WELCOME!

Welcome to the summer 2012 issue of the Leading Edge. There is a lot happening inside and outside of AHS and we hope this issue provides a few new insights.

Outside of AHS, the healthcare environment continues to evolve. In particular, it is becoming clearer every day that the path to “payment reform” is gaining momentum. In fact, one expert commentator said last week, regardless of the pending Supreme Court decision, that payment reform has passed the “event horizon” or the point of no return. So we’ve taken some time in this issue with an attempt to show how many government initiatives, including PQRS, eRx, ICD-10, EMR / Meaningful Use, ACO’s, etc. comprise a “big picture” that shows us the future of healthcare reimbursement. Like any forecast, it isn’t perfect, but I believe you will find it extremely useful.

Our “day in and day out” service for clients continues to provide lots of highlights. You will find a few of them in the ClientFirst section. Plus some great examples where AHS employees are making a difference in the community and for their teammates.

You will find the first of a new series describing how AHS delivers superior results every day. As we pointed out last time, many of our activities are not very visible to you as a client, even though they are critical to the financial success of your practice. This is as it should be: AHS is hired to perform a difficult task so that you don’t have to be a coding and billing expert. In this issue, you will find an overview of the AHS Denial Management process, an important part of making sure you receive every dollar to which you are entitled.

As usual, we have some great AHS news to report in this issue. In our last issue, we welcomed the team in Akron, Ohio. In this issue, we profile the latest AHS office—AHS Delaware—and the new capabilities in Emergency Medicine and Ambulance billing that this new team brings for our customers.

These newsletters benefit from your feedback and suggestions. We are always looking for new topics and new stories.

Please call or email me with your suggestions for the next issue: bgilbert@ahsrcm.com or 908.279.8120

One new option: follow us on Twitter or Facebook to get regular industry and AHS updates: just click on the icons below.

Bill Gilbert

THE LEADING EDGEVol. 8 | Summer 2012Billing Technology Results

WELCOME | page 1

AHS PROFILEAHS Completes SOC1 | page 2AHS Delaware | page 2

FEATURED ARTICLES Denial Management; A Core AHS Capability | page 2 The Big Picture of “Payment Reform”, EMRs, ACOs, etc. Plus SGR | page 3

FEATURED EMPLOYEES Client First | page 9 Honoring Those Who Serve | page 10Congrats & Welcome | page 10AHS Presents at AAPC Meeting | page 11AHS Lombard Sponsors Community Service Event | page 11 Chambersburg Office | page 11

COMPLIAnCE CORnER | page 12 Provider Education3-Day Rule DID YOU KnOW? | page 12 CALEnDAR | page 13

SPECIALTY InSIGHTS

Radiology | page 14- RBMA Summit 2012: The Status & Direction of Radiology- Don’t Confuse OB and Pelvic Ultrasounds- ICD9/ICD-10 Comparison

ahsrcm.com

Radiology Coding and Billing

BillingTechnologyResults®

AHS COMPLETES SOC1In May, AHS completed a SOC 1, also known as a Statement on Standards for Attestation Engagements No. 16 (SSAE 16) Type I examination, for the first operations center: Portland. The certification process is underway for the other centers. The completion of this annual SOC 1 examination demonstrates that AHS is able to offer a substantially higher level of assurance and operational visibility than organizations that do not complete the SOC 1. This certification was previously known as “SAS-70.”

The completion of the SOC 1 Type I examination typifies AHS’ continued commitment to create and maintain the most stringent controls needed to ensure the highest quality and security of services provided to its customers. The Service Auditors’ Report issued by 360 Advanced, with an unqualified opinion, proves that AHS’ control activities were effectively placed in operation as of the report date.

In the press release announcing the certification, David Langsam, President and CEO of AHS said, “The SOC 1 certification demonstrates our commitment to providing quality service and transparency to customers who entrust us with critical information. As regulations become more stringent and difficult to navigate, hospitals, large physician groups, and surgery centers can look to AHS as a trusted partner for managing billing and other financial processes, and meet the standards established by their internal and external auditors.”

The Service Auditors’ Report includes a detailed description of AHS’ controls and an independent assessment of whether the controls are placed in operation and suitably designed.

AHS DELAWAREAHS is proud to announce its newest office in Newark, Delaware. This office and its team of 50 coding and billing experts joined AHS in April. AHS Delaware expands the company’s scope of Emergency Medicine services. The office also serves a number of ambulance and rescue services—important new capabilities and services for AHS. The Delaware office will become the AHS center of excellence in these two important specialties. The Delaware team averages over 12 years of service and is led by Maryann Kirk, Vice President Operations.

ahsrcm.com

THE LEADING EDGE Summer 2012

page 2

The Delaware office serves a dozen important emergency medicine practices, nearly fifty ambulance and rescue services and a number of smaller practices. Like other AHS offices, Delaware takes pride in delivering superior results for its clients with ClientFirst service. As Delaware clients move onto AHS systems, they will benefit from the InfoEdge dashboard and other leading AHS technologies.

The new office also expands the AHS geographic footprint with a large number of clients in the mid-Atlantic region. With over 30 years of experience in the mid-Atlantic and with a “critical mass” in ambulance and emergency medicine billing, AHS Delaware is an important addition to the AHS family.

Denial Management: A Core AHS CapabilityEveryone knows that denials happen every day, even in an environment like AHS where every claim that can be, is filed electronically. Even though AHS claims are clean (over 99% are accepted by payers), denials happen. There are many reasons: medical necessity (the insurer questions whether the procedure was required), the patient’s insurance has changed, the coding is questioned and many more. One of the key performance items that differentiates AHS from other billing companies is our ability to consistently, day in and day out, work and resolve denials. By doing so, we make sure our clients are collecting every dollar to which they are entitled.

The process of working denials is referred to as “Denial Man-agement.” This article provides an overview of the AHS De-nial Management process. This critical process is dependent upon key AHS technology and the know-how of many AHS team members.

Virtual Manager has an automated denial management sys-tem that automatically routes denials electronically to AHS insurance specialists and coders for resolution based upon the type of denial code. The process is driven by carrier-specific rules (master files). Based on denial codes and oth-er triggers, actions can include auto re-file of the claim, an appeal letter, or routing to the appropriate specialist. The denials are placed in the appropriate staff member’s work queue, where they are “aged” every day. If a denial isn’t addressed within a pre-determined timeframe, typically 2 or 3 days, Virtual Manager escalates the denial to the appropri-ate supervisor.

