge, From the very moment I picked up the phone to call the 2008 chapter president to introduce myself and obtain information, I felt welcomed and proud to be a part of such an intelligent, diverse, and fun group of people. Mary Figuereo, CPC, feels the Savannah chapter has passion, love, and dedication to coding excellence and that her chapter enjoys learning about coding and always finds ways to teach and share the knowledge and expertise with our fellow members. We love to invite different speakers to help enhance our understanding and to challenge our comfort coding zone. This is a team that is extremely dedicated in making sure the members reach and achieve their utmost potential by expanding and taking coding to the next level. Chapter member Adrienne Woods said, I am proud to be a part of the chapter because of the continual effort to educate the coders on changes taking place with the government and commercial insurance payers. The chapter is able to collaborate with other coders to gain knowledge in a particular area of coding that some of us may not have expertise in. June

24 cover This isn t the last we ll see of the Savannah chapter, 2009 New Member Development Officer Lisa M. Smith said, Like The Little Engine That Could, our chapter continues to keep on going and growing strong. Brinson said, We are proud of ourselves, our chapter, and the AAPC. We support our chapter by attending chapter meetings. We engage our speakers and bond with them... I have had so many speakers contact me after their presentations and tell me that they enjoyed speaking to our group and how comfortable they were with us. We respect each other and all chapter visitors. We are professionals. Open Arm Policy There is one common thread that binds this chapter together they care about each other. Tober said, We truly care about each other. I saw that first hand in December when I lost my husband in a motorcycle accident. The outpouring of s from my fellow coders was amazing. One from Freda Brinson, our president, was truly heartfelt and so comforting to me that I still go back and read it from time to time. Savannah member Kathleen Craven, CPC-A, was first introduced to coding when she attended Coding Boot Camp. Kathleen Craven s sister, Mollie Craven, asked her to attend her first chapter meeting at a Bring a Friend meeting in May Craven said, I work for a veterinarian and I had an interest in moving to human medicine. The members were very friendly and interested in what I did. They were very helpful and enthusiastic about me taking part in the boot camp. She said, After that meeting I decided if I was going to make a career change to coding, I needed to join. Due to everyone s help and support I passed the coding exam in November, without any other formal classes. Recently, Kathleen has spoken at the January Coders Teaching Coders chapter meeting. Chapter meetings combine coding with personal, real-life situations. Member Dorothy E. Carswell, CPC, said, In our Coders Teaching Coders chapter meetings, a few of our own members take a subject and present for minutes. Because the subject is up to that coder, we share some very personal information experienced in our own lives. Carswell added, This draws us together not only as coders but as friends. We are educated by one another and we learn together. When Brinson became Savannah president, she set a compassionate coding standard for the Savannah chapter. Figuereo said, Freda Brinson is our best example of passion, love, and dedication to our AAPC Savannah Local Chapter She is an inspiration to all of us. Growing Strong This isn t the last we ll see of the Savannah chapter. Lisa M. Smith said, Like The Little Engine That Could, our chapter continues to keep on going and growing strong. The Savannah chapter doesn t intend to stop at the 2008 Local Chapter of the Year award. Tober says the future holds a chapter that will grow in numbers and have more outstanding speakers. Freda said Savannah will continue following the rules of AAPC and the coding profession, continue having fun while learning, continue growing in numbers and in closeness to each other, and continue supporting and respecting each other. We ll sweep the 2009 AAPC awards. Figuereo concluded, I can sincerely say that we are a really GREAT group of people to be associated with. I encourage you to come and visit our AAPC Savannah local chapter you would love us! 24 AAPC Coding Edge

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26 letters to the editor Letters to the Editor: LCDs, Critical Care Clarification, and Correction LC or LD? Check Your LCD Dear Coding Edge, I am contacting you for clarification on Dr. Zielske s article published in the February 2009 issue of Coding Edge. My understanding of his suggestion is that if a procedure is selective in the ramus intermedius (RI) and another selective procedure is done in the left circumflex (LC) or the left anterior descending (LD) coronary arteries, to code the RI as the opposite. In other words, for separate procedures involving both the LC and RI, code the procedure done in the RI with modifier LD Left anterior descending coronary artery. Is that right? My coding partner found our (Michigan) Medicare local coverage determination (LCD) on percutaneous coronary intervention (PCI), last updated Feb. 16 (pg. 2), to state that the RI must be considered a branch of one or the other (LC or LD) and not coded separately. The article did not reflect if Dr. Zielske is basing this direction on a LCD or national coverage determination (NCD). I would appreciate some clarification, in addition to sharing it with AAPC members in a future issue. Thanks to Dr. Zielske for his support and guidance in the coding industry. Sincerely, Colleen Rexin, CPC, PCS Heart Center for Excellence Author responds: Dear Colleen, In reference to RI intervention, an astute coder from Michigan brought it to my attention that their LCD considers the RI vessel to be a branch of either the LD or the LC. The ramus is actually the middle artery of a trifurcating left main coronary artery. Sometimes it appears more like a branch off one of the named LC or LD arteries, but more commonly it is equal to or larger than one of these. That said, if intervention is performed in the LC, the ramus should be considered the LD for intervention and if intervention is performed in the LD, the ramus should be coded to modifier LC Left circumflex coronary artery for intervention. Ramus intervention can be coded regardless of payer; however, it cannot be coded separately with some payers if interventions are performed in all three vessels: the LD, LC and RI. Fortunately, this is quite rare. In this case, some payers recognize the ramus as only a branch of either the LC or LD and it would not be separately coded. All branch interventions are considered part of the named vessel intervention. This maintains the maximum coronary artery interventions performed in native coronary arteries to three even if a RI is present. I hope this clarifies the ramus issue. Most important, review your LCD for coronary artery intervention for the rules in your area. Sincerely, David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC Clarification: Payer Matters When Reporting Time-Based Critical Care Services Dear Coding Edge, The article Pediatric Critical Care Codes Moved for Easier Coding (Coding Edge, April 2009) appears to have an error. The code descriptors for and specify minutes and each additional 30 minutes, respectively. For a service lasting 80 minutes, as referenced in question 3 of Test Your Knowledge in the same issue, you would report according to the Pediatric Critical Care Patient Transport Quick Coding chart on page 17. But according to the CPT code descriptors, you would report 99466, for the same, 80-minute service. Why the discrepancy? Thanks, Susan Stevens, CPC 26 AAPC Coding Edge

27 letters to the editor Dear Susan, The descriptors for Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first minutes of hands-on care during transport and Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; each additional 30 minutes (List separately in addition to code for primary service), as well as the Pediatric Critical Care Patient Transport Quick Coding chart, are all correct depending on the payer. Medicare rules, as stated in Section F, Hours and Days of Critical Care that May Be Billed, of the Centers for Medicare & Medicaid Services (CMS) Transmittal 1530, Change Request (CR) 5993, dated June 6, 2008, specify, Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not separately payable. Resource tip: You can view Transmittal 1530, CR 5993 at: The Medicare instructions refer specifically to critical care codes , but would apply to pediatric transport , which are also critical care services using the same time definitions as A chart that accompanies in the CPT manual recommends reporting additional units of critical care beginning at 75 minutes (rather than 90 minutes, as stated in the Pediatric Critical Care Patient Transport Quick Coding chart on page 17 of the April Coding Edge). The CPT chart, however, contradicts Medicare instructions that critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not separately payable. Although not stated explicitly, the information in the Pediatric Critical Care Patient Transport Quick Coding chart reflects the most conservative coding option, per CMS guidelines. In adherence to CMS guidelines, you would report an 80-minute pediatric critical care transport service using alone for Medicare payers. For those payers observing CPT guidelines, you may bill additional units of critical care beginning at 75 minutes rather than at 90 minutes. For these payers, you would report an 80-minute pediatric critical care transport service using 99466, Coding Edge After Further Examination, Mohs Typo is Revealed Dear Coding Edge, In the April 2009 Coding Edge, page 47, in the article Examine Mohs Micrographic Surgery for Clear Coding, there is reference to the add-on code The article says, Claim as an add-on code only with It should read, Claim as an add-on code only with Thanks, Donna Klug Dear Donna, Thank you for pointing the error out to us so that we may inform our readers. Coding Edge Please send your letters to the editor to: letterstotheeditor@aapc.com. June

28 las vegas conference Coders Hit the Jackpot in Vegas By Michelle A. Dick, senior editor Attendees had a lot to say about this year s AAPC National Conference. The American Academy of Professional Coders (AAPC) 17 th annual National Conference held April 5-8 in Las Vegas and hosted at the Rio Hotel far exceeded conference goers expectations. Attendees, staff, presenters, and vendors all used the electric Las Vegas ambiance to energize their coding know-how. Location, Location, Location If a location can make or break a conference, then this conference was destined for success. Conference attendees soaked in all that the city and hotel had to offer. National Advisory Board (NAB) President Terry Leone CPC, CPC-I, CPC-P, CIRCC, said about the accommodations, The Rio Hotel had a wonderful conference facility that fit our conference perfectly NAB President Deborah Grider, CPC, CPC-H, CPC-P, CEMC, CPC-I, CCS, CCS-P agreed, saying, I liked the conference center. The rooms were spacious, well decorated, and the reception area was centrally located so members could ask conference staff questions, browse in the product store, or meet friends. AAPC CEO and President Reed Pew said that because everything was all under one roof hotel and conference center, with the conference center on one floor, attendees were able to experience Vegas while receiving a coding education without ever having to leave the Rio. Conference Gets Rolling Prior to the conference kick-off, students and teachers took advantage of credential exams, the PMCC Instructor Approval Program, and the Teach the Teacher Workshop. 28 AAPC Coding Edge

29 las vegas conference On Sunday, April 5, attendees were greeted at the funny, witty, and inspirational Conference Welcome. Comedian Johnny Biscuit led NAB skits, which ended with the audience singing and dancing YMCA, AAPC-style. Pew told Coding Edge this was a highlight for him. The AAPC s Legal Advisory Board discussed legal concerns for practices and facilities facing increased financial scrutiny in the general session Legal Trends and Issues, hosted by Sheri Bernard, CPC, CPC-H, CPC-P. Attendees came armed with questions in an anonymous atmosphere. After all what happens in Vegas, stays in Vegas. Local chapters were given the opportunity to network and exchange ideas with other officers at the Local Chapter Officer Meeting. Also Sunday evening, attendees visited local chapters from around the country at the Get to Know Your Local Chapter event. Behind the scenes, the conference team Amy Evans, Kira Golding, and Sandra Nestman, and Melanie Mestas planned and executed every detail. Even with all their hard work, the conference team took advantage of the learning opportunities. Conference Coordinator Amy Evans said, My very favorite part of conference is meeting the people. It s fun to finally put a few names with faces and get to know some new ones as well it s fun to see people enjoying themselves. Three Days of Coding Excitement There was something for every coder. The next three days were filled with unforgettable general and breakout sessions, networking, vendors, prizes, and good food. Sessions included everything from anatomy to electronic health records (EHRs); ICD-10 preparation to neoplasm tables; and coding ethics to hormone replacement therapy. AAPC NAB member Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, CRA, was impressed with the Coding Ethics presentation by Brad Hart, BA, MS, CMPE, CPC. Miscoe said Hart gave an excellent presentation on a topic that is critical to maintaining the integrity of the coding profession. All those who attended this presentation are better for it. Anatomy Expo Pays Off This year s conference featured a three-hour Anatomy Expo with nine specialty physicians who each focused on different parts of the human anatomy. Topics included obstetrics, dermatology, gastroenterology, and urology and featured anatomic models, surgical tools and videos, and question and answer periods. I really liked the Anatomy Expo, said Grider. I think it got the members excited about learning anatomy in a new and different way. The Anatomy Expo piqued the interest of non-coders, as well. During a work break, AAPC Conference Coordinator Amy Evans attended a session for the first time. This year I got to attend the hand surgery class, said Evans. It was so interesting to watch the video and listen to the presentation. Although I m not a coder, I found it fascinating. I hope to attend another presentation in the Expo again next year it was great! Members of the Bahama Local Chapter celebrate Junkeroo. Reed Pew performed with the Bahama chapter and received this headdress. Dr. David Zielske demonstrates a catheter during the Anatomy Expo. You never know what you re getting into when Johnny Biscuit grabs you. June

