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www.aapc.com June 2009 3

[contents] 5 Letter From the President

7 Letter From Member Leadership

26 Letters to the Editor

44 Extreme Coding

47 Coding News

In Every Issue

10 Coding Consultations When Components or Time is a Factor AAPC Coding Communications Director G. John Verhovshek, MA, CPC, concludes

his two-part consultation series with an explanation of how to apply consultation codes in the inpatient and outpatient settings.

14 Identify Binding Rules for Defensible Coding Medicare’s way isn’t always the right way. Michael D. Miscoe, JD, CPC, CASCC, CUC,

CHCC, tells us how reporting accurately, as defined by the billed carrier, will help you avoid substantial post payment liability.

22 Savannah Doubles, Taking the 2008 Chapter Award Savannah, Ga. sets exemplary standards in 2008 by having fun while learning, dou-

bling in numbers, growing in closeness, and supporting and respecting each other.

28 Coders Hit the Jackpot in Vegas Attendees had a lot to say about this year’s AAPC National Conference held in Las

Vegas, Nev. Michelle A. Dick, senior editor, reports.

32 The Driving Components of E/M Level Selection AAPC Exam Director Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC, provides an in-

depth look at the history component in this first of a three-part series.

36 EHRs Pose Challenges, Provide Opportunities Electronic health records (EHRs) are an important part of a federal plan to improve

the quality and cost effectiveness of health care. Michael Stearns, MD, CPC, CFPC, explains why it’s important for coders to learn as much as they can about health information technology (HIT).

On the Cover: The Savannah, Ga. Chapter radiates coding excellence and camaraderie. Together, they enjoy their day in the sun sharing coding tidbits at Forsyth Park. Cover photo taken by Matt Propst (www.mattpropst.com).

Education

People

Coming Up

contents

June 200932

50 Test Yourself

31 Kudos

38 Newly Credentialed Members

48 Minute with a Member

2810

ICD-10 Implementation

Coding From Home

Sentinel Node Imaging

Compliance Plan

Finger Tip Injuries

Stimulus Package HIPAA Provisions

Features

22

4 AAPC Coding Edge

AAPC Code of Ethics

Members of the American Academy of Professional Coders (AAPC) shall be dedicated to providing the highest standard of professional coding and billing services to employers, clients, and patients. Professional and personal behavior of AAPC members must be exemplary.

AAPC members shall maintain the highest standard zof personal and professional conduct. Members shall respect the rights of patients, clients, employers, and all other colleagues.Members shall use only legal and ethical means in all zprofessional dealings, and shall refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive, or illegal acts.Members shall respect and adhere to the laws and regulations zof the land, and uphold the mission statement of the AAPC.Members shall pursue excellence through continuing zeducation in all areas applicable to their profession.Members shall strive to maintain and enhance the dignity, zstatus, competence, and standards of coding for profes-sional services.Members shall not exploit professional relationships with zpatients, employees, clients, or employers for personal gain.

This code of ethical standards for members of the AAPC strives to promote and maintain the highest standard of professional service and conduct among its members. Adherence to these standards assures public confidence in the integrity and service of professional coders who are members of the AAPC.

Failure to adhere to these standards, as determined by AAPC, will result in the loss of credentials and membership with the American Academy of Professional Coders.

Volume 20 Number 6 June 1, 2009Coding Edge (ISSN: 1941-5036) is published monthly by the American Academy of Professional Coders, 2480 South 3850 West, Suite B. Salt Lake City, Utah, 84120, for its paid members. Periodical postage

paid at the Salt Lake City mailing office and others. POSTMASTER: Send address changes to:

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

CEO and PresidentReed E. Pew

[email protected]

Vice President of Clinical Coding ContentSheri Poe Bernard, CPC, CPC-H, CPC-P

[email protected]

Vice President of Product ManagementStephanie L. Jones, CPC, CEMC

[email protected]

Vice President of MarketingBevan Erickson

[email protected]

Director of Business and Member DevelopmentRhonda Buckholtz, CPC, [email protected]

(814) 673-7178

Director of Coding CommunicationsJohn Verhovshek, MA, [email protected]

Director of Member ServicesDanielle Fenochietti

[email protected]

Director of PublicationsBrad Ericson, MPC, CPC, COSC

[email protected]

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

Production ArtistTina M. Smith, AAS Graphics

[email protected]

Display AdvertisingJamie Zayach, BS

[email protected]

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

Coding EdgePO Box 704004

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

© 2009 American Academy of Professional Coders, Coding Edge. All rights reserved. Reproduction in whole or in part, in any form, without written permission from the AAPC is prohibited. Contributions are welcome. Coding Edge is a publication for members of the American Academy of Professional Coders. Statements of fact or opinion are the respon-sibility of the authors alone and do not represent an opinion of the AAPC, or sponsoring organizations. Current Procedural Terminology (CPT®) is copyright 2008 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein.

CPC®, CPC-H®, and CPC-P® are registered trademarks of the American Academy of Professional Coders.

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

APPRENTICE

PROFESSIONAL

EXPERT

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

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

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

Serving 78,000 Members – Including You

June 2009


This month completes the first half of 2009, and the year’s midpoint seems like a perfect occasion to pause to see where we’ve been and to look ahead at rest of the year’s goals.

Mid-year Accomplishments to Celebrate in 2009 We redesigned and launched 19 new specialty credentials, including corre-sponding online practicums complete with audio lessons and interactive practice tests, providing examinees with rationales for answers. For students who prefer classroom learning, we created a 10-hour, face-to-face curriculum. Professional Medical Coding Curriculum (PMCC) instructors across the country can now access these to develop spe-cialty exam classes.

We made quality our clarion call. Whether we’re talking about Coding Edge, AAPC staffs’ responsiveness to national office calls, or content quality in workshops, audio conferences, curriculum, or exams, AAPC has raised the bar, improving its offerings from month to month.

We were instrumental in getting ICD-10 implementation delayed until Oct. 1, 2013. As an added benefit, your input on the proposed rule has provided us a much closer working relationship with the federal agencies that regulate health care in our country. We’ve also brought past National Advisory Board (NAB) President Deborah Grider on board as an AAPC employee to lead our ICD-10 education efforts.

We keep on growing. During the first half of 2009, we have grown another 9 percent. With almost 80,000 members, we continue to grow at a rate that outpaces all other health care organizations. Check the chart below to see how far we’ve come.

Exciting Plans for the Remainder of 2009Our code book deals are the best value in our business. AAPC ICD-9-CM and HCPCS Level II code books are as good as any competitors’. Exclusively for members, we sell them at a lower cost than any other vendor. With these books, we also provide a free resource that educates readers about code changes, using simple explanations in an easy to follow format. You’ll be hard-pressed to find a better deal anywhere.

Regional conferences have quality cur-riculum with a slice of paradise. Oahu, Hawaii in September and Norfolk, Va. in October promise to feed your mind and your soul at the lower rates expected from AAPC regional events.

Educational opportunities will expand. Previously, our PMCC instructor training program was limited to annual events tied to our national conference. Later this year, the instructor training pro-gram will expand its online format,

making the curriculum available 24/7 to anyone with Internet access. If you’ve ever thought about becoming a certified instruc-tor (CPC-I®), but couldn’t afford the time away from work or the travel costs, this will make your teaching dream more possible.

Business is still as usual. We expect our growth trajectory to continue into 2010, and with it is the continued promise of quality products and communications, as well as legendary member service. Please let me know if we are meeting your needs by emailing me. Just go to the Member Area on the AAPC Web site, and click on the “Talk to Reed” button in the lower-left corner. We continue to use the many ideas generated from this.

letter from the president

Half Way to 2010 and Growing Strong

Sincerely,

Reed E. PewCEO and President

SPECIALTY CREDENTIAL SPECIALTY CREDENTIALAMBULATORY SURGICAL CENTER CASCC™ GENERAL SURGERY CGSC™

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Perhaps it was the idea of four days of non-stop entertainment in the city that never sleeps. Maybe it was the desire for warm desert breezes and an azure sky. It could’ve been the allure of hitting it big. I am rea-sonably certain, however, that what brought nearly 2,000 coders to Las Vegas April 5-8 was the AAPC’s 17th National Coding Con-ference. And I am absolutely positive about what made this year’s conference a huge success.

Oh, What a NightIt all started with a Sunday night confer-ence kick-off filled with laughter, dancing, reflection, and inspiration as the National Advisory Board (NAB) put on a comical skit—an adaptation of the movie “It’s a Wonderful Life” and the Charles Dickens’ story, “A Christmas Carol.” Johnny Biscuit, our resident comedian and AAPC friend, led NAB members through the ages, from the 1960s to the future to help them see how far they’ve come and how far they have yet to go. For a grand finale, the entire audience performed a rousing rendition of “YMCA,” AAPC-style.

Also Sunday evening, attendees visited and scored trinkets from chapter representatives who came from all parts of the country. Many thanks to participating chapters for bringing a part of home to conference, not to mention all the laughs and door prizes enjoyed by all.

A Learning ExperienceThe next three days were equally riveting—filled with top notch educational classes led by outstanding speakers. General sessions included AAPC CEO and President Reed Pew giving a well-received talk addressing the issues regarding the future of health

care. Attendees warmly received a motiva-tional speaker who shared his fight and tri-umph with cancer at age 23. General session speakers addressed issues pertaining to the future of health care. And a multitude of breakout sessions covered an array of topics and specialties that surely met the individ-ual needs of attendees.

And a Side of GravyAt the awards luncheon, we said goodbye to the 2007-2009 NAB, including Presi-dent Deborah Grider—who received well deserved accolades for her accomplishments over the past two years—and welcomed into the fold the new 2009-2010 NAB, including myself. Plaques and farewells were given to outgoing NAB members as well as the American Academy of Professional Coders Chapter Association (AAPCCA) Board members leaving their positions. The national winners for 2008 Networker of the Year, Coder of the Year, and Chapter of the Year were also recognized during the lun-cheon. These awards were well deserved by these folks.

Set Your SightsFour days later—after making new friends and spending time with old friends we rarely have an opportunity to see; after talking to vendors and comparing the most updated books and software of our trade; and after soaking our brains with the knowledge we thrive on—parting was sweet sorrow. The conference, however, pro-vided the professional boost of energy we all needed. We left rejuvenated and, for some, richer in more ways than one!

I hope to see all of you at the Opryland Hotel, Nashville, Tenn., June 6-9, 2010, for the next AAPC National Conference.

Regards,

letter from member leadership

Terry Leone, CPC, CPC-P, CPC-I, CIRCC

President, National Advisory Board

National Conference Brings a Higher Standard to Las Vegas

8 AAPC Coding Edge

Janet Dunkerley, CPC, CPC-I, CMC, was omitted from the May Coding Edge article side bar “Regional Pick: 2008 Networker/Coder of the Year Awards.” Having tied with Louise Hilliard, CPC, MT (AMT), for Region 3 – Mid-Atlantic’s Networker of the Year, Janet should have been included. We regret the omission.