Unpaid claims are also identified by automatic system rules that flag claims that are not paid within a pre-determined period of time.

ahsrcm.com

THE LEADING EDGE Summer 2012

page 3

For example, if a specific carrier normally pays in 38 days, an escalation will be raised if the claim remains unpaid after 42 days.

Individuals specialize in denials and unpaid claims based on the specific denial type. For example, denials related to cod-ing are typically put in a certified coder’s work queue. Spe-cific A/R staff are assigned to work other denials and unpaid claims, usually by carrier. Virtual Manager is set up to enable the A/R follow-up person to contact a carrier, e.g. Aetna, re-garding one claim or denial and, upon resolution, immediate-ly provide the staff member with the next unresolved Aetna claim or denial. This process for phone work is both efficient and effective at resolving denials and related issues. For all staff members, automation and job aids speed the process: e.g. standard letters are stored in Virtual Manager and can be generated and sent by the specialist with the push of a button.

In many cases, an appeal is required and second level ap-peals are pursued as well.

Reporting of denials is available by client, doctor, insurance carrier, and type of denial as well as the dollars involved and the resolution of the denial. Periodic feedback to clients is an essential part of Denial Management, particularly for areas that the client can impact. Coding documentation and pro-cesses are one example. Medical necessity is another that is often related to documentation. Another example is the front end patient demographic data capture by the client’s hospital. While the client may not have direct control over the intake process, they can often make suggestions to hospital administration that benefit the client and the hospital.

An overview of the denial management process is shown below.

THE BIG PICTURE OF “PAYMEnT REFORM”, EMR’S, ACO’S, ETC. PLUS SGR Healthcare reform legislation (known as the Affordable Care Act or ACA) introduced and accelerated alternative payment models which may eventually supplant today’s Fee For Ser-vice model, regardless of the Supreme Court decision. At the same time, many private insurance companies are moving in the same direction and some argue, at a faster pace.

All of the new payment models have a number of pre-requi-sites. At their most basic level, every model intends to lower costs while improving patient outcomes: i.e. quality. The hard part is measuring these factors: costs and outcomes.

This article describes how a number of government programs fit into this larger “payment reform” picture.

To measure outcomes and quality, key programs include:• PQRS• eRx• EMR’s and Meaningful Use• ICD-10

The new models for payment are often described as “Pay for Performance” and include ACO’s, Bundled Payments and Capitation.

The government programs are listed in the sidebar with incentives and penalties where appropriate. At this point, each practice should be evaluating their participation, if they aren’t already.

A final “wild card” issue that threatens to overshadow all of the others in the short term is the never-ending SGR saga, described further below.

QUALITY MEASURE InCEnTIvE PROGRAMSThe PQRS (Physician Quality Reporting System) Incen-tive Program, eRx Incentive Program (e-prescribe) and the EHR Meaningful Use Incentive Program are all based on reporting clinical quality measures either by document-ing and performing particular measures or by having the ability to report those measures and other clinical informa-tion through electronic systems.

Although the programs are all administered by CMS and many measures are similar, each program requires a sepa-

ahsrcm.com

THE LEADING EDGE Summer 2012

page 4

rate and distinct work flow and has different requirements for reporting their measures. Stage 1 of EHR did not align its quality program with the PQRS program, although many of the measures are similar. This increases the costs of par-ticipation by providers as they have to document the same service in different ways. In Stage 2 of EHR, CMS proposes to choose the same measures for different programs and standardize measure development and specification pro-cesses across all CMS programs. All three programs offer incentives in their early stages to encourage provider participation but eventually apply penal-ties if providers do not successfully participate. The PQRS and EHR programs both begin their penalty years at the same time, in 2015. The eRx program instituted penalty payment adjustments this year and will continue adjust-ments through 2014. Currently, there are no eRx incentives or payment penalties beyond 2014, in hopes that providers will be submitting prescriptions through their EHR system by 2015.

Comments on the proposed Stage 2 of the EHR Program were due on May 7th and MGMA reiterated the need to align these three programs by “harmonizing the rewards and looming penalties for noncompliance in the EHR incen-tive program with those of separate and different rules and penalties for the PQRS and e-prescribing programs. CMS should deem as compliant with the e-prescribing require-ment all physicians who meet the separate EHR incentive program’s meaningful use requirements, which includes e-prescribing and reporting clinical quality measures.”1

With statistics only available through 2010, CMS reports that the PQRS and eRx programs showed significant gains in participation and incentives paid to eligible professionals. They have also identified key areas in which physician-level quality measures point toward future measureable results in improved quality of care delivered to Medicare beneficia-ries (see sidebar on next page).

It is also agreed that CMS should survey physicians on Stage 1 EHR criteria to find out what worked and what did not be-fore implementing more stringent measures and that Stage 2 should be carefully evaluated with respect to impact, value, cost, risks, administrative burden and technological standards.

QUALITY MEASURE InCEnTIvE PROGRAMS

Physician Quality Reporting System (PQRS)Effective Date 7/1/2007Legislation Tax Relief and Health Care Act of 2006Description Quality measure reporting program Measures 210 individual measures, 20 measurement groups, Certificate of Maintenance, EHR reporting for 51 of the 210 measures.Payments 2012-2014: .5% of the year’s Medicare Allowed Charges (MAC) 2014 is the last year for incentive paymentsPenalties 2015: 1.5% of Medicare Allowed Charges 2016 forward: 2% of Medicare Allowed Charges

eRx Incentive Program (e-prescribe)Effective Date 1/1/2009Legislation Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)Description Reporting program that uses a combination of payments and penalties to encourage the use of electronic prescribing by EPsMeasures OnePayments 2012: 1% of Medicare Allowed Charges (MAC) 2013: .5% of Medicare Allowed Charges 2014 forward: no incentivesPenalties 2012: 1.0% of MAC (Reporting Period – Jan- Dec 2010 or Jan-June 2011) 2013: 1.5% of MAC (Jan –Dec 2011 or Jan–June 2012) 2014: 2.0% of MAC (Jan-Dec 2012 or Jan-June 2013)

Electronic Health Records (EHR) and Meaningful Use (MU) Program Effective Date 2/1/2011Legislation American Recovery & Reinvestment Act of 2009, followed by CMS & ONC regulations in 12/2009 which implemented the programDescription Incentive program under Medicare and Medicaid to encourage the meaningful use of certified electronic health records Measures Stage 1: 25 core objectives and 10 elective (menu) measures Stage 2: Proposed 17 core objectives and 10 menu objectivesPayments Medicare: up to 75% of Yearly Medicare Allowed Charges with maximum of $44,000 over 4 years (2011-2015) Medicaid: Up to $63,750 over 6 years (2011-2021)Penalties 2015: 1% 2016: 2% 2017: 3% 2018: 4% Subsequent years: 3-5% Glossary:EP Eligible ProfessionalCMS Center for Medicare and Medicaid ServicesONC Office of the National Coordinator for Health Information

ahsrcm.com

THE LEADING EDGE Summer 2012

page 5

ICD-10 PROGRAMIn the midst of all these afore-mentioned programs, the transition to ICD-10 is also on the horizon. The Department of Health and Human Services (HHS), under political pres-sure, recently proposed to push back the start date from Oc-tober 1, 2013 to October 1, 2014.