30 las vegas conference Deborah Grider, NAB President, passes the torch to incoming President Terry Leone, receiving the thanks of many, including President Jerry Leong. Presenters Get the Best of Both Worlds Majella Doyle, MD, FACS, and Shelly Bauguss, CPC, CGSC, CANPC, CGIC, took attendees through a surgeon s guided tour of a liver transplant in Liver Transplantation A Coder s Trip to the OR. Bauguss said she found both presenting and networking at the conference to be very rewarding and wants to do it all over again. What I enjoyed the most about presenting at the conference was having the opportunity to share knowledge on that high of a level, said Bauguss. I also enjoyed the professional bond that the surgeons and I developed while creating and editing the presentation. I am proud of the presentation that we gave and the information that was shared. Above all other presenting aspects that I enjoyed most was meeting the members/attendees after the presentation and networking with them. I have attended five AAPC national conferences since I became certified and I met more people by being a speaker than I met at all of the other conferences combined. I am looking forward to presenting again next year in Nashville. Kerin Draak, MS, WHNP-BC, CPC, CEMC, presenter of It Starts with a Pap, said she feels networking is the best part of presenting as well. I love to teach and really enjoy the interaction with a large group, said Draak. The biggest compliment is when people come after the presentation and ask questions. The best part about attending and speaking at the conference was making great contacts to use in the future as a resource/reference for coding questions. Suzanne Quinton, CPC, COSC, CPC-I, CCS-P, was busy as a conference monitor and as the presenter of Stereotactic Radiosurgery, an introduction of treating tumors with radiosurgery. Although Quinton was only able to attend the sessions she monitored and presented, she took advantage of the educational opportunity. She said, I went to the classes that I was supposed to monitor; they were all enjoyable and I learned a little something from each of them. Emotions Spin like a Roulette Wheel Those who attended the awards luncheon experienced overwhelming emotions as Deborah Grider passed the NAB president gavel to Terry Leone. Everyone, including the AAPC president, was touched by the awards ceremony. The most memorable highlight of the conference, Pew said, was the passing of the NAB gavel from Deb to Terry the farewell to Deb. Leone agreed that it was a special moment. The awards luncheon was extremely special as I received the president s gavel from Deb Grider in front of my family and 1,800 of my coder peers, Leone said. The congratulations I received from many of them throughout the conference were special, thoughtful, and will remain with me for years to come. The luncheon evoked mixed feelings for Grider, too. I must admit it was an emotional conference for me turning over the reigns to a new president, said Grider. The NAB and I have spent so much time together working on helping the AAPC and the membership it was bittersweet turning over the reigns to a new president. Many attendees recognized the strong NAB leadership during her presidency. Grider said, I was terribly touched by the kindness and the overwhelming thanks to the entire NAB for all of our hard work and effort by the conference attendees. Up Next, Nashville For more conference highlights, go to Don t miss the next AAPC National Conference, June 6-9, 2010 at the Opryland Hotel in Nashville, Tenn. Expect nothing less than a grand ole time! Also, check out upcoming regional conferences in Oahu, Hawaii, September 10-12, 2009 and Virginia Beach, Va., October 8-9, AAPC Coding Edge

31 Kudos Working Hard and Moving Up Congratulations to Deborah A. Beeman, CPC-A, for Upholding a Higher Standard. She has been a busy coder this past year. She attended Adult Career and Technical Education in Canton, Ohio and earned CPC-A and CMBS credentials in June 2008, graduating at the top of her class. In July 2008, she landed a billing and coding position at American Med Systems, Inc. (a third-party medical billing company). In January, she was promoted to manager in the hospital billing department, where they follow up on worker s compensation claims. Deborah is a member of the Canton, Ohio local chapter. Career Education Corporation selected Dorothy D. Steed, CPC-H, CPC-I, CFPC, CEMC, as a high achieving instructor in the Medical Billing and Coding Program for She was recognized and received her award at the corporate conference in Nassau, Bahamas. She is also a past president of the Greater Atlanta Chapter. If you deserve kudos, please your accomplishments to our editors at kudos@aapc.com. June

32 feature The Driving Parts of E/M Level Selection Part 1 of this three-part series provides an in-depth look at the history component. By Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC APPRENTICE Although evaluation and management (E/M) comprises a significant portion of coded services in most physician practices and medical facilities, selecting an appropriate E/M service level can flummox even an experienced coder. Over the next several months, Coding Edge will discuss, in turn, each of the three key components that drive level selection for the majority of E/M services: history, examination, and medical decision-making (MDM). This series will provide the basic information you need to not only choose E/M service levels with confidence, but also audit E/M claims for accuracy and consistency. We begin with the history component. CPT defines four levels of history, as determined by the amount and depth of information the practitioner collects from the patient. These include: Problem focused Expanded problem-focused Detailed Comprehensive The history component of any E/M service is further divided into constituent elements, as defined by 1995 and 1997 documentation guidelines for Evaluation and Management Services. The specific elements that determine the history level include: History of present illness (HPI) Review of systems (ROS) Past family and social history (PFSH) You can access both 1995 and 1997 E/M documentation guidelines on the Centers for Medicare & Medicaid Services (CMS) Web site at www. cms.hhs.gov/mlnedwebguide/25_emdoc.asp. Slot HPI Into One of Two Levels The HPI is a chronological description the patient s present illness development, from the first sign or symptom, or previous encounter, to the present. Under both the 1995 and 1997 E/M documentation guidelines, the HPI can be quantified by a patient s statements regarding: Location: The anatomical place, position, or site of the chief complaint (eg, back pain, sore elbow, cut on leg, etc.) Quality: A problem s characteristics, such as how it looks or feels (eg, yellow discharge, popping knee, throbbing pain, etc.) Severity: A degree or measurement of how bad it is (eg, improved, unbearable pain, blood sugar 205, etc.) Duration: How long the complaint has been occurring, or when it first occurred (eg, since childhood, first noticed a month ago, on and off for several weeks, etc.) Timing: A measurement of when, or at what frequency, he or she notices a problem (eg, intermittent, constant, only in the evening, etc.) Context: What the patient was doing, environmental factors, and/or circumstances surrounding the complaint (eg, while standing, during exercise, after a fall, etc.) Modifying factors: Anything that makes the problem better or worse (eg, improves with aspirin, worse when sitting, better when lying down, etc.) Associated signs and symptoms: Additional complaints that may be related. 32 AAPC Coding Edge

33 feature The 1997 E/M documentation guidelines also allow credit in the HPI for patients who are seen for chronic conditions, such as if the patient states, I am here today to follow up with my COPD. Statements of this type are not credited specifically under the 1995 E/M documentation guidelines, but may be given credit by the 1997 E/M documentation guidelines as chronic conditions when the status of those conditions are the reason for the visit. Important: Do not mix and match 1995 and 1997 documentation guidelines. If you select 1997 E/M documentation guidelines for the history component, you should use the same guidelines to determine the exam level and medical decision making level. There are only two HPI levels. The least amount of credit defined by the HPI (assuming that HPI is documented) is a brief HPI, which correlates to an expanded problemfocused work level. For both 1995 and 1997 E/M documentation guidelines, the HPI is brief if at least one of the eight elements that quantify HPI (location, quality, severity, etc.) is documented. The second HPI level, an extended HPI, correlates to a comprehensive work level. For both 1995 and 1997 documentation guidelines, the HPI is extended if at least four of the eight elements that quantify HPI are documented. For 1997 E/M documentation guidelines only, patient statements regarding the status of at least three chronic conditions may also be considered an extended HPI. Refer to the History Level Selection Chart to determine how HPI correlates to the four levels of the overall history component: For example, a comprehensive history is required for a level IV new patient visit (99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; a comprehensive examination; 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 45 minutes face-to-face with the patient and/or family). To meet the work of a comprehensive history, an extended HPI (four of eight HPI quantifiers or the status of at least three chronic conditions when using 1997 documentation guidelines) must be documented. Calculate ROS by Reviewed Body Systems Both 1995 and 1997 E/M documentation guidelines define the ROS as an account of body systems obtained through questioning to identify patient signs and/or symptoms. The ROS might include verbal questioning by the provider or by a separate patient intake or questionnaire form. The ROS may include the systems directly related to the problems identified in the HPI and/or additional body systems. The ROS recognized 14 body systems are: 1. Constitutional 2. Respiratory 3. Integumentary 4. Psychiatric 5. Eyes 6. Gastrointestinal 7. Neurological 8. Allergic 9. Ears, Nose and Throat 10. Genitourinary 11. Endocrine 12. Cardiovascular 13. Musculoskeletal 14. Hematologic and Lymphatic There are only three ROS levels. The least amount of credit defined by the ROS assuming that at least one system is reviewed and documented is a problem-pertinent ROS. The second ROS level, an extended ROS, requires a documented review of at least two of the 14 organ systems. The final ROS level, a complete ROS, requires a documented review of at least 10 of the 14 organ systems. June