Janet is a senior medical consultant for QuadraMed and in 1995, founded Capital Coders, the Colum-bia, S.C. chapter. She enjoys 20 years of coding experience and has worked as a medical consultant, coder, auditor, instructor, and director of physician services. A certified PMCC instructor, Janet is an original member of the AAPC Chapter Association (AAPCCA) Board of Directors, where she serves as secretary.

We congratulate her on being chosen.

Coding Edge

Dunkerley Also Region 3 Networker of the Year

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10 AAPC Coding Edge

Part 1 of this feature (“Consult or Not? Here’s How to Know for Sure,” May 2009 Coding Edge) discussed how to differentiate a consultation service from other E/M services. This month, we conclude with an explanation of how to apply consultation codes in inpatient and outpatient settings.

In addition to the usual medical necessity requirements, any consultation service must include a reason, request, and response. Having confirmed that these standards were met and documented, and having established that the intent of the service was to allow the requesting physician to continue to treat the patient with the advice of the consulting physician, you can get down to the business of selecting the appropriate consultation code for the service provided.

We explained that in addition to the usual medical necessity requirements, any consultation service must include a reason, request, and response. After these standards are met and doc-umented, and it is established that the service’s intent was to allow the requesting physician to continue treating the patient with the help of the consulting physician’s advice, you can get down to the business of selecting the appropriate consultation code for the service provided.

This month, we’ll conclude this two-part consultation series with an explanation of how to apply consultation codes in the inpatient and outpatient settings.

Consultation codes do not distinguish between new and established patients. A physician may report a consultation for his or her own patient, as long as all the consultation require-ments are met. CPT® does, however, assign unique codes for outpatient and inpatient services.

Select outpatient consultation codes 99241-99245 for “consul-

tations provided in the physician’s office or in an outpatient or other ambulatory facility, including hospital observation ser-vices, home services, domiciliary, rest home, custodial care or emergency department,” according to CPT® instructions.

To report physician consultations “provided to hospital inpa-tients, residents of nursing facilities or patients in a partial hospital setting,” select from the inpatient consultation codes (99251-99255), CPT® continues.

Three of Three Required to Support Service LevelTo report a given service level, coding guidelines require the consulting physician to meet all three key components: history, exam, and medical decision making (MDM). For example, to report a level III outpatient consult (99243 Office consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family), the physician must document, at mini-mum, a detailed history, a detailed examination, and MDM of low complexity. If any one of the three components falls below the minimum requirement, you may not report 99243.

In practice, the least or lowest of the three components will always dictate the appropriate service level when reporting a consultation. For example, if the physician documents an out-patient consultation with a comprehensive history, a compre-hensive exam, and straightforward MDM, the code selection will default to 99252 Inpatient consultation for a new or established patient, which requires these three key components: An expanded prob-

PR

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feature

By G. John Verhovshek, MA, CPC

Selecting a ConsultationService Level?

Part 2


feature

lem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordi-nation of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit. Although the history and exam meet the require-ments of a level IV visit (99254 Inpatient consultation for a new or established patient, which requires three key components: A compre-hensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usu-ally, the presenting problem(s) are of moderate to high severity. Physi-cians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit), the MDM component supports only a level II service.

Keep in mind: “Medical necessity of a service is the over-arching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically nec-essary or appropriate to bill a higher level of E/M service when a lower level of service is warranted,” according to the Medi-care Claims Processing Manual, chapter 12, section 30.6.1.A (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf).

Time May Factor Into Code SelectionIf more than 50 percent of the total, documented time dedi-cated to a verifiable consultation service is spent in patient counseling or physician care coordination, you may determine an appropriate consultation service level using time (rather than history, exam, and MDM) as the key component. Each consul-tation code (inpatient and outpatient) includes a reference time to guide you when using time as the key component.

For instance, CPT® specifies for a level II outpatient service (99242 Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straight-forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient(s) and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physi-cians typically spend 30 minutes face-to-face with the patient and/or family), “Physicians typically spend 30 minutes face-to-face with the patient and/or family.” For a typical 30-minute visit,

the physician would have to document at least 16 minutes of face-to-face counseling or coordination of care to report 99242 using time as the key component.

In the inpatient setting, physician time includes time spent at the patient’s bedside (face-to-face time), as well as time on the patient’s hospital floor or unit.

Multiple Outpatient Consults Are PossibleA physician may report more than one outpatient consult for the same patient. The subsequent visit, however, must meet all the consultation service criteria to bill it as such, according to the Medicare Claims Processing Manual, chapter 12, section 30.6.10.C. Subsequent visits not meeting the consultation service requirements should be reported using the appropri-ate inpatient or established outpatient E/M service code. The Claims Processing Manual reiterates, “If the consultant contin-ues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported by this physician or qualified NPP during his/her ongoing management of this condition.”

For example, a primary care physician (PCP) examines an established patient and diagnoses a breast mass. The PCP sends the patient to a general surgeon for advice. The gen-eral surgeon examines the patient and recommends a breast biopsy. The surgeon schedules the biopsy and sends a written report of his recommendations to the requesting physician. The general surgeon subsequently performs the biopsy, and continues to see the patient on a yearly basis for follow-up. Following the advice and intervention by the surgeon, the PCP resumes the patient’s general medical care.

In this case, the initial visit with the general surgeon meets all the requirements of an outpatient consultation, and may be reported as such (eg, 99242). Subsequent visits provided by the surgeon, however, should be billed as an established patient visit in the office or other outpatient setting (99211-99215), as appropriate.

In a second example, the patient from the previous example visits her PCP some months later with a new complaint of lower abdominal pain. The PCP requests a consult from the same general surgeon. In this case, as long as the visit for abdominal pain meets all the consultation requirements, the general surgeon may report another consultation service, as appropriate to the documented service level provided.

Consultation codes do not distinguish between new and established patients. A physician may report a consultation for his or her own patient as long as all the consultation requirements are met.

12 AAPC Coding Edge

feature

Report One Inpatient Consult per StayA physician may report only a single inpatient consult per inpatient stay. CPT® instructions state, “Only one consul-tation should be reported by a consultant per admission. Subsequent services during the same admission are reported using Subsequent Hospital Care codes 99231-99233 or Sub-sequent Nursing Facility Care codes 99307-99310,” depend-ing on the setting.

For example, a hospital inpatient experiences a new onset of atrial fibrillation. The managing physician requests a con-sultation from a cardiologist for her advice on the patient’s care and management. The cardiologist examines the patient, schedules a cardiac catheterization and other diagnostic tests, and sends a written report to the requesting physician. Fol-lowing the advice and intervention by the cardiologist, the managing physician resumes the patient’s general medical care. In this case, the cardiologist may report an inpatient consultation for her services at the level supported by docu-mentation. If the cardiologist follows up with the patient during the same inpatient stay; however, she must report the visit(s) as subsequent inpatient care (99231-99233), as appro-priate to the documented service level.

If the same physician provides a legitimate consult service during a different inpatient stay for the same patient (whether for the same or a different problem), the physician may report another inpatient consult code, as appropriate to the docu-mented service level.

For instance, the patient in the previous example has been discharged, only to be re-admitted several weeks later. If the same cardiologist who reported the previous consultation meets the requirements for a consultation service during the subsequent stay, she once again may report an inpatient con-sultation code (99251-99255) for her services.

For an excellent summary of Medicare rules regarding consul-tations, see MLN Matters article MM4215 on the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/mm4215.pdf.

Avoid Shared Visits When Reporting ConsultationsA non-physician practitioner (NPP) may perform a consultation service within the scope of practice and licensure requirements for NPPs in the state where he or she practices, and when the requirements for physi-cian collaboration and physician supervision are met, according to the Medicare Claims Processing Manual, chapter 12, section 30.6.10.A. State and payer guidelines vary, however, so research your particular state and payer requirements before reporting as a consultation any service provided by an NPP.

The Claims Processing Manual states flatly that a consultation “will not be performed as a split/shared E/M visit.”

A shared visit describes an E/M service during which a physician and an NPP each see a patient for a portion of the same visit. For example, if the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service, according to the Claims Processing Manual, section 30.6.1.B. “In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the ‘incident to’ requirements are met, the physician reports the service. If the ‘incident to’ requirements are not met, the service must be reported using the NPP’s UPIN/PIN,” the Manual continues.

Coding Edge–sidebar

CMS Defines Pre- and Postoperative Consultations RulesThe rules for reporting a consultation for preoperative clear-ance, as well as for postoperative care by the physician who provided a preoperative clearance consultation, are spelled out in the Medicare Claims Processing Manual, chapter 12, sec-tions 30.6.10.G and 30.6.10.H, respectively.

Specifically, preoperative consultations are payable for new or established patients when performed by a physician or qualified NPP at the surgeon’s request as long as all of the requirements of a consultation are met and the service is medically necessary and not routine screening. Typically, a V code (for example, V72.81 Preoperative examination, cardiovascular) is linked to the appropriate consultation code to describe the service.

A physician should not report a post-operative consultation if, following completion of a preoperative consultation (whether in the office or hospital), the consulting physician assumes responsibility for the management of a portion or the entire patient’s condition(s) during the postoperative period. Rather, in an inpatient setting, the physician would report the appro-priate Subsequent Hospital Care (99231-99233) or Subsequent Nursing Facility Care (99307-99310) code(s), depending on the setting. In the outpatient setting, the appropriate estab-lished patient visit codes (99211-99215) should be used during the postoperative period.

A physician (primary care or specialist) or qualified NPP “who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate con-sultation code for evaluation and management services furnished during the postoperative period following surgery when all of the criteria for the use of the consultation codes are met and that same physician has not already performed a preoperative consul-tation,” according to the Claims Processing Manual.

G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.[ ]

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14 AAPC Coding Edge

coding compass

There is an old adage that if you are right with Medi-care, you are right with the rest of the (payer) world. Although such a universal truth would make both coders’ and auditors’ jobs much easier, it simply isn’t true.

In 1996, the federal government established the Admin-istrative Simplification Act (the Act), which required the Department of Health and Human Services (HHS) to develop regulations standardizing the codes used by all entities cov-ered by the Act. Covered entities included all insurance car-riers and nearly all health care providers reporting services to third-party payers and/or federal government benefit pro-grams. Regulations implementing this statutory mandate are commonly known as the Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code set stan-dards (the formal title is 45 CFR Parts 160 and 162, Health Insurance Reform: Standards for Electronic Transactions, 65 FR 50312-01, 2000 WL 1157638).

