of Contract Negotiations of Contract Negotiations - AAPC

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Oct 25, 2012 - Follow us on Twitter: twitter.com/hbollc ...... Jennifer Hart,CPC-A. Jennifer Heiser,CPC-A ... Keri Caspe
August 2012

The Big Picture of Contract

Negotiations

Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ

Plus: HCC • Word on ICD-10 • Risk Adjustment • Ultrasounds • E/M Modifiers

NAMAS 4th Annual Auditing Conference

Conference held at Grove Park Inn, Asheville, NC December 3-4, 2012

The ONLY National Conference that is AUDITING SPECIFIC Preconference Events Include: “Hands-on” Specialty-Specific Auditing CPMA® Training Course Training for Effective Managed Care Negotiations This month’s conference special is: Bring your physician for 1/2 Price! Purchase a ticket to the conference and bring your physician for only $495!

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Conference Agenda Provides two tracks each day. During each session the attendee will chose from: General topics relevant to all fields of auditing Specialty-specific auditing breakout sessions General Sessions relevant to all auditors and include speakers such as: Shannon DeConda, President of NAMAS Sean Weiss, VP of Decision Health Kelly Custer a well-known Fraud & Stark Attorney Expert For a complete listing of sessions, please visit our website www.NAMAS-

This 4th Annual conference is being supported by:

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Contents

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22

41

[contents]

August 2012

In Every Issue 7 Letter from the Chairman and CEO 9 Letter from Member Leadership 10 Letters to the Editor

Contra ct

10 Kudos

Negotia

13 Coding News

tions 29

Features 18 Strengthen Your Diagnosis Coding for Risk Adjustment

Serine A. Haugsness, CPC

20 Coding from EHRs: It’s Documented, but Did It Happen?

Erin Andersen, CPC, CHC

Special Features 12 Quick Tips: Morton’s Neuroma, PMDD 16 Hot Topic: Wellness Visits 41 ICD-10 Roadmap: Word is … 50 Minute with a Member

Education

22 Bedside Ultrasounds: Take a Closer Look

14 AAPCCA: Chapter Speakers



15 Handbook Corner: Smartphones

Sarah Todt, RN, CPC, CPMA, CEDC

24 Factor HCC with a Two-pronged Approach to Risk Adjustment

Holly J. Cassano, CPC

26 Practice Managers Succeed with Practical Know-how

Dixon Davis, MBA, MHSA, CPPM

29 The Big Picture of Contract Negotiations

Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ

34 Identify the Correct Global Period E/M Modifier

Nancy Clark, CPC, CPC-I

38 It’s Time to Re-evaluate Your E/M Coding Suzan Berman, CPC, CEMC, CEDC

45 A&P Quiz 47 Newly Credentialed Members Online Test Yourself – Earn 1 CEU

Go to: www.aapc.com/resources/ publications/coding-edge/archive.aspx

Coming Up • PT/OT • Surgical Modifiers • Colonoscopy

On the Cover: Physicians’ Ally, Inc. is lined up at the box office of the Paramount Theatre in Denver, Colo. to see Marcia Brauchler’s big picture, “Payer Contract Negotiations.” Cover photo by Brian Kraft Photography (www.briankraft.com).

• EHRs that Code • Acronyms www.aapc.com

August 2012

3

Serving 116,000 Members – Including You!

Be Green!

August 2012

Why should you sign up to receive Coding Edge in digital format?

Chairman and CEO

Here are some great reasons:

Reed E. Pew [email protected]

• You will save a few trees.

Vice President of Finance and Strategic Planning Korb Matosich [email protected]

• You won’t have to wait for issues to come in the mail. • You can read Coding Edge on your computer, tablet, or other mobile device-anywhere, anytime.

Vice President of Marketing Bevan Erickson [email protected]

• You will always know where your issues are. • Digital issues take up a lot less room in your house or office than paper issues.

Vice President of ICD-10 Education and Training Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC [email protected]

advertising index

Go into your Profile on www.aapc.com and make the change!

Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC [email protected] Katherine Abel, CPC, CPMA, CPC-I, CMRS [email protected]

Advanced Career Solutions, LLC...................17 www.CodingCert.com www.CodingConferences.com

Director of Member Services Danielle Montgomery [email protected]

American Medical Association..................... 40 www.amabookstore.com

Director of Publishing Brad Ericson, MPC, CPC, COSC [email protected]

CaseCoder, LLC.............................................37 www.casecoder.com Coding Institute, LLC.....................................15 www.SuperCoder.com CodingWebU.com.......................................... 46 www.CodingWebU.com Contexo Media...............................................33 www.contexomedia.com HealthcareBusinessOffice, LLC.....................27 www.HealthcareBusinessOffice.com Ingenix is now OptumInsight ,.....................28 part of OptumTM www.optumcoding.com TM

MedAssets........................................................5 www.knowledgesourcepro.com/signup Medicare Learning Network® (MLN)...............8 Official CMS Information for Medicare Fee-For-Service Providers http://www.cms.gov/MLNGenInfo NAMAS/DoctorsManagement.................. 2, 51 www.NAMAS-auditing.com ZHealth Publishing, LLC................................11 www.zhealthpublishing.com

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Directors, Pre-Certification Education and Exams

AAPC Coding Edge

Managing Editor John Verhovshek, MA, CPC [email protected]

Executive Editors

Michelle A. Dick, BS [email protected]



Tina M. Smith, AAS [email protected]

Renee Dustman, BS [email protected]

Production Artists Renee Dustman, BS [email protected]

Advertising/Exhibiting Sales Manager Jamie Zayach, BS [email protected]

Address all inquires, contributions and change of address notices to: Coding Edge PO Box 704004 Salt Lake City, UT 84170 (800) 626-CODE (2633) ©2012 AAPC, Coding Edge. All rights reserved. Reproduction in whole or in part, in any form, without written permission from AAPC is prohibited. Contributions are welcome. Coding Edge is a publication for members of AAPC. Statements of fact or opinion are the responsibility of the authors alone and do not represent an opinion of AAPC, or sponsoring organizations. Current Procedural Terminology (CPT®) is copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein. CPC®, CPC-H®, CPC-P®, CPCOTM, CPMA® and CIRCC® are registered trademarks of AAPC. Volume 23 Number 8

August 1, 2012

Coding Edge (ISSN: 1941-5036) is published monthly by AAPC, 2480 South 3850 West, Suite B, Salt Lake City UT 84120-7208, for its paid members. Periodicals Postage Paid at Salt Lake City UT and at additional mailing office. POSTMASTER: Send address changes to: Coding Edge c/o AAPC, 2480 South 3850 West, Suite B, Salt Lake City UT 84120-7208.

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Letter from the Chairman and CEO

Find AAPC Support as ACA Unfolds

A

s this Coding Edge goes to the printer, the Supreme Court’s decision to uphold the 2010 Patient Protection and Affordable Care Act (ACA) is only a couple of weeks old. Speculation about the ACA’s impact and future continue to fill our airways and hallways. Even though many provisions have already been enacted, most view the ACA the same way a boy regards his first suit: complicated, uncomfortable, and restrictive. Survival of the ACA is up in the air. The Supreme Court’s ruling leaves the future of the act to the voters in November, and allows the Senate to overturn it by simple majority, rather than 60 votes, to prevent a filibuster. By agreeing with the solicitor general’s argument that the individual mandate is a tax only manageable by Congress, the outcome of presidential and congressional elections will determine the ACA’s future beyond January 2013.

What the ACA Means for Health Professionals Coders, billers, auditors, practice managers, and payers are adapting to ACA changes already in effect, such as preventive services at no cost, access to coverage and care for those with chronic or pre-existing conditions, and simpler, standardized information for consumers. Upcoming rules, however, for both physicians and employers still are not fully developed. The day after the Supreme Court decision, the U.S. Department of Health & Human Services (HHS) Secretary Kathleen Sebelius announced new funding opportunities for states implementing ACA’s health information exchanges (HIEs). Other parts of the act on hold while awaiting the Supreme Court’s decision are being jump-started during the ACA’s guaranteed seven months of implementation. Impacts on coding, billing, and practice management from the ACA and other recent events include: • Billing changes resulting from the











• •

new Version 5010 electronic data interchange (EDI) standard, effective last month Changes to coverage and reimbursement as self-paying patients evaporate and insurance rules are changed to meet ACA Additional payment-altering quality management guidelines and reporting Incentive programs to primary care physicians and others based on case mix and specialty that may improve or cut reimbursement Enhanced documentation requirements for new coding, quality, and payment regulations More stringent compliance efforts to meeting additional Health Insurance Portability and Accountability Act (HIPAA) regulation Revised physician reimbursement schedules and rates New Medicaid billing rules

Members, as Always, Adapt with Success AAPC members who code, bill, manage, audit, and adjudicate are no strangers to change and varying regulations. In many cases, it will be AAPC members who will successfully implement the ACA in their workplaces. This is because of members’ knowledge, flexibility, networking, and courage.

Stay Informed AAPC is here to help. AAPC publications, workshops, webinars, online forums, and the expertise of your colleagues at local chapter meetings offer valuable support as the ACA is enacted. We are testifying on our members’ behalf before federal committees and working with lawmakers to assure no changes are made without important input. For example, Rhonda Buckholtz, CPC, CPMA, CPC-I, AAPC’s vice president of

ICD-10 Education and Training, testified in June on how the ICD-10 implementation delay impacts providers and their staffs. AAPC staff, members of the National Advisory Board (NAB), and the AAPC Chapter Association (AAPCCA) Board of Directors are visiting local chapters to help you understand what is happening and how it affects you. We share what we learn and hear from members during our visits with each other and department heads, adjusting our processes, rules, and benefits, so being an AAPC member is always more valuable than the day before. The ACA’s future and impact on health care and our jobs are still to be realized. Coders, billers, auditors, managers, and payers will all see different consequences, but our dedication and professionalism will get us through. AAPC and your member colleagues are there for you. Sincerely,

Reed E. Pew AAPC Chairman and CEO

www.aapc.com

August 2012

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The Medicare Learning Network (MLN) It’s never been easier to understand Medicare Program enrollment, billing and coverage.

As you know, every business day can bring an avalanche of information about new policies, regulations and procedures. The Evaluation and Management Services Guide provides education on medical record documentation, evaluation and management billing and coding considerations. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

R

Evaluation and Management Services Guide

Learn more today.

http://go.cms.gov/EvaluationManagement

R

December 2010 / ICN: 006764

Official CMS Information for Medicare Fee-For-Service Providers

Letter from Member Leadership

Weather the Storm T

he past few years have brought a myriad of changes in health care, many of which have had a direct impact on AAPC members. Among theses changes are health care reform, technological advances in medicine, meaningful use of electronic health records (EHRs), increased federal and state regulations on documentation and coding requirements, and so on. While these changes present challenges for us all, they also provide a wealth of opportunity for those who are prepared, knowledgeable, and not afraid of change (and work).

Credentials Do Matter In addition to the Medicare and Medicaid EHR Incentive Programs, which provide incentive payments to providers able to demonstrate meaningful use of a certified EHR, the American Recovery and Reinvestment Act of 2009 (ARRA) allocated funds for the federal government to wage a battle against health care fraud, waste, and abuse—making complete documentation and accurate coding, as well as regular auditing, an even more important part of every health care entity. As our industry moves forward with electronic data interchange (EDI), the role of medical coders will continue to evolve, as well. Adapting to these changes will require strategic thinking and planning to steer the direction of our career. For many of our members, the EHR will necessitate a change from coding to auditing, which will provide opportunity and incentive for many coders to advance in their careers. To rise to the challenge of entering into the auditing realm, Deborah Grider, former AAPC president and CEO, says it best in her article “CPCs® Branch out into Medical Auditing” (Coding Edge, August 2010): “Coders who seek an auditing position should be experienced in medical coding and hold coding certification.”

Health Care Reform Will Bring New Challenges Coding medical records has always been about payment and the search for statistical outliers that may indicate problems in the billing and payment process. Health care reform and the 2010 Patient Protection and Affordable Care Act (ACA) add components that will require an even more critical review of health insurance claims: risk management and quality reporting management. These two components are intertwined and may involve changes to existing, comfortable provider practices. For example, it will become essential under the proposed structure for providers to submit claims with the most specific diagnosis possible, including a historical health status that doesn’t necessarily impact the current medical condition.

Our Membership Tells the Story There is a correlation between the rigorous process a person must go through to become a credentialed coder and/or auditor, and that person’s success in the field. This holds true for most professional occupations. The evidence of this truth is easy to see when AAPC’s “continued growth expresses the value many physicians and outpatient practices have with our credentialed professionals,” according to Grider in a November 2010 press release. Best Wishes,

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

www.aapc.com

August 2012

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Kudos

Please send your Kudos to: [email protected]

Surge of New Chapters Spread Coding Cheer Thank you new chapters for your hard work and dedication to our field. We congratulate these upcoming chapters: Waterloo, Iowa

Poughkeepsie, N.Y.

Morrilton, Ark.

Orange Park, Fla.

Natchitoches, La. Corona, Calif. Green Valley, Ariz.

Statesville, N.C. Silverdale, Wash. Middletown, N.Y.

Midland, Texas

Grants Pass, Ore.

Selden, N.Y.

Haverhill, Mass.

Mount Juliet, Tenn.

Watertown, Mass.

Northbrook, Ill.

Stockton, Calif.

Petersburg, Va.

Spring Hill, Fla.

Woodhaven, Mich.

Tampa Southeast, Fla.

Chino Hills, Calif.

Pontiac, Mich.

Carson, Calif.

Jackson, Mich.

Blue Bell, Pa.

Letters to the Editor Code 93315, Not 99315 On page 22 of July’s issue, the article “Documentation is Key for TEE and OLV” mistakenly referenced code 93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report as 99315. Dana A. Chock, CPC-A

Advice on Separate E/M and Chiropractic Services I enjoyed your article about E/M coding in the June’s Coding Edge (“Be Aggressive with Same-day E/M and Office Procedure,” pages 14-15). I am a CPC® and a CCPC™, and this issue of evaluation and management (E/M) on the same day as a “minor procedure” is very common for chiropractors. Page F16 of the 2012 ChiroCode Deskbook suggests the following situations qualify as “significant separately identifiable” (or “non-routine,” as it relates to chiropractic manipulative therapy (CMT) codes 9894098942): • Initial evaluation • Periodic reevaluation • Exacerbation or re-injury • Counseling (less than 50 percent face-to-face time) • Release/discharge from active care • Consultation (requested by an appropriate source) When I teach coding seminars to other doctors of chiropractic (DCs), I encourage them to ask if one of these six scenarios applies before they bill an E/M code (and attach modifier 25 Significant, separately identifi10

AAPC Coding Edge

Susan Edwards, Awarded for Excellence Copley Health Systems honored Susan Edwards CPC, CEDC, of Vermont for her excellence during the organization’s annual Employee Awards Banquet. According to a Copley Health Systems’ May 18 press release (http://copleyvt.org/interior.php/pid/67/sid/454/ nid/119): “Susan Edwards of Health Information Management was honored with the Goddard Family Award, an award that recognizes excellence in a non-nursing position. Dr. Silverstein shared how impressed the Medical Staff was with how Sue tackled coding-related education this past year.” Edwards began her career at Copley Hospital in Morrisville, Vt. in 2002 as a medical transcriptionist and later discovered an interest in coding. She is now Copley’s coding specialist, Northeast region one representative for AAPCCA, secretary on the Board of Directors, and a member of the AAPC Ethics Committee.

Please send your letters to the editor to: [email protected] able evaluation and management service by the same physician on the same day of the procedure or other service) during a visit where other services are rendered. I think that this can apply in other specialties, as well. I have not been able to find any Centers for Medicare & Medicaid Services (CMS) or American Medical Association (AMA) guidelines that are this specific, but this general approach may be useful for your readers. Evan M. Gwilliam, DC, CPC, CCPC, NCICS, CCCPC

Clarification: Medicare Covers Spinal Manipulation Only for Chiropractors “Document Chiropractic Group and Individual Therapy Differences” (July 2012, pages 36-39) reviewed Medicare documentation and coding requirements for individual and group therapy codes. Although insurers may follow the Centers for Medicare & Medicaid Services (CMS) guidelines for documenting and coding therapy services, Medicare will not cover therapy services provided by a chiropractor. Chapter 15, section 30.5 of the Medicare Benefit Policy Manual states that coverage of chiropractor’s services “extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. All other services furnished or ordered by chiropractors are not covered.” CPT® 98940-98942 Chiropractic manipulative treatment (CMT) ... are the only codes covered by Medicare, when properly billed by a chiropractor and supported by documentation; therapy codes, therapeutic activities, and self-care training are not. For more information, see “Medicare Outpatient Therapy Billing” on the CMS website at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/Medicare_Outpatient_Therapy_Billing_ICN903663.pdf.

Quick Tips

By G.J. Verhovshek, MA, CPC

Morton’s neuroma (355.6 Lesion of plantar nerve)—also called Morton’s metatarsalgia or Morton’s neuralgia—is a benign growth of fibrous tissue occurring on the plantar nerve, most commonly between the third and fourth toes. Symptoms may include burning, numbness, tingling, and shooting pains. Many patients describe the feeling as “having a pebble in my shoe.” The condition may develop from injuries or excess pressure (such as from tight-fitting shoes). Treatment for Morton’s neuroma commonly involves corticosteroid injections into the affected tissue for pain relief. Report these injections using CPT® 64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton’s neuroma). Less frequently, the physician may employ a neurolytic agent to destroy the plantar nerve. Injections of this type are reported using 64632 Destruction by neurolytic agent; plantar common digital nerve. Report either 64455 or 64632 only once per foot, regardless of the number of injections. Both codes are unilateral, however, so you may append modifier 50 Bilateral procedure to either code if the physician injects the plantar nerve on both feet.