34 feature Important: You may not mix and match 1995 and 1997 Documentation Guidelines. If you select 1997 E/M documentation guidelines for the history component, you should use the same guidelines to determine the exam level and medical decision making level. Refer to the History Level Selection Chart to determine how ROS correlates to the overall history component s four levels. For example, a level IV new patient visit (99204) requires a comprehensive history. To meet the work of a comprehensive history, a complete ROS (review of at least 10 of 14 organ systems) must be documented. Medical necessity determines the extent of the ROS. For instance, it might be considered necessary to obtain a complete ROS when a new patient presents, but medically unnecessary to repeat that complete review on every follow-up. For most payers, if there is separate documentation of at least one pertinent positive or negative ROS element, and the provider states the remaining systems are reviewed and negative, credit should be given for a complete ROS. For example, the ROS in a new patient visiting a cardiologist may read, Denies additional cardiac complaints; the remaining systems were reviewed and otherwise negative. PFSH is Either Pertinent or Complete The patient s past history includes previous diseases, illnesses, operations, injuries, treatments, and medications. If a patient presents for follow-up on a chronic condition, both the HPI and past history should be considered. Positive findings of past diagnoses discovered on ROS should also be considered. Family history is a review of medical events in the patient s family, including the parents and other relatives age of death, and diseases that may be hereditary or place the patient at an increased risk. Social history is a review of the patient s past and current activities, such as the patient s occupation, whether he or she smokes or drinks alcohol, engages in sexual activity, and is married. Social history should be age appropriate. For example, it would not be reasonable to document that a 6-year-old is not married. Inquiries about the patient s PFSH may be made by the provider, obtained by the staff, or gathered via a form completed by the patient. There are only two PFSH levels. The least amount of credit defined by the PFSH assuming that PFSH is documented is a pertinent PFSH, which correlates to (at least) a detailed work level. For both 1995 and 1997 documentation guidelines, the PFSH is pertinent if at least one of the three constituent categories (past history, family history or social history) is documented. The second level of PFSH, a complete PFSH, correlates to a comprehensive work level. This requires a documented review of two of three constituent categories (past history, family history, and social history) for established patient office or other outpatient services, emergency department, established patient domiciliary care, and established patient home care; or documented review of all three constituent categories (past history, family history, and social history) for new patient office or other outpatient services, hospital observation services, hospital inpatient services, consultations, comprehensive nursing facility assessments, new patient domiciliary care, and new patient home care. Refer to the History Level Selection Chart to determine how PFSH correlates to the overall history component s four levels: For example, a level IV new patient visit (99204) requires a comprehensive history. To meet the comprehensive history work, a complete PFSH must be documented. Put It All Together All three history elements must support the work level to meet the overall history level requirement. The lowest element within the history component will always determine the overall history level. For example, if the HPI and ROS both support a detailed history level, but the PFSH supports only an expanded problem-focused history level, the history level will stay at the expanded problem-focused level. Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC is the AAPC s director of exam content. 34 AAPC Coding Edge

35 feature History Level Selection Chart Overall Level of History Problem Focused Expanded Problem Focused Detailed Comprehensive Minimum HPI Element Not Specified Brief HPI Brief HPI Extended HPI Minimum ROS Element Not Specified Problem Pertinent ROS Extended ROS Complete ROS Minimum PFSH Element Not Specified Not specified Pertinent PFSH Complete PFSH Five Key Points to Consider When Selecting a History Level A chief complaint is a medically-necessary reason for the patient to meet with the physician. If there is no chief complaint, the service is preventive and should not be reported using a non-preventive medicine code. If documentation establishes that the provider cannot obtain a history from the patient or other source (for example, if the patient is unconscious), the provider is not penalized, nor are the overall medical necessity level and provider work discounted automatically. Additional history supplied by a family member or a caregiver and documented by the provider can be credited toward the overall E/M service s MDM component. An ROS and/or PFSH taken from a previous encounter may be updated without complete re-documentation for most payers. The provider should indicate the new history status and indicate where the original documentation is stored. There is a fine line between the signs and symptoms that the patient shares in the HPI and those obtained via the ROS, but they are distinct. For example, if the documentation reads, The patient states that her hip has been painful, credit would not be given to both the HPI location and to the musculoskeletal ROS (this is double-dipping ). If, on the other hand, the documentation reads, The patient states that her hip has been painful. She denies any other musculoskeletal complaint, there is a distinct component of both the HPI (painful hip) and also the separate musculoskeletal ROS (no other musculoskeletal complaint). There are times when two separate audits of the same service may produce different results, and neither party can be proven technically or medically wrong. A reviewer may argue that an HPI element is a quality versus an associated sign and symptom or other element, or that no known drug allergies documentation constitutes an ROS element rather than a past history element. Correct interpretation requires consistency, verifiable references, a logical argument, and ultimately medical necessity. Raemarie Jimenez, [ CPC, CPC-I, CANPC, CRHC ] June

36 feature By Michael Stearns, MD, CPC, CFPC EHRs Pose Challenges, Provide Opportunities PROFESSIONAL A recent survey published in the New England Journal of Medicine found that only approximately 17 percent of U.S. physician offices are using electronic health records (EHRs). EHRs are an important part of a federal plan to improve the quality and cost effectiveness of health care. The American Recovery and Reinvestment Act of 2009 was signed into law by President Obama on Feb. 17 and allocated an estimated $34 billion to be used by the Centers for Medicare & Medicaid Services (CMS) as incentives to increase the adoption of EHRs. Individual physicians can qualify for $44,000 $62,000 in incentives for using certified EHRs in a meaningful way. To qualify as meaningful use, the EHR must be capable of sending and receiving codified data to other EHRs and disease registries through health information exchanges (HIEs). The current administration stated that their goal is to have more than 75 percent of physicians become meaningful EHR users by the year Starting in 2015, there will be penalties in the form of reduced Medicare payments for physicians who are not using EHRs. As EHR adoption rates increase, coding professionals will be presented with new challenges and opportunities requiring increased knowledge about health information technology (HIT) in particular, how codified data generated by EHRs is managed for billing and reporting. Many of these opportunities represent relatively minor changes in professional coders skill sets. Here are just five examples of how coding professionals can benefit from playing an active role in health care s evolution into the digital era. 1. Assist Practice Evaluation of EHR Coding Tools and Content Prior to Purchase The majority of EHRs offer tools to assist clinicians with documenting and determining which evaluation and management (E/M) code should be assigned to an outpatient visit. Because E/M services are the primary source of revenue for the majority of physician practices in the United States, coding professionals can help evaluate how an EHR under consideration by a practice generates suggested E/M codes and modifiers. EHRs also offer content and tools to assist with improved charge capture, ensure CPT codes are supported by correct ICD codes, and identify payer specific billing requirements. An in-depth evaluation of how information is added to each visit note through automated processes, such as the reuse of information from old notes, templates, patient entered data, etc., is a critical part of each EHR evaluation. Certain systems may encourage users to add inaccurate information or to include information that was not obtained on the appropriate visit date, putting clinicians at risk for committing fraud. Nuances surrounding the use of 1995 vs Documentation Guidelines for Evaluation and Management Services should also be explored, as many systems may only support one type of examination type. 2. Provide Ongoing Coding Support for EHRs during Implementation and Usage EHRs generally support the incorporation of specific billing codes within the clinical content (eg, templates) used by clinicians to determine what codes are used for billing processes. Coding professionals should carefully review the clinical content provided by EHR vendors and developed by their facilities for accuracy and completeness. When familiar with the application, sophisticated users can take full advantage of the EHRs ability to support clinician billing activities at a more granular level. EHRs typically allow for payer-specific template creation and related tools to address complex billing scenarios and challenges, such as payer-specific coding requirements. This can lead to significant decreases in denials and can improve the efficiency of the billing process. Numer- 36 AAPC Coding Edge

37 feature To discuss this article or topic, go to member As EHR adoption rates increase, coding professionals will be presented with new challenges and opportunities requiring increased knowledge about health information technology (HIT) in particular, how codified data generated by EHRs is managed for billing and reporting. ous challenges exist with how EHR tools calculate E/M coding levels and how clinicians use this information when determining the E/M service level. As with any software application, automated E/M coding tools are only effective and accurate if used properly. Ensuring that clinicians using EHRs remain adherent to accurate coding principles will require ongoing diligence from coding professionals. 3. Facilitate the Implementation and Use of Advanced Medical Terminologies For the quality and efficiency of health care to improve, a much greater percentage of clinical information needs to be captured and stored as codified and structured data. This offers marked improvements over free text as computers can process codified information in a way that greatly facilitates reporting, clinical decision making, information sharing between health care enterprises, and researching. This process becomes far more powerful if what is referred to as a reference terminology, like Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), is used. Reference terminologies obey strict rules and are designed specifically for use by software applications, making them far more useful to computer applications than administrative terminologies such as ICD-9-CM or ICD-10-CM. Over the next several years, certain payer programs, such as pay-forperformance, will likely start requiring reporting using SNOMED CTR and/or other reference terminologies. Modern EHRs are capable of storing information as SNOMED CT codes; however, linking clinical information in EHRs to reference terminologies requires a great deal of coding expertise. Professionals with in-depth coding knowledge will be needed to map the information within EHRs to ICD-9/10-CM, HCPCS Level II, CPT codes, SNOMED CT, and other supported terminologies. 4. Provide Data Exchange Support between Health Care Enterprises A major requirement for meaningful use of EHRs is the ability to share information that is converted into codified clinical data using standard code sets such as ICD-9-CM and, eventually, SNOMED CT. This has the potential to significantly reduce medical errors and to improve the efficiency of health care. Considerable challenges remain, however. Information that is exchanged needs to be accurate and complete. Validating the integrity of codified data shared through health information exchanges requires extensive oversight by health care professionals with coding expertise. 5. Assess Clinical Reporting for Compliance For physicians to become meaningful users, they need to submit reports that document their ability to meet specified clinical objectives (eg, what percentage of their patient population has undergone recommended preventative screening tests). In addition to the incentive funds tied to meaningful EHR use, there has been a shift in reimbursement towards pay-for-performance programs designed to reward clinicians for providing high quality care. Another challenge is that these guidelines, of which there are hundreds, are rapidly increasing in number and are subject to frequent modifications. For this process to be efficient, the codes contained within EHR content that are used to collect guideline information will need to be updated on a continual basis. Constant vigilance will also be needed to monitor the ability of clinicians to assess compliance with clinical guidelines. This will require detailed knowledge of how codified information is captured in EHRs, stored, and processed by applications. This is an ideal role for individuals with coding expertise. Michael Stearns, MD, CPC, CFPC, is a board certified neurologist with 15 years of experience in clinical and academic medicine and over 10 years in the areas of HIT and coding. Dr. Stearns has presented on medical terminology, EHRs, coding, and genomic medicine. He has worked on several projects involving computers in medicine at the National Institute of Health and was a key contributor to the development of SNOMED CT. A member of the AAPC Family Practice Steering Committee, he is president and CEO of e-mds, Inc. June