A Matter of InterpretationThe key to understanding the mandated rules’ significance is that only the codes and descriptions, including modifiers and their descriptions, are incorporated in the mandated code set. Although these rules eliminated local codes, the code set rules purposely did not eliminate local rules pertaining to standard codes usage—or even what they mean beyond the descrip-tion. The rules for how codes are used are reserved to the payer. Because payers determine code utilization rules, there is no single answer to any coding question. When the payer is someone other than the local Medicare contractor, using Centers for Medicare & Medicaid Services (CMS) guidance to report a service may lead to an inaccurate result.

There are examples where a controlling standard has you report services in a grossly different way than you might when following guidance published by CMS. Following the CMS guidance, particularly use of National Correct Coding Initia-tive (CCI) bundling rules, may result in less reimbursement than you are entitled to.

Why bundle according to CCI if you do not have to? Because coding is about correctly representing a service so the billed carrier can make the correct payment determination. Impor-tantly, consider how a carrier will interpret the codes you report and how they want you to use the existing codes for a particular situation.

Speak their LanguageIf coding is a language, think of each carrier having its own dialect. While the words (codes) are the same, they potentially mean something different to each carrier. Some may not allow you to use certain codes in combination, some will. Some may recognize modifiers in certain circumstances, some may not.

The lack of standardization in what codes mean and how they should be used presents an interesting dilemma, as well as a unique challenge to coders. The better you understand individual carrier policies and rules pertaining to coding, the more valuable you are to your organization. Proving your value establishes job security and also helps you progress within your organization and the profession of coding.

Caution: Applying the appropriate rules isn’t necessarily about getting paid. Sometimes, reporting a service accurately means the carrier is not obligated to pay for the service. In such cases, the payment burden usually falls on the patient. Coding to avoid such a result is often the genesis of many False Claims Act (FCA) cases. Coders must describe procedures and services so the carrier can understand what was done and can make an appropriate payment determination. When the selected code causes the carrier to misinterpret what was done under the car-rier’s coding policy, and an improper payment is made based on that misinterpretation; the provider may get paid, but will usually be forced to return the money and potentially more in the form of penalties at some point in the future. When coders report accurately as defined by the billed carrier, it is unlikely the provider will be exposed to any substantial post payment liability. With the number of post-payment audits on the rise, this should be particularly concerning to all.

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC

IdentifyBinding Rules for Defensible Coding

Medicare’s way isn’t always the right way.

EXPE

RT


Get the Right AnswerWhen billing carriers, there are questions that should come to mind to help you determine appropriate codes:

Who is the carrier?

Is there a statutory code utilization rule that applies?If yes, does the statute provide guidance as to what

code utilization standards should be applied?

Are you contracted with that carrier?If yes, does the contract provide guidance as to

what code utilization standards should be applied?

Does the contract bind the carrier’s medical policies?

When there isn’t a contract or the policies aren’t incorporated into the contract, is there guidance available in the carrier’s medical policies to assist in correctly reporting the services at issue?

In the absence of a specific carrier rule, what gener-ally accepted guidance will you use persuasively to guide your coding decisions?

Obtaining an accurate (or at least defensible) answer in any situation requires sorting out controlling guidance from persuasive guidance. For example, some may think a news-letter from a national organization is considered controlling guidance. I have seen similar cases where an auditor found guidance in the CPT® Assistant and terminated the analysis. In these cases, both individuals failed to look for the author-ity making either reference binding with respect to payment. In reality, both were incorrect and the guidance was merely persuasive.

Controlling Guidance vs. Persuasive GuidanceControlling guidance can arise either by statute/regulation or by contractual agreement with the carrier (most com-monly the beneficiary contract and, in some cases, a provider contract). Controlling guidance establishes “must do” rules. By contrast, persuasive guidance can be anything, including CPT® Assistant, association coding advice, and articles such as this one. The value of persuasive authority pieces vary based on the source’s credibility and accuracy. Never assume that coding advice, even from a respectable source, is accurate for your particular circumstance. Failure to follow persuasive advice can never establish a payment error.

Identifying controlling guidance requires an objective analyti-cal process. The most critical element of this process is what the HHS, Office of Inspector General (OIG), and Office of Audit Services (OAS) auditing guide calls “criteria analysis.”

Criteria analysis is nothing more than identifying and under-standing the binding rules that apply in your specific coding situation.

Binding Beneficiary Rules Take Legal PrecedenceThe OAS Audit Process Manual defines criteria as “the stan-dards against which the audit team measures the activity or performance of the auditee … Criteria can come in many forms, including Federal laws and regulations, state plans, contract provisions and program guidelines.” (HHS, OIG, OAS, “The Audit Process,” 2nd ed., 2005)

The OAS manual provides additional guidance with respect to criteria hierarchy:

“It is important to determine a criteria hierarchy. In other words, if laws, regulations and guidelines on the same program appear to contradict each other, the audit team must decide which criterion takes precedence. In cases where the criteria are not clear, or when laws and regulations are significant to the audit objectives, the audit team should seek a legal opinion.”

The first rule in our criteria hierarchy, regardless of the case, is the HIPAA code set rule identified earlier. When applying this rule, remember that your code set is nothing more than the CPT®, HCPCS Level II, and ICD-9-CM codes with their descriptions. The instructions contained within these manuals detailing the publishers’ guidance for how to use the codes are not part of the code set. As a result, these instructions are not controlling (binding) unless the carrier formally adopts these instructions in a binding policy. After isolating your codes and descriptions, coders must identify and list all possible code choices that fairly and accurately describe the service performed. Refining this list to a single code requires more analysis.

The next level in our rule hierarchy is a statutory or regula-tory rule pertaining to the case being billed. Some states, for example, have adopted the published code guidance of the CPT® Editorial Panel; otherwise known as the CPT® manual. It is probably relevant to point out that this does not include the CPT® Assistant, which is published by a separate division of the American Medical Association (AMA). Where such statutory guidance doesn’t exist, you must turn to the benefi-ciary contract. Because the beneficiary contract is the docu-ment that spells out the payment obligation of the carrier, it is available to the enrollee (patient) but you, as a provider, may have difficulty getting a copy of it. When beneficiary contract guidance exists, it must be applied to the pos-sible correct code choices list you identified after description matching under the code set rules.

The lack of standardization in what codes mean and how they should be used presents an interesting dilemma, as well as a unique challenge to coders. The better you understand individual carrier policies and rules pertaining to coding, the more valuable you are to your organization.

coding compass

coding compass

Beyond the beneficiary contract, you are usually entering persuasive guidance. Even when you are a participating pro-vider, most standard provider contracts establish conditions of participation, not conditions of payment. Nonetheless, some contracts, usually in larger specialty physician groups, may establish binding coding and payment standards—so be alert!

Without Controlling Guidance, Turn to Persuasive Guidance Where statutory/regulatory or binding contractual guid-ance does not exist, you are forced to resolve your coding issues with persuasive guidance, which also has a hierarchy. Start with carrier guidance before going out to other stan-dards. When looking at any persuasive standard, evaluate the standard’s credibility by looking at the review process the guidance was subjected to prior to publication. Beyond the provider contract, you can usually find carrier guidance published in medical policies or billing guides. Lower on the carrier totem pole are carrier newsletters. Although these are useful information sources, they are rarely controlling. Non-contracted providers should also consider this guidance when making coding decisions because such guidance alerts the provider either to what the carrier expects to see, or how they will interpret the codes you report.

The remaining problem is the situation where there is no con-trolling statutory, regulatory, or contractual guidance nor is there carrier generated persuasive guidance. At this point, you must turn to other persuasive guidance. In such a circum-

stance, following CMS, AMA, or other national association guidance would provide a reasonable basis for your coding decisions. When there is no controlling or carrier generated persuasive guidance, selecting the external standard that pro-vides the best reimbursement result is proper. Before doing so, however, make sure there is no controlling criterion requiring you to report differently.

Substantiate Code ChoicesNever make coding decisions based on the unsubstantiated advice of others, and absolutely never rely on payment to establish the validity of your code choice (“They paid it so it must be okay.”). Research the criteria applying to each coding situation. Although this is time consuming initially, when you identify relevant controlling criteria, and credible persua-sive criteria where no controlling criteria exists, your ability to apply these rules and code correctly will not only make you a more competent professional coder, but also an invaluable asset to your employer.

(484) 433-0495 www.CodingWebU.com

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Michael D. Miscoe JD, CPC, CASCC, CUC, CHCC, is president of Practice Masters, Inc., a past member of the AAPC National Advisory Board (NAB) and current member of the Legal Advisory Board (LAB). He is admitted to the Bar in the state of California as well as to the practice of law before the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. Mr. Miscoe has nearly 20 years of experience in health care coding and over 12

years as a compliance expert testifying in civil and criminal cases.

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18 AAPC Coding Edge

feature

Knowing which guidelines to follow ensures successful

E/M reporting.

Avoid Prolonged Services

Pitfalls


PR

OFE

SSIO

NAL


Before reporting prolonged service codes 99354-99357, consider that American Medical Association (AMA) and the Center for Medicare & Medicaid Services (CMS) coding requirements may differ.

For CPT® 2009, AMA revised the descriptors of inpatient critical care codes +99356 Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual ser-vice; first hour (list separately in addition to code for inpatient Evaluation and Management service) and +99357 Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged physician service) to eliminate the phrase “direct (face-to-face) patient contact” and replace it with “unit/floor time.”

For instance, physicians may bill unit/floor time for reviewing medical records, documenting, and discuss-ing the case with other providers. The descriptor change brings consistency with other inpatient service codes (such as inpatient consults 99251-99255) that also mea-sure unit/floor time, rather than face-to-face time.

Medicare, however, still requires direct face-to-face time for all inpatient prolonged services. Medlearn Matters number MM5972 (www.cms.hhs.gov/MLNMattersAr-ticles/downloads/MM5972.pdf), effective July 1, 2008, specifies, “You cannot bill as prolonged services … In the hospital setting, time spent reviewing charts or discuss-ing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities.”

This means, when reporting inpatient prolonged services codes 99356-99357 to Medicare or any payer that follows CMS guidelines, count only the time the provider spends in direct contact with the patient.

Outpatient Service Requirements MatchCMS and CPT® requirements for outpatient prolonged services both require you to count only time spent in direct contact with the patient. The descriptors for +99354 Prolonged physician service in the office or other out-patient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Manage-ment service) and +99355 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; each additional 30

minutes (List separately in addition to code for prolonged physi-cian service) specify “face-to-face.” As well, Medlearn Mat-ters MM5972 stresses, “You may count only the duration of direct face-to-face contact with the patient.”