Never report 64455 and 64632 together for the same foot. Per CPT® Assistant, January 2009, “Because the treatment therapies described by codes 64455 and 64632 are distinctly different, it would not be appropriate to report codes 64455 and 64632 for each of these therapies at the same session.” CPT® now bundles fluoroscopic guidance for needle placement with many injection procedures (for example, 64479-64484 and 6463364636). This is not the case for 64455 and 64632, however. You may separately report 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) for fluoroscopic guidance when provided and properly documented. Report the guidance code only once per session, regardless of the number of injections. Append modifier 26 Professional component for services in the facility setting, or if the physician performing the guidance does not own the equipment. In some cases, surgical excision may be necessary to remove the neuroma. This is reported with CPT® 28080 Excision, interdigital (Morton) neuroma, single, each. Per the code descriptor, you may report one unit of 28080 for each neuroma excised.

photo by iStockphoto©EKenneth C. Zirkel

Stand Up for Correct Morton’s Neuroma Coding

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

By Susan M. Edwards, CPC, CEDC

Premenstrual dysphoric disorder (PMDD) is the current term for what previously was known as premenstrual tension syndrome, or premenstrual syndrome (PMS). Premenstrual dysphoric disorder affects 3-5 percent of menstruating women, and is characterized by severe mood and physical symptoms around a woman’s menstrual cycle. Until 2012, PMDD was not referenced in the ICD-9-CM code book. PMDD is now an inclusion term to code 625.4, as follows: 625.4 Premenstrual tension syndromes Menstrual molimen Premenstrual dysphoric disorder Premenstrual syndrome Premenstrual tension NOS The acronym PMDD is directly referenced in the alphabetic index. This update makes it clear that premenstrual tension syndrome and PMDD are related conditions coded the same; however, PMDD is technically more severe than PMS, with symptoms that can be debilitating. The mood symptoms of PMDD predominate and can cause social impairment. According to the Mayo Clinic, PMDD symptoms occur during the week or two before the menstrual period and remit soon after the onset of the menstrual period. Most sources agree that at least five or more specified symptoms must be present most of the time during each symptomatic phase. These symptoms include: 12

AAPC Coding Edge

• • • •

Depressed mood Mood swings Irritability Decreased interest in usual activities • Difficulty concentrating • Lack of energy • Marked change in appetite • Insomnia or hypersomnia • Feeling overwhelmed • Physical symptoms, such as breast tenderness or bloating • Tension • Food cravings Physicians now have a simple screening tool to help women identify whether they are suffering from PMS or PMDD. Susan M. Edwards, CPC, CEDC, works at Copley Hospital in Morrisville, Vt. She is a member of the AAPC Chapter Association (AAPCCA) Board of Directors, Northeast Region 1, and is AAPC Newport, Vt. local chapter president.

photo by iStockphoto©Erik Reis

Know Symptoms and Code for Premenstrual Dysphoric Disorder

Coding News Update Your esMD Processing Expect Tighter Controls The Centers for Medicare & Medicaid Services (CMS) instructs for Diabetic Supply Claims

review contractors in transmittal 426 on the process for handling late esMD. When a provider has failed to submit a response to an Additional Documentation Request (ADR) letter by the deadline, CMS says, Medicare administrative contractors (MACs) should use the esMD content transport services (CTS) receipt date as the date the documentation was received. If the CTS receipt date is outside the contractor’s normal business hours, the following business day may be used as the receipt date. See CMS transmittal 42 for more information: www.cms.gov/ Regulations-and-Guidance/Guidance/Transmittals/Downloads/R426PI.pdf.

URL Change for OIG’s Compliance Guidelines The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) is updating its website reference in Pub. 100-08 Medicare Program Integrity, section 1.3.9 for accessing compliance program guidelines and statistical sampling. OIG compliance program guidelines and statistical sampling can be found on the OIG website at http://oig.hhs.gov/authorities/docs/selfdisclosure.pdf.

As a result of an OIG June 2012 report, expect increased scrutiny of high utilization claims for test strips and lancets. The OIG estimates contractors overpaid as much as $271 million for these types of claims in 2007. Medicare Part B covers home blood-glucose test strips and lancet that physicians prescribe for their diabetic patients. The National Coverage Determination (NCD) does not specify utilization guidelines and documentation requirements; however, Local Coverage Determinations (LCDs) for the four durable medical equipment Medicare administrative contractors (DME MACs) reviewed by the OIG indicate coverage for up to 100 test strips and 100 lancets every month for insulin-treated diabetics, and 100 test strips and 100 lancets every three months for non-insulin-treated diabetics. Medicare considers 50 test strips as 1 unit and 100 lancets as 1 unit, so a standard claim for a patient’s monthly (or three-month) allotment of these supplies would be two units of A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips and 1 unit of A4259 Lancets, per box of 100. For complete details of the OIG review, see the June 2012 report, available at: http://oig.hhs.gov/oas/reports/region9/91102027.pdf.

AAPC REGIONAL CONFERENCE CHICAGO | OCT. 25-27, 2012 Early Bird Registration Extended Through Aug. 24

CHICAGO 2012 AAPC REGIONAL CONFERENCE

CHICAGO HYATT REGENCY Come join us in Chicago! 3-Days | 14 CEUs | $350 $325 www.aapc.com/2012regional Through Aug. 24

www.aapc.com

August 2012

13

AAPC Chapter Association

By Susan Edwards, CPC, CEDC

Help! I Need Chapter Meeting Speakers When you’ve exhausted your speaker pool, here’s where to look.

F

inding speakers is a common problem many AAPC chapters face, but it isn’t because of a lack of candidates. There are many speakers available to you, if you know where to look. In the medical field, almost anyone can be a resource and most people are willing to share what they know, if you just ask. As an education officer for my local chapter, I began my search for speakers with coworkers. When I asked a coworker to consider speaking at a chapter meeting, the initial reaction was almost always the same: “I don’t know anything about teaching coding,” my coworker would reply. Once I explained what I was looking for in a speaker, however, I wasn’t turned down. I would explain that our chapter doesn’t need to hear what he or she knows about coding, we’d just like to know more about his or her job. Learning about other health care jobs allows us to be better coders; and hearing how other medical professionals perform procedures, and the techniques they use, helps us understand the process more clearly and assign codes more accurately.

Tap into Your Professional Resources In beginning your search for speakers, use resources around you and near your facility. Don’t limit yourself to only physicians; reach out to other professionals. For example: • Nurse practitioners and physician assistants • Diabetic and nutritional counselors • Respiratory therapists • Radiology technicians

• • • • • • • • •

• • • •

Wellness nurses Compliance officers Local insurance carriers Medical librarians Local colleges Professional Medical Coding Curriculum (PMCC) instructors State departments of banking and insurance officials County or state department of health administrators and professionals Medicare carriers’ provider training and events centers (or your area provider) Regulatory agencies like the FBI or your Medicare fraud unit Associations for supporting patients and families dealing with diseases Your hospital speakers’ bureau Manufacturers of medical products, materials, and drugs

Look to Coders and AAPC Don’t forget to look to your fellow coders. They’re great resources as speakers and they are right next to you. Your regional representatives from AAPC boards, the National Advisory Board (NAB), and AAPCCA Chapter Association (AAPCCA) may be available to visit local chapter meetings. Official visits are arranged through the Local Chapter Department and must be prescheduled. When possible, board members make every effort to meet the needs of our local chapters. Another option for obtaining speakers is from your own membership. Chapter members can be creative, bringing variety to your

Don’t limit yourself to only physicians; reach out to other professionals. 14

AAPC Coding Edge

meetings. This, in turn, will help the speaker feel more connected to his or her chapter.

Have Fun with Open Discussions or Games Instead of finding a speaker, consider a Code-A-Round. Ask your members to bring the most difficult or confusing cases they have come across and conduct an open discussion. Remember: All identifying patient information must be left out. Games are another great way to add friendly competition and excitement to a chapter meeting. Games to consider include Coding Jeopardy, “Who Wants to Be a Millionaire?” Coding Bingo, Coder’s Feud, etc. More game suggestions can be found by searching the AAPC Chapter Officer forum at www.aapc.com.

Our Website Is Full of Topics and Presentations AAPC’s website and forums can be a meeting topic in itself. A chapter officer can provide a demonstration on where and how to find information online. Have an instructional meeting on using the forums. Under the Chapter Resources tab, your officers can also find PowerPoint presentations with audio recordings to use for your local chapter meetings. Look around you. If you think outside of the coders’ circle, you may be pleasantly surprised at the ideas you come up with. Susan Edwards, CPC, CEDC, is a coding specialist at Copley Hospital in Morrisville, Vt. She is the president of the Newport, Vt. chapter, and teaches medical terminology at a local adult learning center. Ms. Edwards is Northeast Region One representative for AAPCCA, and secretary on the Board of Directors. She is also on the AAPC Ethics Committee.

AAPCCA Handbook Corner

By Erin Andersen, CPC, CHC

photo by iStockphoto©UmbertoPantalone

Are Smartphones OK to Bring into an Exam? There has been discussion recently about whether smartphones should be allowed into an AAPC credentialing examination because it may increase opportunities for cheating or distraction. AAPC feels it is important for test takers to have access to phones in case of emergency. We trust coders and coders-to-be are ethical and would not actively seek ways to cheat or to intentionally disrupt others during the exam. Hearing “Ding Dong! The Witch Is Dead” when your mother-in-law calls during a test, (albeit amusing) may break someone’s concentration. The proctoring instructions, referred to in the Local Chapter Handbook, allow “cell phones” to be brought into credentialing exams, but they need to be turned off and stowed away. The guidelines then state, “electronic devices capable of storing and retrieving texts, audio-books, etc. may not be brought into the examination room.” This rule was written prior to advancements in cell phone technology (such as smartphones, which are capable of data storage). The Examination Department has since voiced their

intention to update the rule to allow smartphones into an examination room, but they must be turned off and stowed away. If you are uncertain whether you may bring a particular item with you to an exam, or if you have any other questions about the exam or exam etiquette, please contact the Examination or Local Chapter Departments at AAPC.

We trust that coders and coders-to-be are ethical and would not actively seek ways to cheat or to intentionally disrupt others during the exam.

Be it breaking news from Part B Insider or essential compliance tools like Fee Schedules, LCDs CCI Edits Checker, and more, Part B Coder provides everything you need to ensure your Part B coding’s profitable and on track!

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August 2012

15

Hot Topic

By Jacqueline Nash Bloink, MBA, CPC-I, CHC

Create Order from Wellness Visit Chaos Let your patients know what to expect from these visits.

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he Centers for Medicare & Medicaid Services (CMS) has begun a campaign to educate Medicare beneficiaries about preventive services, including wellness visits, available to them. There is even a YouTube clip to promote these visits. If CMS believes these visits are such a great service for the beneficiary, why do so many physicians cringe when they hear an appointment has been scheduled for such a service?

Takeaways: • • •

CMS has many educational resources available to physician offices to assist with explaining wellness visits to patients, including a downloadable patient brochure, found at: www.cms.gov/Outreach-and-Education/Medi​

Manage Patient Expectations Beneficiaries often expect a head to toe examination during the wellness visit, but this is not what it delivers. Office staff must begin to educate the beneficiary that the wellness visit is a plan of care. When the beneficiary understands the wellness visit was created to take a snap shot of his or her current health status, and the physician won’t be performing a physical examination, the situation will be better controlled—meaning fewer angry beneficiaries and more physicians willing to perform the service. Staff should also inform beneficiaries they will not incur a co-pay for a wellness visit, but if another service is provided during the visit, there will be a co-pay for that portion of the visit.

care-Learning-Network-MLN/MLNProducts/down​ loads/Annual_Wellness_Visit.pdf.

Three Visit Types, Three Sets of Requirements

photo by iStockphoto©Patrick Heagney

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AAPC Coding Edge

Wellness visits are a plan of care rather than a head-to-toe exam. There are three visit types with three sets of requirements. Ease visit for both providers and patients by developing a template for documentation.

There are three types of wellness visits, each of which has different requirements. 1. G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment describes the “welcome to Medicare preventive visit.” The beneficiary can only receive this visit during the first year that he or she is eligible and enrolled in Medicare. If the patient does not exercise his or her right to request this visit during that first year, he or she will never again have the chance to request it. During this visit, the beneficiary is eligible for a screening electrocardiograph (EKG) (G0403-G0405) and aortic aneurism ultrasound (AAU), if he or she meets the following requirements: • Patients may be eligible for the screening EKG if a referral is given during the welcome to Medicare preventive visit (G0402). • AAU is provided as a one-time screening if the beneficiary gets a referral as a result of the welcome to Medicare preventive visit (G0402). Eligible patients are those who either have a family history of abdominal

aortic aneurysm or if the patient is male, aged 65-75, who has smoked at least 100 cigarettes during his lifetime, and the patient has never had an AAU paid for by Medicare during his or her lifetime. For more detail on the EKG and AAU screenings, visit the CMS website: www. medicare.gov/navigation/manage-your-health/pre​ ventive-services/preventive-service-overview.aspx).

2. After 11 full months have passed, the beneficiary is eligible for the next wellness visit. G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit describes the “initial Medicare wellness visit.” This visit can be performed at any point in the beneficiary’s life, but only once during his or her lifetime. This code was implemented by CMS in 2011. 3. After 11 full months have passed since the initial wellness visit, the beneficiary is eligible for the “subsequent” wellness visit (G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit). A beneficiary can request this visit every year (after 11 full months have passed between visits), if so desired. You can find a summary of the requirements of all Medicare wellness visits on the CMS website: www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/ downloads//MPS_QuickReferenceChart_1.pdf.

Create a Template to Make Documentation Easy If the physician’s office combined all of the components of each of the three visits together to create one master template, as shown in Example A, the beneficiary would get a few extra benefits each year, while making things easier for the physician. Items in red represent the services the physician provided during the visit that may have not been needed during that particular visit, but were required in one of the other visits. If all 10 steps are performed during the

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Example A:

10 Easy Steps to Document Medicare Wellness Visits 1. Patient completes the required “Health Risk Assessment Questionnaire” prior to the visit with the physician (this is new for 2012). Guidelines for creating a form with all of the necessary components can be found at the Centers for Disease Control and Prevention (CDC) website: http://prevent.org/data/files/news/ healthriskas​sessmentscdcfinal.pdf. 2. Office staff documents the patient’s height, weight, blood pressure, body mass index (BMI), and visual acuity. 3. Patient’s medical history, family history, and social history are discussed and documented. Special attention is paid to past illnesses, surgeries, allergies, and injuries. Family history is pertinent with hopes of catching high-risk areas that may be modifiable or identified with special screening tools. The social history will be helpful in documentation of substance abuse such as smoking or alcohol. 4. Patient is queried about current or past events of depression. Make sure to list the type of depression tool used to determine the risk. Examples of such tools might include PQ1, PQ2, or Zing. 5. List all current medications, including vitamin supplements. 6. List all current providers and suppliers that the patient is seeing (specialists, diabetic suppliers, etc.). 7. Assessment of functional ability and safety: This must include: • Hearing • Daily living activities • Risk of falling • Safety/home life/risks 8. Cognitive impairment assessment and observation. Information may also be obtained from the patient’s family, caregivers, or friends. 9. End-of-life planning and advance directives. Does the physician agree with this plan? 10. Written plan of preventive services that the patient is eligible for the next one to 10 years. The patient takes this plan when he or she leaves the office.

Hot Topic

Beneficiaries often expect a head to toe examination during the wellness visit, but this is not what it delivers. G0402, G0439, or G0438 visit, the provider does need to stop and think which component he or she is missing, making life much easier for both physician and patient. By following a template for documenting wellness visits, the staff becomes familiar with the steps, and patients become accustomed to the questions and are prepared to answer them each year. The health care team at the office (medical assistant, licensed practical nurse, or registered nurse) may be able to assist the health care professional (nurse practitioner or physician assistant) in obtaining 75 percent of the information prior to the physician entering the room to talk with the patient. Each year,

the physician will have a written description of the beneficiary’s lifestyle and will be better prepared to address various risks that the patient may face as he or she ages. With the wellness visit well-documented, all that remains is scheduling next year’s wellness visit (remember: at least 11 full months after this visit). Jacqueline Nash Bloink, MBA, CPC-I, CHC, lives in Tucson, Ariz. and is director of compliance for Arizona Community Physicians.

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August 2012

17

Feature

By Serine A. Haugsness, CPC

Strengthen Your Diagnosis Coding for Risk Adjustment Do it for more accurate coding; do it for better patient care.

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he concept of risk adjustment was “born” upon passage of the Balanced Budget Act of 1997 and refined by the Beneficiary Improvement Act of 2000, which mandated that the Centers for Medicare & Medicaid Services (CMS) implement risk adjustment for Medicare Advantage organizations (MAOs) in 2004 and achieve 100 percent risk-adjusted payments by 2007. To achieve this, CMS uses the CMS-Hierarchical Condition Category (HCC) model. Risk adjustment has also been adopted by a number of states using other models, such as the Chronic Illness Disability Payment System (CDPS), Episode Risk Groups (ERGs), Diagnostic Cost Group (DCG), and others—mainly because state populations are more diverse than the rather narrow group of Medicareeligible patients.

Why Should a Coder Care About Risk Adjustment? CMS requires accurate and complete diagnosis coding, and for all coding to be done in accordance with official guidelines and CMS regulations. If that’s not a good enough reason, think of your patients. Great documentation and accurate diagnosis data provides information for care management activities, trends in chronic illness among populations, and increased communication among specialists treating the same patient. Conversely, poor documentation and diagnosis coding can lead to missed diagnoses (and lack of treatment), poor communication among treating physicians (leading to duplicate or contradictory treatment), and even incorrect diagnoses (like coding a “rule-out” as a confirmed 18

AAPC Coding Edge

Takeaways: • The CMS-HCC Risk Adjustment Model requires all providers to submit accurate and complete diagnoses. • Accurate diagnosis coding is important for disease monitoring and tracking, as well as risk adjustment. • Teaching your providers to document fully and clearly will assist in the transition to ICD-10-CM.

condition). Incorrect diagnoses can follow a patient for the rest of his or her life and potentially exclude him or her from obtaining life or health insurance in the future.

How Can a Coder Keep Risk Adjustment Models Straight? Here’s the best news: You don’t have to! Coding supports all risk adjustment models while documentation and guidelines support coding; but because payment generally revolves around CPT® and HCPCS Level II coding, ICD-9-CM coding tends to be put on the back burner. CMS recognizes this and encourages MAOs to educate coders, physicians, and facilities about the need for correct and complete diagnosis information. Here’s more good news: Becoming a better diagnosis coder NOW will help you in the transition to ICD-10-CM. The ICD-10CM guidelines are similar to those for ICD9-CM, so take advantage of the one-year delay to become a great diagnosis coder. Here’s how: 1. Read the Official ICD-9-CM Guidelines for Coding and Reporting.

2. Skip the cheat sheets. Use the alphabetic index AND tabular listing every time (even if you THINK you know the code), and follow all of the listed rules. 3. If you need clarification, go to the American Hospital Association’s AHA Coding Clinic for ICD-9-CM. 4. Learn or brush up on anatomy and physiology (A&P) to help you understand when something doesn’t make sense for the condition you’re coding. This will also help you determine when you need to ask the physician to provide more clarity about the condition.