38 newly credentialed members Missed your name in 2008? Because of audits and other factors, some names didn t make it into Coding Edge. Please look below if you didn t see your name in newly credentialed members Patricia L Gorbulev, CPC Anchorage AK Marian A Reynolds, CPC Anchorage AK Dannye F Cunningham, CPC Birmingham AL Melissa Akins, CPC Fort Mitchell AL Julie Marie Smith, CPC Pell City AL Nancy S Craig, CPC Jonesboro AR Annette Mosqueda, CPC Buckeye AZ Jeanne Yvette Daniel, CPC Chino Valley AZ Barbara A Hexem, CPC Gilbert AZ Abby A Catalan, CPC Phoenix AZ Amy Poindexter, CPC Phoenix AZ Jan Marschke, CPC Prescott AZ Jean Barbea, CPC Tucson AZ Jeanette Blanck, CPC Tucson AZ Eileen M Davis, CPC Tucson AZ Susan Quinn, CPC Tucson AZ Jannifer Meshell Owens, CPC, CIRCC Queen Creek AZ Lene Hudson, CPC Scottsdale AZ Isabel Monzon, CPC, CPC-H Bell CA Margaret A Bianchino, CPC Hemet CA Anna Maria Cervantes, CPC Lawndale CA Courtney M Brown, CPC, CPC-H Los Angeles CA Lanell Otomo, CPC Los Angeles CA Cheryl D Finch, CPC Modesto CA Inna P Stepanyan, CPC San Francisco CA Kathleen M Brady-Porter, CPC San Francisco CA Laurie D Stanley, CPC San Pedro CA Carvelina Rios, CPC Vallejo CA Ingrid Sua, CPC Anaheim CA Leslie Coggin, CPC, CPC-H Lawndale CA Angie Waller, CPC Oakhurst CA Michele Freutel, CPC Pacifica CA Kelly Duim, CPC Pasadena CA Caroline R Epperly, CPC Petaluma CA Jennifer L Jordon, CPC S. San Francisco CA Rebecca Torres, CPC Vallejo CA Yollete Capalla, CPC Van Nuys CA Jane Yimyam, CPC-H Winnetka CA Jan Maruyama, CPC Denver CO Rhonda Jean Boyce, CPC Edgewater CO Bridget S Peterson, CPC Pueblo CO Juanita F Quintana-Frazier, CPC Pueblo CO Mary Jo Thompson, CPC Pueblo CO Sandra Laree Wagner, CPC Pueblo CO Sarrah Ann Filer, CPC Pueblo West CO Mary A Dahm, CPC, CPC-H Westminster CO Tabitha R Brooks, CPC Evergreen CO Terry Walker, CPC Westminster CO Janice Forcella, CPC Ansonia CT Kelly Anne Ditmore, CPC Gales Ferry CT Tracie Nicola McDonald, CPC Groton CT Rae S Kangas, CPC Wolcott CT Patricia Sardinha, CPC Faifield CT Vidalina Bonilla, CPC New Haven CT 38 AAPC Coding Edge Michelle J Morgan Herb, CPC Stratford CT Linda Susan Weygandt, CPC Viola DE Adrienne J Royster, CPC Gainesville FL Carla H Williams, CPC High Springs FL Carolyn Thomas Ivey, CPC, CPC-I Jacksonville FL Amanda Ann Rivera, CPC Tampa FL Vicki Chauncey, CPC Jacksonville FL Theresa McGee, CPC Leisure City FL Brigida Ordonez, CPC Loxahatchee FL Wendy Brutus, CPC Miami FL Maite Fernandez, CPC Miami FL Rosario Nunez, CPC Miami Lake FL Lois A Meyers, CPC Ormond Beach FL Kerry Ann Treshock, CPC Palm Bay FL Catherine J Wheale, CPC Palm Coast FL Maribel Lara, CPC Pensacola FL Marcia R Tomlinson, CPC Pensacola FL Magalie L Nau, CPC-H Sunrise FL Karen Kinser, CPC Tallahasee FL Tonya M Green-Bembow, CPC Tampa FL Alfredia L Mincey, CPC Williston FL Vicki Coleman, CPC Adrian GA Kathy Kane, CIRCC Atlanta GA Sissy J Jackson, CPC Byron GA Shirley Deems, CPC, CPC-H Douglas GA Charmaine A Ashison, CPC Douglasville GA Debbie R Justice, CPC, CPC-H Fitzgerald GA Georgianna Constance Perry, CPC, CPC-H Louisville GA Christi Bryant, CIRCC Tifton GA Tracy D Thompson, CPC Warner Robins GA Thille Gabrielle Ridley, CPC Augusta GA Maureen Chastain, CPC Buford GA Brenda D Shepherd, CPC Covington GA Denise Pigford-Frazier, CPC Jonesboro GA LaShun R Green, CPC Lithonia GA Cynthia Price, CPC Martinez GA Joanne Danita McKay, CPC Riverside GA Janene Hill, CPC Roswell GA Annette Roberts, CPC Stockbridge GA Doreen M Fujita-Hino, CPC Honolulu HI Gina P Holdorff, CPC, CPC-H Honolulu HI Mari K Nekoba, CPC Honolulu HI Jaime C Sumitomo, CPC Honolulu HI Derek Wong, CPC Honolulu HI Carol F Willacker, CPC Kailua HI Laraine Lynne-Adams Torrate, CPC Waipahu HI Kimberly S Jordan, CPC Kailua Kona HI Javonne Marie Hahn-O Hara, CPC, CIRCC Elmhurst IL Kimberly K Bridges, CPC Charleston IL Mindi J Marcum, CPC Le Roy IL Amica L Kenyon, CPC Lowpoint IL Sheryl Chenoweth, CPC Normal IL Bonnie L Goodwin, CPC Pekin IL Janet K VanDyke, CPC Pekin IL Jill R Sank, CPC Peoria Heights IL Leanne Katherine Sobkowiak, CPC Peru IL Lisa Ross, CPC Shirley IL Susan E Waremburg, CPC Tremont IL Cynthia Kay Anderson, CPC Washington IL Karen Callahan, CPC Johnsburg IL Keri Ann Hitz, CIRCC Bargersville IN Jacqueline R Meeker, CPC Overland Park KS Chisa D Shoemake, CPC Overland Park KS Tracie Bullock, CPC Benton KY Marsha Tucker, CPC Murray KY Deborah L Griffin, CPC Bowling Green KY Shawntrise Williams, CPC-P Baton Rouge LA Kim Bordelon, CPC Dry Prong LA Melody P Golden, CPC Keithville LA Angela Kaye Beard, CPC Plain Dealing LA Chastity Cecil, CPC Denham Springs LA Phadria Lemelle, CPC Opelousas LA Kathleen Pennington, CPC, CPC-P Pride LA Brenda Gamble, CPC-H Shreveport LA Gabrielle Ann Susi, CPC, CPC-H Canton MA Jarod Boissonneault, CPC Erving MA Heather D Marean, CPC, CPC-H Holden MA Gianna Elisa Frezzo, CPC Lynn MA Donna Jackman, CPC Northbridge MA Kimberly E Simpson, CPC Plymouth MA Hoang Nguyen, CIRCC Quincy MA Kerry McGrath, CPC Rochdale MA Lyssa Soucy, CPC Waltham MA Debra A Leigher, CPC-H Charlton MA Barbara Bazarian, CPC Marlborough MA Rebecca Quinn, CPC Palmer MA Rosalie Sparrow, CPC Baltimore MD Dianne Marie Pierson, CPC Elkridge MD Robin L Stover, CPC, CPC-H Ellicott City MD Kathy Marshall, CPC Frederick MD Gizelle Chrisafis, CPC, CPC-P Gaithersburg MD Saundra E Lee, CPC-H Aberdeen MD Alexena M Campbell, CPC Cumberland ME Tracie Reynolds, CPC Waldoboro ME Peggy Sue Viers, CPC Cadillac MI Karen Sue Reger, CPC Coleman MI Lisa M Van Buskirk, CPC Coleman MI Lisa Ann Shelpman, CPC Eaton Rapids MI Cynthia L Davidson, CPC Milan MI Lisa Ann Ellis, CPC-H Sault Ste Marie MI Michelle R Higley, CPC-H Sault Ste Marie MI Barb Watkin, CPC Bloomingdale MI Leslie Maring, CPC Muskegon MI Lisa Marie Heikes, CPC Plainwell MI Heather Lange Kinsella, CPC Quinnesec MI Patricia Shol, CPC Fergus Falls MN Laura Capetillo, CPC Saint Paul MN Marilyn J Yeager, CPC Arnold MO Tori Ann Welch, CPC Cape Girardeau MO Kay F Barker, CPC Lake Saint Louis MO Beverly L Jernigan, CPC Saint Louis MO Sara Enlow, CPC St Louis MO Barbara Porter, CPC-H Birch Tree MO Elaine Hayes, CPC Hazelwood MO Vicki L Plumlee, CPC Joplin MO Nan B Goodwin, CPC Biloxi MS Michelle H Coccaro, CPC Vicksburg MS Christopher J Kowalski, CPC, CPC-H Bozeman MT Steven T Barrett, CPC Cary NC Rebecca K Lane Baggett, CPC Durham NC Melissa Pulliam, CPC Durham NC Pamela Jones Putnam, CPC Kings Mountain NC Coralee M Oates, CPC Raleigh NC Katrina Roberts, CPC Raleigh NC Lisa Davis, CPC Sneads Ferry NC Shellie M Steele, CPC Statesville NC Mindy Ann Mills, CPC Thomasville NC Jennifer Lynn Kirk, CPC Charlotte NC Janet Roach, CPC Charlotte NC Linda K Williams, CPC Durham NC Katherine Jensen Hayes, CPC Fuquay Varina NC Christi Nicole Jenkins, CPC Salisbury NC Shauna M Jones, CPC Sanford NC Mary May, CIRCC Sherrills Ford NC Amanda Victoria Lewis, CPC Spencer NC Carrie Gaddy, CPC Wingate NC Robin Oldham, CPC Winston Salem NC Michelle Wilson, CPC Fargo ND Michelle Marie Davis, CPC Omaha NE Leeann Wirth, CPC Hooksett NH Robert Gilbert, CPC-H Rochester NH Janet Godfrey, CPC Salem NH Renee Thomas Jackson, CPC Newark NJ Jean Cameron Deitch, CPC Short Hills NJ Laurie B Dudley, CPC Los Alamos NM Lawanna Johnson, CPC N. Las Vegas NV Jennifer A Esposito, CPC E. Patchogue NY Susan Hall, CPC East Setauket NY Cynthia Greig, CPC Glen Head NY Juliana Winges-Daniels, CPC Huntington Station NY Keith Patrick McDonald, CPC, CPC-H Smithtown NY Elaine Brandt, CPC St James NY Stephen Hassett, CPC West Coxsackie NY Theresa Tighe, RHIA, CPC Syracuse NY Mary K Gilbert, CPC Massillon OH Ryan Church, CPC North Canton OH Jennifer M Coleman, CPC Rocky River OH Melody Williams, CPC Grants Pass OR Coral Catherine Denham, CPC Athena OR Cherie Janine Heddens, CPC Beaverton OR Louise Larson, CPC Lafayette OR Annette Diane Guido, CPC Portland OR Diane M Laducer, CPC Portland OR Isabel Bickle, CPC Salem OR Sara Marie Waggoner, CPC Weston OR Kimberly K Metcalfe, CPC Greensburg PA Tosha Moore, CPC Hanover PA Renee Elizabeth Aston, CPC New Salem PA Heather A Celidonia, CPC Pittsburgh PA Lisa Mannheimer, CPC Pittsburgh PA Ruth Olliffe, CPC Pittsburgh PA Michelle Walter, CIRCC Pittsburgh PA Cathy Abouna, CIRCC Radnor PA Pattie Mahoney, CIRCC Wallingford PA Sandra R Earnest, CPC York Haven PA Hilda Andrews, CPC Bethlehem PA Mary Ratto, CPC Bushkill PA Laurie A Wilson, CPC Wellsboro PA Mitzi Bedenbaugh, CPC Bishopville SC Betsy Padgett, CPC Florence SC Maureen Riordan, CPC Bluffton SC Mary Lee Judice, CPC, CPC-H Leesville SC Patricia C Maccariella-Hafey, CIRCC Myrtle Beach SC Cathy B Varn, CPC Orangeburg SC C Richelle Stafford, CIRCC Pawleys Island SC Ruth Broek, CIRCC Brentwood TN Pamela Richardson, CPC-H Elizabethton TN Tracy Merrill, CPC Medina TN Drucilla A Luna, CPC Memphis TN Jerri C Hinch, CPC Piney Flats TN Joan M Johns, CPC Columbia TN Loretta M Jarrett-McDonald, CPC Franklin TN Robin L Thomas, CPC Honewald TN Shanetta Laurice Bell, CPC Lewisburg TN Wendi M Harvey, CPC Lewisburg TN Robin R Potts, CPC Mount Pleasant TN Casey Cambre Wallace, CPC Smyrna TN Marjorie Stigleman, CPC Allen TX Patricia A Nagle, CPC Dallas TX Emma D Vital, CPC El Paso TX Kimberly D Smith, CPC San Antonio TX Amberly D Cox, CPC Wichita Falls TX Eunice N Ndungu, CPC Arlington TX Robin A Surrey, CPC Austin TX Mary Krumme, CPC Frisco TX Donna J Cope, CPC, CIRCC Mansfield TX Lourdes C Baker, CPC San Antonio TX Cindi Evans, CPC San Antonio TX Revonda Kay Roark, CPC Bristol VA Kathleen D Rhodes, CPC Cumberland VA Shaiye Marie Shorts, CPC Herndon VA Julie Baumann, CPC Lynchburg VA Elizabeth A D Aquino, CPC Middlebrook VA Mitzi T Grove, CPC, CPC-H S. Boston VA Denise Wood Meek, CPC-H Waynesboro VA Elecia H Gammons, CPC Claudville VA Stacey Lynn White, CPC Fredericksburg VA Sandra Johnson, CPC Hampton VA Jessica M Giles, CPC Richmond VA Dolores (Lorrie) Valenta, CPC Richmond VA Susan Kapral, CPC Dummerston VT Gina M Smiley, CPC Burlington VT Leslie Llewellyn, CPC Waterbury VT Sarah L Ford, CPC Bellevue WA Lori Carlin, CPC, CPC-H Burien WA Sharon Hebert, CPC Kent WA Ann M Matlack, CPC Olympia WA Adeste L Trim, CPC Olympia WA Tabatha R Newman, CPC Olympia WA Joy Lynn Rodriguez, CPC Puyallup WA Mary Catherine McLinden, CPC Seattle WA Martina Caspers, CPC Woodinville WA Sonya Mclain, CPC Florence WI Sharon J Alder, CPC Janesville WI Audra Geving, CPC Janesville WI Joan Larock, CPC Little Chute WI Kelli Lynn Kahlenberg, CPC Manitowoc WI Christine K Kritner, CPC Mequon WI Ann Whitley, CPC Graham WA Tracy Goretti, CPC Tacoma WA Teresa Lee Zoito, CPC Vancouver WA Renee Nimmer, CPC, CPC-H Menomonee Falls WI Nicole Apuzzo, CPC New Berlin WI Kimberly J Laffin, CPC West Allis WI Johnna Lynn Ferrell, CPC Charleston WV Apprentices Wanda Reed, CPC-A Anchorage AK Christina A Smallwood, CPC-A Anchorage AK Yelena Foreman, CPC-A North Pole AK Courtney Layman, CPC-A Gilbert AZ P. Ramamoorthy, CPC-A El Sobrante CA Helen Dayao, CPC-A Glendale CA Lynn A Blinsky, CPC-A Greenbrae CA Dustin Dusuk Song, CPC-A Lakewood CA Bonnie Cox, CPC-A Millville CA Susan Sliter, CPC-A Orangevale CA Sandra Asuncion Calderon, CPC-A Pacifica CA Shahriar Salehi Tabar, CPC-A Rancho Santa Margarita CA Renata A Espinoza, CPC-A South San Francisco CA Reena Kumari Maharaj, CPC-A South San Francisco CA Sonia Maharaj, CPC-A South San Francisco CA Pravina Singh, CPC-A South San Francisco CA Julia Ann Musekamp, CPC-A, CPC-H-A Arcadia CA Eric G Maglalang, CPC-A Hayward CA Terry Allen, CPC-A Lake Forest CA Lucy Saucedo, CPC-A Rowland Heights CA Terry Lee Phillips, CPC-A San Francisco CA