Document Time with Precision“You must appropriately and sufficiently document in the medical record that [the provider] personally furnished the direct face-to-face time with the patient specified in the CPT® code definitions,” according to Medlearn Matters MM5972. For all payers (even those not requiring face-to-face time for inpatient services), document the start and end times of the visit, along with the date of service.

The time counted toward prolonged services need not be continuous, but must occur on the same date of service. CPT® specifies that prolonged service codes “should be used only once per date, even if the time spent by the physician is not continuous on that date.” For instance, the physician may consult with a patient in the hospital, spend 30 minutes discussing his condition, leave to per-form regular rounds, and return later in the day to that patient for another 40 minutes of counseling. The time spent with the patient both before and after the physician made rounds can contribute toward prolonged services.

Finally, documentation must explain why the physician provided prolonged services. Medlearn Matters MM5972 states, “Documentation is required to be in the medi-cal record about the duration and content of the medi-cally necessary evaluation and management service and prolonged services that you bill.” For instance, simply noting the physician spent an extra 60 minutes with the patient is not adequate to support a claim. The medical record must show the medical necessity for the extra time spent.“Unless you have been selected for medical review, you do not need to send the medical record documenta-tion with the bill for prolonged services.”

The message is clear: Payers may not want full documen-tation upon initial claims submission, but it had better be available on request.

Add-on Prolonged Services with Approved E/M CodesYou may report prolonged service add-on codes only in addition to E/M codes including a reference time. As such, you would report outpatient services 99354 and 99355 with:

feature

20 AAPC Coding Edge

99201-99215 Office or other outpatient visit

99241-99245 Office or other outpatient consultation

99324-99337 Domiciliary, rest home, or custodial care services

99341-99350 Home services

Similarly, you must apply 99356 and 99357 only in addition to:

99221-99223 Initial hospital care

99231-99233 Subsequent hospital care

99251-99255 Inpatient consultation

99304-99310, 99318 Nursing facility services

Document at Least 30 Additional MinutesTo report an initial prolonged services code (99354 out-patient or 99356 inpatient), the physician must document at least an additional 30 minutes beyond the reference time of the chosen E/M service level, according to CPT® guidelines. CMS requirements also stress, “You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the evaluation & management (E/M) codes.”

You may use +99355 (outpatient) or +99357 (inpatient) to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15-30 minutes of prolonged service on a given date, if not otherwise billed. “Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately,” according to Medlearn Matters MM5972.

See Charts A and B for a complete list of threshold times (that is, minimum total documented time for the service) for reporting prolonged services.

Generally, you will select an E/M service using the key components of history, exam, and medical decision making (MDM), using the prolonged services codes, as appropriate, to account for physician time over and above the reference time for that service.

For example, a physician performs an expanded problem-focused history, an expanded problem-focused exam, and MDM of low complexity for an established outpatient. By these criteria, the visit meets the requirements of:

99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused his-tory; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate sever-ity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. The total visit time is 65 minutes, or 50 minutes greater than the reference time for 99213, so you may report 99213 with one unit of 99354.

When counseling and/or coordination of care comprise more than 50 percent of the total time with the patient, you may use time as the determining factor when select-ing an E/M service level. In such a case, however, you may only report prolonged services with the highest code level in that code family as the companion code.

For example, a physician performs an office visit with an established patient. Of a total visit time of 75 minutes, 60 minutes was spent on face-to-face counseling and coordi-nation of care with the patient. Based on time alone, the physician may report a level V established outpatient visit (99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A compre-hensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family), which has a 40 minute reference time. Based on the addi-tional 35 minutes over and above this reference time, the physician may also report a single unit of 99354.

feature

Generally, you will select an E/M service using the key components of history, exam, and medical decision making (MDM) using the prolonged services codes, as appropriate, to account for physician time over and above the reference time for that service.


Chart A: Threshold Time for Prolonged Visit Codes Billed With Office/Outpatient and Consultation Codes

CodeTypical Time

for Code

Threshold Time to Bill Code 99354

Threshold Time to Bill Codes

99354 and 99355

99201 10 40 85

99202 20 50 95

99203 30 60 105

99204 45 75 120

99205 60 90 135

99212 10 40 85

99213 15 45 90

99214 25 55 100

99215 40 70 115

99241 15 45 90

99242 30 60 105

99243 40 70 115

99244 60 90 135

99245 80 110 155

99324 20 50 95

99325 30 60 105

99326 45 75 120

99327 60 90 135

99328 75 105 150

99334 15 45 90

99335 25 55 100

99336 40 70 115

99337 60 90 135

99341 20 50 95

99342 30 60 105

99343 45 75 120

99344 60 90 135

99345 75 105 150

99347 15 45 90

99348 25 55 100

99349 40 70 115

99350 60 90 135

feature

Chart B: Threshold Time for Prolonged Visit Codes 99356 and/or 99357 Billed with Inpatient Setting Codes

Code Typical Time

for Code

Threshold Time to Bill Code 99356

Threshold Time to Bill Codes 99356

and 99357

99221 30 60 105

99222 50 80 125

99223 70 100 145

99231 15 45 90

99232 25 55 100

99233 35 65 110

99251 20 50 95

99252 40 70 115

99253 55 85 130

99254 80 110 155

99255 110 140 185

99304 25 55 100

99305 35 65 110

99306 45 75 120

99307 10 40 85

99308 15 45 90

99309 25 55 100

99310 35 65 110

99318 30 60 105


22 AAPC Coding Edge

The Savannah, Ga. chapter works hard to pro-mote the coding profession and this dedication won

them the 2008 Chapter of the Year Award. Freda Brin-son, CPC, CPC-H, 2008 chapter president, said she set high standards for Savannah “When I became president, there were so many things I wanted for our chapter. I was very ambitious and eager to bring Savannah into the run-ning for Chapter of the Year.”

When Coding Edge asked AAPC Director of Local Chap-ter Support Marti Johnson why she thought the chapter won 2008 Chapter of the Year award, she said, “These guys are full of enthusiasm and they try to do everything perfectly by the book. They make sure they follow all the rules. They met all the qualifications plus held an extra exam and two review classes.” Linda Litster, local chapter member relations, feels the Savannah chapter sets exem-plary standards. “Because they are a chapter that is truly committed to ‘Upholding a Higher Standard,’ they are committed to excellence,” she said.

In 2008, they doubled their size from 10-15 attending members to 20-33 attending members. Chapter member Mary C. Figuereo, CPC, said, “Over the past year our local chapter has more than doubled. In December 2007 we had 11 members and as of December 2008 we had reached 25 members. That is awesome!”

The Savannah chapter now has a total of 164 members assigned to it. Brinson made chapter information easily accessible for members who couldn’t attend meetings. “I received emails from members who couldn’t attend our chapter meetings but would respond to the information provided in our monthly newsletter and our monthly meeting summaries,” said Brinson. “All members know what’s going on in and with the chapter and that’s important to me. Every time I receive an email from a member or see each member walking into our chapter meeting, I know our chapter is growing.”

cover

Savannah Doubles, Taking the 2008 Chapter AwardBy Michelle A. Dick, senior editor

Most of the members of Savannah chapter pose in front of one of the city’s famous fountains.


cover

The Savannah chapter also earned the honor through the following:

Reviewing the Chapter of the Year requirement list in the handbook and thinking “We can do some of this.”

Fulfilling member requests. When a member made a request, they did it.

Starting the “Coders Teaching Coders” seminar.

When a member asked for a class where expe-rienced coders could share their knowledge and experiences with new coders, Savannah started the Coders Teaching Coders seminar,

which was on the Chapter of the Year list.

Offering a CPC® review class upon a student’s request.

Deciding to offer a review classes prior to every exam Savannah proctored because of the first review class success. Totaling four review classes.

Creating a chapter newsletter. This offered better com-munication to all chapter members providing up-to-date

chapter news to all.

More than doubling chapter attendance.

Getting chapter members involved in the

chapter meetings.

Making meetings both professional and fun.

What Makes the Savannah Chapter Special?When Savannah members were asked, “why do you think Savannah won the 2008 Local chapter of the Year Award?” Debbie Tober, 2008 secretary/treasurer, said, “That is obvious—we had an outstanding president. She worked hard to make the Savannah Chapter what it is today—number 1.” Brinson disagrees with Tober’s assess-ment. She said, “It’s because of our members who actively participate in chapter meetings. That’s why we won. It wasn’t the president—it was the members.

“I told our members back in January 2008 in our news-letter and at the first meeting that I wanted us to win. I honestly never thought we had a chance. Everything we did during that year was because a member asked about it. We would NEVER have just decided to do four review classes or a seminar. But as president, I thought

it was my duty to try and provide anything a member asked for.”

The Savannah chapter has “Great speakers. You actu-ally feel that if you miss a meeting, you will miss out on some very useful information,” Faye Grile, CPC, said. She tries not to miss a meeting because she puts that infor-mation to real-world use. “There is no such thing as too much good information!” Grile said.

“We offer exams four times a year. We also offer ‘Coders Teaching Coders.’ This allows training and education for many different specialties. It is so easy for coders to get into only one specialty, feel comfortable, and not expand their knowledge. This [Coders Teaching Coders] can really open a door with some great information. In larger facilities, this can also open the door for opportunities.”

2009 President Tamara M. Gentry, RHIT, CPAR, CPC, said, “With any efforts I put into the chapter I receive back tenfold in the form of information I can directly use in my career, cohesive relationships with other members, and as part of the AAPC.”

Gentry thanks the Savannah chapter for what they have given her. She is “proud as a peacock” of her chapter. She told Coding Edge, “From the very moment I picked up the phone to call the 2008 chapter president to intro-duce myself and obtain information, I felt welcomed and proud to be a part of such an intelligent, diverse, and fun group of people.”

Mary Figuereo, CPC, feels the Savannah chapter has “passion, love, and dedication” to coding excellence and that her chapter “enjoys learning about coding and always finds ways to teach and share the knowledge and expertise with our fellow members. We love to invite dif-ferent speakers to help enhance our understanding and to challenge our comfort coding zone. This is a team that is extremely dedicated in making sure the members reach and achieve their utmost potential by expanding and taking coding to the next level.”

Chapter member Adrienne Woods said, “I am proud to be a part of the chapter because of the continual effort to educate the coders on changes taking place with the gov-ernment and commercial insurance payers.” The chapter is “able to collaborate with other coders to gain knowl-edge in a particular area of coding that some of us may not have expertise in.”

Most of the members of Savannah chapter pose in front of one of the city’s famous fountains.

24 AAPC Coding Edge

cover

Brinson said, “We are proud of ourselves, our chapter, and the AAPC. We support our chapter by attending chapter meetings. We engage our speakers and bond with them ... I have had so many speakers contact me after their pre-sentations and tell me that they enjoyed speaking to our group and how comfortable they were with us. We respect each other and all chapter visitors. We are professionals.”