How Can Coders Help Providers Document Dx Better? Providers who document well are a coder’s dream. Here are some things you can do to make that dream come true:  Make sure all of the required technical elements are present in every progress note. If required elements are not present, the auditor doesn’t have to go any further and can fail the note on a technicality. Required elements include: • A legible signature with credentials • Patient name on each page • Date of service is evident • Note is complete and legible (meaning someone coming in and auditing this note would not have to ask questions). You don’t want to fail an audit because the note cannot be deciphered.

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Feature

Becoming a better diagnosis coder now will help you in the transition to ICD-10-CM.

 Print out a few progress notes from your electronic health record (EHR). In many cases, the note you see when you’re coding from the EHR is not the same as the note the auditor sees printed out from your EHR. Audit some notes from the printed version or whatever version you provide to those who request medical records. Look for contradictory information and laundry lists of codes dating back to when the patient was in utero not supported in the documentation on that date of service. Use that information to provide feedback to physicians, managers, compliance officers, or whoever else might need to know in your organization.  Stress descriptive documentation. The Official ICD-9-CM Guidelines for Coding and Reporting, section IV.K, instructs, “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.” Remind physicians that simply listing a condition in the progress note is not necessarily sufficient to support that the condition is current. The progress note must support the diagnoses by showing evidence they were monitored, addressed, assessed, treated, or evaluated. Providing this information not only allows you to capture the diagnosis codes, it can help support medical necessity by showing what, how, and why the listed conditions affected the provider’s medical decision-making during that encounter. Pay attention also to generic diagnoses such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF),

Teach providers to document the timing of the disease process clearly so there is no question as to whether it is historical or current.

pain, and others. Providers are creatures of habit and may default to a generic diagnosis when a more descriptive diagnosis may be more appropriate.  Introduce providers to the golden rule: “Document for others what you would have them document for you.” Remember that every patient they see has probably been seen by another provider at some point and will probably see another provider some time in the future. Just like receiving good documentation with a solid history from the patient’s previous provider is helpful in diagnosing and treating the patient now, their good documentation will help another provider give great patient care in the future.  History versus current condition. When a physician documents “history of,” he or she might mean a condition that is chronic and is being treated, but causing no symptoms. Unfortunately, “history of” to a coder (and an auditor) means the condition no longer exists. On the other end of the spectrum, many providers will document “breast cancer” to describe a patient who had a mastectomy in 1979 and has had no evidence of recurrence. It would be incorrect to code 174.9 Malignant neoplasm of breast (female), unspecified because there is no evidence of current disease.

 Rule-outs are dangerous! Ruleouts, probable, or possible diagnoses are not to be coded per outpatient rules. To avoid confusion and give coders something to code, providers should document the symptoms or reason the test is being ordered.  Remind your providers that CODERS MAY NEVER ASSUME. Everything coded needs to be spelled out and supported in the progress note for that date of service. Just because the provider knows the patient has a leg ulcer and that leg ulcer was caused by diabetes does not mean the coder can code it. Causality must be documented clearly in every note on every date of service (for example: “diabetic ulcer on the patient’s right heel”).  Give positive feedback when providers get it right! Providers tend to be high achievers. They are often motivated to provide excellent patient care by making their records complete and meaningful. We all like to receive credit for a job well done.

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Serine A. Haugsness, CPC, is a coding analyst at Buckeye Community Health Plan, with risk adjustment and coding education as a primary responsibility. She holds an associate degree in medical billing and coding and has over 11 years of health care experience. Serine is pursuing a bachelor’s degree in health care management.

August 2012

19

Feature

By Erin Andersen, CPC, CHC

Coding from EHRs: It’s Documented, but Did It Happen? Help providers document appropriately by showing the pitfalls of EHR documentation habits.

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he age of electronic health records (EHRs) has begun. The days of deciphering illegible chicken scratches, cajoling busy physicians to write more than 10 words, and extensive searches for missing charts will one day be extinct. The EHR allows coders to work from home, promises a more complete record, timesaving templates and legible notes, and offers hope for better communication between health care providers. But EHRs bring their own coding and compliance risks. These include: ƒƒ Using entries from another person or source (such as another provider, resident, or student) as their own documentation. ƒƒ Using documentation from a previous visit to document a current visit. ƒƒ Using templates that may not represent what happened at the current visit. ƒƒ Misrepresenting the nature of the visit by carrying forward past clinical data that does not apply to the current visit.

Look for Telltale Signs in the Chart How do coders know when these things are occurring? A progress note should be an accurate reflection of what occurred at the current visit. Although you were not present in the room with the patient and provider to know what happened, you can look for certain signs when reading chart notes. Examples include: ƒƒ Established outpatient or subsequent hospital visit documentation that includes one or more of the following: àà Long and detailed history of present illness (HPI) àà Past medical, family, and social history (PFSH) àà Allergies àà Medication list àà Comprehensive review of systems (ROS), either as a detailed table or “otherwise negative” àà Conflicting information (i.e., “Patient reports SOB” in HPI, with “Resp: No SOB” in ROS.) àà Same exam as previous visit(s), or same for every patient, every visit 20

AAPC Coding Edge

Takeaways: • • • •

EHRs raise several new compliance issues. Look for certain signs of misuse of EHRs in documentation. Sit with your provider. Get more information and use the meeting to educate the physician on proper documentation. It’s documented, but did it happen?

àà Labs and/or radiology from weeks/months/years prior to visit àà Same assessment and plan as previous visit(s) àà Same amount of time documented as previous visit(s), or for every patient, every visit ƒƒ Initial hospital visit (e.g., admits, history, and physicals (H&Ps), consults) documentation is or has: àà Abnormally long, given the usual documentation habits of the provider àà A comprehensive history documented for a patient that is well known to the provider àà A comprehensive history and exam stated as having spent 10-20 minutes with the patient, given that over half was spent in counseling or coordination of care ƒƒ Procedure documentation is or has: àà The same documentation for every patient, every time it is performed àà Conflicting information

Approach Providers Tactfully Now that you have identified certain providers who show these signs, how do you approach them in a way that does not offend them? Try these seven tactics: 1. Set up a time to meet with the provider in person. Talking with a provider about his or her documentation can be a touchy subject, and nonverbal cues are essential for avoiding confusion and misunderstandings. 2. Be prepared with examples of the provider’s documentation illustrating your areas of concern. Have supporting guidelines on hand to show the provider. 3. Offer positive feedback first. What does the provider do

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Feature

Although you were not present in the room with the patient and provider to know what happened, you can look for certain signs when reading chart notes.

well? This sets an optimistic tone that will be the spoonful of sugar needed when you begin recommending changes. 4. Ask questions before you request changes. Get all the facts first to confirm your assumptions about what you are seeing. Perhaps this provider does ask about social history at each visit because the patient’s medication requires the patient to abstain from alcohol. You shouldn’t assume it was not asked. Here are some specific questions you may wish to ask the provider: ƒƒ When you are seeing an established patient, do you discuss the patient’s PFSH at each visit? ƒƒ I see that you have a detailed ROS table in all of your chart notes. Are each of the questions asked for each system or is it part of your template? ƒƒ It looks like you always spend 25 minutes with each of your clinic patients. Is that an approximation of the time you spend? How do you count your time? ƒƒ When one of your patients is admitted to the hospital, do you re-obtain the history that is documented? ƒƒ I see you often bring the last five lab results into your notes. Are you discussing these results with the patient at the visit or do you bring them into the note for historical purposes? 5. Acknowledge, explain, suggest. Let the provider know you have listened. Explain why you are asking for a change to get his or her buy-in. Because most of us do not like to be told what to do, offer suggestions or recommendations rather than demanding a change. It is a gentler, more effective way to bring about compliance with your request. Suggestions to begin the conversation include: ƒƒ “I hear what you are saying about wanting to have a complete snapshot of the patient’s history in your chart note so you only need to look back at your last visit for all the needed information. It is fine to bring all of that information into your note but, as a coder, I need to be able to identify what happened at today’s visit, so I can determine the appropriate level of service. What if you were to label the historical data as ‘Previously Obtained?’” ƒƒ “When you are determining the amount of time you spend with your patients, you look at when your clinic started and

ended and divide the time by the number of patients. In looking at your clinic schedule, I can see that you are very busy and I’m sure it is difficult to determine how much time you spend with each individual patient. In coding, we may only bill for the time you spend face-to-face with the patient. Knowing this, what do you think is the best way for you to count your time more accurately? Some providers I’ve talked with like to print a copy of their schedule so they can note enter and exit times on it. Would that work for you?” 6. Overcome objections. Listen very carefully to what the provider has told you. What is important to this provider? Timesaving documentation techniques? Billing at a higher level? Better patient care? Knowing your provider’s agenda is essential to dissolving his or her objections. Here are some questions and suggestions to keep the conversation moving in a positive direction: ƒƒ “It sounds like adding ‘Previously Obtained’ to your notes each time would be too time-consuming to do for each patient visit. What if I were to create a template for you that already had everything labeled this way?” ƒƒ “In listening to you talk about your patients, it sounds like you might be grossly underestimating the time you spend with some of them. Because you are basing your level of service on the time you document, you might be underbilling for some of the patients. It sounds like it would be worth an extra moment of your time to note your enter and exit time so you can be accurately paid for your time.” 7. Thank the provider for his or her time. Providers are very busy and it is important to honor his or her participation in the meeting. EHRs are a great tool in improving documentation when used responsibly. Most providers want to document appropriately, but may not realize the pitfalls of certain documentation habits. Prior to EHRs, the old coder saying was, “If it wasn’t documented, it didn’t happen.” Now, we must ask, “It’s documented, but did it happen?” Erin Andersen, CPC, CHC, has worked in coding and compliance since 2003 at Oregon Health & Science University performing chart audits and educating providers, coders, and staff about coding and billing. Ms. Andersen is the education officer in the Rose City chapter in Portland, Ore. and she is one of the Region 8 representatives on the AAPCCA Board of Directors.

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August 2012

21

Facility

By Sarah Todt, RN, CPC, CPMA, CEDC

Bedside Ultrasounds:

Take a Closer Look

As handheld devices become more readily available, it’s important to know the procedure codes.

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ltrasound technology has evolved with recent changes allowing for these diagnostic studies to be performed at the patient’s bedside. The machines are more portable and affordable than ever, which has led to increased use of services. Many residency programs require training in the performance and interpretation of bedside ultrasounds. Ultrasound services are not limited to radiologists, but may be performed by other specialties, such as emergency physicians and anesthesiologists.

Bedside Ultrasound Defined Ultrasound is a medical imaging technique using high frequency sound waves and their echoes to create an image for evaluation. Providers may use ultrasound to evaluate the patient for a condition or to assist with a procedure. CPT® codes related to ultrasound are found in the radiology section. The codes are identified by the anatomical location evaluated, or by the diagnostic procedure performed with the assistance of ultrasound. The anatomical codes are further delineated by the detail amount of the study (complete or limited). A “complete” study represents an attempt to view and evaluate all of the major structures in an anatomical location. For example, a complete abdominal ultrasound (76700 Ultrasound, abdominal, real time with image documentation; complete) would include evaluation of all the major abdominal organs, including the liver, gall bladder, bile duct, spleen, pancreas, kidneys, and major vessels, in addition to any abnormality. A “limited” study represents a directed evaluation of one or more organs for a suspected condition. For example, a provider performs a limited abdominal study to assess the presence of gallstones. This service would be reported with CPT® code 76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow up). If a limited ultrasound is performed on an anatomical location for which there is no CPT® code for a limited study, the complete study may be reported with modifier 52 Reduced services to indicate the reduced service. For example, there is no limited study code equivalent of 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal. To report such a limited study, you would claim 76817-52.

22

AAPC Coding Edge

Takeaways: • • •

Ultrasound is performed more frequently at the patient’s bedside for guidance or diagnoses. CPT® codes reflect complete and limited ultrasounds. Include anatomical locations and medical necessity for the imaging in documentation.

Bedside Ultrasound Indications Bedside ultrasound may be used in support of another procedure. For instance, ultrasound guidance is frequently used for needle placement and vascular access. Ultrasound guidance used for needle placement for procedures, such as needle biopsy or aspiration or injections, would be reported with CPT® 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. The ultrasound is used to aid localization with a needle. Ultrasound guidance for central venous line placement would be reported with +76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). Ultrasound guidance codes should be reported in addition to the primary procedure. For example, a provider uses ultrasound guidance to place a subclavian central venous line. The central line would be reported 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older, with +76937. Bedside ultrasound may also be used to evaluate soft tissue for diagnostic purposes. The codes for these ultrasounds depend on the location of what is being evaluated. • Evaluation of an extremity (i.e., arm including axilla or leg (non-vascular)) would be reported with 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific. • Evaluation of soft tissue of the neck would be reported with 76536 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation. • Chest wall and upper back would be reported with 76604

Facility

Ultrasound, chest (includes mediastinum), real time with image documentation. • Lower back and abdominal wall would be reported with 76705. • Soft tissue areas of the lower abdomen, pelvis, and buttocks would be reported with 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles). Bedside ultrasounds are also used for diagnostic evaluations. In the emergency department (ED), providers may perform a Focused Assessment Sonogram for Trauma (FAST) exam to evaluate for traumatic injuries. FAST generally represents two distinct ultrasounds: a limited transthoracic echocardiogram (CPT® 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study) as well as a limited abdominal ultrasound (76705). Documentation requirements must be met for both services to report them. There are many more indications for bedside ultrasounds for diagnostic purposes. Retroperitoneal ultrasound (76775 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited) would be used when evaluating for abdominal aortic aneurysm or for renal disease. Limited abdominal ultrasound (76705) may be used for the evaluation of biliary tract disease or other abdominal pathology.

Pelvic Ultrasound Depends on Pregnancy Status Female pelvic and transvaginal ultrasounds code selection depends on whether the patient is known to be pregnant prior to the test. A limited pelvic ultrasound is reported with 76857 if the patient is not known to be pregnant prior to the study. If the patient is known to be pregnant prior to the study, 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses should be reported. The transvaginal ultrasound codes for non-pregnant (76830 Ultrasound, transvaginal) and pregnant (76817) uterus do not have a selection for limited study. If you must report a limited study of this

photo by iStockphoto©zilli

Bedside ultrasound may be used in support of another procedure. For instance, ultrasound guidance is frequently used for needle placement and vascular access.

type, append modifier 52 to either 76830 or 76817, as appropriate. For example, a provider performs a limited transvaginal ultrasound to assess for possible tubal pregnancy. You would report this service with 76817-52.

Required Documentation Bedside ultrasound documentation should include the anatomical location evaluated, and the reason for the test to show medical necessity. The interpretation and report with findings should be recorded in the patient’s record. The record should include an impression and who performed the test. There is also a requirement of image retention. The image may be placed in the chart or stored in a retrievable location. Ultrasound has become a useful modality in patient care and gives providers a powerful tool to aid in diagnoses and treatments. Be aware of the many types of ultrasounds and their documentation requirements. As technology advances and these handheld devices are more readily available, more of these services will be provided. Sarah Todt, RN, CPC, CPMA, CEDC, is the director of Provider Education and Audit at LogixHealth, an ED-specialized provider of coding, billing, and end-to-end revenue cycle services for hospitals, office-based practices, and EDs nationwide. Ms. Todt specializes in emergency medicine and critical care. She has served on the AAPC National Advisory Board (NAB) and the ED specialty exam steering committee, and she presents on ED reimbursement topics.

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August 2012

23

Feature

By Holly J. Cassano, CPC

Factor HCC with a Two-pronged

Approach to Risk Adjustment

Don’t lose money due to under-reported HCC codes.

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roper hierarchal condition category (HCC) classification depends on a plan’s ability to obtain accurate diagnostic HCC information and report that information accurately to the Centers for Medicare & Medicaid Services (CMS).

If a plan focuses solely on disease management to decrease costs (neglecting to develop an effective HCC strategy), it runs the risk of losing money due to under-reported HCC codes. Although the plan may still save $150$250 per member, it will be deficient if it does not factor HCC coding into its business model and work aggressively on a two-pronged approach that incorporates both prospective and retrospective HCC capture.

Prong No. 1: Retrospective A plan generally relies on algorithms (risk adjustment software) to search for unreported diagnosis codes via chart reviews. A plan’s coding staff, or a third-party vendor contracted by the plan, extracts large numbers of charts from network physician offices to capture chronic disease processes. After review, any previously unreported codes are submitted to CMS.

Prong No. 2: Prospective Plans provide ongoing education to assist physicians in the process of developing a complete and accurate member profile that resonates with all current ICD-9-CM codes identified at each encounter. Taking a prospective approach increases a plan’s ability to capture more accurate data. Providers must report all diagnoses that affect the patient’s evaluation, care, and treatment, including: • Nature of the presenting problem • All chronic conditions (such as atrial fibrillation, congestive heart failure (CHF), chronic kidney disease (CKD), rheumatoid arthritis, diabetes with manifestations, chronic obstruction pulmonary disease (COPD), all active cancers) • History on any relevant past conditions • V codes (factors that influence health/status codes) • E codes (external causes of injury and poisoning) HCC scores on individual members determine CMS reimbursement to the plan. Diagnosis and demographic information should be captured at each face-to-face encounter to obtain a health-based measure of that member’s future medical needs.

Knowledge = Recovered Reimbursement Consider the following: • More than 50 percent of a plan’s revenue comes from captured HCC codes. • More than 30 percent of HCC codes do not pass the CMS validation process, due to lack of supporting documentation in the medical record. • Providers do not report greater than 40 percent of active chronic conditions. With those disturbing statistics, it is imperative that a plan employs certified coders who have a thorough understanding of CMS’ HCC methodology and HCC coding process to ensure capture of all documented chronic conditions that risk adjust to HCCs. Coders must also be able to identify documentation deficiencies and review with network providers for improvement. HCC coding processes include: 1. Assessments, plans, all active chronic conditions, and diagnosis codes documented in charts annually. 2. Coding precision and specificity: Coders have the ability to conduct prospective chart reviews to capture missed chronic conditions that have been documented, but not submitted, by the provider or group. 3. The provider’s ability to submit at least eight diagnosis codes to maximize HCC reporting to plans (CMS has accepted eight diagnosis codes since 2007). You may claim 99080 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form for providers who submit to Medicare Advantage plans to report additional diagnosis codes for chronic conditions. Some providers who use an electronic health record (EHR) may not have the ability within the EHR to submit more than four diagnosis codes to a plan. Code 99080 has no relative value units (RVUs), and may be used as an adjunct to the evaluation and management (E/M) code to capture additional diagnosis codes without skewing the provider’s accounts receivable (A/R) report. 4. The plan sends to risk adjustment processing system (RAPS) diagnosis codes that are converted to HCC codes. 5. CMS factors the plan’s risk adjustment.