In response to the proposed delay, some organizations are proposing alternatives to the 2014 deadline stating that too many other programs are being launched at the same time and providers are overwhelmed with these multiple pro-gram requirements.

Some of these proposals are:

• A longer postponement, • Offer an easier ICD-10 code set,• Wait for ICD-11, which is due in 2015, or• Eliminate transitioning to ICD-10 altogether and expand ICD-9

The MGMA states that ICD-10 implementation is expected to cost small physician practices $83,000 and large prac-tices up to $2.7 million, with the highest cost coming from increased documentation.2 Training of providers, staff and coders, as well as system upgrades, will be needed to suc-cessfully implement the coding set and the start-up period will slow down coding for several months, resulting in de-layed reimbursement for providers.

Another reason for requesting a delay comes from the re-cent experience of the transition from 4010 to 5010. Im-plementation of 5010 is a much easier transition and many practices were financially affected (though few AHS clients) because there was no standard definition of “5010 ready.” Many insurance plans and vendors’ systems were not ready to go live on January 1, 2012. The deadline was postponed two times, because there were still provider, vendor and in-surer systems that were not working properly. The current deadline is June 30, 2012.

In response to this, HBMA and others are requesting that CMS adopt a uniform definition of “ICD-10 ready,” which would mean at a minimum, the complete end-to-end test-ing of 837 and 835 transactions in full production before go-ing live and creating full transparency of where health plans are at all times in the readiness to accept ICD-10 diagnosis codes.

PAY-FOR-PERFORMAnCE PROGRAMS The programs listed here are federal programs. There are numerous other programs offered by private carriers and other entities. For example, Becker’s Hospital Review recently published a list of the top 80 ACOs.

Shared Savings ProgramEffective Date April 1, 2012 & 7/1/2012Legislation Accountable Care Act (ACA)Description Medicare ACO program using a shared savings model to reward integrated or coordinated groups of providers that organize to deliver quality care at a reduced cost.Measures Must perform 23 out of 32 measures in 4 domains. EHR measure counts the most.Payments Track 1: Achieve savings in excess of a minimum savings rate on a “first dollar” basis. No penalties for lossesPenalties Track 2: Achieve savings in excess of a minimum savings rate on a “first dollar” basis. Penalties all 3 years if actual costs are higher than shared savingsStatus On 4/10/2012, 27 organizations were selected to participate in the April 1st program.Site https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/sharedsavingsprogram/index. html?redirect=/sharedsavingsprogram/

Pioneer ACOEffective Date 1/1/2012Legislation Accountable Care Act (ACA)Description Developed for organizations that have already begun or currently operate an ACO-type model. It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Savings type model.Status 12/19/2011: 32 Organizations signed to begin participation on 1/1/2012 05/17/2012: Applications for 2013 program released 08/17/2012: Applications for 2013 program are dueSite: http://innovations.cms.gov/initiatives/ACO/Pioneer/index.html

Advanced Payment ModelEffective Date 4/1/2012 & 7/1/2012Legislation Accountable Care Act (ACA)Description: Initiatives designed for participants in need of pre-payment of expected shared savings to build their own ACOs.Status 5 participants as of the 4/1/2012 opening.50 appli- cants being reviewed for the 7/1/2012 start date 06/29/2012: Notice of Intent to apply for 2013 program due 09/19/2012: Applications for 2013 program are dueSite http://innovation.cms.gov/initiatives/ACO/Advance- Payment/index.html

ahsrcm.com

THE LEADING EDGE Summer 2012

page 6

Those in favor of keeping the 2013 deadline state that ICD-10 contains a robust database of patient illnesses and treat-ments, and these codes are needed to effectively measure outcomes and efficiency. The data are an essential compo-nent for all of the innovative payment mechanisms currently being proposed, including ACOs. Therefore a delay in ICD-10 may well postpone the benefits that many believe are the primary path to containing US healthcare costs.

The proposed delay has also caused some practices and hospitals to put ICD-10 on the back burner, without taking advantage of the delay to catch up on preparing for this tran-sition. The result is that delaying the deadline benefits those who were least prepared and penalizes the many organiza-tions who have invested substantial resources to meet the original date.

PAY-FOR PERFORMAnCEThe ACA is responsible for launching most of the federal pay-for-performance (PFP) programs. Many private insur-ers offered PFP programs before the ACA and actually pro-vided a base for many of the CMS models. Whether or not the ACA is struck down by the Supreme Court, experts see a strong movement toward revamping healthcare along ACO principles in an effort to rein in soaring spending.3 ACOs will not survive on Medicare participation alone but must focus on a larger market which will include commercial health plans, spreading shared savings and pay-for-performance programs to a population beyond Medicare. ACOs are de-signed for health care providers to achieve health care qual-ity improvements and reduce the rate of growth in costs. The end goal of encouraging quality care rather than generation of volume is important for both public and private insurers.

Medicare’s ACO and other pay-for-performance programs are based on quality measures, including PQRS and EHR. Although EHR usage is not a condition of ACO participation (for the Medicare program), it is weighted higher than other measures for quality-scoring purposes. CMS originally pro-posed that ACO participants be “meaningful users” of an EHR, but reduced the requirement in their final rule so that an ACO participant only needs to “successfully qualify” for an EHR Incentive Program.