39 newly credentialed members Pilar Macaranas Zabanal, CPC-A San Francisco CA Theresa E Salsbury, CPC-A San Jose CA Valerie Claire Amiel, CPC-A San Mateo CA Teri Rae Smith, CPC-A Aurora CO Kelly P Story, CPC-A Grand Junction CO Marylynn Bock, CPC-A Loveland CO Nicole Powell, CPC-A Aurora CO Tammy S Eve, CPC-A Pueblo CO Gail Rapacchietta, CPC-A Westminster CO Candace J Ford, CPC-A New Haven CT Kathleen M Edwards, CPC-A Branford CT Jillane Whitsett, CPC-A Moosup CT Lisa Z Castelli, CPC-A North Haven CT Stacey Malin, CPC-A West Haven CT Amanda Cahill, CPC-A Windsor Locks CT Sabitha Karangot Kaidery, CPC-A Bear, DE Harriet Roberta Alexander, CPC-A Davie FL Kathy Booth, CPC-A Edgewater FL Irene Aguirre, CPC-A Indiantown FL Marcia Shannon, CPC-A Lynn Haven FL Barbara J Angell, CPC-A Orlando FL Maria Aragunde, CPC-A Pembroke Pines FL Edith Marisela Bobadilla, CPC-A Plantation FL Flora Brown, CPC-A St. Petersburg FL Norma Ilarraza, CPC-A Tampa FL Helen Edwards, CPC-A Acworth GA Toni Pirkle, CPC-A Athens GA Jennifer Minge, CPC-A Atlanta GA Wayne D Syverson, CPC-A Decatur GA Miranda Young, CPC-A Hephzibah GA Rachel L Wilson, CPC-A, CPC-H-A Macon GA Latonya Lewis, CPC-A Stone Mountain GA Ebony Steele, CPC-A Stone Mountain GA Rebecca Mayne, CPC-A Woodstock GA Sandra Delois Terry, CPC-A Dublin GA Christine Salacup Longgat, CPC-A Ewa Beach HI Arceli Cabanilla Chan, CPC-A Honolulu HI Gernell Kaliana Kiyoko Yamada, CPC-A Honolulu HI Mandy L Barger, CPC-A Kailua HI Bernadette A Cokee Dexter, CPC-A Kaneohe HI Darlene Aquino Flores, CPC-A Mililani HI Tristan A Harder, CPC-A Cedar Rapids IA Amy JoAnne Brown, CPC-A Vinton IA Lisa Ann Oliveri, CPC-A Barrington IL Rudolph K Gartner, CPC-A Chicago IL Debra M Melesio, CPC-A Lake Villa IL Sharon Gablin, CPC-A Oswego IL Janelle Fleck, CPC-A Peotone IL Michelle M Youngs, CPC-A Spring Grove IL Deshaunda R Carter, CPC-A Springfield IL Charlotte J Wildman, CPC-A Springfield IL Melania Ward, CPC-A Clarksville IN Michelle Harrison, CPC-A Cambridge City IN Wendy Nichols, CPC-A Scottsburg IN Jamie Lynn Trun, CPC-A Granite City IL Charla K Grafton, CPC-A Mattoon IL Lisa Marie Harter, CPC-A O Fallon IL Kasandra D.M. Bogatay, CPC-A Harper KS Jennifer R Wilson, CPC-A Lawrence KS De Forya Calloway, CPC-A Minden LA Kristina M Maxey, CPC-A Denham Springs LA Tammy G Heim, CPC-A Lafayette LA Melissa A Mason, CPC-A W. Brookfield MA Doreen Bentley, CPC-A Marblehead MA Michael P Iarrobino, CPC-A Marblehead MA Melissa D Osborn, CPC-A Marblehead MA Penny J Richards, CPC-A North Reading MA Ben James Amirault, CPC-A Peadbody MA Srdjan Perisic, CPC-A Salem MA Darlene B Vendittelli, CPC-A Saugus MA Judy Gaboury, CPC-A West Brookfield MA Nicole Orange, CPC-A Linthicum MD Paulina Esi Kangah, CPC-A Springdale MD Heather Rogers, CPC-A Shady Side MD Sandra D Rowe, CPC-A Freeport ME Sherry Ann Hall, CPC-A North Berwick ME Kristi Wyman, CPC-A North Waterboro ME Ami Jo Graper, CPC-A Flint MI Angeline Johnson, CPC-A Flint MI Melissa Miller, CPC-A Livonia MI Mallory Jones, CPC-A Waterford MI Amanda Bott, CPC-A Ypsilanti MI Carla Ann Kent, CPC-A Grand Blanc MI Stacy Maria Miller, CPC-A Hanover MI Sirisha Mallavaram, CPC-A Novi MI Nirmala D Shah, CPC-A Okemos MI Nicole Rose Mullen, CPC-A Royal Oak MI Mary Jo Surma, CPC-H-A Saginaw MI Ronda Blume, CPC-A Herman MN Kristi Johnson, CPC-A Moorhead MN Stacey Diane Finley, CPC-A Bloomsdale MO Amy Jo Kage, CPC-A Carl Junction MO Bonita Jean Payton, CPC-A Carthage MO Nancy Jo Hensley, CPC-A Herculaneum MO Joyce Ann Davis, CPC-A House Springs MO Janis W Smith, CPC-A Kansas City MO Elizabeth Giocondi, CPC-A Raytown MO Heather L Blacksher, CPC-A Saint Louis MO Andrea D Whittier, CPC-A Saint Louis MO Amanda Dawn Croft, CPC-A St Louis MO Peggy A Fahrenkamp, CPC-A St Louis MO Penny K Hampton, CPC-A St Louis MO Myla Shamese Hogue, CPC-A St. Louis MO Lynnette Gant, CPC-A Kansas City MO Jennifer L Ayers, CPC-A Bessemer City NC Sarina Jenkins, CPC-A Charlotte NC Roberta M Mazingo, CPC-A Charlotte NC Terry Smith, CPC-A Charlotte NC Christopher Reinhard, CPC-A Creedmoor NC Debra B Teer, CPC-A Haw River NC Terry Lynn Williams, CPC-A Monroe NC Miranda Paige East, CPC-A Mooresville NC Jennifer Killian, CPC-A Murphy NC Lisa Gragson, CPC-A Waxhaw NC Hemangi Gaitonde, CPC-A Cary NC Cecilia Gorzkowski, CPC-A Charlotte NC Jamie Dionne Harrell, CPC-A Charlotte NC Sandra T Boyles, CPC-A Denton NC Diane Paulette Miller, CPC-A Mebane NC Tami Albert, CPC-A Fargo ND Maria Ramos-Loza, CPC-A Derry NH Kimberly Ann Dailey, CPC-A Rochester NH George Mammen, CPC-A Swedesboro NJ Stacey Souders, CPC-A Lakewood NJ Linda A Myhre, CPC-A Princeton NJ Gina Maria Foster, CPC-A Baldwinsville NY Lisa M Smith, CPC-A Bloomingdale NY Lisa M Vercillo, CPC-A Cicero NY Amanda Deleva, CPC-A Horseheads NY Patricia Hitchcock, CPC-A Horseheads NY Melissa M Carmona, CPC-A Mattydale NY Gina Marie Alford, CPC-A Syracuse NY Leila R DeDominicis, CPC-A Syracuse NY Tanisha C Martin, CPC-A Syracuse NY Anne Richard, CPC-A Holbrook NY Diana Scotto, CPC-A N Massapeque NY Karen Ann Kelley, CPC-A Ashland OH Kimberly Ann Aberts, CPC-A Loudonville OH Laura Rene Opper, CPC-A Broken Arrow OK Amie Lynn Ratterree, CPC-A Skiatook OK Alberto Castillo, CPC-A Tulsa OK Tammy Lynn Edwards, CPC-A Tulsa OK Natalya Yelchaninov, CPC-A Portland OR Laura Piperato, CPC-A Tatamy PA Donna Jones, CPC-A Walnutport PA Rosemary E Millan, CPC-A Carlisle PA Hae Young Eum, CPC-A Enola PA Erin E Stellar, CPC-A Kulpmont PA Adrienne Heatley, CPC-A Columbia SC Ann A Doolittle, CPC-A Ft Mill SC Jennifer Rodgers, CPC-A Gaston SC Patrick Abrams, CPC-A West Columbia SC Patricia May, CPC-A Spearfish SD Rae Lynne Adkins, CPC-A Memphis TN Vickie Wood, CPC-A Mt. Juliet TN Cathy Bingham, CPC-A Murfreesboro TN Brandon Petty-Perry, CPC-A Nashville TN Megan Cadogan, CPC-A Portland TN Robi Love Fortune, CPC-A Springfield TN Joan W Johnson, CPC-A Springfield TN Joanna M Gott, CPC-A Eddy TX Bhagya L Alloju, CPC-A Frisco TX Christy Samford, CPC-A Mckinney TX Annie Tapiawala, CPC-A Plano TX Vernon Selvidge, CPC-A Rowlett TX Trish Spaziani, CPC-A Waxahachie TX Sandra Mireles, CPC-A El Paso TX Sona Palankar, CPC-A, CPC-H-A Irving TX Jean Stellon, CPC-A Virginia Beach VA Lorraine G Paine, CPC-A Morrisville VT Kenyon A Moshovetis, CPC-A Williston VT Sherry Johnson, CPC-A Charlottesville VA Gloria Evans, CPC-A Edinburg VA Cheryl Ann Hopkins, CPC-A Elkton VA Tamara Gordon, CPC-A Grottoes VA Erin Patterson, CPC-A Lyndhurst VA Kelly Washington, CPC-A Orange VA Robin Hunley, CPC-A Rocky Mount VA Ruth L Jones, CPC-A Stanardsville VA Scott Heynderickx, CPC-A Battle Ground WA Scott Nicholson, CPC-A Bunker Hill WV Valerie Jill Chapman, CPC-A Elkview WV Kaila Monaghan, CPC-A Greenacres WA Lori Babcock, CPC-A Seattle WA Teresa Greene, CPC-A Wenatchee WA Marcy Kemp, CPC-A Stoughton WI Jessica Lee Chandler, CPC-A Dunbar WV Specialties Stephanie L Timmons, CPC, CEMC Maricopa AZ Schawn Anne Pedersen, CPC, CEMC Phoenix AZ Judith A Hallas, CPC, CDERC Scottsdale AZ Corie L Payne, CPC, CEMC Tucson AZ Alex C Au-Yeung, CPC, CIRCC Santa Rosa CA Brenda Ann Currie, CPC, CASCC, CGSC Broomfield CO Tincy Von Atzingen, CPC, CASCC, CGSC Broomfield CO Sheila Key, CPC, CPC-H, CASCC, CGSC Thornton CO Betty Johnson, CPC, CPC-I, CDERC Homewood IL Brenda K Kuhnert, CPC, CUC Lawrence KS Laura Renee Valmont, CEDC Church Point LA Sandra Foreman, CEDC Rayne LA Connie Joy Murphy, CPC, CEMC Poplar Bluff MO Rita C Weeks, CPC, CEMC Wake Forest NC Andrea Beck, CASCC St Libory NE Casey C Bzdak, CPC, CFPC, CGSC, COBGC Derry NH Deborah Ann Wilson, CPC, CEDC Clifton Park NY Christiana Oji, CPC, CCC, CCVTC Queens Village NY Kathleen M Gasiewski, CPC, CEDC Selden NY Sharee Luckeydoo, CPC, CPC-H, CANPC Bidwell OH Tracey Christine Glenn, CPC, CPC-H, CEMC Harrisburg PA Katrina M. Moultrie, CPC, CFPC North Richland Hills TX Yolanda A. Stapleton, CFPC Robinson TX Michael E Brown, CPC, CIRCC Houston TX Vanessa Bryant, CCC Spokane WA Kathleen Casey, CPC, CEMC Greenfield WI June