Coders must also be able to identify documentation deficiencies and review with network providers for improvement. 24

AAPC Coding Edge

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

Feature Here is a checklist of what a plan should look for in a third-party vendor to assist in retrospective reviews:

Understand HCC Methodology HCC payment rationale was developed to mirror the individual health risk profile (HRP) of Medicare Advantage members, and uses ICD9-CM information as the primary indicator to determine a member’s health status. Thousands of ICD-9-CM codes map to less than 100 HCCs, which are what ultimately drive risk adjustment factor (RAF) scores and per member per month (PMPM) premiums paid to a Medicare Advantage plan.

This process allows plans and providers to deliver better benefits and care. For example, at the plan level: • CMS reimburses health plans on a risk-adjusted basis. • The sicker a member is expected to be, the more CMS pays a plan. • Diagnoses reported in one year affect payments for the next year. • Increased reimbursement from CMS (due to better and accurate reporting from providers) allows the plan to provide richer benefits to members for the following year, and allows for bonuses and better reimbursement to providers for fee-for-service (FFS)/ capitation models. Providers also are better able to: • Completely and accurately assess member’s health status. • Monitor and document all active diagnoses, past illnesses, and status conditions. • Monitor readmissions to hospitals. • Review medication. • Identify potential new problems early. • Reinforce self-care and prevention strategies. Plans that implement a two-pronged approach (prospective AND retrospective) to capture HCC codes will see increased revenue and cost containment through better disease management by including a defined HCC coding initiative. A plan that combines both approaches can potentially increase revenue anywhere from $1,500-$2,500 per member.

❏❏ Vendor has established relationships in physician network ❏❏ Current number of clients: Can the vendor handle your plan’s volume on time to scan appointments and minimize rescheduling? ❏❏ Ability to generate pursuits and set scan appointments ❏❏ Ability to identify what the extractions should or should not include (health care effectiveness data and information set (HEDIS) measures, special needs plan (SNP) forms, progress notes) ❏❏ Flexible chart retrieval services based on the specific needs of the plan ❏❏ Number of scan techs on staff: Does the geographic range and staff support the provider network area? ❏❏ Security and Health Insurance Portability and Accountability Act (HIPAA) compliance—equipment types (for example, flash drives, portable scanners, etc.): Do they bring paper if records have to be printed, so as not to use the provider’s resources? ❏❏ Diverse staff to meet different market needs: Excellent provider and plan relationship skills ❏❏ Ability to view the electronic images of all medical records ❏❏ Number of certified coders on staff (in-house and remote) ❏❏ Ability to generate accurate coding reports based on scans to minimize duplications and errors ❏❏ Ability to code each record using online magnetic resonance angiography (MRA) reporting, capture for diagnosis, or HCC codes ❏❏ Ability to accurately identify areas in the record that support HCC findings and risk adjustment data validation (RADV) ❏❏ Ability to identify provider deficiencies in documentation and coding, and report to the plan on results ❏❏ Annotate the electronically coded record with notes and report generation to assist the plan in targeting deficient providers ❏❏ Year-to-date, month-to-date, and real-time (within the past 30 days) report generation to identify low RAF score providers and providers whose HCC reporting is low in comparison to panel size ❏❏ Ability to identify members who have not had any HCC codes reported from a provider panel ❏❏ HEDIS reporting abilities to assist providers and plan to obtain four- and five-star ratings

The 411 on Third-party Vendors

❏❏ Pharmacy utilization and facility tracking

If a plan chooses to work with a third-party vendor to aid in the retrospective aspect of HCC capture, it should have a checklist clearly defining the plan’s expectations. A vendor’s ability to successfully conduct a majority of the retrospective coding initiatives (the first prong) is imperative, as it allows the plan to focus on prospective coding initiatives (the second prong).

❏❏ Turn-around time (TAT) from time of scan to coding, with report generation to the plan

When a plan has a targeted approach to HCC capture, it can better identify high-risk members and channel them into an appropriate disease management program. At the end of the day, when a plan is successful at HCC capture, it creates a win-win outcome for the plan, the providers, and ultimately the members who are served. Holly J. Cassano has worked in practice management, coding, auditing, teaching, and consulting for multiple specialties for the past 16 years. She served two terms as an AAPC local chapter officer, maintains an online column for Advance for Health Information Professionals, writes for Justcoding.com, and is the host blogger for: Coding Notes for Consumer Media Network (CMN) www.medicalbillingandcoding.org/blog/welcome-to-my-new-blog/. This past April, she presented at the Third Annual HCC Best Practices for Proactive Medical Management from Generalities to Interventions to Outcomes for Physician Groups and Health Plans, in Jacksonville, via Opal Events. She works for Preferred Care Partners as a CDI specialist, based out of The Villages, Fla and is the founder of ACCUCODE Consulting, LLC ([email protected]). You can reach her at [email protected] or follow her on Twitter @HollyCassano.

❏❏ Ability to identify members who have not been seen and are new to the provider panel within the past six months

A vendor also should provide the plan with a monthly accounting that identifies errors and generates corrective actions from all pursuits. The report should contain at the very least the following: ❏❏ A list of members charts scanned from provider or group ❏❏ A list of charts that were coded from provider or group ❏❏ A list of charts that weren’t coded from provider or group with logic to pursue with provider/group ❏❏ By member, a list of captured HCC or prescription drug hierarchical condition category (RxHCC) codes that can be submitted ❏❏ By member, a list of dropped HCC or RxHCC codes that need to be addressed with the provider or group ❏❏ By member, a list of reduced HCC or RxHCC codes that need to be addressed with the provider or group ❏❏ By member, a list of new HCC or RxHCC codes

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August 2012

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Practice Management

By Dixon Davis, MBA, MHSA, CPPM

Practice Managers Succeed with Practical Know-how Obtain the necessary skills to manage an exceptional practice.

H

ealth care provides opportunity to work in a variety of settings, from medical clinics to hospitals, and from long term care centers to home health. Within this industry there are many exciting employment opportunities. Physicians and other clinicians provide direct care to patients while the front office registers patients and schedules appointments. Coders and billers verify accurate and complete revenue flows, as auditors and compliance officers ensure the practice follows federal and state regulations. And then, there’s the practice manager who oversees, organizes, and directs all of these efforts. Effective practice managers are increasing in demand. Most independent medical practices are owned by physicians who have very little, if any, training in the business side of medicine; the majority of their education and training is on providing excellent clinical skills, not in running a business. A practice manager who can effectively organize and manage a medical practice is crucial to the physician business owner.

Managers Are Essential to a Practice’s Success Successfully managing a medical practice is one of the most challenging, yet rewarding, leadership opportunities in health care. The complexities of the revenue cycle and compliance regulations in our health care system, along with human resource knowledge and general business and management skill requirements, make this an exciting and demanding profession. Successful managers are those who have the skill set and expertise to ensure the mission and goals of the practice are met. The industry places many demands on medical clinics, such as advanced technology, a complex payment structure, federal and state regulations, documentation and coding requirements, laws prohibiting certain relationships, and health care reform. These demands create an increasing need for managers who not only understand the basics of practice management, 26

AAPC Coding Edge

but who are able to apply these principles in real life situations. I have associated with managers who can talk about accounts receivable (A/R), denials, and even contract negotiations, but if they had to actually find a way to reduce A/R, to decrease denials, or to renegotiate a contract, they’d be in trouble.

Hands-on Approach Reaches Higher Success Levels As with most positions, some practice managers get by with mediocre performance while others dive in and really make a difference. Some managers struggle to keep the business afloat while others lead, directing successful medical practices to provide quality services with financial strength. This is even more evident in small- to mid-sized clinics where the practice manager must be directly involved in all aspects of the clinic because there are no resources for “extra” staff. Here are real scenarios to illustrate my point: Scenario One: This manager knows the basic theory of managing the financials of a practice, either through education or limited experience, and can talk about A/R and how the number of days in A/R needs to be kept low. When it comes time to meet with the billing supervisor or billing staff, the manager explains that the days in A/R need to be lower and directs the billing department to get the aging buckets in line with benchmarked numbers; however, the manager does it without providing specific direction or assistance. Without a practical understanding of how the A/R can be improved, the manager is only able to provide theories, not real life solutions, for the billers, which compromises financial success, as well as the confidence the billing staff has in their manager. Scenario Two: This manager has received training in the practical application of practice management and not only understands the theory of A/R, but also the practical application of how to manage it. This manager also has practical skills, such as what tactics work to have

clean claims, collect money due, manage denied claims, and administer appropriate adjustment policies. When this manager sits with the billing staff, he or she is able to more effectively make specific goals and plans, provide specific advice when needed, and get in and help out with specific functions when appropriate. When problems or shortfalls occur, this manager also can identify specific areas for correction and improvement because he or she understands the mechanics of what is making the engine work. The principle of practical know-how illustrated in these scenarios also applies to many other duties of running a medical practice. Practice managers who possess the skills and practical knowhow, as demonstrated in Scenario Two, can effectively lead and manage medical practices to a higher level of success. In medical groups, we often see staff recognized at excelling in areas such as coding, billing, clinical skills, or customer service and are rewarded by career advancement—sometimes to a practice management position. These individuals may work hard and still fall short because they are not proficient in the skills necessary for the new breadth of responsibilities handed to them. Other times, we see staff that is very bright and excelling in their current position, but their career advancement is limited because their skills are too specific to take on more responsibilities. Both of these groups may be able to succeed and be knowledgeable in a medical management position if they can fill in that gap and learn the additional management skills necessary.

Training for Practice Management Many scholastic institutions offer management degrees, including bachelor’s and master’s degrees in health care administration. I’m a proponent of education and believe it’s valuable to your career and your life in general. I understand, however, that a college degree is not an option for everyone and that simply understanding the high-level theory surrounding practice management—or business in general—is not going to

Practice Management

Successfully managing a medical practice is one of the most challenging, yet rewarding, leadership opportunities in health care.

be enough to truly help a practice maximize revenue, minimize costs, stay in compliance, manage staff and physicians, and prepare for the future of information technology (IT). Whether you are a coder, biller, college graduate, high school graduate, or a manager looking to be more effective, it’s vital to understand the practical skills needed to effectively run a medical practice daily, and how to apply those skills for real success. It’s these basic skills people often either overlook or don’t know exist. Sometimes, so much time is spent learning high-level theory that the effectiveness in practicality is lost. Oth-

er times, experience and education is so focused that there is no opportunity to learn the necessary skills for effective management over several business disciplines. By understanding these basics, you can find success and fulfillment in this position.

Dixon Davis, MBA, MHSA, CPPM, has held senior leadership positions in independent physician groups and integrated health systems. His operational experiences include the implementation of EHRs, financial restructuring and improvement, acquisitions and divestitures of physician groups, managing several practice start-ups, and successfully leading organizations through change management.

Some say finding a great job opportunity involves a lot of luck. I believe luck is what happens when preparation meets opportunity. Opportunities in practice management are out there. Prepare yourself now to succeed in the opportunities that come your way.

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Cover: Billing and Practice Management

By Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ

The Big Picture of Contract Negotiations Focus on preparing for and benefitting from the lengthy negotiation process. A focused effort on negotiating payer contracts can create much-needed money for any practice, and coders are uniquely qualified to facilitate these negotiations. This month, I’ll provide an overview of the contract negotiation process. In future months, we’ll discuss each step in greater detail to help you level the playing field with insurance companies. www.aapc.com

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Ask for a Pay Raise Health plan contracts drive the majority of revenue in most medical practices. You’ll likely never get a rate increase unless you ask for it, but if you make such renegotiations a priority, you should succeed. You can’t negotiate mandated government fee schedules (Medicare, Medicaid, and TRICARE), so concentrate on commercial payer rates. Note: As payers get consolidated through mergers (such as UnitedHealth Group’s acquisition of PacifiCare or CIGNA’s purchase of Great-West), you may find your fees dropping to match the lower of the two fee schedules. You can use this as a reason to renegotiate fees.

Define Your Payer Mix Prioritize your payers to determine where you will gain the most benefit (see Chart A for example). In this example, Medicare is 22 percent of the practice’s business. The next four payers represent 70 percent of the practice’s income. Those four payers should be your priority. Don’t waste hours negotiating a contract for a payer that might only be 1 percent of your business. Chart A: Revenue Based on Payers

Determine Contract Reimbursement Don’t try to negotiate rates without knowing where you stand. You might find, for instance, that a payer’s fee schedule results in payments less than what Medicaid pays. This is a really good reason to ask that payer for a rate increase. Most commonly you’ll be told that your fee schedule is based on a percentage of a given year of the Medicare Resource Based Relative

Value Scale (RBRVS) (e.g., 120 percent of 2008 RBRVS). Find out if (and when) the payer updates its fees. Consider also what components of RBRVS the payer uses (e.g., geographic practice cost indices (GPCI) adjustment, site of service differential, multiple procedure discounts, etc.).

Identify Often-used Codes Coders are uniquely qualified to identify those services/procedures billed most frequently. Gather the following: • Superbill with CPT® and HCPCS Level II codes - HCPCS Level II codes are often neglected, but may constitute a significant monthly expense. If you don’t include them, they become a cost rather than a revenue center. • Frequency count of CPT® and HCPCS Level II codes - Your billing system should generate a report to define which codes your practice uses, and how often. Realize that history is the best predictor of the future. If evaluation and management (E/M) constitutes 80 percent of what the practice does, one negotiation strategy would be to accept a lower reimbursement on procedures to increase reimbursement for E/M services. • Fee schedule with charges for each code - Evaluate whether your charge is in excess of the current contract allowed amount. Often charges below the current allowed amounts are uncovered. • Commonly used ICD-9 codes - Gathering this information will help you to define patient mix. For example, most payers consider dermatology an “elective specialty,” and may not prioritize a rate increase. The payer’s attitude may change, however, if the top diagnostic codes you report are for neoplasm treatment (an “essential” service).

Know the Contract Negotiation Process After you’ve determined your baseline utilization and current rates, you’re ready to begin negotiations. This will take time and energy. If you dive in naively with no idea of the scope and phases of the process, you’re bound to burn out and give up. Your apathy only benefits the payer.

You’ll likely never get a rate increase unless you ask for it, but if you make such renegotiations a priority, you should succeed. 30

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Don’t try to negotiate rates without knowing where you stand.

Here’s a quick rundown of making progress toward your goal: 0 Percent: Identify Payer Contact Identify a specific person in charge of contracting for an entire network. Create a database for your contacts with as much information as possible (e.g., full name, title, phone number, address, and email address). 10 Percent: Draft and Send Health Plan Proposal Letter Drafting this letter helps you gather your thoughts, and literally gets you on the same page as physicians and other stakeholders at your practice. Include your demographic information (practice name, tax identification number, office address(es), and contact information). Spell out the strengths your practice brings to the payer and the market and state your rate request. For example, if your current contract is for 120 percent of current-year Medicare rates, and you’re requesting 140 percent, state that; and, provide a few reasons for the rate increase. The health plan proposal should be mailed and certified with a return receipt requested. Be prepared to follow up. As a general rule, if letters are sent to 10 different health plans, one or two might respond without you having to make a follow-up call. 20 Percent: Follow Up with Payer The health plan representative may have already told you during the initial phone call the typical fee schedule for physicians of your geographic location and specialty. During the same call, you may be able to express what alternate rates would be acceptable. Save time by getting a verbal commitment from the payer that they’ll offer and send the agreed-upon, acceptable rates before they send out a fee schedule and contract to you. 30 Percent: Receive Offer from Payer When the offer of new rates is received (either as part of a contract or as a standalone fee schedule for preliminary approval), you’ll need to make the entire offer (rates and contract language) acceptable to the unique needs of the practice. As such, you should request the complete agreement for review. You may want to have certain codes carved out as fixed amounts. Check the fees for rates for in-office radiology, clinical labs, consultation codes, preventive exams, and unlisted procedures—anything that might cause future payment problems. These additional specifics about the fee schedule should be defined to your satisfaction in the offer under consideration.

40 Percent: Read Language and Draft Revisions Unless you’re desperate for the payer contract, review the language and fee schedule terms for acceptability. If you find areas of disagreement or concern over the language of the contract, prepare a letter or email specifically citing the problematic contract language, why you object, and the proposed alternate language you’d find acceptable. Go back and forth with the payer on requested language revisions, and review all contract drafts. The bulk of the work (the negotiations) is over. Now begins the administrative endurance test to confirm the contract terms get implemented. 50 Percent: Language and Rates Acceptable Initial each page of the contract. This will prevent anyone questioning whether you overlooked a page of the agreement or an attachment. Even if the agreement drafts were redlined throughout the negotiation, compare the final draft to the exact text you desire. 60 Percent: Signature on Contract Print the agreement provided by the health plan, if via email, and prepare the agreement by assembling it in the proper order, with all pages completed and exhibits/addenda attached. Have the physician sign all relevant areas. Fill in the other necessary information, such as adding the practice address to the “notice” section of the contract, the signature page, or any exhibits requiring demographic information such as the tax identification number, billing address, etc. 70 Percent: Credentialing Packet Complete and Submitted Generally, a new agreement comes with an associated credentialing packet. Complete the packet, providing copies of all requested documents. Now is a great time to set up online payer log-ins, if you don’t already have them. 80 Percent: Contract Returned Correctly Send the agreement with a tracking number. Keep a hard copy of the partially executed documents, and follow up until you receive a fully executed (counter-signed) copy for your files. Save the agreement in an easy-to-locate place within the practice. Have a copy for your records, in case you need to supply the payer with a copy. 90 Percent: Credentialing Approved When the plan gets the credentialing packet, the internal review by the payer starts. Be proactive, and find out when the credentialing committee will review the applications. Respond quickly when asked for additional information.

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

Cover

Physicians’ Ally, Inc. (l-r): Lynn Holmes, Lindsey H. Daly, MSHA, CPC, Marcia L. Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ, John Williams, Crystal Lytle, Lynn Hooper

100 Percent: Effective Date At this point, the credentials are approved and the contract is received by the plan. Now you wait for an effective date. Generally, a “welcome letter” stating the effective date is sent to the practice address. This often accompanies your fully executed agreement. If you are in need of an expedited effective date, you may be able to get one over the phone or via email by your payer contact. Having the effective date is the ultimate confirmation that you are done with the contracting process. Most practices we come across only have partially executed versions of their agreements, which are not legal documents.