Similar to the incentive programs, primary care physicians are the core of most pay-for-performance programs. The AMA holds a strong belief that there needs to be a transi-

Comprehensive Primary Care Initiative (CPC)Effective Date Not Available YetLegislation Accountable Care Act (ACA)Description CMS led multi-payer initiative fostering collaboration between public and private health care payors to strengthen primary care services. 4 year demonstrations for 7 selected markets with 75 practices per market and will test a service delivery model and a payment model.Status 04/11/2012: 7 market locations selected 06/07/2012: All participating payers signed a Memoran- dum of Understanding June 2012: Applications for providers in the 7 locations will be made availableSite: http://innovations.cms.gov/initiatives/Comprehensive- Primary-Care-Initiative/index.htmlBundled Payments for Care ImprovementsEffective Date Not Available YetLegislation Accountable Care Act (ACA)Description Program that bundles Medicare payments to hospitals, physician groups, non-physician practitioners, and others to promote patient-centered care within the hospi- tal setting and post-discharge. Participants have a choice of four models and will apply to CMS and bid on a target price for given medical services/episodes of care and will be paid under the traditional Medicare fee- for-service system. Total payments will be compared to the target cost level and the groups could share in Medicare’s savings.Status: Applications for Models 2-4 were due on June 28, 2012.Site: http://innovations.cms.gov/initiatives/Bundled-Payments/index.htmlIndependence at Home DemonstrationEffective Date Not Available YetLegislation Accountable Care Act (ACA)Description CMS will work with medical practices to test the effec- tiveness of delivering comprehensive primary care services at home to see if it improves care for Medicare beneficiaries with multiple chronic conditions. Demonstration will also reward health care providers that provide high quality care while reducing costs. This is a 3 year program.Status 16 medical practices are currently participating in this program.Site: http://innovations.cms.gov/initiatives/Financial-Align ment/index.html

OTHER FEDERAL PROGRAMSICD-10Effective Date 10/1/2013 Legislation HIPAA Administrative Simplification – August 2008Description Replacement of ICD-9 diagnosis codes with ICD-10 codes, increasing the code set from 13,000 ICD-9 codes to more than 68,000 ICD-10 codesStatus Proposed rule issued to postpone the start date from 10/1/2013 to 10/1/2014. Comments were due in May. Final Rule should be issued this summer.Site: https://www.cms.gov/Medicare/Coding/ICD10/index. html?redirect=/ICD10

ahsrcm.com

THE LEADING EDGE Summer 2012

page 7

tion period with opportunities for all physicians to move into these models in ways that enable them to gain skills and gain experience in taking accountability for improving care and lowering growth in costs.

Within a short period of time, 65 organizations signed up to participate in the Medicare Shared Savings program and more are participating in pay-for-performance programs through other insurers or entities (see Pay-for-Performance sidebar).

In addition to the ACO program, CMS is also conducting a number of bundled payment trials and programs. When viewed in the context of private insurer efforts (an AHS Whitepaper is available that describes private pay for per-formance programs), the number of these initiatives is quite impressive.

IMPLICATIOnSIt appears that more medical practices and providers are joining the better quality for less cost movement. But for the programs with large financial investments, it is still the larger practices, and primarily primary care that are signing up.

Collecting data will be critical not only for working with ACOs, but for a number of programs in medicine, from maintenance of certification to any form of pay-for-perfor-mance program or incentive program, including the PQRS program. Systems will need to provide platforms that sup-port Health Information Exchanges (HIE), analytics and care management applications. Practices need to look at their bottom lines to see what they can afford to do and who they can go to for help. You can request the AHS white paper on Private Insurer ACOs for more details.

Although these programs’ timeframes are slightly stag-gered, participation in them began within the last few years and will continue to be tested through the next few years; bringing with them payment initiatives for successful par-ticipants and payment penalties for those not able to make the transition.

2010 RESULTS OF THE PQRS AnD ERx PROGRAMS

(FACT SHEET Released from CMS on March 30, 2012)

PQRS Program1,017,664 eligible providers (EP’s)

EPs participating as individuals and part of group practices2010: 268,968 (26% of eligible participants)2009: 210,5592008: 153,839

Incentive Eligible (of participating EPs)2010: 72%2009: 57%2008: 56%

PQRS Incentives earned by individual EPs:2010: $364,254,8042009: $236,696,4322008: $ 95,080,976

2010 Average incentive per individual EP: $2,000

Most performed measures:• Performance of EKGs in the ER to help diagnose patients with chest pain for potential heart attack

• Adoption or use of EHR to help organize and man- age care for patients

• Administration of timely and appropriate antibiot- ics for patients undergoing surgery to reduce the risk of infection before the procedure begins

Measures with improved performance rates:• Tests of patients with stroke for difficulty swallow- ing before patients took in foods, fluids or medica- tion by mouth: from 47% in 2007 to 87% in 2010

• Tests of patients with diabetes for potential eye- related complications and communicating those results to the patient’s diabetes doctor: from 70% in 2007 to 93% in 2010

ahsrcm.com

THE LEADING EDGE Summer 2012

page 8

THE SGR, AnD ALTERnATIvES?The proposed Medicare Physician Fee Schedule for 2013 will be published soon. It will contain a 30.9% reduction in Medicare payments for 2013 as determined by the sustain-able growth rate (SGR) formula. SGR status is one of the most anxiety-producing concerns facing medical practices as it destabilizes business operations and decreases access to care for Medicare beneficiaries. For years there has been talk of revising this payment system, but to no avail. This year there is more movement within the medical community to propose alternative payment methods. No one thinks that the SGR is working but the key is how to replace it and how to pay for it.

Some organizations are proposing pay-for-performance programs as an alternative, including bundled payments, partial capitation, ACOs, medical homes or other hybrid ap-proaches that couple fee-for-service payments with a risk-based bonus opportunity to eventually replace the SGR pay-ment method.

Notably, the AMA has proposed that the SGR be abolished and replaced with a 5 year transition period where physi-cians would move away from fee-for-service reimbursement to new payment models, which base physician reimburse-ment on quality and cost of care. Executive Vice President and CEO James L. Madara, MD, in a May 25 letter to the House Ways and Means Committee, said the new payment models should be expanded from the current shared sav-ings and ACO programs to encompass bundled payments, performance-based payments, global and condition-specific payment systems, warranties for care and medical homes. An MGMA letter to the same committee made similar points and stressed the need for flexibility.

However, none of the pay for performance programs are sufficiently mature to provide cost savings equivalent to the SGR formula. And the AMA letter did not spell out how to “pay for” eliminating the SGR formula. As a result, while few expect to see the SGR cuts actually take place, many observ-ers expect to see yet another “temporary fix” when Congress takes up this issue, probably in its lame duck session in De-cember.