Open Arm PolicyThere is one common thread that binds this chapter together—they care about each other. Tober said, “We truly care about each other. I saw that first hand in December when I lost my husband in a motorcycle acci-dent. The outpouring of emails from my fellow coders was amazing. One from Freda Brinson, our president, was truly heartfelt and so comforting to me that I still go back and read it from time to time.”

Savannah member Kathleen Craven, CPC-A, was first introduced to coding when she attended Coding Boot Camp. Kathleen Craven’s sister, Mollie Craven, asked her to attend her first chapter meeting at a “Bring a Friend” meeting in May 2008. Craven said, “I work for a veterinar-ian and I had an interest in moving to human medicine. The members were very friendly and interested in what I did. They were very helpful and enthusiastic about me taking part in the boot camp.” She said, “After that meet-ing I decided if I was going to make a career change to coding, I needed to join. Due to everyone’s help and sup-port I passed the coding exam in November, without any other formal classes.” Recently, Kathleen has spoken at the January “Coders Teaching Coders” chapter meeting.

Chapter meetings combine coding with personal, real-life situations. Member Dorothy E. Carswell, CPC, said, “In

our ‘Coders Teaching Coders’ chapter meetings, a few of our own members take a subject and present for 15-20 minutes. Because the subject is up to that coder, we share some very personal information experienced in our own lives.” Carswell added, “This draws us together not only as coders but as friends. We are educated by one another and we learn together.”

When Brinson became Savannah president, she set a compassionate coding standard for the Savannah chapter. Figuereo said, “Freda Brinson is our best example of pas-sion, love, and dedication to our AAPC Savannah Local Chapter … She is an inspiration to all of us.”

Growing StrongThis isn’t the last we’ll see of the Savannah chapter. Lisa M. Smith said, “Like The Little Engine That Could, our chapter continues to keep on going and growing strong.”

The Savannah chapter doesn’t intend to stop at the 2008 Local Chapter of the Year award. Tober says the future holds a chapter that will “grow in numbers and have more outstanding speakers.” Freda said Savannah will “continue following the rules of AAPC and the coding profession, continue having fun while learning, continue growing in numbers and in closeness to each other, and continue supporting and respecting each other. We’ll sweep the 2009 AAPC awards.”

Figuereo concluded, “I can sincerely say that we are a really GREAT group of people to be associated with. I encourage you to come and visit our AAPC Savannah local chapter—you would love us!”

This isn’t the last we’ll see of the Savannah chapter, 2009 New Member Development Officer Lisa M. Smith said, “Like The Little Engine That Could, our chapter continues to keep on going and growing strong.”

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26 AAPC Coding Edge

letters to the editor

LC or LD? Check Your LCDDear Coding Edge,

I am contacting you for clarification on Dr. Zielske’s article published in the February 2009 issue of Coding Edge.

My understanding of his suggestion is that if a procedure is selective in the ramus intermedius (RI) and another selective procedure is done in the left circumflex (LC) or the left anterior descending (LD) coronary arteries, to code the RI as the oppo-site. In other words, for separate procedures involving both the LC and RI, code the procedure done in the RI with modifier LD Left anterior descending coronary artery. Is that right?

My coding partner found our (Michigan) Medicare local cov-erage determination (LCD) on percutaneous coronary inter-vention (PCI), last updated Feb. 16 (pg. 2), to state that the RI must be considered a branch of one or the other (LC or LD) and not coded separately.

The article did not reflect if Dr. Zielske is basing this direc-tion on a LCD or national coverage determination (NCD). I would appreciate some clarification, in addition to sharing it with AAPC members in a future issue.

Thanks to Dr. Zielske for his support and guidance in the coding industry.

Sincerely,

Colleen Rexin, CPC, PCSHeart Center for Excellence

Author responds: Dear Colleen,

In reference to RI intervention, an astute coder from Michigan brought it to my attention that their LCD considers the RI vessel to be a branch of either the LD or the LC.

The ramus is actually the middle artery of a trifurcating left main coronary artery. Sometimes it appears more like a branch off one of the named LC or LD arteries, but more com-monly it is equal to or larger than one of these. That said,

if intervention is performed in the LC, the ramus should be considered the LD for intervention and if intervention is per-formed in the LD, the ramus should be coded to modifier LC Left circumflex coronary artery for intervention.

Ramus intervention can be coded regardless of payer; however, it cannot be coded separately with some payers if interven-tions are performed in all three vessels: the LD, LC and RI. Fortunately, this is quite rare. In this case, some payers recog-nize the ramus as only a branch of either the LC or LD and it would not be separately coded. All branch interventions are considered part of the named vessel intervention. This main-tains the maximum coronary artery interventions performed in native coronary arteries to three even if a RI is present.

I hope this clarifies the ramus issue. Most important, review your LCD for coronary artery intervention for the rules in your area.

Sincerely,

David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC

Clarification: Payer Matters When Reporting Time-Based Critical Care ServicesDear Coding Edge,

The article “Pediatric Critical Care Codes Moved for Easier Coding” (Coding Edge, April 2009) appears to have an error. The code descriptors for 99466 and +99467 specify “30-74 minutes” and “each additional 30 minutes,” respectively. For a service lasting 80 minutes, as referenced in question 3 of “Test Your Knowledge” in the same issue, you would report 99466 according to the “Pediatric Critical Care Patient Transport Quick Coding” chart on page 17. But according to the CPT® code descriptors, you would report 99466, 99467 for the same, 80-minute service. Why the discrepancy?

Thanks,Susan Stevens, CPC

Letters to the Editor: LCDs, Critical Care Clarification, and Correction


letters to the editor

Dear Susan,

The descriptors for 99466 Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport and +99467 Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pedi-atric patient, 24 months of age or less; each additional 30 minutes (List separately in addition to code for primary service), as well as the “Pediatric Critical Care Patient Transport Quick Coding” chart, are all correct—depending on the payer.

Medicare rules, as stated in Section F, “Hours and Days of Critical Care that May Be Billed,” of the Centers for Medi-care & Medicaid Services (CMS) Transmittal 1530, Change Request (CR) 5993, dated June 6, 2008, specify, “Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not separately payable.”

Resource tip: You can view Transmittal 1530, CR 5993 at: www.cms.hhs.gov/transmittals/downloads/R1530CP.pdf.

The Medicare instructions refer specifically to critical care codes 99291-99292, but would apply to pediatric transport 99466-99467, which are also critical care services using the same time definitions as 99291-99292.

A chart that accompanies 99291-99292 in the CPT® manual recommends reporting additional units of critical care begin-ning at 75 minutes (rather than 90 minutes, as stated in the “Pediatric Critical Care Patient Transport Quick Coding” chart on page 17 of the April Coding Edge). The CPT® chart, however, contradicts Medicare instructions that “critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not separately payable.”

Although not stated explicitly, the information in the “Pedi-atric Critical Care Patient Transport Quick Coding” chart reflects the most conservative coding option, per CMS

guidelines. In adherence to CMS guidelines, you would report an 80-minute pediatric critical care transport service using 99466 alone for Medicare payers. For those payers observing CPT® guidelines, you may bill additional units of critical care beginning at 75 minutes rather than at 90 minutes. For these payers, you would report an 80-minute pediatric critical care transport service using 99466, +99467.

Coding Edge

After Further Examination, Mohs Typo is RevealedDear Coding Edge,

In the April 2009 Coding Edge, page 47, in the article “Exam-ine Mohs Micrographic Surgery for Clear Coding,” there is reference to the add-on code +17314. The article says, “Claim +17314 as an add-on code only with 17311.”

It should read, “Claim +17314 as an add-on code only with 17313.”

Thanks,

Donna Klug

Dear Donna,

Thank you for pointing the error out to us so that we may inform our readers.

Coding Edge

Please send your letters to the editor to: [email protected].

28 AAPC Coding Edge

Attendees had a lot to say about this year’s AAPC National Conference.

las vegas conference

The American Academy of Professional Coders’ (AAPC) 17th annual National Conference—held April 5-8 in Las Vegas and hosted at the Rio Hotel—far exceeded confer-ence goers’ expectations. Attendees, staff, presenters, and ven-dors all used the electric Las Vegas ambiance to energize their coding know-how.

Location, Location, LocationIf a location can make or break a conference, then this confer-ence was destined for success. Conference attendees soaked in all that the city and hotel had to offer. National Advisory Board (NAB) President Terry Leone CPC, CPC-I, CPC-P, CIRCC, said about the accommodations, “The Rio Hotel had a wonderful conference facility that fit our conference perfectly.” 2007-2008 NAB President Deborah Grider, CPC, CPC-H, CPC-P, CEMC,

CPC-I, CCS, CCS-P agreed, saying, “I liked the conference center. The rooms were spacious, well decorated, and the recep-tion area was centrally located so members could ask conference staff questions, browse in the product store, or meet friends.”

AAPC CEO and President Reed Pew said that because every-thing was “all under one roof—hotel and conference center, with the conference center on one floor,” attendees were able to experience Vegas while receiving a coding education with-out ever having to leave the Rio.

Conference Gets RollingPrior to the conference kick-off, students and teachers took advantage of credential exams, the “PMCC Instructor Approval Program,” and the “Teach the Teacher Workshop.”

Coders Hit the Jackpot in Vegas

By Michelle A. Dick, senior editor


Attendees had a lot to say about this year’s AAPC National Conference.


On Sunday, April 5, attendees were greeted at the funny, witty, and inspirational Conference Welcome. Comedian Johnny Biscuit led NAB skits, which ended with the audience singing and dancing “YMCA,” AAPC-style. Pew told Coding Edge this was a highlight for him.

The AAPC’s Legal Advisory Board discussed legal concerns for practices and facilities facing increased financial scrutiny in the general session “Legal Trends and Issues,” hosted by Sheri Bernard, CPC, CPC-H, CPC-P. Attendees came armed with questions in an anonymous atmosphere. After all—what happens in Vegas, stays in Vegas.

Local chapters were given the opportunity to network and exchange ideas with other officers at the Local Chapter Officer Meeting. Also Sunday evening, attendees visited local chap-ters from around the country at the “Get to Know Your Local Chapter” event.

Behind the scenes, the conference team—Amy Evans, Kira Golding, and Sandra Nestman, and Melanie Mestas—planned and executed every detail. Even with all their hard work, the conference team took advantage of the learning opportunities.

Conference Coordinator Amy Evans said, “My very favorite part of conference is meeting the people. It’s fun to finally put a few names with faces and get to know some new ones as well … it’s fun to see people enjoying themselves.”

Three Days of Coding ExcitementThere was something for every coder. The next three days were filled with unforgettable general and breakout sessions, networking, vendors, prizes, and good food. Sessions included everything from anatomy to electronic health records (EHRs); ICD-10 preparation to neoplasm tables; and coding ethics to hormone replacement therapy.