Chart B: Example of Payer Monitoring

Monitor for Continued Success With the contract enacted, be sure to monitor payments and other terms to be certain that you are receiving the improvements you’ve worked to achieve. Summarize the agreement in fewer than two pages, with essential terms identified for all stakeholders. This cheat sheet will be the primary reference for everyone involved with the contract in the future. Ideally, the actual agreement will need to be referenced only for specific details on a rare occasion. Provide your front desk schedulers and pre-authorization coordinators with a list of payers the practice accepts and online payer log-ins. Share the effective date and new rates with the billing staff. Chart B is a format that is useful.

Having the effective date is the ultimate confirmation that you are done with the contracting process. 32

AAPC Coding Edge

Mark your calendar for a renegotiation in the future. If you have escalators built in for your rates, mark those on the calendar, too, so you can be assured they will take effect. The value of staying organized throughout the contract negotiation process is essential. The aforementioned steps should help you prepare for—and endure—the lengthy negotiation process. Any rate increase should make the endurance test worthwhile. Stay tuned: We will provide additional tips and specifics to improve your success during contract negotiations. Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ, is the founder and president of Physicians’ Ally, Inc., a health care consulting firm and concierge billing company for specialty physician practices in Denver. She works with physicians on managed care contracts, reimbursement, and practice administration. Her experience includes hospital, health plan, and independent practice association administration. Her firm sells updated Health Insurance Portability and Accountability Act (HIPAA) policies and procedures and online staff training. She is a published researcher and a frequent public speaker.

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By Nancy Clark, CPC, CPC-I

Identify the Correct Global Period E/M Modifier Here’s how to determine and append a modifier that best tells the story of the E/M claim. Modifiers are crucial in telling the story of the claim by identifying procedures that have been altered in some way without changing the core meaning of the code(s) submitted. Let’s look at the modifiers that can be appended to evaluation and management (E/M) codes used within the global period.

The Global Surgical Package Understanding global modifiers begins with a comprehension of the global surgical package. The CPT® surgical package definition indicates that for every surgical procedure, there are integral services included that cannot be reported or billed separately, as indicated in Example A. The Centers for Medicare & Medicaid Services (CMS) refers to the surgical package concept as the “global period.” In minor procedures, such as removal of skin lesions or endoscopies, a zero- to 10day global period after the procedure applies. For major surgeries, the global period is extended to one day prior to and 90 days after the procedure. An example of a major surgery would be an appendectomy. Note that commercial carriers may place different global periods on procedure codes. One way to determine the global period for Medicare is by using the Medicare Physician Fee Schedule Database (MPFSDB). Global surgery status indicators are attached to each procedure code from the surgery section of CPT®, as shown in Example B. Modifiers 24, 25, and 57 (see descriptors below) can be appended to E/M codes, which include CPT® 99201-99499, and ophthalmology codes 92002-92014; the latter codes are found in the medicine section of CPT®.

Modifier 24 Modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period shows the E/M being billed is not part of the global surgical package and is separately reimbursable. To further indicate the procedure is unrelated, we usually—although not necessarily—use a different diagnosis from that linked to the previous procedure. For example, on May 1, the patient undergoes an appendectomy for acute appendicitis. The appropriate coding based on this information is 44950 Appendectomy with 540.9 Acute appendicitis; without mention of peritonitis. On May 19, the patient presents to the same 34

AAPC Coding Edge

Takeaways •

• • •

The CPT® surgical package definition indicates that for every surgical procedure, there are integral services included that cannot be reported or billed separately. The Centers for Medicare & Medicaid Services (CMS) refers to the surgical package concept as the “global period.” Modifiers 24, 25, and 57 can be appended to E/M codes, including CPT® 99201-99499 and ophthalmology codes 92002-92014. The OIG is targeting claims where certain modifiers are appended to services performed during the global period.

operating surgeon with a new onset of right upper quadrant (RUQ) abdominal pain. At this visit, the surgeon examines the patient and suspects cholecystitis. He orders a complete blood count (CBC) and abdominal ultrasound, and documents an expanded problem-focused history, expanded problem-focused exam, and medical decision-making of low complexity. The appropriate coding on May 19 is 99213-24 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity … with a diagnosis of 789.01 Abdominal pain; right upper quadrant. Modifier 24 is appended to indicate that this E/M is unrelated to the previous surgery. Notice the use of different diagnoses. In this next example, it is appropriate for the same diagnosis to be used for both the surgery and the subsequent E/M service: On June 1, the patient presents for a closed treatment of a single metacarpal fracture in his left hand. The appropriate coding is 26600-LT Closed treatment of metacarpal fracture, single; without manipulation, each bone, which has a 90-day global period. Modifier LT Left side is appended to indicate location. The diagnosis is 815.03 Fracture of metacarpal bone(s); closed; shaft of metacarpal bones(s). On July 1, the patient presents to the same operating surgeon, complaining of a possible fracture in his right hand. The physician performs an expanded problem-focused history and exam and his medical decision-making is of low complexity. After review of the Xrays, which may be separately billable, the physician identifies a new metacarpal shaft fracture. The appropriate coding is 99213-24, with 815.03. Note the use of the same diagnosis. Modifier RT Right side for the right hand would not be appropriate for the E/M code.

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Keep in mind that commercial payers’ policies vary. Some will not pay for two E/Ms on one date of service and some payers may reduce the amount of the second E/M reimbursement.

Example A

CPT® Surgical Package Definition Pre-operative services, such as:

For example, an established patient presents to the office complaining of left eye pain and feel• Subsequent to the decision for surgery, one related E/M encounter on the date ing as if sand is in his eye after doing some repair immediately prior to, or on the date of, the procedure (including history and physical) work around his house. The physician performs Intraoperative services that are normally a usual and necessary part of a surgical procedure an examination, finds a wood splinter in the cornea, and removes it. He documents a problemPost-operative services, such as: focused history and exam and straightforward • Immediate postoperative care, including dictating operative notes, talking with the medical decision-making. The appropriate codfamily and other physicians ing is 99212-25 Office or other outpatient visit for • Writing orders the evaluation and management of an established • Evaluating the patient in the post-anesthesia recovery area patient, which requires at least 2 of these 3 key com• Typical postoperative follow-up care ponents: A problem focused history; A problem foSource: CPT® 2012, American Medical Association (AMA), adapted cused examination; Straightforward medical deciExample B sion making … and 65220-LT Removal of foreign body, external eye; corneal, without slit lamp with 930.0 CorCMS Definition of Global Period neal foreign body. Minor procedures: 0 to 10-day global period after procedure Alternatively, for an eye examination, report 92012-25 OphMajor procedures: 1 day prior and 90 days after procedure thalmological services: medical examination and evaluation, 000 = 0 global days with initiation or continuation of diagnostic and treatment program; intermediate, established patient and 65220-LT. 010 = 10 global days •

Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

090 = 90 global days

Modifier 25 for Combo Sick/Well Visits Modifier 25 also may be used when a preventive service (well YYY = carrier determines global period visit) and a problem-oriented E/M (“sick visit”) occur during the same encounter. CMS instructs, “Medicare payment ZZZ = add-on codes can be made for a significant, separately identifiable mediGlobal period calculator (MPFSDB): www.cms.hhs.gov/pfslookup/02_PFSsearch.asp cally necessary E/M service (Current Procedural TerminolSource: Medicare Claims Processing Manual, chapter 12, section 40 ogy codes 99201-99215) billed at the same visit as the Annual Wellness Visit (AWV) when billed with modifier -25. That Modifier 25 portion of the visit must be medically necessary to treat the benefiAppend modifier 25 Significant, separately identifiable evaluation ciary’s illness or injury, or to improve the functioning of a malformed and management service by the same physician on the same day of the body member.” (https://questions.cms.gov/) procedure or other service to indicate that an E/M service is separate In this instance, be sure the documentation can substantiate two from what is normally required for a minor procedure. There must distinct E/M codes. One visit would be measured by the key combe a clearly documented, distinct, and significantly identifiable E/M ponents of history, examination, and medical decision-making (or, service, above and beyond the usual preoperative and postoperative possibly the time component). The other service needs to indicate care associated with the procedure. The CPT® description of moda full preventive care service. The modifier is appended to CPT® ifier 25 specifies, “The E/M service may be prompted by the sympproblem-based codes. Keep in mind that commercial payers’ politom or condition for which the procedure and/or service was providcies vary. Some will not pay for two E/Ms on one date of service and ed. As such, different diagnoses are not required for reporting of the some payers may reduce the amount of the second E/M reimburseE/M service on the same date.” XXX = global concept does not apply

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August 2012

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Featured Coder

OIG Targets Use of Modifiers During the Global Surgery Period As part of its 2012 Work Plan, the Office of Inspector General (OIG) “will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements.” To stay clear of the OIG, remember, “visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed,” per the Medicare Claims Processing Manual, chapter 12, section 40.1. For example, on March 1, a patient schedules removal of a skin lesion. On March 3, the patient presents to the office for removal of a benign skin lesion of the left arm, 1 cm, as measured by CPT® instructions. No other problems are discussed in detail. Appropriate billing on March 3 is 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm. A significant, separate E/M service was not provided.

ment. It is important to check with the payer to verify both the coding policy and the patient’s benefits. For example, a 35-year-old established patient had previously scheduled an appointment for a routine examination. On the day of the appointment she injures her ankle. The documentation of the visit supports a problem-focused history related to the ankle injury, a problem-focused examination of the ankle, and medical decision-making of straightforward complexity. The documentation also separately supports a comprehensive preventive medicine E/M service. The appropriate coding of this service for a commercial payer is 99212-25, with a diagnosis of 845.00 Sprains and strains of ankle; unspecified site. You would also report 99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years with a diagnosis of V70.0 Routine general medical examination at a health care facility. For Medicare, there are several options for reporting the wellness exams: • For a Medicare Initial Preventive Physical Exam (IPPE), use HCPCS Level II code G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. • For a Medicare AWV, use HCPCS Level II code G0438 Annual well visit; includes a personalized prevention plan of service (PPS), initial visit for a new patient or G0439 Annual well visit; includes a personalized prevention plan of service (PPS), subsequent visit for an established patient. For clarification of the Medicare IPPE and AWV guidelines, see the Medicare Claims Processing Manual chapter 12, 30.6.1.1, “Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV).” 36

AAPC Coding Edge

Whether reporting to commercial payers or Medicare, the use of different diagnoses for sick and well visits further differentiates the services.

Modifier 57 Modifier 57 Decision for surgery is similar to modifier 25, except that the surgical package includes one day prior to the procedure and usually has a 90-day global period after the procedure. Note: The CPT® description of the modifier does not actually indicate a global period, but most payers’ guidelines indicate use for a major global period. The E/M may be for the same or for a different diagnosis than the surgery. Remember CPT® surgical package guidelines include one related E/M encounter subsequent to the decision for surgery. So, if the operating physician performs an E/M on the day before a previously scheduled surgery that includes normal preoperative care for the surgery, the E/M is not separately reportable because it is included in the global package. If the operating physician sees the patient the day before the surgery and at that visit decides to perform surgery, however, modifier 57 can be properly appended to indicate the E/M is not “bundled” into the surgery because a decision for surgery was made at this visit. For example, a non-Medicare patient presents to the emergency department (ED) with acute right, lower-quadrant abdominal pain and fever. The ED physician requests a surgical consult. The consulting surgeon documents a level 3 outpatient consult and decides at that visit to perform an emergency appendectomy. The appropriate coding is 99243-57 Office consultation for a new or established patient … , 44950, and 540.9. Note: The global period of the performed procedure determines whether it is appropriate to append modifier 25 or modifier 57 to the E/M code. Nancy Clark, CPC, CPC-I, is a member of the 2011-2013 AAPC National Advisory Board (NAB). She is director of the Healthcare Business Resource Center in New Jersey. She also She also is a PMCC-approved instructor and a health care consultant. Ms. Clark participates in the Novitas Medicare Provider Outreach and Education Advisory Group.

Spine Claims Auditing Technology to Revamp Your Revenue Cycle www.casecoder.com 888-337-8220 option 5

Coding Compass

By Suzan Berman, CPC, CEMC, CEDC

It’s Time to Re-evaluate

Your E/M Coding

Because EHRs may affect your billing, verify that your evaluation and management levels remain compliant.

W

ith implementation of the electronic health record (EHR), it’s more important than ever to ensure documentation supports the individual level of service for each patient. Templates, smart phrases, easy text, and other shortcuts allow clinicians to document effortlessly without taking medical necessity into account. This is troubling to payers, and should be to the companies creating the records (as well as the providers using them).

OIG Does the Math: E/M Levels Rising In May 2012, the Office of Inspector General (OIG) published “Coding Trends of Medicare Evaluation and Management Services,” illustrating a marked shift over time toward billing for higher-level evaluation and management (E/M) services. The OIG doesn’t directly blame EHR use for the trend in the report; however, it’s clear that the OIG is keenly aware of how EHRs can affect E/M billing. Details of the report show that between 2001 and 2010, Medicare increased the payment of E/M services from $22.7 billion to $33.5 billion. Dates of services toward the end of the survey period include a larger sample of electronically documented records. The OIG concluded in the top three categories reviewed (subsequent hospital visits, established patient visits, and emergency room services), the “middle” code (e.g., level 3 for the established and emergency services) was the most often billed service; however, higher levels of service are being billed more frequently. A statistical comparison is made in Table A for established patient visits. Table A

• • •

The OIG finds E/M levels are rising and believes EHRs are the likely cause. Rising rates appear not to result from seeing sicker patients. CMS is identifying, auditing, and training providers whose E/M levels have risen.

With regard to subsequent hospital services, 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components; An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity (mid-level code) is submitted most often. As you can see in Table B, however, there is a shift between 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components; A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity and 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components; A detailed interval history; A detailed examination ; Medical decision making of high complexity from 2001-2010.

Table B

Code

2001

2005

2010

Code

2001

2005

2010

99211

6%

5%

4%

99231

31%

22%

15%

99212

16%

12%

9%

99232

53%

58%

59%

99213

54%

52%

46%

99233

16%

20%

25%

99214

21%

28%

36%

99215

3%

3%

5%

Source: OIG analysis of 2001 and 2010 Part B Analytic Reports (PBAR) National Procedure Summary File (http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf), appendix C, page 21.

38

Takeaways

AAPC Coding Edge

As shown in Table C on the next page, emergency service codes saw the biggest change between levels of service.

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

Coding Compass

The OIG has already provided CMS contractors with the names of physicians who it found to be consistently billing higher levels of services …

Table C Code

2001

2005

2010

99281

2%

1%

0%

99282

9%

5%

3%

99283

31%

27%

20%

99284

32%

30%

29%

99285

27%

38%

48%

Specialties billing higher services more often were family practice, emergency medicine, and internal medicine, with obstetrics/gynecology (OB/GYN), showing the largest percentage increase (4.3 percent, versus 1.9 percent overall) of physicians who billed only higher-level services. Geographic location was not a factor in the results. Only three states didn’t have physicians who consistently billed higher service levels in 2010: Montana, Nebraska, and Wyoming. Physicians who bill higher levels of service might argue that they are seeing older patients, sicker patients, or patients with co-morbid conditions. OIG results didn’t support this theory. Patient populations were approximately the same age across the study, with the same diagnosis codes submitted, and the patients of those physicians consistently billing high-level services were, in aggregate, no sicker than average.

CMS Is Gunning for E/M Upcoders As a result of this report, the OIG recommended the Centers for Medicare & Medicaid Services (CMS) continue to educate the physician community on the appropriate application of documentation guidelines. This could include letters, inperson seminars, teleconferences, etc. Medicare carriers also will be reviewing a greater number of E/M services. The OIG has already provided CMS contractors with the names of physicians who it found to be consistently billing higher levels of services and, depending on a cost/benefit analysis, there will be more extensive reviews done for those physicians. EHRs are an amazing tool in the health care environment. When designed and used properly, they help to improve of-

fice flow, patient care, and the revenue stream. The higher levels of service the OIG found in its recent study might have been billed appropriately (The OIG says in the report that it “did not determine whether the services billed by physicians who consistently billed higher level E/M codes were inappropriate or fraudulent.”), but without proper documentation in the medical record, there’s nothing to substantiate both the level of service and medical necessity.

Get Moving, Start Educating The provider community could view this report as a call to order. Documentation is becoming more robust and more transparent amongst agencies and other providers. It must be clear, clean, and relevant. The provider community must put in place appropriate documentation improvement plans— and not just in preparation for ICD-10-CM, but for cleaner claims, more appropriate billing, and clearer care plans that ultimately result in better outcomes for patients. Clinician education should be continual and timely. Physicians should welcome the education and not feel overwhelmed, over-scrutinized, or threatened. Educators should be accommodating as to where and when education is done, and must understand the providers’ prospective. Training tools should be developed to deliver information in a variety of ways. Meeting in small spans of times (taking a short break from patients or meeting early in the morning, for instance) might be appropriate alternatives to lengthy sessions. Weekend seminars and evening meetings with colleagues might also be great settings to provide billing and coding education. Webinars and teleconferences are also very productive ways to convey this information. The more the guidelines are reviewed, the easier they are to adapt into the patient visit workflow. Suzan Berman, CPC, CEMC, CEDC, is the senior director of Physician Services for Health Revenue Assurance Associates. She serves on the OptumInsight Advisory Board and as Coding Institute Editorial Advisory Board member. She is a former AAPC National Advisory Board (NAB) and AAPC Chapter Association (AAPCCA) Board of Directors member. She speaks nationally for organizations such as the University of Pittsburgh, The Coding Institute, Advanced Career Solutions, AAPC, MGMA, and OptumInsight.

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August 2012

39

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ICD-10 Roadmap

By Kathy Rowland, CPC, CEMC, CPC-I, CHC

e e tr S e h t n o

t

Provides ICD-10-CM Insight

d r o W photo by iStockphoto©pialhovik

You have heard from many qualified, trained professionals in ICD10-CM over the last several months, with some very informative articles on varying ICD-10-CM topics. As you prepare for the ICD10-CM transition and implementation in your practice, you may benefit from hearing other health professionals speak on the topic of ICD-10-CM. I asked several individuals in key positions at different practices the question, “What is your biggest concern with ICD10-CM implementation?” Their responses can offer you helpful insight as you continue to prepare for the transition to ICD-10-CM.