1Daly, Rich, MGMA-ACMPE: Align meaningful-use, eRx requirements,” May 16, 2012, 2MGMA letter to Marilyn Tavenner, Acting Administrator, CMS, May 16, 20123Fitzgerald, Beth, “Medicare ACOs: Coming Soon to a Healthcare Provider Near You,” Healthcare, January 24, 2012, http://www.njspotlignt.com/stories/12/0124/0144

• That patients diagnosed with chronic obstructive pulmonary disease received appropriate prescrip- tions for drugs to help with breathing: from 78.4 percent to 99.3 percent

• Care teams effectively stopped post-surgical antibiotics in cardiac patients (to prevent overmed- ication and the formation of potentially drug-resis- tant “superbugs”): from 81.6 percent to 99.6 per- cent.

eRx Program696,663 eligible providers (EP’s)

EPs participating2010: 130,953 (19%)2009: 89,752 (13%)

Incentive Eligible (of EPs who submitted data)2010: 82,950 (63%)2009: 48,354 (54%)

eRx Incentives earned:2010: $270,895,5402009: $148,007,816

2010 Average incentive per individual EP: $3,000

Highest Participation Rates in 2010Cardiology: 35%Ophthalmology: 34%Rheumatology: 32%Non-physician specialties (mostly NPs and PAs): 10%

FEATURED EMPLOYEES: Client First

LOMBARD, ILLInOISRecognized by Sue Ann Zahrt, Collections and Reimbursement (CNR) Manager

Nicole Bertuca, Reporting, is the ‘go-to’ person for last minute, critical client projects and reports. She consistently replies “of course!” to hard-to-meet deadline requests, then digs in to get it done. She keeps her superiors abreast of progress, works the reports with accuracy and efficiency, and always meets deadlines. She understands the urgency and dedication needed to complete these reports, and has always been a champion for AHS Lombard clients.

DeWayne Thompson, Vouchers, is a new member of the AR team and has been paying very close attention to his numbers every day, since a significant spike could be a red flag. In ear-ly May, he noticed a considerable spike for a particular client and immediately sent an email to the appropriate managers to notify them of a possible problem. The managers were able to quickly identify the source of the aberra-tion. Because of his diligence, AHS identified a potential issue before it impacted an important client and, potentially other clients.

PORTLAnD, MAInERecognized by Mary Ireland, Operations Manager

Esmeralda Sirois, AR Representative, volunteered to take on the AR responsibilities for a payer that recently made a very significant policy change for one of our largest pathology clients. This policy change has completely changed the way we handle our AR for this payer and Esmeralda has been diligent in finding and communicating new information to the team to ensure that we are processing the claims efficiently

ahsrcm.com

THE LEADING EDGE Summer 2012

page 9

and effectively. With her bilingual skills, Esmeralda frequent-ly handles calls for Spanish-speaking patients for all clients served by the Portland office, providing the best communica-tions possible.

SALEM, nHRecognized by Nancy Mamis, Coding Manager

Linda Frizzell, Batching Representative – Linda’s dedication is illustrated every day in her attention to detail with her daily batching assignments. As a batcher, Linda is on the first line for receipt of client charges. Client charges are handled with “client first” focus to ensure the beginning steps of the billing process are accurate and prepared for the rest of the coding and billing process. To do this, Linda must review each charge ticket for completeness and then batch charges according to each client’s pre-determined categories such as service date, provider, type of service, etc. Her attention to detail and especially her knowledge of client specifics result in outstanding work. Lin-da’s “client first” focus is particularly noteworthy since she is responsible for the most difficult and detailed paper charges for our clients.

Recognized by Shelly Baker, Director of A/R

Ray Baker, A/R Team Leader – Over the past six months, Ray Baker has been asked to meet a series of challenging goals for one of our largest radiology clients. As the Team Leader, Ray guides his staff to work effectively and efficiently to meet the client’s expectations. Ray watches every facet of this high profile client, including but not limited to, charges in and out, receipts, carrier contractual obligations, and denial manage-ment. His dedication, work ethic, and “client first” focus has led his team to meet, and in many areas, exceed our client’s

HOnORInG THOSE WHO SERvE

In honor of our upcoming Independence Day holiday, AHS is proud to recognize AHS team members who are supporting loved ones serving our country. Each one of us at AHS appreciates the service these family members provide to our country and we offer a collec-tive and heartfelt “Thank You.”

Employee Name: Val Basile (see photo)

Office: Lombard, ILName of Service Person: PFC Vito Basile, Jr.Relationship to Employee: SonDivision of Armed Forces: Army AirborneCurrently Stationed: Fort Campbell, KY, just returned from Afghanistan

Employee Name: Cheri Biscuiti MittelmanEmployee Location: Staten Island, NYName of Service Person: Sergeant Scott Biscuiti – Combat Correspondent Relationship to Employee: First CousinDivision of Armed Forces: Marines, currently reenlisted for another 4yrsCurrently Stationed: Baltimore, MD

Employee Name: Laurie HaramesEmployee Location: Lombard, ILName of Service Person: Nathan GuildeRelationship to Employee: SonDivision of Armed Forces: Army, Route ClearanceCurrently Stationed: Southeast Afghanistan

ahsrcm.com

THE LEADING EDGE Summer 2012

page 10

Employee Name: Barbara LewisEmployee Location: Lombard, ILName of Service Person: Sergeant Amy Lewis - Medic / EMTRelationship to Employee: DaughterDivision of Armed Forces: National GuardCurrently Stationed: Chicago, IL

Employee Name: Karin McCarthy Employee Location: Salem, NHName of Service person: 1st Lieutenant Aaron McCarthyRelationship to Employee: SonDivision of Armed Forces: Air National GuardCurrently Stationed: Peace International, Portsmouth, NHWing Executive OfficerServed one tour in Abu Dhabi

Employee Name: Kimberly NutwellEmployee Location: Chambersburg, PAName of Service Persons: Kelly Abigail Sarroll and Rod SarrollRelationship to Employee: Daughter and Son-in-lawDivision of Armed Forces: U.S. NavyCurrently Stationed: San Diego, CA

COnGRATULATIOnS AnD WELCOME

AHS Lombard partners with several local colleges to host externships for students in their medical billing and coding programs. Many of the students are offered a position with AHS after completion of the program. In the past few months, two of the externs-turned-employees graduated from the college program with special recognition for their efforts.

We congratulate them on their achievement, and hope that they have a successful career at AHS:

Rosemary Marshall: Salutatorian for her graduating class, graduating with Highest Honors and the recipient of a Gold Medal.

Aaron Jenkins: Graduated with honors, Director’s List. Aar-on was also asked to be a speaker during Everest College’s ‘Inspire’ conference in June.