40 feature Low-level E/M Defines Self-Injection Training By G. John Verhovshek, MA, CPC APPRENTICE Erika Heiges, MPH, CHES, senior health educator with HealthEd in Clark, NJ recently asked Coding Edge, Which CPT code is appropriate when a provider instructs a patient how to inject a self-administered drug? Self-injection Training is Self-injection training often is provided by a non-physician practitioner (NPP), and includes educating patients on injection procedures, possible side effects, and other pertinent information. Face-to-face dialogue, classes, and/or video recordings may be used to provide instruction. Patients that may require self-injection training include those with chronic disease, such as rheumatoid arthritis Humira and Enbrel are the drugs for these patients, notes Linda Martien, CPC, CPC-H, RCM education specialist at National Healing, Inc. Additional conditions that may require self-injection training include relapsing-remitting multiple sclerosis, hepatitis, erectile dysfunction, psoriasis, and migraine headaches, among others. Report the Who, What, and Where Code selection for self-injection training will depend on who is providing the service, and in what setting, adds Nancy L. Reading, RN, BS, CPC, of Cedar Edge Medical Coding and Reimbursement. An office nurse would be most likely to provide this service, although the provider would have to be in suite at the time. These are incident-to services, and you d have to report Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. From my understanding, when the self-injection training is provided by staff under the supervision of a credentialed provider, rather than by the credentialed provider, the only coding option would be 99211, confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, with MJH Consulting. Note that self-injection training sessions may far exceed the typical 5 minute reference time for The practice simply has to absorb the cost of the NPP s additional time. Be aware of scope-of-practice issues when an NPP provides patient services. In some states, for instance, an MA [medical assistant] must pass additional certification exams to be able to give injectables. So they may not always be the personnel to train, Reading continues. Research the scope-of-practice Note that self-injection training sessions may far exceed the typical 5-minute reference time for The practice simply has to absorb the cost of the NPP s additional time. guidelines in your state to verify that the NPPs in your practice are providing and reporting services appropriately. Reading warns, This issue really begs the incident-to criteria if self-injection training is done in place of service 11 [Office]. All other POS [place of service] would not bill or code for this service for Medicare Part B because the staff is not the physician s and the physician is seldom the person doing the training. An in-depth analysis of where the service is performed and who owns the clinic and pays the staff is essential to determine prior to even discussing the service. In the Event of a Shared Visit Occasionally, injection training in the office may be part of a shared visit, in which the NPP provides the injection training and the physician sees the patient for additional, medically-necessary evaluation. This, too, is an incident-to service, for which the physician may report an appropriate evaluation and management (E/M) service level for the total work. The Medicare Claims Processing Manual, section B, explains, When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS, or CNM [nurse practitioner, physician assistant, clinical nurse specialist or certified nurse midwife]), the service [in POS 11] is considered to have been performed incident to if the requirements for incident to are met and the patient is an established patient. If incident to requirements are not met for the shared/split E/M service, the service must be billed under the NPP s UPIN/PIN [Unique Physician Identification Number/Provider Identification Number], and payment will be made at the appropriate physician fee schedule payment. In a hospital setting, when an E/M is shared between a physician and an NPP from the same group practice, and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician s or the NPP s UPIN/PIN number. Document Each Encounter In all cases, documentation of patient education would be necessary, Reading says. As well, I would recommend documentation of a return demonstration. This is crucial to ensure that the patient really can self-inject. You also might want to document support systems at home, such as a medical alert bracelet, in case the patient gets into trouble. 40 AAPC Coding Edge

41 STILL NEED CEUs? 40 CEUS 20 AAPC AUDIO CONFERENCES $395! Order the remaining 2009 Audio Conferences and save $400 off the subscription price Earn up to 40 CEUs per listener Entire office can listen in (on one phone line) 60-minute presentations Expert presenters DATE TOPIC PRESENTER 06/03/09 THE CONFIDENT CODER: HOW TO ACCURATELY CODE FOR PROFESSIONAL SERVICES IN PEDIATRICS 06/10/09 HOW TO USE PQRI TO CAPTURE MORE REVENUE: AN OUNCE OF PREVENTION IS WORTH 2% 06/17/09 THE CONFIDENT CODER: HOW TO ACCURATELY CODE FOR PROFESSIONAL SERVICES IN GI 06/24/09 HOW TO AVOID TOP CODING AND BILLING MISTAKES BY ACSCS: THE FREE STANDING FREE FALL 07/01/09 THE CONFIDENT CODER: HOW TO ACCURATELY CODE FOR PROFESSIONAL SERVICES IN ANESTHESIOLOGY 07/08/09 HOW TO GET PAID BY THE PATIENT AS THE CONSUMER: MY VISIT COST HOW MUCH? 07/15/09 MEDICAL CLASSIFICATION SYSTEMS: CODERS AND CODE SETS OUTSIDE OF THE BILLING WORLD 07/22/09 MEDICAL NECESSITY DO AND DON TS FOR THE CODER: ENSURING PROPER PAYMENT RHONDA BUCKHOLTZ, CPC, CPC-I CYNTHIA A. TRAPP, CPC, CPC-I DEBORAH GRIDER, CPC, CPC-H, CPC-P, CPC-I, CPC-E/M DONNA SANGIOVANNI, CPC MARC LEIB, MD SUSAN WARD, CPC, CPC-H, CPC-I, CPC-E/M MICHAEL STEARNS, CPC SUZAN BERMAN-HVIZDASH, CPC, CPC-E/M, CPC-ED 07/29/09 BEST PRACTICE: CODERS AND BILLERS WHO MAKE A DIFFERENCE RHONDA BUCKHOLTZ, CPC, CPC-I 09/16/09 MODIFIERS KATHERINE ABEL, CPC, CPC-I 11/24/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN DIAGNOSTIC RADIOLOGY + OIG REPORT 12/02/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN EMERGENCY MEDICINE + OIG REPORT 12/03/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN OBSTETRICS/GYN + OIG REPORT 12/08/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN ORTHOPEDICS + OIG REPORT 12/09/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN INTERNAL MEDICINE/FAMILY PRACTICE + OIG REPORT 12/10/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN CARDIOLOGY + OIG REPORT 12/11/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN PEDIATRICS + OIG REPORT 12/15/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN ANESTHESIOLOGY + OIG REPORT 12/16/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN GENERAL SURGERY + OIG REPORT 12/17/ COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN GI + OIG REPORT TERRY LEONE, CPC, CPC-P, CIRCC, CPC-I RAEMARIE JIMENEZ, CPC RHONDA BUCKHOLTZ, CPC, CPC-I LYNN M ANDERANIN, CPC, CPC-I BRUCE RAPPOPORT, CPC BETTY JOHNSON, CPC, CPC-I RHONDA BUCKHOLTZ, CPC, CPC-I MARC LEIB, MD LUANN C. JENKINS, CPC, CPC-E/M, CPC-FP DEBORAH GRIDER, CPC, CPC-H, CPC-P, CPC-I, CPC-E/M * EVENT TOPICS, DATES, AND TIMES ARE SUBJECT TO CHANGE CALL CODE OR GO TO