Medical Director “My main concern is that one of the stated advantages of ICD-10 is, ‘Specificity improves coding accuracy and depth of data for analysis.’ I say, ‘Garbage in, garbage out.’ For providers who are currently not using the specificity that exists with ICD-9, ICD-10 gives them more ‘garbage’ to choose from or to ignore. Also, as you know, you can only code what is documented in the record. I think lack of specificity will remain more often the problem, rather than miscoding a specific diagnosis.” Kenneth W. Patric, MD, chief medical officer, The Little Clinic One of the largest impacted areas will be the clinical documentation. Auditors and coders already struggle with this issue, and documentation may become even more problematic with ICD-10-CM because it is data driven. If only unspecified codes are used in ICD-10-CM, we are no further in capturing the specific clinical picture of the patient. In time, payers may not reimburse for unspecified codes when the documentation supports a more specific code. Solution: The best way to confront this issue is through monitoring and education. If you are not already performing documentation audits, begin now. Incorporate an ICD-10-CM readiness section in your audits or conduct a separate ICD-10-CM readiness review as a benchmark. Run a frequency report of the top diagnosis codes being used by the practice. Pull a sample of documentation for each provider who represents these top codes. The auditor will assess the documentation and determine:

1. Does the documentation support the diagnoses reported? 2. Will the documentation support an ICD-10-CM code? The auditor must be familiar with the ICD-10-CM guidelines and codes to make this determination. After the audit has been conducted and analyzed, the practice will have a good assessment of documentation deficiencies and can develop a priority list of diagnoses requiring more detail. The audit will also identify providers who will benefit from focused ICD-10-CM training. Implement a documentation improvement program within the practice and monitor the documentation on an ongoing basis. This will ensure improvement and identify areas where providers are deficient and those who need more assistance and training. These audits should be conducted periodically to validate ICD-10-CM compliance. As with any audit, submit a report to senior management and the provider. If you do not have a trained Certified Professional Coder (CPC®) on staff to perform these audits, contact AAPC Physician Services to schedule a “ICD-10-CM Assessment: Documentation Readiness Evaluation” (www.aapcps.com/services/icd-10-assessment.aspx). Do not skip this step! This is a critical element as you begin the preparation and implementation process.

Physician “My biggest concern is the additional amount of time it will take me to look up codes. I am expecting that to really eat into my patient time. If you multiply an extra 30 to 60 seconds per patient, times 25 patients a day, you have effectively eliminated a 15 minute exam slot!” Stephen C. Spain, MD, FAAFP, CPC, CEO Doc-U-Chart There will be a learning curve for physicians, as well as for coders. Solution: Consider developing a cheat sheet of the top 50 ICD-9CM codes used in your practice. Have a trained CPC® convert the ICD-9 options to ICD-10. If you do not have anyone on staff that is trained to make the conversions, or just don’t have the time, AAPC offers laminated double-sided cards by specialty to make it easy. www.aapc.com

August 2012

41

ICD-10 Roadmap

Begin by developing an ICD-10-CM steering committee or implementation committee that will help identify any areas of impact for the practice. AAPC lists the Fast Forward Top 50 ICD-9 Codes Crosswalked to ICD-10 (by specialty) for $14.95 for members (www.aapc.com/icd-10/ crosswalks/index.aspx). Be resourceful and begin talking with your information technology (IT) system staff/vendor to evaluate what tools will be available. Codes provided by a system may be crosswalked to unspecified codes via a matrix or general equivalency mappings (GEMs) file. Do not select the final code for the visit without validating it is the most specific diagnosis code supported by the documentation. An “ICD-10-CM Assessment: Documentation Readiness Evaluation” will help in this area, as well, by providing specific documentation feedback and education, and familiarizing everyone with the most frequently used codes in your practice.

Administrator “My biggest concerns are electronic implementation and making sure we do not lose revenue by missing things or ‘miscoding.’” Marianna D. Forsythe, MBA, chief operating officer/Vice President of administraton, The Heart & Vascular Center of West Tenn./Delta Convenient Care, PC Solution: To address a possible short-term, adverse impact on revenue stream, consider increasing your practice’s cash reserve and/ or securing an increased line of credit. This will ensure the practice can continue to meet its expenses should there be any delays in reimbursement. Strategic planning and anticipation of productivity issues can help a practice minimize any hurdles. Begin by developing an ICD-10CM steering committee or implementation committee that will help identify any areas of impact for the practice. This may be a committee of one or two staff members in a smaller practice or a cross-section of billers, coders, IT staff, managers, physicians, administrators, etc. in a larger practice. Get representation for each area of the practice and be sure every affected area is identified and explored. Involve physicians early on so they understand the importance of preparation as the migration to ICD-10-CM occurs. The team should meet initially to identify the elements necessary for a smooth transition, and then analyze what areas will be affected. The resulting information should be shared with providers and management. Set boundaries for this committee to avoid “project creep.” Keep a priority list of identifying what will be addressed, including anticipated deadlines, to keep the efforts focused and on track. Any issues that do not directly affect the implementation can be put on another action list for follow up after priorities involving the ICD-10 transition are addressed. 42

AAPC Coding Edge

This planning effort will not only identify areas affected by the transition, but also how communication will be handled, training needs and education plans, as well as coordination with vendors, business partners, and other providers.

Billing Manager “How do we ensure that currently certified coders are trained on ICD10? Will this be a separate certification? Will they be tested? How long will it take someone to learn ICD-10? And, since this will be new to everyone, is the industry really ready for this?” Deanna Allen, A/R consultant Second only to system upgrades, training will be the biggest expense for the practice. Solution: Develop a separate education plan specifically for ICD10-CM. Do the training in phases, beginning with the background and history, rationale for change, and final rule highlights, and continue through guidelines and code set training. Measure the retention of what you learn by conducting post testing. As you begin to evaluate the training needs of the practice, ask yourself: Who must receive training on the ICD-10 code set? All areas of your practice will need some degree of training in ICD10 CM. On average, it is estimated that: • Providers will require 8-16 hours • Nurses will require 6-10 hours • Ancillary staff will require 6-10 hours • Coders will require 20-40 hours, not counting recommended A&P courses What options are available to train staff? Look into training options such as onsite, vendor training, community courses, webinars, and certification courses. Check out AAPC’s plan for training on www.AAPC.com. Which training format(s) will work best for your staff? Consider classroom training, web-based training, or self-guided materials to meet your staff needs. How much will the training cost? Develop a budget once your methods are determined. What resources will staff need after training to resolve questions as they arise? Resources could include any available tools, manuals, or frequently asked questions (FAQ) lists.

Suffering from

Pathophysi-itis? Pathophysi-itis [path-oh-fiz-ee-ahy-tis]: A syndrome affecting coders whose confidence and efficiency are greatly hindered due to a lack of understanding of disease processes (Pathophysiology).

Symptoms: · · · · · ·

Irritability when deciphering clinical documentation Confusion about the disease process Lack of confidence when speaking to clinical staff Overuse of search engines to research answers Loss of productivity when coding Denials as a result of coding inaccuracies

Treatment: Attend our 4-hour workshop this August and cure yourself of this debilitating syndrome plaguing thousands of coders.

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Author: Glade Curtis, MD, MPH, FACOG, CPC, CPC-I, COBGC Co-Author: Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGIC, CGSC

Up to 6 CEUs 40+ Cities $149.95 Find a workshop location near you! www.aapc.com/pathophysiitis 1-800-626-CODE (2633)

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

ICD-10 Roadmap

Begin by communicating to all of your vendors and contracted payers to get an idea of where they are in regard to ICD-10 readiness.

Will this be a separate certification? A separate certification will not be required for coders; however, to ensure certified coders maintain their ability to accurately code the code sets, AAPC certified members will have two years to pass an open-book, online, unproctored assessment. Due to the clinical nature of ICD-10-CM, a strong understanding of anatomy and pathophysiology (A&P) is recommended. AAPC offers “ICD-10 Anatomy and Pathophysiology Training” that covers all body systems in 14 modules (www.aapc.com/ICD-10/anatomy-pathophysiology.aspx). The curriculum blends online multimedia presentations (www.aapc.com/ICD10/sample/sample.html) with downloadable manuals (http://static.aapc. com/ppdf/sample1.pdf) and evaluation quizzes to ensure your comprehension of the material. At minimum, a refreshers course in A&P will be necessary to code using ICD-10-CM. Is the industry really ready for this? The ICD-9-CM system is more than 30 years old. Think of how much medicine has changed in 30 years. The ICD-9-CM categories are full and do not represent contemporary medicine. Although the extended proposed implementation date (Oct. 1, 2014) provides more time to prepare, you should begin now. Create a list of your practice’s electronic systems and work flow processes using ICD-9 codes, both clinical and administrative—including payers, contractors, clearing houses and vendors. If you’re not sure if your circle of vendors, contractors, payers, clearing houses, and billing companies are ready, ask. Begin by communicating to all of your vendors and contracted payers to get an idea of where they are in regard to ICD-10 readiness. Determine which existing vendors will be affected by the ICD-10 transition. Define requirements you will need from vendors to support your ICD-10 implementation. Determine if systems vendors and/ or clearinghouses/billing services will support changes to systems, supply a timeline and cost estimate for implementation changes, and identify when testing will occur. Determine the anticipated testing time and a schedule. Put everything in writing. Begin testing four to six months before the live date to assess glitches that may affect payment. Identify crosswalk capabilities with your system for operating in ICD-9-CM and ICD-10-CM. Workers compensation carriers are not considered covered entities under Health Insurance Portability and Accountability Act (HIPAA) and are not required to make the transition to ICD-10-CM. If you are contracted with these carriers, contact them and ask them if they will be converting to the ICD-10-CM system. 44

AAPC Coding Edge

Explore “Plan B” options in case your vendor does not progress fast enough, including operational workarounds and vendor replacement alternatives.

Coder “My main concern is getting clinical staff – especially doctors – on board for the transition. I do not see doctors changing their habits to become more specific. Coding will take twice as long, if not longer, by having to dissect every word into pulling out the perfect diagnosis when the doctor or provider could have provided the needed information all along.” Coding Staff of Calypso Enterprises, LLC Unspecified diagnoses will affect the revenue cycle, as well as the possibility of increased denials, because of incomplete or inaccurate translations of existing policies, benefits, and payment rules in payer systems as they attempt to transfer these rules to ICD-10-CM. Payments delays due to challenges in claim processing in the ICD10 environment will include: • Can the system maintain both ICD-9-CM and ICD-10 CM for a time? • Can the database support so many codes? • Can it distinguish ICD-9-CM and ICD-10-CM code? • How will the code set updates be managed? Solution: Explore these areas with your staff, vendors, and clearing houses. Planning and implementing ICD-10-CM must include communication and significant collaboration on IT, finance, education, and problem solving. Knowing whether clinician documentation is specific enough can be determined using the aforementioned AAPC Physician Services “ICD-10-CM Assessment: Documentation Readiness Evaluation.” Regardless of the size of your practice, steps toward implementation must begin now. As Winston Churchill said, “He who fails to plan is planning to fail.” Kathy Rowland, CPC, CPC-I, CEMC, CHC, of Integrity Compliance, LLC, has over 25 years in the areas of health care administration and management. Nine years were spent specifically in the development and implementation of practice-based compliance plans, auditing documentation, and litigation support. She holds certifications in evaluation and management coding, compliance, and as an AAPC instructor. Ms. Rowland is also an ICD-10 trainer for AAPC.

Resources: 1. Centers for Medicare & Medicaid Services (CMS): www.cms.gov/Medicare/Coding/ICD10/downloads/ICD10SmallandMediumPractices508.pdf 2. AAPC: www.aapc.com/icd-10/index.aspx

A&P Quiz

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

Think You Know A&P? Let’s See … For arthritis patients, the two clinical clues most helpful for diagnosis are the joint pattern and the presence or absence of extra-articular manifestations. The joint pattern is identified by the answers to three questions: 1. Is inflammation present?

diseases frequently cause prominent involvement of the DIP joint: osteoarthritis and psoriatic arthritis. Extra-articular manifestations, such as fever, rash, nodules, or neuropathy, narrow the differential diagnosis further.

2. How many joints are involved?

Answer this question to find out where your A&P skills rank.

3. What joints are affected? Joint inflammation manifests as redness, warmth, swelling, and morning stiffness lasting at least 30 minutes. Both the number of affected joints and the specific sites of involvement affect the differential diagnosis. Some diseases, such as gout, are characteristically monarticular (affecting one joint), whereas other diseases, such as rheumatoid arthritis, are usually polyarticular (affecting many joints). The location of joint involvement can also be distinctive. Only two

Test Yourself What does the acronym DIP stand for? A. Diabetic insipid polyarthropathy B. Distalinterphalangeal joint C. Dormantinterphalangeal joint D. Distal intra-articular joint You will find the answer to this question on page 49. Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is vice president of ICD-10 Training and Education at AAPC.

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August 2012

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newly credentialed members Abby J Miles, CPC Adneris Quinonez, CPC-H Adria Sampson, CPC Adriana Ruiz, CPC Adriene Coles Ellis, CPC Alina Diaz, CPC Allison J. Hogan, CPC Alma Salcedo, CPC Amanda A Pierson, CPC Amanda C Solon, CPC Amanda Lynn Martin, CPC-H Amy Rose, CPC Amy Kohlmann, CPC Amy Phillips, CPC Amy Purdy, CPC Ana Wagner, CPC Angela Blackwell, CPC Angela Lynn Galea, CPC Angella Grim, CPC Ani Damatian, CPC Ann Allison, CPC Anne Morris, CPC Arvella Oglesby, CPC Ashley C Thomas, CPC Ashley Ryall, CPC Ashley Yawn, CPC Barbara Gentilini, CPC Becky D Alston, CPC, CPC-H Belinda Vasquez, CPC Beth Ann Buchanan, CPC Beth W West, CPC-H Betty Goolsby, CPC Bonnie Aldrich, CPC Brenda Cooper, CPC-H Brittany M Lemmons, CPC Candace Griffin, CPC Candice Brown, CPC Carol A Farnsworth, CPC Carol Dison, CPC Carol Fisher, CPC Carol S Ross, CPC Carol Wilson, CPC Carole Lynn Sharp, CPC Carrie Mann, CPC Cathy L Chipman, CPC Chelsea Elizabeth Ring, CPC Cheryl Fliszar, CPC Cheryl Lynn Valdez, CPC Cheryl Posey, CPC Cheryll Lynn Arthur, CPC Christa Williams, CPC Christina Gee, CPC Christine Ruth Miller, CPC Christine Varner, CPC Christopher West, CPC Clarice Cote, CPC Coleen Lissa Miller, CPC Connie Curtis, CPC Connie Lea Bray, CPC Costinela Breahna, CPC Couralisa Little, CPC Craig Moural, CPC Cresta Christensen, CPC Cynthia Gunera, CPC Cynthia M Trudeau, CPC-H Cynthia Murdock, CPC Dana M Cruttenden, CPC Darlene Johnson Lovett, CPC, CPC-H, CPCO, CPMA Daryl Lee Nache, CPC, CPC-H, CPMA

Dawn Marie Mailloux, CPC Dawn Pruitt, CPC, CPEDC Deanna E Kwak, CPC Deborah A London, CPC, CPC-H Deborah Broyles, CPC Deborah R Terry, CPC Debra Esham, CPC Debra A Baker, CPC Debra Farley, CPC-H DeeAnn Springfield, CPC, CPC-H, CPC-P, CUC Dena M Terry, CPC-H Desiree Bernadette Johns, CPC Desiree Deirdre McCann, CPC, CPC-H, CPMA Diana Ana Valdez, CPC Diana Davis, CPC Dianna Gilmore, CPC Diedra Mallory, CPC Donna Stuber, CPC Edith Cardiff, CPC Elena Rodriguez, CPC Elizabeth Chapman, CPC Elizabeth P Field, CPC Elizabeth Rodriguez, CPC Emilee Ann Catelo, CPC Emily Miller, CPC Erica Brownawell, CPC Erika Lambright, CPC Erin Alana Barnette, CPC Eugene Defrees, CPC Faye Skrdla, CPC Frank Louis Ungvary, CPC Gabriela Vazquez, CPC Gail D Schilling, CPC Gail Parravicini, CPC, CPC-H Gigina L Moran, CPC Gina U Singson, CPC Hailey Renee Baxter, CPC-H Heather Diaz, CPC Heather Dunlap, CPC Heather M Gales, CPC Heather Michelle Willis, CPC Heather Tadlock, CPC Heidi Ann Summerlin, CPC Helen Le, CPC Helen M Larkins, CPC Holly Sheetz, CPC Hope S Conner, CPC Iris Suarez, CPC Jacqueline D Joyner, CPC Jacquelyn Ferguson, CPC Jamie Werts, CPC-H Jan Mattson, CPC Jan Moses, CPC Janeil Addison, CPC Janet Seymour, CPC Janet Marie Pollard, CPC Janet S Hodgdon, CPC Jeanneann M Talasazan, CPC-H Jeff Krider, CPC Jennifer Grippando, CPC-H Jennifer Fenstermaker, CPC Jennifer Lynn Heuer, CPC Jennifer Lysa Kelley, CPC Jennifer Strouth, CPC Jenny Y Lopez, CPC Jessee Nichole Snow, CPC Jill Ward, CPC John Chau, CPC-H Joyce Dalton, CPC Judy Lynn Naples, CPC

Judybeth Fernandez, CPC, CPC-P Julie Anne Rezendes, CPC Julie Lynn Eavenson, CPC Julie Maffetone, CPC Julie Zick, CPC Kahlynn Lawrence, CPC Karen Lynn Stanley, CPC Katherine Paguio Magpantay, CPC, CPC-H Kathleen Louise Whitley, CPC Kathryn E Riley, CPC Kathy A Schnautz, CPC, CPC-H Kathy A Smith, CPC Kathy Raymer, CPC Katrina Bell, CPC Katy Pegorsch, CPC Keisha Allmond, CPC Kelly E Mayo, CPC, CPC-H Kelly Jackson, CPC Kerri L Hewitt, CPC Kerry Allen, CPC Kerry Skolnick, CPC Kim Vasarab, CPC Kimberly D Morgan, CPC Kimberly Haas, CPC Kimberly Steele, CPC Kizzy Lashon Williams, CPC Kris L Lang, CPC, COSC Kris Smith, CPC Krista K Edwards, CPC Kristi Elliott, CPC Kristin Brace, CPC Kristin E Piccolo, CPC Kristin Joy Seara, CPC Lacey Springer, CPC Lara Aiken, CPC Laura Hicks, CPC Laurie Anne Tanner, CPC Leianna Gladden, CPC Lesa Applegate Smiley, CPC Linda S Scarlett, CPC Lindsay Chriss, CPC Lindsey Hoffman, CPC-H Lisa M Poitra, CPC Lisa M Rice, CPC-H Lisa Maria Archer, CPC Lizzy Randleman, CPC-P Lolita Joyce, CPC Loretta M Vittoria, CPC Lori Gibbs, CPC Lori Lee Snyder, CPC, CPC-H Lori M Stapel, CPC Lorinda Bolton, CPC Ludmila Yanishak, CPC Lynda Eileen Jimenez, CPC, CPC-P, CPMA, CEMC Magda Rodriguez, CPC MaraLynn Hudock, CPC Margret Wunsch, CPC Marguerite Marsh, CPC Mariana C Lalloz, CPC Marilyn Martinus, CPC Marne L Lasky, CPC Marta Moscicka-Tecza, CPC Martha Veronica Rangel, CPC Mary Catherine Blevins, CPC-H Mary Dax, CPC-P Maya Krishana Jinwright, CPC Megan Helen Foley, CPC Megan Skeans, CPC Melanie Amelia Mclin, CPC Melissa Ann Borgel, CPC, CEDC