AHS Lombard Employee Input Committee Sponsors First Community Service Event!The newly formed Employee Input Committee chose the Food Pantry as their first Community Service sponsor-ship. AHS Lombard already conducted a food drive dur-ing the holiday season, so this food drive has two missions: 1) help stock shelves during the summer months, when donations to the pantry typically slow down, and 2) provide fun and healthy snack bags for children that are used to re-ceiving lunch subsidies during the school year.

The Food Drive, which was held May 21 – June 7th, broke all previous records! Last Holiday season, 602 items were collected. For this summer drive, almost 1,300 items were collected, and 200 lunch bags filled with snacks, a juice box and some toys were assembled. The Food Pantry received the much-needed items on Thursday, June 7th, and loved the idea of the kid’s bags, which had never been thought of before.

The Food Drive also was conducted in the spirit of a friendly competition between departments, similar to the Holiday Food Drive. Once again, the Collections and Reimburse-ments Department was named the winner, so they were able to keep their Most Charitable trophy in its current location.

As Cyndee Moreau, AHS Lombard’s Reimbursement Analyst and this project’s coordinator, said, “The real winner is the food pantry and the many families who use it.”

In a press release on June 13, York Township supervisor John W. Valles said,” We are proud to be partners with AdvantEdge in the fight against hunger. We are grateful that they decided to increase their support of the York Township Food Pantry by

ahsrcm.com

THE LEADING EDGE Summer 2012

page 11

Gloria Stitely and several other managers recently took shifts repre-senting AHS at a local job fair in the Chambersburg Mall.

adding a summertime food drive to their holiday food drive. On behalf of the citizens of York Township I want to express our appreciation to the employees and management of Ad-vantEdge for their public spirited efforts to improve the qual-ity of life in our community.”

AHS PRESEnTS AT AAPC MEETInGAHS Lombard’s Coding Supervisor, JaVonne Hahn-O’Hara, spoke at the OakBrook AAPC meeting in May in a session titled “Coding for Interventional Radiology.” She presented a number of coding examples to approximately 50 AAPC mem-bers, offering insights on the challenges and nuances of cod-ing for this specialty. JaVonne holds a certification in Inter-ventional Radiology and has been coding for this specialty for six years. Chris Walters, AHS Lombard’s Coding Manager and the president of the OakBrook chapter, said that the ses-sion was offered as an overview for members who might be interested in pursuing the specialized certification.

CHAMBERSBURGThe Chambersburg office not only works well together to serve our clients but also to help our fellow employees. When one of the Chambersburg staff members, Pat Moats, was diagnosed with cancer, the office organized a fundraiser to help Pat and her family pay for medical expenses.

Jen Rogers and Shannon Barr came up with the idea of mak-ing coasters and created the designs, one for each of the four coasters in the set, which focused on the support and fight against cancer. They, along with Jan Group, Sarah Kennedy and Amanda Ocker handmade each set as orders came in from others in the office.

So far, the office has sold 70 coaster sets raising $350 while also raising an additional $213 in separate donations. We know that Pat and her family will appreciate the efforts and kindness of all the Chambersburg staff.

CHAMBERSBuRg JOB FAIR

ahsrcm.com

THE LEADING EDGE Summer 2012

page 12

COMPLIAnCE CORnEREducational Podcasts for Physicians The Healthcare Fraud Prevention and Enforcement Action Team and the Office of Inspector General (OIG) have posted a Toolkit on OIG’s website with a series of podcast training videos that cover:• How to Use the Exclusions Database• How to Report Fraud to the OIG• OIG’s Self-Disclosure Protocol• Importance of Documentation• Tips for Implementing an Effective Compliance Program• Compliance Program Basics• OIG Guidance• Physician Self-Referral Law• False Claims Act• Federal Anti-Kickback Statute

All physician practices regardless of size are required to ad-here to these and other regulatory requirements. The pod-casts listed above provide a wealth of information that can help providers meet the required annual compliance train-ing. The “OIG Guidance” podcast is a 6 minute overview of billing compliance and a provider’s obligation to have an effective written compliance plan. Check it out here: http://oig.hhs.gov/newsroom/podcasts/index.asp.

The 3-Day Payment RuleWhat does “Wholly-Owned or Wholly-Operated by the Hospital” Mean?

The 2012 Medicare Physician Fee Schedule finalized pro-posed rules that impact physician billing for services subject to the 3-Day Payment Window Rule. The 3-Day Payment Rule states that services furnished on or after June 25, 2010 that are provided by the hospital (or an entity “wholly-owned or wholly-operated by the hospital”) are deemed related to the admission and thus must be billed with the inpatient stay if the patient is admitted within three days. The basis for the rule is described in the Implementation of New Statutory Provision Pertaining to Medicare 3-Day Payment Window – Outpatient Services Treated as Inpatient memorandum. The 2012 change adds non-diagnostic services as part of this rule. The implementation date is July 1, 2012.

How do these rules (described in Pub. L. 111-192, the Pres-ervation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010) affect hospital-provider ar-rangements? There are six possible hospital-provider ar-rangements that may be affected as a result of the 3-day payment window.

DID YOU KnOW?

Do you know the difference between an NPI and a PTAN?

With CMS requiring all Medicare providers to complete re-validation applications over the next few years, they have received a substantial number of requests to clarify the difference between an NPI and a PTAN number, both of which are required by Medicare. Here are the differenc-es between these numbers as taken from MLN Matters (SE1216), recently issued by CMS.

nPI – national Provider Identifier• The NPI is a unique identification number for all cov- ered health care providers. Once assigned, a provider’s NPI is permanent and remains with the provider regardless of job or location changes.

• The NPI is issued by the National Plan and Provider Enumeration System (NPPES) and is used for most insurance carriers; not just Medicare.

• Covered health care providers and all health plans and health care clearinghouses must use the NPI in the administrative and financial transactions adopted under HIPAA to identify a provider (for example, insurance claims).

• The NPI is a 10-position numeric identifier. The NPI does not carry information about healthcare provid- ers, such as the state in which they live or their medi- cal specialty.

• Covered providers and suppliers must share their NPI with other suppliers and providers, health plans, and clearinghouses, and any entity that may need it for billing purposes.

• In May 2003, the NPI replaced all legacy provider identifiers, including the Unique Physician Identifica- tion Number (UPIN), as the unique identifier for all providers in HIPAA transactions.

• Individual health care providers may only have one NPI number for themselves (“entity Type 1”) and an additional NPI(s) for their corporation(s) (“Entity Type 2 Organization”).

• Physicians who are sole practitioners, but who have chosen to incorporate are required to obtain both a Type 1 and Type 2 NPI.