42 feature No Code? No Worries! Three tips for getting unlisted procedure CPT codes to work for you. By Torrey Kim, MA, CPC APPRENTICE Question: What do the following procedures all have in common: Retropubic urethrolysis of a previously performed Burch colposuspension, laparoscopic distal pancreatectomy and splenectomy, electrosleep therapy, core decompression of the femoral head, thyroplasty, and endoscopic stapling of the diverticulum? Answer: CPT does not include codes for any of these services. Question: What s a coder to do when encountering one of these procedures in a physician s notes? Answer: Turn to the unlisted procedure codes in CPT. CPT includes unlisted procedure codes allowing you to submit claims for services without specific CPT descriptors assigned to them. You should never report a code that comes close to the procedure your physician performed but doesn t quite fit. If no precise procedure or service code exists, you should report the service using the appropriate unlisted procedure or service code, according to the CPT Instructions for Use section in the CPT manual. Payment for such claims is not automatic. With carefully documented procedures, however, the information you include with your claim can make all the difference. You can streamline your unlisted procedure code claims and ensure your physician gets reimbursed without using specific codes by following these three pointers. Tip 1: Describe the Procedure in Plain English Any time you file a claim using an unlisted-procedure code (for example, Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion), you should include a separate report to explain in simple, straightforward language exactly what the physician did. Make sure to compare it to an existing procedure and give it a relative value to that existing procedure, as well as provide the operative or procedure note. Keep in mind that insurers consider claims for unlisted procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. It s also a good idea to include diagrams or photographs to help the insurer fully understand the procedure. Some practices recommend highlighting or making notes on the actual op report indicating where the provider describes the unlisted procedure. Some practices include copies of articles in medical journals supporting the reasonableness of the procedure, such as clinical trials and medical indications. Don t forget medical necessity documentation to back up the decision to perform the procedure. For instance, you can include details such as electrosleep therapy was performed to treat chronic insomnia that has not responded to other treatments to reinforce medical necessity. For Medicare Administrative Contractors (MACs) or thirdparty payers that no longer accept paper claims or require an electronic claim to proof for timely filing, submit your unlisted CPT code electronically with a short description of what was done in box 19 of the Centers for Medicare & Medicaid Services CMS-1500 form or its electronic equivalent. Some MACs will then expect a faxed or mailed copy of your documentation after seven to 10 days, or will request documentation after receiving the electronic submission. When submitting an unlisted procedure claim, your documentation should also include an explanatory cover letter. For example, a young child requires a post-fistula tracheostomy tube change. The child is restless and unruly and will not submit to the procedure in the physician s office. The doctor elects to perform the procedure in the operating room (OR) with the patient under anesthesia. In this case, your best code choice is Unlisted procedure, trachea, bronchi. Your documentation should state, The physician chose to perform the procedure under anesthesia in the OR rather than in the office because the patient was a young child who could not be safely restrained in the office setting. This was the best method to ensure a positive outcome and prevent any undue harm to the patient. CPT does not contain a code to describe a procedure of this type, and we are submitting an unlisted procedure code. Tip 2: Compare the Procedure An insurer will decide to pay an unlisted procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value. Rather than leave it up to the insurer to determine which code is the next closest, you should explicitly make reference to the nearest equivalent listed procedure. After all, the treating physician is best equipped to make this determination. You also should note the specific ways the unlisted procedure differs from the next-closest CPT procedure listed. This explanation will help relate the procedure performed to an existing procedure as support for reimbursement. Make sure to explain how your procedure differs to show why you didn t choose the existing code. Basing your fee on a similar procedure is helpful in claims processing, but is not mandatory. 42 AAPC Coding Edge

43 feature For example, the surgeon performs an arthroscopic bicep tenotomy, for which CPT does not include a specific code. For this scenario, most coders recommend reporting Unlisted procedure, arthroscopy and requesting reimbursement at a level similar to Tenotomy, shoulder area; single tendon. The surgeon s letter should explain the similarities and/or differences between the performed bicep tenotomy and a shoulder tenotomy. Tip 3: Solicit Outside Advice When You Can Your surgeon s professional association might offer recommendations of when an unlisted code is warranted and, if so, which compare codes they recommend. The AMA often offers unlisted coding guidance in its CPT Assistant and other publications. If the physician uses equipment and techniques for which there is no dedicated CPT code, you may ask for the manufacturer s aid to receive appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies. Use caution when applying manufacturers suggestions, however, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain payment. If your practice performs a particular procedure often for which there is no specific code, consider meeting with the MAC s or payer s medical director to discuss how you can get paid for this service without having to jump through hoops every time it takes place. The payer may create a dummy code for the procedure, or set a fee for the unlisted code, facilitating automatic adjudication. Torrey Kim, MA, CPC, is the editor-in-chief of Part B Insider, a weekly publication that offers news and analysis on Medicare Part B issues. Visit the Part B Insider Web site at A National Auditing Certification Program Approved for 12 CEU s by the AAPC 2009 Auditing Certification Class Schedule Las Vegas, NV April 4-5 Mesa, AZ April Charlotte, NC April, Minneapolis, MN May 6-7 Atlanta, GA May Buffalo, NY June 3-4 Portland, OR June Knoxville, TN June Des Moines, IA July 8-9 Nashville, TN July NEW! Boston, MA August 3-4 Cincinnati, OH August Anaheim, CA September Detroit, MI September Kansas City, MO September Anchorage, AK October 8-9 Baltimore, MD October Knoxville, TN October Denver, CO October Chicago, IL November 9-10 Biloxi, MS December 2-3 Denver, CO June 4 Orlando, FL July 30 Gatlinburg, TN Sept 3 June

44 The Case of an Accessory Ovary Ectopic ovarian tissue is extremely rare, occurring perhaps once per 500,000 (or more) gynecologic admissions. A precise estimate of occurrence is difficult due to a confusing (and still disputed) classification system, as well as the frequently asymptomatic nature of the condition. In this case, a morbidly obese 13-year-old girl is seen with a giant serous cystadenoma arising from an accessory ovary. Indications: A 13-year-old girl presented with two bouts of abdominal and left flank pain during a six-month period, described as non-radiating and an 8 out of 10 in intensity. The pain was accompanied by nausea and one episode of vomiting. The patient also noticed a decrease in urinary frequency during the same interval. She denied fever, dysuria, hematuria, or bloody stools. Past medical and family history was unremarkable. The patient had no history of hospitalizations, surgeries, or chronic illness. Menarche was at the age of 11, followed by irregular cycles occurring every 40 to 50 days with very heavy flow. Physical examination revealed a morbidly obese (weight: 225 lbs., BMI: 40) adolescent girl. Her abdomen was soft and depressible and no masses were identified on palpation. Various imaging studies were performed including a pelvic ultrasound, which identified an 18.5 cm 10.0 cm 15.5 cm cystic lesion that extended into the abdomen approximately to the level of the umbilicus. MRI studies were ordered and identified a large cystic structure appearing to originate from the right adnexa, suggesting an ovarian tumor. Due to the size and location of the cyst, a left salpingectomy was performed to remove it completely. The patient was left with two intact ovaries and her right fallopian tube. Due to the identification of two eutopic ovaries and the attachment to the mass to the left fallopian tube, a postoperative presumptive diagnosis of a left paratubal cyst was made. The final histopathological diagnosis was hemorrhagic serous cystadenoma arising from ovarian tissue. Solution: The removal of the cyst would be reported with Ovarian cystectomy, unilateral or bilateral. Due the documented size and location of the cyst, however, another possible option depending on the documentation in the op note would be Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter. In this scenario, Salpingectomy, complete or partial unilateral or bilateral (separate procedure) would also be reported. Final diagnosis was hemorrhagic serous cystadenoma. In the ICD-9-CM Index, Cystadenoma/serous refers the reader to see Neoplasm by site, benign. The histopathology identifies the cystadenoma source as ovarian. Report 220 Benign neoplasm of ovary. The patient s weight could also be reported with Morbid obesity with V85.54 Body Mass Index, pediatric, greater than or equal to 95th percentile for age. Codes identifying specific BMI are for patients 20 years or older. For this patient, the pediatric percentile codes were used instead. Although the percentile was not provided in the medical documentation, by knowing the age, weight, and BMI of the patient, it could be computed on the Centers for Disease Control (CDC) Web site ( dnpabmi/calculator.aspx). 44 AAPC Coding Edge

45 extreme coding Can You Code This Note? The Case of the Impaled Roofer Sometimes the circumstance can seem more extreme than the clinical reality, as in the case of this construction worker who was impaled on a tree branch when he fell from a rooftop. But we all know, in coding, sometimes the devil is in the details. Code this scenario based on the operative services and diagnoses. Can you code this? A 24-year-old roofer fell 12 feet from a one-story rooftop onto a tree and was impaled by a tree branch in his left flank at the level of the umbilicus. On arrival at the ED, he had a blood pressure of 136/110 mm Hg, pulse of 115 beats per minute, and a respiratory rate of 32 breaths per minute. Physical examination revealed equal breath sounds on auscultation and peritoneal signs on palpation. The patient was resuscitated in the emergency department with crystalloids, which were administered through two large-bore venous catheters. He was transferred to the operating room conscious and supine. Extreme care was taken to avoid manipulating the branch, and rapid-sequence intubation was used to gain control of his airway. The abdominal cavity was explored through a vertical midline incision. During the operation, bile-stained fluid was encountered in the right upper quadrant of the patient s abdomen, and a perforation of the lateral aspect of the second portion of the duodenum was noted. The gallbladder, pancreas, liver, and inferior vena cava were negative for injury. The tree branch was removed under direct vision once the extent of the patient s injuries had been assessed. A Kocher maneuver was used to mobilize the patient s duodenum and the injury was repaired with transverse closure in two layers. A distal feeding jejunostomy tube was placed. The entrance wound was debrided of dirt and splinters, lavaged, and allowed to heal by secondary intention. The patient had a satisfactory recovery and was discharged to home on postoperative day seven. The jejunostomy was removed as an outpatient procedure on postoperative day 21. Have You Gone to Extremes? Have you got a challenging scenario you d like to see discussed in this forum? Send your op report to extreme.coding@aapc.com. Before forwarding it to us, please safeguard the patient s personal information by changing dates and removing unique identifiers. June