AAPC NAB member Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, CRA, was impressed with the “Coding Ethics” presentation by Brad Hart, BA, MS, CMPE, CPC. Miscoe said Hart “gave an excellent presentation on a topic that is criti-cal to maintaining the integrity of the coding profession. All those who attended this presentation are better for it.”

Anatomy Expo Pays OffThis year’s conference featured a three-hour Anatomy Expo with nine specialty physicians who each focused on differ-ent parts of the human anatomy. Topics included obstetrics, dermatology, gastroenterology, and urology and featured anatomic models, surgical tools and videos, and question and answer periods.

“I really liked the Anatomy Expo,” said Grider. “I think it got the members excited about learning anatomy in a new and different way.”

The Anatomy Expo piqued the interest of non-coders, as well. During a work break, AAPC Conference Coordinator Amy Evans attended a session for the first time. “This year I got to attend … the hand surgery class,” said Evans. “It was so interesting to watch the video and listen to the presentation. Although I’m not a coder, I found it fascinating. I hope to attend another presenta-tion in the Expo again next year—it was great!” You never know what you’re getting into when Johnny Biscuit grabs you.

Dr. David Zielske demonstrates a catheter during the Anatomy Expo.

Reed Pew performed with the Bahama chapter and received this headdress.

Members of the Bahama Local Chapter celebrate Junkeroo.

30 AAPC Coding Edge

Presenters Get the Best of Both WorldsMajella Doyle, MD, FACS, and Shelly Bauguss, CPC, CGSC, CANPC, CGIC, took attendees through a surgeon’s guided tour of a liver transplant in “Liver Transplantation—A Coder’s Trip to the OR.”

Bauguss said she found both presenting and networking at the conference to be very rewarding and wants to do it all over again. “What I enjoyed the most about presenting at the conference was having the opportunity to share knowledge on that high of a level,” said Bauguss. “I also enjoyed the profes-sional bond that the surgeons and I developed while creating and editing the presentation. I am proud of the presentation that we gave and the information that was shared.

“Above all other presenting aspects that I enjoyed most was meeting the members/attendees after the presentation and networking with them. I have attended five AAPC national conferences since I became certified and I met more people by being a speaker than I met at all of the other conferences combined. I am looking forward to presenting again next year in Nashville.”

Kerin Draak, MS, WHNP-BC, CPC, CEMC, presenter of “It Starts with a Pap,” said she feels networking is the best part of presenting as well. “I love to teach and really enjoy the interaction with a large group,” said Draak. “The biggest compliment is when people come after the presentation and ask questions. The best part about attending and speaking at the conference was making great contacts to use in the future as a resource/reference for coding questions.”

Suzanne Quinton, CPC, COSC, CPC-I, CCS-P, was busy as a conference monitor and as the presenter of “Stereotac-tic Radiosurgery,” an introduction of treating tumors with radiosurgery. Although Quinton was only able to attend the sessions she monitored and presented, she took advantage of the educational opportunity. She said, “I went to the classes

that I was supposed to monitor; they were all enjoyable and I learned a little something from each of them.”

Emotions Spin like a Roulette WheelThose who attended the awards luncheon experienced over-whelming emotions as Deborah Grider passed the NAB president gavel to Terry Leone. Everyone, including the AAPC president, was touched by the awards ceremony. The most memo-rable highlight of the conference, Pew said, “was the passing of the NAB gavel from Deb to Terry—the farewell to Deb.”

Leone agreed that it was a special moment. “The awards lun-cheon was extremely special as I received the president’s gavel from Deb Grider in front of my family and 1,800 of my coder peers,” Leone said. “The congratulations I received from many of them throughout the conference were special, thoughtful, and will remain with me for years to come.”

The luncheon evoked mixed feelings for Grider, too. “I must admit it was an emotional conference for me turning over the reigns to a new president,” said Grider. “The NAB and I have spent so much time together working on helping the AAPC and the membership—it was bittersweet turning over the reigns to a new president.” Many attendees recognized the strong NAB leadership during her presidency. Grider said, “I was terribly touched by the kindness and the overwhelming thanks to the entire NAB for all of our hard work and effort by the conference attendees.”

Up Next, NashvilleFor more conference highlights, go to www.aapc.com. Don’t miss the next AAPC National Conference, June 6-9, 2010 at the Opryland Hotel in Nashville, Tenn. Expect nothing less than a grand ole time! Also, check out upcoming regional conferences in Oahu, Hawaii, September 10-12, 2009 and Virginia Beach, Va., October 8-9, 2009.


Deborah Grider, 2007-2009 NAB President, passes the torch to incoming President Terry Leone, receiving the thanks of many, including 2003-2005 President Jerry Leong.


Kudos

Congratulations to Deborah A. Beeman, CPC-A, for Upholding a Higher Standard. She has been a busy coder this past year. She attended Adult Career and Technical Education in Canton, Ohio and earned CPC-A® and CMBS credentials in June 2008, graduat-ing at the top of her class. In July 2008, she landed a billing and coding posi-tion at American Med Systems, Inc. (a third-party medical billing company). In January, she was promoted to manager in the hospital billing department, where they follow up on worker’s compensa-tion claims. Deborah is a member of the Canton, Ohio local chapter.

Career Education Corporation selected Dorothy D. Steed, CPC-H, CPC-I, CFPC,

CEMC, as a high achieving

instructor in the Medical Billing and

Coding Program for 2008. She was

recognized and received her award at the corporate conference in Nassau,

Bahamas. She is also a past president of the Greater Atlanta Chapter.

If you deserve kudos, please email your accomplishments to our editors at [email protected].

Working Hard and Moving Up

32 AAPC Coding Edge

feature

Although evaluation and management (E/M) comprises a significant portion of coded services in most physician practices and medical facili-ties, selecting an appropriate E/M service level can flummox even an experienced coder. Over the next several months, Coding Edge will dis-cuss, in turn, each of the three key components that drive level selection for the majority of E/M services: history, examination, and medical decision-making (MDM). This series will pro-vide the basic information you need to not only choose E/M service levels with confidence, but also audit E/M claims for accuracy and consis-tency. We begin with the history component.

CPT® defines four levels of history, as determined by the amount and depth of information the prac-titioner collects from the patient. These include:

Problem focused

Expanded problem-focused

Detailed

Comprehensive

The history component of any E/M service is further divided into constituent elements, as defined by 1995 and 1997 documentation guidelines for Evaluation and Management Ser-vices. The specific elements that determine the history level include:

History of present illness (HPI)

Review of systems (ROS)

Past family and social history (PFSH)

You can access both 1995 and 1997 E/M docu-mentation guidelines on the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp.

Slot HPI Into One of Two LevelsThe HPI is a chronological description the patient’s present illness development, from the first sign or symptom, or previous encounter, to the present. Under both the 1995 and 1997 E/M documentation guidelines, the HPI can be quantified by a patient’s statements regarding:

Location: The anatomical place, posi-tion, or site of the chief complaint (eg, back pain, sore elbow, cut on leg, etc.)

Quality: A problem’s characteristics, such as how it looks or feels (eg, yellow dis-charge, popping knee, throbbing pain, etc.)

Severity: A degree or measurement of how bad it is (eg, improved, unbearable pain, blood sugar 205, etc.)

Duration: How long the complaint has been occurring, or when it first occurred (eg, since childhood, first noticed a month ago, on and off for several weeks, etc.)

Timing: A measurement of when, or at what frequency, he or she notices a prob-lem (eg, intermittent, constant, only in the evening, etc.)

Context: What the patient was doing, environmental factors, and/or circumstances surrounding the complaint (eg, while stand-ing, during exercise, after a fall, etc.)

Modifying factors: Anything that makes the problem better or worse (eg, improves with aspirin, worse when sit-ting, better when lying down, etc.)

Associated signs and symptoms: Addi-tional complaints that may be related.

The Driving Parts of E/M Level SelectionPart 1 of this three-part series provides an in-depth look at the history component.

By Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC

APPR

ENTI

CE


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The 1997 E/M documentation guidelines also allow credit in the HPI for patients who are seen for chronic conditions, such as if the patient states, “I am here today to follow up with my COPD.” Statements of this type are not credited specifically under the 1995 E/M documenta-tion guidelines, but may be given credit by the 1997 E/M documentation guidelines as chronic conditions when the status of those conditions are the reason for the visit.

Important: Do not “mix and match” 1995 and 1997 documentation guidelines. If you select 1997 E/M docu-mentation guidelines for the history component, you should use the same guidelines to determine the exam level and medical decision making level.

There are only two HPI levels. The least amount of credit defined by the HPI (assuming that HPI is documented) is a brief HPI, which correlates to an expanded problem-focused work level. For both 1995 and 1997 E/M docu-mentation guidelines, the HPI is brief if at least one of the eight elements that quantify HPI (location, quality, severity, etc.) is documented.

The second HPI level, an extended HPI, correlates to a comprehensive work level. For both 1995 and 1997 docu-mentation guidelines, the HPI is extended if at least four of the eight elements that quantify HPI are documented. For 1997 E/M documentation guidelines only, patient statements regarding the status of at least three chronic conditions may also be considered an extended HPI.

Refer to the History Level Selection Chart to determine how HPI correlates to the four levels of the overall his-tory component:

For example, a comprehensive history is required for a level IV new patient visit (99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive his-tory; a comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s

needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family). To meet the work of a com-prehensive history, an extended HPI (four of eight HPI quantifiers or the status of at least three chronic condi-tions when using 1997 documentation guidelines) must be documented.

Calculate ROS by Reviewed Body SystemsBoth 1995 and 1997 E/M documentation guidelines define the ROS as an account of body systems obtained through questioning to identify patient signs and/or symptoms. The ROS might include verbal questioning by the provider or by a separate patient intake or questionnaire form. The ROS may include the systems directly related to the problems identified in the HPI and/or additional body systems.

The ROS recognized 14 body systems are:

1. Constitutional 2. Respiratory 3. Integumentary 4. Psychiatric 5. Eyes 6. Gastrointestinal 7. Neurological 8. Allergic 9. Ears, Nose and Throat 10. Genitourinary 11. Endocrine 12. Cardiovascular 13. Musculoskeletal 14. Hematologic and Lymphatic

There are only three ROS levels. The least amount of credit defined by the ROS—assuming that at least one system is reviewed and documented—is a problem-pertinent ROS. The second ROS level, an extended ROS, requires a docu-mented review of at least two of the 14 organ systems. The final ROS level, a complete ROS, requires a documented review of at least 10 of the 14 organ systems.

34 AAPC Coding Edge

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Refer to the History Level Selection Chart to determine how ROS correlates to the overall history component’s four levels.