• Organizations that render health care or furnish health care supplies may obtain NPIs (Entity Type 2 Organiza- tion) for their organizations and their subparts, if applicable.

1.

2.

3.

4.

5.

6.

For further questions, please refer to CMS’ (formerly HCFA) 1998 rule in Federal Register, Vol 63, No 28, Wednesday, February 11, 1998 and the August 9, 2010 Notice to Provid-ers at the following link http://www.gpo.gov/fdsys/pkg/FR-1998-02-11/pdf/98-3362.pdf

ahsrcm.com

THE LEADING EDGE Summer 2012

page 13

If a physician practice is owned or operated by the hospi-tal then all services are subject to the preadmission 3-day window.

A hospital network is affected by the 3-day payment win-dow. For example, if Hospital A owns Hospital B, which in turn owns Hospital C and preadmission services are performed at Hospital C although the patient is admitted to Hospital A.

A corporation that owns two hospitals; if Hospital A per-forms preadmission services and the patient is admitted to Hospital B, the payment window does not apply. This is because both the admitting hospital and the hospital that furnished the preadmission services are owned by a third entity (the corporation).

Consider a similar situation where Hospital A is owned jointly by Corporations Y and Z. Corporation Z is also the sole owner of Hospital B. If one of the hospitals furnish-es preadmission services and the patient is admitted to the other hospital; the 3-day payment window provision does not apply because both the admitting hospital and the hospital that furnished the preadmission services are owned or operated by a third entity (Corporations Y and Z).

The payment window also does not apply if a hospital refers its patient to an independent laboratory for pre-admission testing services because the admitting hospi-tal is not the sole owner or operator of the independent laboratory performing the preadmission testing. The laboratory does not have an arrangement with the ad-mitting hospital.

A clinic is solely owned by a corporation and is jointly operated by both the corporation and a hospital. The payment window does not apply because the hospital is neither the sole owner nor operator of the clinic

PTAn – Provider Transaction Access numberA PTAN is a Medicare-only number issued to providers by Medicare contractors upon enrollment with Medicare. When a Medicare contractor approves enrollment and is-sues an approval letter, the letter will contain the PTAN assigned to the provider.

• The approval letter will note that the NPI must be used to bill the Medicare program and that the PTAN will be used to authenticate the provider when using Medicare contractor self-help tools such as the Interactive Voice Response (IVR) phone system, internet portal, on-line ap- plication status, etc.

• The PTAN’s use should generally be limited to the provider’s contact with Medicare contractors.

Relationship of the nPI to the PTAnThe NPI and PTAN are related to each other for Medicare purposes. A provider must have one NPI and will have one, or more, PTAN(s) related to it in the Medicare sys-tem. If the provider has relationships with one or more medical groups or practices or with multiple Medicare contractors, separate PTANS are generally assigned.

CMS maintains both the NPI and the PTAN in the Pro-vider Enrollment Chain and Ownership System (PECOS), the master provider and supplier enrollment system. For more information on NPI, PTAN and provider enroll-ment, visit: https://pecos.cms.hhs.gov/pecos/help-main/faq.jsp

CALEnDAR SUMMER 2012

June 2012 - Supreme Court decision on ACA lawJune 30, 2012 – Deadline: eRx Submission of 10 encounters to avoid 2013 penalty

Mid-Summer 2012 – Final Rule: EHR Incentive Program and Meaningful Use – Stage II

July 4, 2012 – Holiday: AHS is closed

October 5-7 – 4th Annual ACR/RBMA Forum, Chandler, AZ

October 7-10 – RBMA Fall Educational Conference, Chandler, AZ

October 8-11 – ACEP Scientific Assembly, Dallas, TX

October 13-17 – ASA Annual Meeting, Washington, DC: AHS ExhibitingNovember 25-30 – RSNA 2012, Chicago, IL

ahsrcm.com

THE LEADING EDGE Summer 2012

page 14

RADIOLOGY–RBMA SUMMIT 2012: THE STATUS & DIRECTIOn OF RADIOLOGYBill Gilbert, VP of Marketing, AHS

I’ve just returned from the RBMA Summit where a number of speakers offered their views on the direction of the radiology business. RBMA is the Radiology Business Management Asso-ciation, so the emphasis was on business direction, not clinical. One caveat: I’ve quoted a number of speakers below but the con-clusions and implications are mine, not necessarily theirs.

Although there were a number of sessions covering a variety of topics over the three days of the summit, recurrent topics cross-ing several sessions described 3 strategic guideposts that radi-ology practices and radiologists ignore at their peril: Proactive, DSS and data.

Proactive is best captured by a comment during an ACO (ac-countable care organization) discussion: “Radiologists are either at the table or on the table.” While the exact role of radiology in most ACO’s (to use the term generically) hasn’t been determined, it is clear that radiology has a big role to play in the cost, qual-ity and outcomes equation. Josh Gray, Managing Director of the Advisory Board Company, said that IDN’s (integrated delivery networks) are looking to radiologists for help defining appropri-ateness, and that is much more nuanced than it appears on the surface. Another speaker mentioned a radiology group that pro-actively approached their hospital for ACO discussions. While the hospital isn’t ready to proceed (yet), the group is now extremely well positioned. Translation: your radiology group needs to be at the ACO table. A similar conclusion was reached by the ACR® Future Trends Committee which recently published a whitepa-per about ACO’s and radiology.1 There are short-term steps to be taken as well. Mike Suddendorf, Executive Director of Premier Radiology Marketing, described how to link your practice’s mar-keting efforts with that of your health system and hospital(s). He offered practical ideas that no group should overlook: e.g. quar-terly meetings with hospital marketing and PR leaders, coordi-nated promotional efforts, etc. Some groups are adjusting their work to better match their customer (the hospital) requirements. For example, one group described adjusting their prime shift to later in the day because 60% of their work comes in after 3 PM.

DSS – Decision Support Systems - What is the solution to steer-ing and the debate about “over use” of imaging? Decision Support Systems (DSS) provide a sophisticated way for referring physi-cians to determine when and what type of test to order. The rules that these systems will need are far from determined. And most current efforts have a limited scope, though one or two advanced

systems were mentioned but not described. But since this type of system is essential for the future (and radiologists have always been at the forefront of computer technology in medicine), it is an essential area for radiologists to be proactive. Of course, this means radiology groups must work with their hospital and with their referring physicians plus others (e.g. payers, ACO, etc). This work can’t be done from the reading room!