46 added edge SEPARATE Professional & Technical Components with 26 and TC By G. John Verhovshek, MA, CPC APPRENTICE Certain services defined within CPT contain separate professional and technical components. That is, the complete service, as reported by a single CPT code, includes reimbursement for the physician s work of the service generally physician interpretation and report, or a diagnostic test s administration and separate payment for necessary equipment usage and ancillary costs. As a rule, codes with both a professional and technical component describe equipment-intensive diagnostic services, including many services found in the radiology (70000 series) and medicine ( ) sections of the CPT manual. When reporting these codes, you may separate a service s professional and technical components from one another with proper application of modifiers 26 Professional component and TC Technical component. Identifying Qualifying Codes The CPT manual does not identify specifically codes with separate professional and technical components. You may identify them readily, however: The Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (PFS) Relative Value File lists such codes on three separate lines, each with a different relative value unit (RVU) total. The first line describes the global service; the second line describes the service s technical component (as indicated by TC in column B of the fee schedule), and; the third line describes the service s professional component (as indicated by 26 in column B of the fee schedule). Resource tip: You may download the CMS National PFS Relative Value File from the CMS Web site at: asp?listpage=4. Be sure to select the most recent file. Applying Modifiers 26 and TC Most often, you will append modifier 26 when the physician does not own the equipment necessary to provide the service, such as when the physician provides the interpretation and report for an X-ray taken in a facility setting. When billing Medicare, physicians providing services in a facility setting cannot claim the procedure s technical When billing Medicare, physicians providing services in a facility setting cannot claim the procedure s technical portion regardless of whether they own the equipment. portion regardless of whether they own the equipment. For instance, if a neurologist performs electromyography (EMG) (such as Needle electromyography; one extremity with or without related paraspinal areas) for a Medicare inpatient using his own machine, he must append modifier 26. The hospital receives the payment for the technical component of any service provided in the facility as part of the diagnosis-related group (DRG) payment for Medicare inpatients. This is true even if the physician performs the service for a hospital patient in his or her office. If, however, the physician provides the complete outpatient service in his office, using his own equipment, you may report the appropriate CPT code without a modifier appended to receive reimbursement for the complete service. For example, per the 2009 PFS Relative Value file, the neurologist reporting to Medicare in the facility setting recovers 0.96 RVUs for the professional portion of the service only. If the neurologist provides the same service for an outpatient in his own office, using his own equipment, he reports without a modifier, and receives a total of 2.16 RVUs for the complete service. A physician practice may report a service with modifier TC only, but it would happen rarely. For example, suppose that several ophthalmology practices lease space within the same office complex. Practice A has had equipment difficulties, and arranges with Practice B to provide the technical portion of, for instance, visual field testing (92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination [eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) for Practice A s patients. Practice B provides the printouts for Practice A, and Practice A performs the interpretation and report. In this case, Practice A would report , and Practice B would report TC. G. John Verhovshek, MA, CPC, is AAPC s [ director of clinical coding communications. ] 46 AAPC Coding Edge

47 coding news coding news By Renee Dustman FTC Delays Red Flags Rule Ready? Set? Stop! Physicians have a bit more time to develop and implement a written identify theft prevention program in accordance with the Red Flags Rule. The Federal Trade Commission (FTC) extended the compliance deadline for creditors and financial institutions covered under the rule to Aug. 1 three months later than the May 1 extension and nine months later than the original Nov. 1, 2008 enforcement date. The latest extension was announced April 30. In addition, the FTC is creating a template designed to help entities that have a low risk of identity theft, such as physicians who know their customers personally, comply with the law. Given the ongoing debate about whether Congress wrote this provision too broadly, delaying enforcement of the Red Flags Rule will allow industries and associations to share guidance with their members, provide low-risk entities an opportunity to use the template in developing their programs, and give Congress time to consider the issue further, FTC Chairman Jon Leibowitz said in an April 30 press release. As stated in an American Medical Association (AMA) press release, issued May 1, The AMA will utilize this time to convince the FTC and Congress that physicians are not creditors and should not be subject to this rule. The Fair and Accurate Credit Transactions Act of 2003 (FACTA) the impetus of the Red Flags Rule applies the term creditor to any entity that regularly extends or renews credit, or arranges others to do so, and includes all entities that regularly permit deferred payments for goods and services. Realizing that several industries, such as health care, were uncertain about their participation in the effort, the FTC has prepared a number of training materials to help businesses develop their identify theft prevention programs. For more information regarding the Rule s requirements, read an alert at bcp/edu/pubs/business/alerts/alt050.shtm. For resources on how to design and implement identity theft prevention programs, and for the FTC compliance template, go to ftc.gov/redflagsrule. The AMA has also prepared a sample policy template, available at mm/368/red-flags-rule-policy.pdf. Coding Edge will continue coverage of the Red Flags Rule as details develop. Articles in February and April issues are excellent resources. June

48 minute with a member Kenneth Cable Camilleis, CPC Allied Health Instructor, Lincoln Technical Institute, Boston, Mass. Coding Edge (CE): Tell us a little bit about your career how you got into coding, what you ve done during your coding career, what you re doing now? Kenneth: My work experience in allied health goes back to my childhood. When I was 8 years old, I filed and pulled records at a clinic where my mother worked. I took note of strange numbers on the charts, which I later learned were ICD codes. As a teen, I worked in an ophthalmologist s office where I prepared insurance claims and patient statements, filled contact lens orders, maintained the postage meter, stuffed envelopes, pulled charts, and typed schedules. This is where I was introduced to ICD coding. In 1989, I joined a practice management business serving a multitude of specialties, where I was senior biller for many years. In the spring of 2006, I received a call from a career school s regional director in need of a billing and coding instructor. I seized the opportunity to bring my knowledge into the classroom. Besides billing and coding, I teach a variety of subjects, such as front office skills, practice management software, and electronic health records. I joined the AAPC last summer; and completed the PMCC program in December CE: What is your involvement level with your local AAPC chapter? Ken: I am a member of the Quincy Bay Coders; the chapter is based in Quincy, which is just south of Boston. Although I ve only been a member for a few months, I partake in as many of their activities as time allows. To further expand my knowledge as a coder, I also attend seminars at other nearby chapters. CE: What has been your biggest challenge as a coder? Ken: Coding seems to be one of the more taxing subjects for some students. My objective is to have them not only learn their basic way around a CPT book, but also pay close attention to coding conventions, key words, and nuances such as the location of a semicolon. Students need to become familiar with coding guidelines and to understand when certain codes are not separately reportable. In the hospital/clinical setting, I still see some challenges in consistently bridging the communication gap between coders and doctors. It all comes down to whether the physician is responsive and compliant. CE: What do you advise other coders to do if they disagree with the way a physician has coded his chart? Do you approach the physician, or have a monthly meeting? Ken: If the discrepancy was an isolated situation, I d suggest the coder approach the physician directly, and focus on whether the error was a wrong code choice based on a properly documented chart or one of underdocumentation for the services provided. Periodic meetings with the physician(s) may be necessary if the problem is ongoing. CE: If you could have any other job, what would it be? Ken: I picture myself playing an integral role in ICD-10-CM implementation consulting activities. I d also enjoy being a PMCC instructor mentoring students, shaping more certified coders, and encouraging students to continue their coding education after they re certified. CE: How do you spend your spare time? Tell us about your hobbies, family, etc. Ken: I am married with two daughters. We like to travel, but due to local business demands, I ve had to stay put for awhile. I am also a historian, mainly focused on the second quarter of the 19th century. I discover sites where people hung out during this era, and use a metal detector to find coins of styles and denominations that were discontinued about 150 years ago. I collect coins from 1821 to I find pieces as old as the late 1700s at research sites. Because of inconsistency in minting technology, studying these items requires attention to detail just as with coding! 48 AAPC Coding Edge

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50 test yourself Coding Edge Tests Your Knowledge June 2009 Index: CE A Get One CEU These questions are answered in articles throughout this news magazine. For answering all questions correctly, you will receive one CEU at the time of your renewal. Test Yourself Online These same questions can be accessed online at Once you go there and take the test, you can automatically grade your answers, correct any mistake, and have your CEUs automatically added to your CEU Tracker for submission. Starting the July issue, Test Yourself will only be accessible online. 1. Which E/M service component is the overarching criterion for E/M level selection? a. history b. exam c. medical decision-making d. time 2. What is the reference time for a level III outpatient consultation service (99243)? a. 10 minutes b. 20 minutes c. 30 minutes d. 40 minutes 3. The coding rules/regulations as published in which of the following take precedence above all others? a. HIPAA b. CPT Manual c. CPT Assistant d. Payer-specific instructions, such as CMS/Medicare and national Correct Coding Initiative guidelines 4. Which of the following statements is NOT true? a. When reporting inpatient prolonged services for payers who follow CPT guidelines, you may count only face-toface time b. When reporting inpatient prolonged services for Medicare payers and others who follow Medicare guidelines, you may count only face-to-face time c. When reporting outpatient prolonged services for payers who follow CPT guidelines, you may count only face-toface time d. When reporting outpatient prolonged services for Medicare payers and others who follow Medicare guidelines, you may count only face-to-face time 5. How many minutes beyond the reference time for a given level of E/M service must the physician document to report prolonged services? a. 15 minutes b. 30 minutes c. 45 minutes d. 60 minutes 6. The physician documents an expanded-problem focused history, a detailed exam and MDM of moderate complexity for an established patient in the outpatient setting. The visit lasts 90 minutes with well-documented medical necessity for that time. What is the appropriate coding? a , b , 99354, c , d , 99354, The physician documents a brief history of present illness, an extended review of systems, and a pertinent past, family, and social history. What is the overall level of the history component in this example? a. Problem Focused b. Expanded Problem Focused c. Detailed d. Comprehensive 8. The physician documents, Patient experiences a popping or clicking sensation of the jaw while chewing. This often leads to headaches and neck pain of mild to moderate severity, as well as discomfort when eating or yawning. Pain subsides after sleep, but increases as the day progresses. Symptoms began approx. two weeks ago. No swelling or bruising is apparent. This qualifies as: a. A problem-focused HPI b. An extended HPI c. A pertinent PFSH d. A complete PFSH 9. True or False. When a physician performs a diagnostic test with both a technical and professional component, for a Medicare patient in a hospital, using his own equipment and/or staff, the physician can report the global service using the appropriate CPT code, without a modifier appended. a. True b. False 10. When reporting an unlisted procedure code, upon initial claims submission, which of the following should you NOT do? a. Include a short description of the procedure in box 19 of the electronic claims form b. Prepare additional documentation for submission, if requested c. Provide the payer with a suggested payment based on a comparison with an already-valued procedure of similar intensity/resource utilization d. Append modifier 22 Increased procedural service to the claim to identify it as unusual 50 AAPC Coding Edge

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52 Travel for vacation not training. Now you can receive expert training streamed over the internet directly to your home or office. Earn CEUs anywhere, anytime at your convenience. Introducing elearning Courses available for: Coding Billing Reimbursement Compliance Medicare Credentialing Learn more at or call