Melissa Francis, CPC Michael Shawn Hammond, CPC, CPC-H Michele Anne Racioppi, CPC Michelle Korbisch, CPC Michiko Uyeke-Esmeria, CPC Mona L Pratt, CPC Nancy Rosales, CPC Nancy Salas, CPC Nicole Andrea Waryn, CPC Nicole L Ellis, CPC Ofelia Urbina, CPC Olivia Deterling, CPC Pamela Dropik, CPC Pamela J Hanna, CPC Patricia Barta, CPC Patricia Gomez, CPC Penny Gaines, CPC Prasanth Kumar Thudukurthi, CPC, CPC-P Rachel Jarmon, CPC Ravikumar Jayaraj, CPC, CPC-P Regina V Williams, CPC Rhonda Birkner, CPC Ric Hanna, CPC Rochelle O Roberts, CPC Rodica Moga, CPC, CPC-H, CPC-P Sandra Gamboa, CPC Sara Michelle Stoll, CPC Seerojnie Ramgobind, CPC Shanda Nicole Munoz, CPC Shannon Swiderski Provenza, CPC Shayna Leigh Decker, CPC Sheena L Booher, CPC Sheri Jensen, CPC Stacey A Kerkache, CPC Stacy Lynn Monell, CPC Stephanie A Holland, CPC Stephanie D Henslee, CPC Stephanie East, CPC Sue Pruden, CPC Susan Pope, CPC Susan Elaine Pringle, CPC Susan K Smith, CPC Susan M Mathews, CPC Susan Morris, CPC Suzan Neel, CPC Suzanne C Edin, CPC Suzanne Elizabeth Carballo-Martinez, CPC Sylvia A Ruffin-Cuffee, CPC Tamara L Lucus, CPC, CPC-H, CPMA, CPC-I Tammie Womack, CPC Tammy Y Mossman, CPC, CPC-H Tara Childers, CPC Taura Way, CPC Tejal Patel, CPC Tenesha Bryan, CPC Tenoya D Bennett-Toyryla, CPC Teresa Raymond, CPC Teressa Cupil, CPC-H Tina Moore, CPC Tonya L Justice, CPC Tracey Denise Pierce, CPC Tracie Ann Henry, CPC Vicki Lizotte, CPC Victoria L Pashia, CPC, CPC-H Victoria Rentrop, CPC Victoria Sloan Orr, CPC Vinoth Ramdass, CPC, CPC-P Wanda Garcia, CPC Wendy Gonzalez, CPC Wendy Shope, CPC

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Apprentices Abbey Gearhart, CPC-A Abigail Erlandson, CPC-A Adam Mask, CPC-A Afroditi Karanikola, CPC-A Aiza Amorsolo, CPC-A Alana French, CPC-A Alberta Laws, CPC-A Alejandra Letic, CPC-A Alexandra Kristine Luna, CPC-A Alexis Ward, CPC-A Alicia Dawn Moseley, CPC-A Alicia Herman, CPC-A Alicia Thorpe, CPC-A Alisha Abel, CPC-A Allyson Brown, CPC-A Amanda Cluck, CPC-H-A Amanda G Pearce, CPC-A Amanda Gail Morris, CPC-A Amanda J Ten Eyck, CPC-A Amanda Kerr, CPC-A Amanda Marie Yankah, CPC-A Amanda Rae Rasmussen, CPC-A Amanda Renee Schuchardt, CPC-A Amanda Richards, CPC-A Amanda Richards, CPC-A Amanda Tate, CPC-A Amara Smith, CPC-A Amber Rashid, CPC-A Amie Adele Orsland, CPC-A Amory Tolbert, CPC-A Amrita Raja, CPC-A Amy Cooper, CPC-A Amy Garrett, CPC-A Amy Goldstein, CPC-H-A Amy Lynn Clark, CPC-A Amy McArdle, CPC-A Amy Ross, CPC-A Anastasha Jett, CPC-A Andrea Hall, CPC-A Andrew W Baker, CPC-A Andy Welch, CPC-A Angela Gregorio, CPC-A Angela Reid, CPC-A Anitha Anandan, CPC-A Ann Crary, CPC-A Anna Creech, CPC-A Annie Randall, CPC-A April Michelle Rigdon, CPC-A Ashley Bates, CPC-A Ashley Hall, CPC-A Ashley Hollon, CPC-A Ashley Rocha, CPC-A Aubrey Antiojo, CPC-A Aubrey Bulaon Ablir, CPC-A Ava Elizabeth Hall, CPC-A Bailey Nicole Vincent, CPC-A Barbara Hetzel, CPC-A Barbara Noble, CPC-H-A Barbara Scaboo, CPC-A Beatriz A. Gonzalez, CPC-A Becky Zhang, CPC-A Bethany Starliper, CPC-A Betty Logan, CPC-A Beverly Ellen Murphey, CPC-A Bobbi Kegler, CPC-A Brandi Glasscock, CPC-A Brandon Edward Koller, CPC-A Brandy Bell, CPC-A

August 2012

47

Newly Credentialed Members

Brenda L Mooneyham, CPC-A Brigitte Fagan, CPC-A Brittany Dull, CPC-A Brittney Winn, CPC-A Brooke Anne Alsup, CPC-A Brooke Stamm, CPC-A Caitlin Brianne Clemons, CPC-A Caitlin Carroll, CPC-A Cameron Masaoka, CPC-A Cammy Renee Duvall, CPC-A Candice Carter, CPC-A Candice Gilliard, CPC-A Carissa Stark, CPC-A Carla Cornwell, CPC-A Carmen Aniece Reed, CPC-A Carol Babson, CPC-A Carol Meade, CPC-A Carole Ludwig, CPC-A Carolyn Axthelm, CPC-A Carolyn E Beers, CPC-A Carrie Ann Sorensen, CPC-A Carrie Cook, CPC-A Carrie Fillar, CPC-A Carrie Nohel, CPC-A Carrie Pennybacker, CPC-A Carrie Smallwood, CPC-A Caryn Slack MD, CPC-P-A Casey Gowers, CPC-A Casey Nicole Horning, CPC-A Casey Smith, CPC-A Cassandra Bugbee, CPC-A Celeste Kotowski, CPC-A Chanel Davenport, CPC-A Chanta Adams, CPC-A Charleen Remedios, CPC-A Charlene Baase, CPC-A Charlene Wilbur, CPC-A Chelsea Frank, CPC-A Chelsea Huff, CPC-A Cherryl Calades De Asis, CPC-A Cheryl A Sutherland, CPC-A Cheryl Castaneda, CPC-A Chris Rouff, CPC-A Christie Hickman, CPC-A Christine A Jones, CPC-A Cindi R Brashear, CPC-A Connie J Clarke, CPC-A Connie M Dixon, CPC-A Connor Manning, CPC-A Corina Garcia, CPC-A Cortney T Nettles, CPC-A Courtney Lane Robinson, CPC-A Crissy Burns, CPC-A Cynthia A Harris, CPC-A Cynthia Denise Wood, CPC-A Cynthia Johnson, CPC-A Cynthia Marie Craig, CPC-A Dan Griffith, CPC-A Dana Chock, CPC-A Daniela Plourde, CPC-A Danielle Lee Eckstein, CPC-A Danielle Thompson, CPC-A Danita Bryant, CPC-A Darlene K Jacobs, CPC-A Darlene M Hubbard, CPC-A Darryl Bowers, CPC-A Darshan Rattenahalli Somashekaraiah, CPC-A David Alexander LeClair, CPC-A David Elkins, CPC-H-A David M Malecki, CPC-A David Westcott, CPC-A Dawn Davenport, CPC-A Deborah Ann Woods, CPC-A Deborah Ladd, CPC-A Deborah McClure, CPC-A

48

AAPC Coding Edge

Deborah Rhoads, CPC-A Debra Mulliken, CPC-A Deedria Johnson, CPC-A Deinna Cervera, CPC-A Demetria Jackson, CPC-A Denette Slafter, CPC-A Denise Cox, CPC-A Denise M Olszewski, CPC-A Diane Borrego, CPC-A Dianne Grant, CPC-A Donna Enste, CPC-A Donna Fortenberry, CPC-A Donna Lane, CPC-A Dorothy Miller Bateman, CPC-A Eden Elizabeth Gusewelle, CPC-A Eileen Rachelle Larroza, CPC-A Elaine A Harbold, CPC-H-A Elaine Beaupied, CPC-A Elisa Wilkerson, CPC-A Elizabeth Davis, CPC-A Elizabeth Hill Vedder, CPC-A Elizabeth Weber, CPC-A Ellen Silverman, CPC-A Ellison David Elizaga, CPC-A Elvira Castelluzzo, CPC-A Emily Moore, CPC-A Emmanuel Ignacio Almeda, CPC-A Eric Pound, CPC-A Erica Stahl, CPC-A Erica Commedo, CPC-A Erica Deza, CPC-A Erin Cantiberry, CPC-A Erin Williams, CPC-A Fae L Price, CPC-A Flor Diaz, CPC-A Francis Paula Parriett, CPC-A Gabriela Yep, CPC-A Gail Stoops, CPC-A Gene Mciver, CPC-A Gina Rouse, CPC-A Ginny Edge, CPC-A Giriraj Parthasarathy, CPC-A Glenn Clark Easterling, CPC-A Gwendolyn Pfeifer Admire, CPC-A Harinder Kaur, CPC-A, CPC-H-A Harini Katam, CPC-A Harriett Marie Soumah, CPC-P-A, CPMA Heather Payne, CPC-H-A Heather R Goldsby, CPC-A Holly Geller, CPC-A Imaiyanvan Varuthappan, CPC-A Inna Verbitskaya, CPC-A Jackie Engleson, CPC-A Jacob Marc Sonkin, CPC-A Jacqueline M Laires, CPC-A Jacqueline S Lai, CPC-A Jamie Perucca, CPC-A Janel Wilson, CPC-A Janet Howell, CPC-A Janet Sue Fike, CPC-H-A Jason Denson, CPC-A Jean Boyer, CPC-A Jean M Page, CPC-A Jeanelle Smith, CPC-A Jeanine S Gallagher, CPC-A Jeanmarie Morse, CPC-H-A Jennifer Aileen Alvara, CPC-A Jennifer Burke, CPC-A Jennifer Ezzell, CPC-A Jennifer Gould, CPC-A Jennifer Hart, CPC-A Jennifer Heiser, CPC-A Jennifer J Johnson, CPC-A Jennifer Leep, CPC-A Jennifer Michelle St John, CPC-A

Jennifer Parks, CPC-A Jennifer Paynter, CPC-H-A Jennifer Reed, CPC-A Jennifer Rumble, CPC-A Jennifer S Shepegi, CPC-A Jennifer Snodgrass, CPC-A Jennipher Wioskowski, CPC-A Jessica Bryant, CPC-A Jessica Lynn McKenna, CPC-A Jessica Noel Rodrigues, CPC-A Jill Sparr, CPC-A Jill Tracy Porter, CPC-A Jo Swanston, CPC-A Joan M Sestili, CPC-A Joelle Thomas, CPC-A Joey Fleury, CPC-A Johanna Johnson, CPC-A John Patrick Atienza, CPC-A John Ruzel Balagtas Urrutia, CPC-A Joleen Somers, CPC-A Jomielyn Rafanan, CPC-A Jonna Davis, CPC-A Jose Manuel Fernandez, CPC-A Jose Rafael Fernandez, CPC-A Joyce Holt, CPC-A Joyce Smith, CPC-A Judith R Plaza, CPC-A Judith Sponkowski, CPC-A Juleah Ryder, CPC-A Julia A Wahler, CPC-A Julie Mace, CPC-A Junaufer Ponce, CPC-A Kaitlin Marie Brown, CPC-A Kalava Rajyalakshmi, CPC-A Kalpana Munagala, CPC-A Karen Anne Hutton, CPC-A Karen Clarke, CPC-A Karen J Sharrah, CPC-A Karen Jones, CPC-A Karen K Rasmussen, CPC-A Karen Y Owens, CPC-A Karie Wessling, CPC-A Karly Sadkovich, CPC-A Karma Sanchez-Garcia, CPC-A Katelynn K Hill, CPC-A Katherine Melendez, CPC-A Kathleen Kleinbauer, CPC-A Kathleen McCorkle, CPC-A Kathleen S Tuinstra, CPC-A Kathryn Danielle Whitney, CPC-A Kathryn Grace Scott, CPC-A Kathy Gunderson, CPC-A Kathy Lephart, CPC-A Kathy Markham, CPC-A Katie Ann Reed, CPC-A Katie Malone, CPC-A Kayla M Beachler, CPC-A Kayla M Fisher, CPC-A Kelly Meeks Childs, CPC-A Kelly Rae Centazzo, CPC-A Kelsie Marie Johnson, CPC-A Keri Casper, CPC-A Kevin Garcia Fajardo, CPC-A Kim Clark-Scott, CPC-A Kim Jo McCollum, CPC-A Kim Keller, CPC-A Kim Oswalt, CPC-A Kim Tillery, CPC-A Kimberly Rodriguez, CPC-A Kimberly Ann Kading, CPC-A Kimberly Jones, CPC-A Kimberly Lynn Robeson, CPC-A Kimberly M Banter, CPC-A Kimberly Marie Cox, CPC-A Kimberly S Stamp, CPC-A

Kimberly Smith, CPC-A Kimberly Smith, CPC-A Kimyatta Bivens-Little, CPC-A Krisha Rayne Kines, CPC-A Kristen Lynn Goodnight, CPC-A Kristen Street, CPC-A Kristi DeAnn Boyd, CPC-A Kristi Elzy, CPC-A Kristi Erickson Wilken, CPC-A Kristi Riendeau, CPC-H-A Kristie L Riches, CPC-A Kristie Pruitt, CPC-A Krystal Wynter, CPC-A Kyle Cole, CPC-A, CPCO, CPC-P-A Kym Carson, CPC-A La’Shanna Corine Goodwin, CPC-A Lacey Williamson, CPC-A Lachelle Robinson-Mason, CPC-A Lacinda Wiles, CPC-A LaDonda Gonsalves, CPC-A Laura Burden, CPC-A Laura Gibbs, CPC-A Lauren Stiller, CPC-A Lauretta Carter, CPC-A Laurie Catherine Norris, CPC-A Laurie L Brown, CPC-A Lavanya Anumala, CPC-A Lawrence Paolo Bautista, CPC-A LeeAnna Arlene Flint, CPC-A Lenore Cioffi, CPC-A Leslie A Van Tilburg, CPC-A Leslie K Aleck, CPC-A Letha Lee, CPC-A Lexi Holder, CPC-H-A Lianette Campos, CPC-A Liliana Suarez, CPC-A Linda Case, CPC-A Linda Lee Aiken, CPC-A Linda Perry Davis, CPC-A Lindsey Marie Austin, CPC-A Lindy Logue, CPC-A Lisa Ann Chamberlin, CPC-A Lisa Bailey, CPC-A Lisa DePietro, CPC-H-A Lisa J Seslar-Lamont, CPC-A Lisa Lopez, CPC-A Lisa Stephens, CPC-A Lisette Katrina Cota, CPC-A Liz McCready, CPC-A Lora Disbro, CPC-A Lori LaClair, CPC-A Lori Bolesta, CPC-A Lori Curtis, CPC-A Lorveline Arviola Penus, CPC-A Louiza Sarkisyan, CPC-A Lourdes Ayala, CPC-A Lusine Barseghyan, CPC-A Lyka Anne Angeles, CPC-A Lynette Ann Nagy, CPC-A Lynn M Leist, CPC-A Lynn Vaughan, CPC-A Ma Theresa Marpa, CPC-A Magdah Reynoso, CPC-A Maggie Dziubek, CPC-A Mahesh Koppachari, CPC-A Mandy Scheiderman, CPC-A Manju Nair, CPC-A Marcy L Linke, CPC-A Margaret Behrmann, CPC-A Margaret Woodcock, CPC-A Margie Kay Alderman, CPC-A Maria Laou, CPC-A Maria Carmela Bautista, CPC-A Maria Cartagena, CPC-H-A Maria Ortiz, CPC-A

Maria Sienna Fe Ochave Pamintuan, CPC-A Maria Teresa Ginez Contreras, CPC-A Mariah M Banks, CPC-A Marie Farrell, CPC-A Mariette Elizee, CPC-A Marilyn Pacheco, CPC-A Marilyn Radtke, CPC-A Marina Spektor, CPC-A Markalene F Earles, CPC-A Marlo Rain De Leon, CPC-A Martha A Skidmore, CPC-A Marti McCall, CPC-A Marvaree Bailey, CPC-A Mary L Poole, CPC-A Mary M Sherrod, CPC-A Mary W Caporale, CPC-A Mary W Clarke, CPC-A Mary Waninger, CPC-A MaryAnn Thompson, CPC-A Maryline Medina, CPC-A Marylou Tammaro, CPC-A Matthew Pyer, CPC-A Megan Podrez, CPC-A Melinda Mae Young, CPC-A Melissa Bodvar, CPC-A Melissa Roberts, CPC-A Melissa Hardy, CPC-A Melissa Jane Kurtz, CPC-A Melissa VanNieulande, CPC-A Mercy Priyadarsini, CPC-A Michaela Michelle Hensley, CPC-A Michele L Gruntz, CPC-A Michele Stone, CPC-A Michelle Johnson, CPC-A Michelle Loera, CPC-A Mindy Ruble, CPC-A Mireya Coria, CPC-A Misty Sparkman, CPC-A Mohammad Azhar Hussain, CPC-A Monica Edwards, CPC-A Monica Shatnawi, CPC-A Mumthas Yoosuf, CPC-A Nancy Ann Feisel, CPC-A Nancy C Mak-Tse, CPC-A Nancy L Bingham, CPC-A Nancy Moreau, CPC-H-A Naomi Jones, CPC-A Natalie A Waddle, CPC-A Natashia Renee Hubbard, CPC-A Nichole Lear, CPC-A Nicole Barcellos, CPC-A Nicole C Haller, CPC-P-A Nicole M Oliver, CPC-A, CPC-H-A Nicole Williams, CPC-P-A Nikki DeGregorio, CPC-A Nikki Real, CPC-A Nuria Dolan, CPC-A Olivia Pace, CPC-A Ophelia Malagayo, CPC-A Pam Gould, CPC-A Pamela Barker, CPC-A Paola Taborda, CPC-A Patricia A Wilson, CPC-A Patricia Fox, CPC-A Paul John Abboud, CPC-A Paul Mora, CPC-A Paula A Folts, CPC-A Paula B Whetstone, CPC-A Paula Kay Dyck, CPC-A Paula Randall, CPC-A Paula V Burklow, CPC-A Penny Geary, CPC-A Penny Waterman, CPC-A Plamena Elenski, CPC-A Praveen Kumar Polepaka, CPC-A