Data captures two inter-related trends. First is the opportunity (really the requirement) for the radiologist to have access to more information. EMR’s mean that the radiologist can (and should) have the patient’s entire history at their fingertips when they are reading and completing their report. The next step, enabled by ICD-10 and outcomes measures, means that a radiologist should (must) know how accurate their diagnoses are across a popula-tion of patients and within a type of test or particular diagnosis. Using this feedback can only improve results for each radiologist and it will obviously lead to continuous improvement in DSS logic. But the biggest beneficiary will be the patient: with more accu-rate diagnoses and testing only where required.

The second data trend, highlighted by Brian Baker, President of Regents Health Resources, is that practices today have much more data than they are aware of and it is time to start leverag-ing it. Others are making similar points as in this recent article.2 Mr. Baker pointed out that reimbursement trends mean only one thing: radiology practices need to get much more efficient. As other industries have gone through similar transitions, a whole set of quality and cost improvement tools evolved, which are now available to radiologists and the healthcare industry. Generally referred to as Six Sigma and/or Lean, they start with simple a mantra: “measure it, publish it, and it will improve.” From a base-line, the next step is to Plan a change (improvement), Do it, Check (measure), then Act (adopt or reject the change). Rinse and re-peat. This is the well-known Deming cycle: PDCA.

In order to use the wealth of data available, Mr. Baker stressed the need to adopt a Business Intelligence tool that can pull ev-erything together: billing information, financial information, RIS, PACS, phone systems, equipment vendors, other vendors, etc. His conclusion: you have much more information than you think and you need to be using it to drive costs down dramatically and improve quality and results.

1Journal of the American College of Radiology, Strategies for Radiologists in the Era of Health Care Reform and Accountable Care Organizations: A Report From the ACR Future Trends Committee. http://www.imagingbiz.com/articles/view/value-based-purchasing-from-theory-to-practice

2Diagnostic Imaging, Data Mining and Analytics in Radiology, http://www.diagnosticim-aging.com/informatics-pacs/content/article/113619/2075240?CID=rss (Login required)

ahsrcm.com

THE LEADING EDGE Summer 2012

page 15

Don’t Confuse OB and Pelvic Ultrasounds

Although there are only a few CPT® codes for obstetrical (OB) ul-trasound, code assignment for these studies can be confusing as there are two parallel sets of codes for pelvic ultrasound studies - one for obstetrical studies and one for non-obstetrical studies. OB ultrasound studies are performed to confirm pregnancy, de-termine gestational age, evaluate the fetal size, growth, and pre-sentation, and evaluate any known or suspected maternal and fetal abnormalities.

Pelvic ultrasounds, which can be performed on both females and males, are performed for the total examination of the pelvic area for bladder measurements and description of any pelvic pathol-ogy. For females, it also includes a description and measure-ment of the uterus and adnexa as well as the measurement of the endometrium. For males, it includes an evaluation of prostate and seminal fluids.

IS IT An OB ULTRASOUnD?

According to the October 2001 CPT® Assistant, you should assign an OB ultrasound code “for female patients with an established diagnosis of pregnancy, determined by any method, and with in-dications for the ultrasound procedure that might be pregnancy related.” This rule applies even when the ultrasound shows that the patient is no longer pregnant or that her symptoms were caused by a non-obstetrical condition. For example, a patient who has had a positive pregnancy test begins spotting, and the pelvic ultrasound reveals that she has had a spontaneous abortion. Even though the patient is no lon-ger pregnant, you should still assign an OB ultrasound code for this exam, since (1) the patient had an established diagnosis of pregnancy and (2) the indications appeared to be related to the pregnancy.

Like all other diagnostic ultrasound studies, OB and pelvic ul-trasounds require a permanently recorded image and a written interpretive report. Also, when billing for the professional com-ponent, remember to add modifier 26 to each code, including the add-on codes.

OB ULTRASOUnDS

76801 Ultrasound: pregnant uterus, real time with image documentation, fetal and maternal evaluation, 1st trimester (< than 14 weeks, 0 days); transabdominal approach; single or first gestation

76802 each additional gestation (in addition to primary code)

76805 pregnant uterus, real time with image documentation, fetal and maternal evaluation, after 1st trimester (> or = 14 weeks, 0 days); transabdominal approach; single or first gestation

76810 each additional gestation (in addition to primary code)

76815 Ultrasound: pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/ or qualitative amniotic fluid volume), 1 or more fetuses

76817 pregnant uterus, real time with image documentation, transvaginal

nOn-OB ULTRASOUnDS

76856 Ultrasound, Pelvic (non OB), real time with image documentation; complete

76857 Ultrasound, Pelvic (non OB), real time with image documentation; limited or follow-up

76830 Ultrasound, transvaginal

ahsrcm.com

THE LEADING EDGE Summer 2012

page 16

RADIOLOGY–ICD9 / ICD-10 Comparison

DIAGnOSIS: Decreased fetal movement – OB ultrasound is performed

ICD9 Code: Listing: Complications of Pregnancy, Childbirth, and the Puer-perium (630-633 codes), Known or suspected fetal abnormality affecting management of mother (655) Decreased fetal move-ments (655.7)

In ICD-9, the following codes may be billed:655.70 Decreased fetal movements – unspecified as to episode of care or

not applicable

655.73 Decreased fetal movements – antepartum condition or complication

ICD-10 Code(s):Listing: Pregnancy, Childbirth and Puerperium (O00-O9A Codes) Maternal care related to the fetus and amniotic cavity and possible delivery problem (O30 – O48 Codes) Decreased fetal movements (036.81)

In ICD-10 coding, the gestation period and number of fetuses should be indicated when coding for decreased fetal move-ments.

Billable ICD-10 Codes:The following codes may be billed but are missing either the trimester or number of fetuses.

O36.8190 Decreased fetal movements, unspecified trimester, not appli-cable or unspecifiedO36.8131–O36.8135 Decreased fetal movements, unspecified trimester; fetuses 1-5O36.8139 Decreased fetal movements, unspecified trimester, other fetus (over 5)O36.8120 Decreased fetal movements, second trimester, not applicable or unspecifiedO36.8130 Decreased fetal movements, third trimester, not applicable or unspecified

The following codes are the most complete codes for billing decreased fetal movements. O36.8121–O36.8135 Decreased fetal movements, second trimester; fetuses 1-5

O36.8129 Decreased fetal movements, second trimester, other fetus (over 5)

O36.8131–O36.8135 Decreased fetal movements, third trimester; fetuses 1-5

O36.8139 Decreased fetal movements, third trimester, other fetus (over 5)

www.ahsrcm.cominformation@ahsrcm.com 908-279-8120

BillingTechnologyResults®