For example, a level IV new patient visit (99204) requires a comprehensive history. To meet the work of a compre-hensive history, a complete ROS (review of at least 10 of 14 organ systems) must be documented.

Medical necessity determines the extent of the ROS. For instance, it might be considered necessary to obtain a complete ROS when a new patient presents, but medi-cally unnecessary to repeat that complete review on every follow-up.

For most payers, if there is separate documentation of at least one pertinent positive or negative ROS element, and the provider states the remaining systems are reviewed and negative, credit should be given for a complete ROS. For example, the ROS in a new patient visiting a cardiolo-gist may read, “Denies additional cardiac complaints; the remaining systems were reviewed and otherwise negative.”

PFSH is Either Pertinent or CompleteThe patient’s past history includes previous diseases, ill-nesses, operations, injuries, treatments, and medications. If a patient presents for follow-up on a chronic condition, both the HPI and past history should be considered. Positive findings of past diagnoses discovered on ROS should also be considered.

Family history is a review of medical events in the patient’s family, including the parents and other relatives’ age of death, and diseases that may be hereditary or place the patient at an increased risk.

Social history is a review of the patient’s past and current activities, such as the patient’s occupation, whether he or she smokes or drinks alcohol, engages in sexual activity, and is married. Social history should be age appropriate. For example, it would not be reasonable to document that a 6-year-old is not married.

Inquiries about the patient’s PFSH may be made by the provider, obtained by the staff, or gathered via a form completed by the patient.

There are only two PFSH levels. The least amount of

credit defined by the PFSH—assuming that PFSH is documented—is a pertinent PFSH, which correlates to (at least) a detailed work level. For both 1995 and 1997 documentation guidelines, the PFSH is pertinent if at least one of the three constituent categories (past history, family history or social history) is documented.

The second level of PFSH, a complete PFSH, correlates to a comprehensive work level. This requires a documented review of two of three constituent categories (past his-tory, family history, and social history) for established patient office or other outpatient services, emergency department, established patient domiciliary care, and established patient home care; or documented review of all three constituent categories (past history, family his-tory, and social history) for new patient office or other outpatient services, hospital observation services, hospital inpatient services, consultations, comprehensive nursing facility assessments, new patient domiciliary care, and new patient home care.

Refer to the History Level Selection Chart to determine how PFSH correlates to the overall history component’s four levels:

For example, a level IV new patient visit (99204) requires a comprehensive history. To meet the comprehensive his-tory work, a complete PFSH must be documented.

Put It All TogetherAll three history elements must support the work level to meet the overall history level requirement. The lowest element within the history component will always deter-mine the overall history level.

For example, if the HPI and ROS both support a detailed history level, but the PFSH supports only an expanded problem-focused history level, the history level will stay at the expanded problem-focused level.

Important: You may not “mix and match” 1995 and 1997 Documentation Guidelines. If you select 1997 E/M documentation guidelines for the history component, you should use the same guidelines to determine the exam level and medical decision making level.

Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC is the AAPC’s director of exam content.


History Level Selection Chart Overall Level of History

Problem Focused

Expanded Problem Focused Detailed Comprehensive

Minimum HPI Element Not Specified Brief HPI Brief HPI Extended HPI

Minimum ROS Element Not SpecifiedProblem Pertinent ROS

Extended ROS

Complete ROS

Minimum PFSH Element Not Specified Not specifiedPertinent PFSH

Complete PFSH

feature

Five Key Points to Consider When Selecting a History Level

A chief complaint is a medically-necessary reason for the patient to meet with the physician. If there is no chief complaint, the service is preventive and should not be reported using a non-preventive medicine code.

If documentation establishes that the provider cannot obtain a history from the patient or other source (for example, if the patient is unconscious), the provider is not penalized, nor are the overall medical necessity level and provider work discounted automatically.

Additional history supplied by a family member or a caregiver and documented by the provider can be credited toward the overall E/M service’s MDM component.

An ROS and/or PFSH taken from a previous encounter may be updated without complete re-documentation for most payers. The provider should indicate the new history status and indicate where the original documentation is stored.

There is a fine line between the signs and symptoms that the patient shares in the HPI and those obtained via the ROS, but they are distinct. For example, if the documentation reads, “The patient states that her hip has been painful,” credit would not be given to both the HPI location and to the musculoskeletal ROS (this is “double-dipping”). If, on the other hand, the documentation reads, “The patient states that her hip has been painful. She denies any other muscu-loskeletal complaint,” there is a distinct component of both the HPI (painful hip) and also the separate musculoskeletal ROS (no other musculoskeletal complaint). There are times when two separate audits of the same service may produce different results, and neither party can be proven technically or medically wrong. A reviewer may argue that an HPI ele-ment is a “quality” versus an “associated sign and symptom or other element,” or that “no known drug allergies” docu-mentation constitutes an ROS element rather than a past history element. Correct interpretation requires consistency, verifiable references, a logical argument, and ultimately medical necessity.

Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC [ ]

36 AAPC Coding Edge

feature

A recent survey published in the New England Journal of Medicine found that only approximately 17 percent of U.S. physician offices are using electronic health records (EHRs). EHRs are an important part of a federal plan to improve the quality and cost effectiveness of health care. The American Recovery and Reinvestment Act of 2009 was signed into law by President Obama on Feb. 17 and allocated an estimated $34 billion to be used by the Cen-ters for Medicare & Medicaid Services (CMS) as incentives to increase the adoption of EHRs. Individual physicians can qualify for $44,000–$62,000 in incentives for using certified EHRs in a “meaningful” way. To qualify as meaningful use, the EHR must be capable of sending and receiving codified data to other EHRs and disease registries through health information exchanges (HIEs). The current administration stated that their goal is to have more than 75 percent of physicians become mean-ingful EHR users by the year 2017. Starting in 2015, there will be penalties in the form of reduced Medicare payments for physicians who are not using EHRs.

As EHR adoption rates increase, coding professionals will be presented with new challenges and opportunities requiring increased knowledge about health informa-tion technology (HIT)—in particular, how codified data generated by EHRs is managed for billing and reporting. Many of these opportunities represent relatively minor changes in professional coders’ skill sets.

Here are just five examples of how coding professionals can benefit from playing an active role in health care’s evolution into the digital era.

1. Assist Practice Evaluation of EHR Coding Tools and Content Prior to PurchaseThe majority of EHRs offer tools to assist clinicians with documenting and determining which evaluation and management (E/M) code should be assigned to an outpa-

tient visit. Because E/M services are the primary source of revenue for the majority of physician practices in the United States, coding professionals can help evaluate how an EHR under consideration by a practice generates sug-gested E/M codes and modifiers. EHRs also offer content and tools to assist with improved charge capture, ensure CPT® codes are supported by correct ICD codes, and identify payer specific billing requirements. An in-depth evaluation of how information is added to each visit note through automated processes, such as the reuse of infor-mation from old notes, templates, patient entered data, etc., is a critical part of each EHR evaluation. Certain systems may encourage users to add inaccurate informa-tion or to include information that was not obtained on the appropriate visit date, putting clinicians at risk for committing fraud. Nuances surrounding the use of 1995 vs. 1997 Documentation Guidelines for Evaluation and Management Services should also be explored, as many systems may only support one type of examination type.

2. Provide Ongoing Coding Support for EHRs during Implementation and UsageEHRs generally support the incorporation of specific billing codes within the clinical content (eg, templates) used by clinicians to determine what codes are used for billing processes. Coding professionals should carefully review the clinical content provided by EHR vendors and developed by their facilities for accuracy and complete-ness. When familiar with the application, sophisticated users can take full advantage of the EHRs ability to sup-port clinician billing activities at a more granular level. EHRs typically allow for payer-specific template creation and related tools to address complex billing scenarios and challenges, such as payer-specific coding requirements. This can lead to significant decreases in denials and can improve the efficiency of the billing process. Numer-

EHRs Pose Challenges, Provide Opportunities

By Michael Stearns, MD, CPC, CFPC

PR

OFE

SSIO

NAL


feature

ous challenges exist with how EHR tools calculate E/M coding levels and how clinicians use this information when determining the E/M service level. As with any software application, automated E/M coding tools are only effective and accurate if used properly. Ensuring that clinicians using EHRs remain adherent to accurate coding principles will require ongoing diligence from coding professionals.

3. Facilitate the Implementation and Use of Advanced Medical TerminologiesFor the quality and efficiency of health care to improve, a much greater percentage of clinical information needs to be captured and stored as codified and structured data. This offers marked improvements over free text as computers can process codified information in a way that greatly facilitates reporting, clinical decision making, information sharing between health care enterprises, and researching. This process becomes far more power-ful if what is referred to as a “reference terminology,” like Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT), is used. Reference terminologies obey strict rules and are designed specifically for use by software applications, making them far more useful to computer applications than administrative terminolo-gies such as ICD-9-CM or ICD-10-CM. Over the next several years, certain payer programs, such as pay-for-performance, will likely start requiring reporting using SNOMED CTR and/or other reference terminologies. Modern EHRs are capable of storing information as SNOMED CT codes; however, linking clinical informa-tion in EHRs to reference terminologies requires a great deal of coding expertise. Professionals with in-depth coding knowledge will be needed to map the information within EHRs to ICD-9/10-CM, HCPCS Level II, CPT® codes, SNOMED CT, and other supported terminologies.

4. Provide Data Exchange Support between Health Care EnterprisesA major requirement for “meaningful use” of EHRs is the ability to share information that is converted into

codified clinical data using standard code sets such as ICD-9-CM and, eventually, SNOMED CT. This has the potential to significantly reduce medical errors and to improve the efficiency of health care. Considerable chal-lenges remain, however. Information that is exchanged needs to be accurate and complete. Validating the integ-rity of codified data shared through health information exchanges requires extensive oversight by health care pro-fessionals with coding expertise.

5. Assess Clinical Reporting for ComplianceFor physicians to become meaningful users, they need to submit reports that document their ability to meet speci-fied clinical objectives (eg, what percentage of their patient population has undergone recommended preventative screening tests). In addition to the incentive funds tied to meaningful EHR use, there has been a shift in reimburse-ment towards pay-for-performance programs designed to reward clinicians for providing high quality care. Another challenge is that these guidelines, of which there are hun-dreds, are rapidly increasing in number and are subject to frequent modifications. For this process to be efficient, the codes contained within EHR content that are used to collect guideline information will need to be updated on a continual basis. Constant vigilance will also be needed to monitor the ability of clinicians to assess compliance with clinical guidelines. This will require detailed knowledge of how codified information is captured in EHRs, stored, and processed by applications. This is an ideal role for indi-viduals with coding expertise.

As EHR adoption rates increase, coding professionals will be presented with new challenges and opportunities requiring increased knowledge about health information technology (HIT)—in particular, how codified data generated by EHRs is managed for billing and reporting.