Newly Credentialed Members

Quenton L Myhand, CPC-A Rachel D Brunswick, CPC-A Rachel Sanchez, CPC-A Rachelle Bonghanoy, CPC-A Radhika Nakirikanti, CPC-A Rafael Antonio de la Vega, CPC-A Rajitha Kandimalla, CPC-A Ramon Gonzalez, CPC-A Ramona Marie Vickrey, CPC-H-A Ramona Grow, CPC-A Randee Moore, CPC-A Raveendra Chagantipati, CPC-A Rebecca A Wallace, CPC-A Rebecca Chatham, CPC-A Rebecca Jaggernauth, CPC-A Rebecca Jewel Brouillette, CPC-A Rebecca Norris, CPC-H-A Rebecca Renee Connors, CPC-A Rebecca W Crytser, CPC-A Redaleen Devibar Garcia, CPC-A Regina Gallagher, CPC-A Renea R Moore, CPC-A Renee Huddleston, CPC-A Renee Reno, CPC-A Rhonda Graf, CPC-A Rhonda Lorenz, CPC-A Rhonda Simonian, CPC-A Rhonda Sphon, CPC-A Robin Stewart, CPC-A Robin D Mccoy, CPC-A Robin Feldman, CPC-A Rodney F Sheets, CPC-A Roger Ramos, CPC-A Ron Hamiter, CPC-A Ronald Lee McKeown, Jr., CPC-A Ronda Day, CPC-A Ruth Flowers Godwin, CPC-A Ruth Lauer, CPC-A Ruth S Sheets, CPC-A Ryan Almero, CPC-A Sabrina Foster, CPC-A Sabrina Leigh Foy, CPC-A Saleh Marette, CPC-A Sam Johnson, CPC-A Samantha Alison Mehne, CPC-A Samantha Stidham, CPC-A Sandra Ryen, CPC-A Sandra Scarberry, CPC-A Sandy Elftman, CPC-A Sandy Watkins, CPC-A Sara Ellen Huffine, CPC-A Sara Shafer, CPC-A Sarah L Mitchell, CPC-A Sarah Lewis, CPC-A Sarah Ortiz, CPC-A Sarina K Mayer, CPC-A Sathiya Seelan, CPC-A Sean Groves, CPC-A Shamelia Perdue, CPC-A Shanna Rose Leonardo, CPC-A Shannon Dearborn, CPC-A Shannon Johnson, CPC-A Shannon Wildenberg, CPC-A Sharon Loeffler, CPC-A Sharon Maniaci, CPC-A Sharon Nolf, CPC-A Shashidhar Ameenpur, CPC-A Shawn Gass, CPC-A Shawntay Michelle Nichols, CPC-A Shea Goodwin, CPC-A Sheeja K R, CPC-A Shejil Babu Padincharethil, CPC-A Shelby Bockman, CPC-A Sherri R Hughes, CPC-A Sherrie Ryan, CPC-A

Sherrvonne Jones, CPC-A Sherry Whitfield, CPC-A Sheryn Payton, CPC-A Shilpa Laggeri, CPC-A Shwetha Kasturi, CPC-A Simone Williams, CPC-A Sireena DeFazio, CPC-A Sirpa Lepisto, CPC-A Sonia Lopez, CPC-A Sonya Getchell, CPC-A Sonya Page, CPC-A Sonya Ramsey, CPC-A Stacey Thomas, CPC-A Stacy Gogel, CPC-A Stefani Belew, CPC-A Stefanie Osborne, CPC-A Stephanie Ann Stines, CPC-A Stephanie Diane Lopez, CPC-A Stephanie Obenour, CPC-A Stephanie Renee McIver, CPC-A Stephanie Smart, CPC-A Stephanie Smith, CPC-A Stephen Hirst, CPC-A Sue McNamara, CPC-A Sunni A Munoz, CPC-A Supriya Vendidandi, CPC-A Suresh Babu, CPC-A Susan A. Boose, CPC-A Susan Bagis, CPC-A Susan Burbank, CPC-A Susan Clark, CPC-A Susan Elizabeth Alterman, CPC-A Susan Hawkins, CPC-A Susan Lute, CPC-A Susan Witzke, CPC-A Susanne Lischer, CPC-H-A Suzanne Honor, CPC-A Suzie Sawyer, CPC-A Swetha Chada, CPC-A Sylwia Struk, CPC-A Tamara Renae Markle, CPC-A Tami Hammond, CPC-A Tammie P McClendon, CPC-A Tammy Jean Wilson, CPC-A Tara Stallwood, CPC-A Tara Blazakis, CPC-A Tara Maurine Bratcher, CPC-A Tara Michelle Secco, CPC-A Teanna Strahin, CPC-A Teddie Kirk, CPC-A Teri Parrish, CPC-A Terri Thompson, CPC-A Terri Gibbs, CPC-A Terrie Lynn Jackson, CPC-A Terry James, CPC-H-A, CIRCC Theresa Ardelean, CPC-A Theresa Clay, CPC-A Therese F Espiritu, CPC-A Tiffannie Lauren Castle, CPC-A Tiffany N Smith, CPC-A Tiffany Pruitt, CPC-A Timothy Ray Baker, CPC-A Tina Marie Martin, CPC-A Tonya L Toney, CPC-A Tonya Reeves, CPC-A Tracy Ann Hughes, CPC-A Tracy Ann Wright, CPC-A Tracy Jo Schreiner, CPC-A Trisha Ching, CPC-A Trisha Nicole Hand, CPC-A Trishelle DeCoite, CPC-A Trista Miller, CPC-A Trista Shoemaker, CPC-A Twila Dykstra, CPC-A Udaya Kumar Gonuguntla, CPC-A

Valerie Jo Rosati, CPC-A Valerie Pachak, CPC-H-A Vanessa Mason, CPC-A Veronica Jean Woolfolk, CPC-A Veronica LaMesha Moss, CPC-A Veronica Lee Jackson, CPC-A Vicki Caudill, CPC-A Victoria Carpenter, CPC-A Vinice L During, CPC-A Virginia M Hall, CPC-A Wendy Grove, CPC-A Whasook Park, CPC-A William Jarred Forrester, CPC-A Winifred Yaa Ekeh, CPC-A Yuliana Teresa Lagarda, CPC-A

Specialties Alyssa Kay Owens, CPC-A, CANPC Amy Debenham, CPC, CPEDC Amy K Morgan, CPC, CPMA, CEMC, CGSC Ana Parrotta, CPC, CANPC Angela Brown, CPCO Angela Kay Smith, CPC, CFPC, COBGC Anila Prasad, CPC, CPMA Anna B Weaver, CPC, CPMA, CEMC Anna M Morissette, CPC, CGIC, CGSC Annette Lewis, CPC, CPMA AnnMarie Charles, CPC, CPMA, CUC Arianne Echemendia, CPC, CPMA Belinda Copeland, CPC, CEMC Bev Callow, CCC Brenda K Mook, CCC Carmela Heshike, CPC, CPMA Carol Ann Brinson, CPC, CPMA Caryn Smith, CPC, CRHC Catherine E Arment, CPC, COSC Chaya Howard, CPC, CIRCC, CCC Chequita A Battle, CPC, COSC Christina Lee Wagner, CPC, CPC-H, CGIC Christina Nichola Olson, CPMA Clifford C Sumner, CPC, CIRCC Colleen Lennon, CPCO Cynthia C Smith, CPC, CPMA Cynthia Hartline, CPC, CPMA Damaysi B Gonzalez, CPC, CPMA Dani Holmes, CGIC Danieyi Martinez, CPC, CPMA Debbie L Hayes, CPC, CPMA Dee Kelly, CPC, CPCO, CPMA, CPCD Deirdre Ann Reid-Fighera, CRHC Denise L Sullivan, CPC, CGSC Doris Eberhardt, CPC, CUC Elizabeth Akopyan, CPC, CPMA Elizabeth Geiss, CRHC Elizabeth Horricks, COBGC Ellen M Dixon, CPC, CPMA Frieda Roshto, CPC, CPC-H, CPMA, CPC-I Geraldine Valdez, CUC Guadalupe Valdepena, CEDC Harriet Thomas-Fryer, CPC-H, CPC-P, CPMA Helen Park, CRHC Izel Silva, CPC, CPMA Jamie L Boltz, CPC, CPC-H, CPC-P, CPMA, CEMC Jane Clay, CPMA Jane Susan Wilson, CPC, CEMC Janel McDaniel, CPC, CPMA Jeannie Davis, CPC, CANPC Jennifer Borngraber, CPC, CGIC Jennifer Mayeaux, CPC-A, CEMC Joanna Fernandez, CPC-A, CPMA Julia Lima, CPC, CEMC Julie Wilson, CGSC, COBGC Julie Anne Fuhriman, CPC, CEMC Julie Ellen Roa, CPC, CPMA Julie Parks, CPC-A, CANPC

Kanmani Senthilkumar, CPC, CPMA Karen Silva, CPC, CPMA Karen Sue Connors, CPC, CPMA Karen W Kelly, CPC, CPMA Kathryn A Heimerman, CPC, CGSC Katie Wells, CPC, CPMA Kelli LeAnn Thompson, CPC, CEMC Kim Renee Butts, CPC, CPMA Krista Lenig, CPC-P, CPMA Lauren Anne Burdick, CPC-A, CPMA Laurie A Wilson, CPC, CPMA Leslie Walden, CPC, COSC Leticia Marrero, CPC, CPMA Lila Halverson, CPC, CPMA Linda Huey, CPC, CGSC Lindsey Lara, CPC, CPMA Lisa Donahue, CPC, CPMA Lisa VanLaan, CPC, CPMA Lisbeht Barrientos, CPC-A, CPMA Liuba Quevedo, CPC-A, CPMA Lori Mahan, CPC, CPMA Lucia Menendez, CPC, CIRCC Maiko Lindblom, CPC, CPMA Manisha D Naik, CRHC Mara Mendez, CPC, CPMA Marea L Aspillaga, CPC, CPC-H, CPMA Maria Gabriela Tardencilla, CPC, CPMA Marianne E Urtel, CPC, CEMC Marlene Diaz, CPC, CPMA Martha Christie Callaghan, CPC, CPMA, CEMC, COSC Martha L Gaviria, CPC, CPMA Matthew Christopher, CCPC Melissa Russo, CPC-A, CIRCC Michele R Cook, CPC, CPMA Michelle Anne Genck, COBGC Michelle Levis, CRHC Michelle Miller, CCC Michelle Renee Rowell, CPC, CGIC Nathan McNew, CPMA Nykia Ann Cabral, CPC, CEMC Polina Eshkol, CPMA Raisy Martinez, CPC-A, CPMA Renee Suzanne Morgan, CPC, CPMA Renee White, CPC, CPMA Robin Sharry Scott, CPC, CEMC Roseanne Brown, CPC, CIRCC Sandra Troade, CPC, CPMA Sandy VanDyke, CPC-H, COSC Sedona Maria Kirby, CPC-H, CPMA Sheryl Annette Huffman, CPC, CPMA Siddharth Shah, CGIC Stacey Lynn Harper, CPC, CPMA Stacie L Hawkins, RHIA, CPC, CEMC Suharmy Jimenez, CPC, CPMA Susan DeBaugh, CFPC Sylvia Doggette, CPMA Tammy Kramlinger, CPC, CANPC Tania G Cruz, CPC, CPMA Tania Lopez, CPC-A, CPMA Teresa L Thomas, CPC, CPC-H, CPMA Teresa Pearce, CPC, CIMC Theresa Allen, CENTC Theresa Fischer, CPC, CPMA Tina M Carr, CPC, CEMC Toni J Hodge, COBGC Tracie Leah Hughes, CPC, CEDC Tracy M Olsten, CPC, CPMA, CPC-I Vennila Inba, CRHC Wanda M Prada, CPC, COSC Wanda Minnix, CPC, CPMA Wendy B Marchessault, CPC, CCC Yamila Prendes, CPC, CPC-H, CPMA Yelina Diaz, CPC, CPMA Yunaides Gonzalez, CPC, CPMA

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Magna Cum Laude Ailed Gonzalez Trujillo, CPC Alicia Meadows, CPC Amanda Ales, CPC Amanda Naulty, CPC Angela M Benkis, CPC-A Camille Morel, CPC-A Christina Cox, CPC-H Heather Stokes, CPC-A Hossein A Maleki, CPC, CIRCC Jeanne Viloria, CPC-A Jennifer Gibson Blankenship, CPC-A Jennifer Hayes, CPC-A Joan Spalletta, CPC-A Katherine Meyer-Cushing, CPC-A Kathy J McClenahan, CPC-A Kimberly Goode, CPC Laura A Grieb, CPC-A Linda Pearl, CPC, CPMA Lisa Marie Suarez, CPC-A Lori Ann Mitchell, CPC, CPMA Lucretia J Miller, CPC Michaela Landseer Seadale, CPC-A Patricia Bouchard-Case, CPC Ranchielie Ritarita, CPC-A Salonica Gray, CPC-A Shane Sindlinger, CIRCC Sindhumathi Ananthasayanam, CPC-A Stephanie Coleman, CPC-A Svitlana Hanson, CPC-H-A Tanya Lyons, CPC Victoria L Koontz, CPC-A

A&P Quiz Answer The correct answer is D. DIP is an acronym for distal intra-articular joint.

August 2012

49

Minute with a Member

president of another Charleston, S.C. chapter; and was a founder and secretary of the Hagerstown, Md. chapter. I have created a basic seminar, striving to keep costs down for maximum continuing education units (CEUs). I have mentored new members and happily report that some of them found employment through our networking.

What AAPC benefits do you like the most? I love networking with people all over the country. I have met many people at AAPC events and I’ve become good friends with some. Help is only a phone call or email away. My biggest AAPC benefit has been finding my position as a coding manager and consultant through my chapter in Washington, D.C. My boss was looking to fill a coding manager position and called the chapter officers from the officers’ list on AAPC’s website. He spoke with me and asked to let our members know about the position. I did as he requested, but after talking with him more about the position, I became very interested myself. I submitted my resume, we spoke again a couple of days later, and he asked me to meet the rest of the staff. I met with the staff the following week and was hired on the spot. If it weren’t for my local chapter, I would have never known about the position because he did not advertise it. I’ve since moved back to South Carolina, but I continue to work for the company as an independent consultant.

What has been your biggest challenge as a coder? One challenge is explaining coding and reimbursement limitations to someone who wants reimbursement for a device and/or procedure when there is no coding for that particular situation. It is also a challenge having to explain that it’s not OK to code for a particular service or item just because it’s payable by insurance. Another challenge is finding the time to read and learn more about coding. Some days I want to know it all!

Machelle Morningstar, CPC, CPC-H, CEMC, COSC Educator, Medical University of South Carolina, and Consultant Tell us a little bit about your coding career.

How is your organization preparing for ICD-10?

bout 30 years ago, I was working in a prison hospital. The inmates’ health care was contracted by the state, so we were required to keep certain statistics using ICD-9 coding. My supervisor offered to teach me coding and I gladly accepted. I went to college for medical office management and clinical arts, thinking eventually of a career in nursing. After learning coding, I took a detour and haven’t looked back. My career has included all aspects of coding, billing, office management, mainly in the physician and outpatient settings, with my previous position being senior reimbursement coding manager/consultant at a national orthopedic consulting firm. I am the ICD-10 educator at the Medical University of South Carolina, and I also do independent coding consulting and teaching.

We have an ICD-10 steering committee, made up with people from health information systems, information technology, finance, and many other departments, and we meet regularly. Our coders are working on Procedure Classification System training and will follow that with Clinical Modification in the fall. We have also gone to computer-assisted coding in preparation for ICD-10 documentation requirements.

A

What is your involvement with your local AAPC chapter? I am a member of the Charleston, S.C. chapter. I was the chapter founder and served as president of the Washington, D.C. chapter; I served as 50

AAPC Coding Edge

If you could do any other job, what would it be? Sports management! I love sports.

How do you spend your spare time? I have a 24-year-old son, Lucas, and between us we have three dogs. I enjoy reading and cross-stitching. I love being outside, especially at the ocean. I am very involved as a volunteer with sea turtle rescue and nesting season on the beach.

Unsure of what direction to take in preparing for the CPMA® exam? Let NAMAS Help! Log onto www.NAMASinfo.com and take the SELF ASSESSMENT TEST This test will suggest the training that is best suited for you based on your current auditing knowledge. Training suggestions may include: ◊ You are ready! Take the exam ◊ Self Study Guide only ◊ AAPC Online Training Program ◊ Live NAMAS Training Event NAMAS proudly offers CPMA® training as well as additional educational opportunities. Visit our website and check our calendar to see all of the exciting places NAMAS will be visiting! NAMAS wants to help coders and auditors “Enhance Your Career Through Education” We want to help make your auditing career propel to the next level! Attend a NAMAS Training session in 2012 and you will be registered for the:

Auditor’s Career Kit

This kit will include: ◊ 2013 CPT®/ICD-9/HCPCS books ◊ 2013 Coding Updates Book ◊ NAMAS and AAPC paid memberships for 2013 ◊ Paid Admission to the NAMAS 5th Annual Auditing Conference ◊ Paid Admission to the 2013 AAPC Annual Conference ◊ A Tablet for making you mobile and on the go EVERY educational session you attend increases your chances of winning this auditors career kit!

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