Michael Stearns, MD, CPC, CFPC, is a board certi-fied neurologist with 15 years of experience in clini-cal and academic medicine and over 10 years in the areas of HIT and coding. Dr. Stearns has presented on medical terminology, EHRs, coding, and genomic medicine. He has worked on several projects involv-ing computers in medicine at the National Institute of Health and was a key contributor to the develop-

ment of SNOMED CT. A member of the AAPC Family Practice Steering Committee, he is president and CEO of e-MDs, Inc.

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Isabel Bickle, CPC Salem ORSara Marie Waggoner, CPC Weston ORKimberly K Metcalfe, CPC Greensburg PATosha Moore, CPC Hanover PARenee Elizabeth Aston, CPC New Salem PAHeather A Celidonia, CPC Pittsburgh PALisa Mannheimer, CPC Pittsburgh PARuth Olliffe, CPC Pittsburgh PAMichelle Walter, CIRCC Pittsburgh PACathy Abouna, CIRCC Radnor PAPattie Mahoney, CIRCC Wallingford PASandra R Earnest, CPC York Haven PAHilda Andrews, CPC Bethlehem PAMary Ratto, CPC Bushkill PALaurie A Wilson, CPC Wellsboro PAMitzi Bedenbaugh, CPC Bishopville SCBetsy Padgett, CPC Florence SCMaureen Riordan, CPC Bluffton SCMary Lee Judice, CPC, CPC-H Leesville SCPatricia C Maccariella-Hafey, CIRCC Myrtle Beach SCCathy B Varn, CPC Orangeburg SCC Richelle Stafford, CIRCC Pawleys Island SCRuth Broek, CIRCC Brentwood TNPamela Richardson, CPC-H Elizabethton TNTracy Merrill, CPC Medina TNDrucilla A Luna, CPC Memphis TNJerri C Hinch, CPC Piney Flats TNJoan M Johns, CPC Columbia TNLoretta M Jarrett-McDonald, CPC Franklin TNRobin L Thomas, CPC Honewald TNShanetta Laurice Bell, CPC Lewisburg TNWendi M Harvey, CPC Lewisburg TNRobin R Potts, CPC Mount Pleasant TNCasey Cambre Wallace, CPC Smyrna TNMarjorie Stigleman, CPC Allen TXPatricia A Nagle, CPC Dallas TXEmma D Vital, CPC El Paso TXKimberly D Smith, CPC San Antonio TXAmberly D Cox, CPC Wichita Falls TXEunice N Ndungu, CPC Arlington TXRobin A Surrey, CPC Austin TXMary Krumme, CPC Frisco TXDonna J Cope, CPC, CIRCC Mansfield TXLourdes C Baker, CPC San Antonio TXCindi Evans, CPC San Antonio TXRevonda Kay Roark, CPC Bristol VAKathleen D Rhodes, CPC Cumberland VAShaiye Marie Shorts, CPC Herndon VAJulie Baumann, CPC Lynchburg VAElizabeth A D’Aquino, CPC Middlebrook VAMitzi T Grove, CPC, CPC-H S. Boston VADenise Wood Meek, CPC-H Waynesboro VAElecia H Gammons, CPC Claudville VAStacey Lynn White, CPC Fredericksburg VASandra Johnson, CPC Hampton VAJessica M Giles, CPC Richmond VA

Dolores (Lorrie) Valenta, CPC Richmond VASusan Kapral, CPC Dummerston VTGina M Smiley, CPC Burlington VTLeslie Llewellyn, CPC Waterbury VTSarah L Ford, CPC Bellevue WALori Carlin, CPC, CPC-H Burien WASharon Hebert, CPC Kent WAAnn M Matlack, CPC Olympia WAAdeste L Trim, CPC Olympia WATabatha R Newman, CPC Olympia WAJoy Lynn Rodriguez, CPC Puyallup WAMary Catherine McLinden, CPC Seattle WAMartina Caspers, CPC Woodinville WASonya Mclain, CPC Florence WISharon J Alder, CPC Janesville WIAudra Geving, CPC Janesville WIJoan Larock, CPC Little Chute WIKelli Lynn Kahlenberg, CPC Manitowoc WIChristine K Kritner, CPC Mequon WIAnn Whitley, CPC Graham WATracy Goretti, CPC Tacoma WATeresa Lee Zoito, CPC Vancouver WARenee Nimmer, CPC, CPC-H Menomonee Falls WINicole Apuzzo, CPC New Berlin WIKimberly J Laffin, CPC West Allis WIJohnna Lynn Ferrell, CPC Charleston WV

Wanda Reed, CPC-A Anchorage AKChristina A Smallwood, CPC-A Anchorage AKYelena Foreman, CPC-A North Pole AKCourtney Layman, CPC-A Gilbert AZP. Ramamoorthy, CPC-A El Sobrante CAHelen Dayao, CPC-A Glendale CALynn A Blinsky, CPC-A Greenbrae CADustin Dusuk Song, CPC-A Lakewood CABonnie Cox, CPC-A Millville CASusan Sliter, CPC-A Orangevale CASandra Asuncion Calderon, CPC-A Pacifica CAShahriar Salehi Tabar, CPC-A Rancho Santa Margarita CARenata A Espinoza, CPC-A South San Francisco CAReena Kumari Maharaj, CPC-A South San Francisco CASonia Maharaj, CPC-A South San Francisco CAPravina Singh, CPC-A South San Francisco CAJulia Ann Musekamp, CPC-A, CPC-H-A Arcadia CAEric G Maglalang, CPC-A Hayward CATerry Allen, CPC-A Lake Forest CALucy Saucedo, CPC-A Rowland Heights CATerry Lee Phillips, CPC-A San Francisco CA

Apprentices


Missed your name in 2008?Because of audits and other factors, some names didn’t make it into Coding Edge. Please look below if you didn’t see your name in 2008.


Pilar Macaranas Zabanal, CPC-A San Francisco CATheresa E Salsbury, CPC-A San Jose CAValerie Claire Amiel, CPC-A San Mateo CATeri Rae Smith, CPC-A Aurora COKelly P Story, CPC-A Grand Junction COMarylynn Bock, CPC-A Loveland CONicole Powell, CPC-A Aurora COTammy S Eve, CPC-A Pueblo COGail Rapacchietta, CPC-A Westminster COCandace J Ford, CPC-A New Haven CTKathleen M Edwards, CPC-A Branford CTJillane Whitsett, CPC-A Moosup CTLisa Z Castelli, CPC-A North Haven CTStacey Malin, CPC-A West Haven CTAmanda Cahill, CPC-A Windsor Locks CTSabitha Karangot Kaidery, CPC-A Bear, DEHarriet Roberta Alexander, CPC-A Davie FLKathy Booth, CPC-A Edgewater FLIrene Aguirre, CPC-A Indiantown FLMarcia Shannon, CPC-A Lynn Haven FLBarbara J Angell, CPC-A Orlando FLMaria Aragunde, CPC-A Pembroke Pines FLEdith Marisela Bobadilla, CPC-A Plantation FLFlora Brown, CPC-A St. Petersburg FLNorma Ilarraza, CPC-A Tampa FLHelen Edwards, CPC-A Acworth GAToni Pirkle, CPC-A Athens GAJennifer Minge, CPC-A Atlanta GAWayne D Syverson, CPC-A Decatur GAMiranda Young, CPC-A Hephzibah GARachel L Wilson, CPC-A, CPC-H-A Macon GALatonya Lewis, CPC-A Stone Mountain GAEbony Steele, CPC-A Stone Mountain GARebecca Mayne, CPC-A Woodstock GASandra Delois Terry, CPC-A Dublin GAChristine Salacup Longgat, CPC-A Ewa Beach HIArceli Cabanilla Chan, CPC-A Honolulu HIGernell Kaliana Kiyoko Yamada, CPC-A Honolulu HIMandy L Barger, CPC-A Kailua HIBernadette A Cokee Dexter, CPC-A Kaneohe HIDarlene Aquino Flores, CPC-A Mililani HITristan A Harder, CPC-A Cedar Rapids IAAmy JoAnne Brown, CPC-A Vinton IALisa Ann Oliveri, CPC-A Barrington ILRudolph K Gartner, CPC-A Chicago ILDebra M Melesio, CPC-A Lake Villa ILSharon Gablin, CPC-A Oswego ILJanelle Fleck, CPC-A Peotone ILMichelle M Youngs, CPC-A Spring Grove ILDeshaunda R Carter, CPC-A Springfield ILCharlotte J Wildman, CPC-A Springfield ILMelania Ward, CPC-A Clarksville INMichelle Harrison, CPC-A Cambridge City INWendy Nichols, CPC-A Scottsburg IN

Jamie Lynn Trun, CPC-A Granite City ILCharla K Grafton, CPC-A Mattoon ILLisa Marie Harter, CPC-A O’Fallon ILKasandra D.M. Bogatay, CPC-A Harper KSJennifer R Wilson, CPC-A Lawrence KSDe’Forya Calloway, CPC-A Minden LAKristina M Maxey, CPC-A Denham Springs LATammy G Heim, CPC-A Lafayette LAMelissa A Mason, CPC-A W. Brookfield MADoreen Bentley, CPC-A Marblehead MAMichael P Iarrobino, CPC-A Marblehead MAMelissa D Osborn, CPC-A Marblehead MAPenny J Richards, CPC-A North Reading MABen James Amirault, CPC-A Peadbody MASrdjan Perisic, CPC-A Salem MADarlene B Vendittelli, CPC-A Saugus MAJudy Gaboury, CPC-A West Brookfield MANicole Orange, CPC-A Linthicum MDPaulina Esi Kangah, CPC-A Springdale MDHeather Rogers, CPC-A Shady Side MDSandra D Rowe, CPC-A Freeport MESherry Ann Hall, CPC-A North Berwick MEKristi Wyman, CPC-A North Waterboro MEAmi Jo Graper, CPC-A Flint MIAngeline Johnson, CPC-A Flint MIMelissa Miller, CPC-A Livonia MIMallory Jones, CPC-A Waterford MIAmanda Bott, CPC-A Ypsilanti MICarla Ann Kent, CPC-A Grand Blanc MIStacy Maria Miller, CPC-A Hanover MISirisha Mallavaram, CPC-A Novi MINirmala D Shah, CPC-A Okemos MINicole Rose Mullen, CPC-A Royal Oak MIMary Jo Surma, CPC-H-A Saginaw MIRonda Blume, CPC-A Herman MNKristi Johnson, CPC-A Moorhead MNStacey Diane Finley, CPC-A Bloomsdale MOAmy Jo Kage, CPC-A Carl Junction MOBonita Jean Payton, CPC-A Carthage MONancy Jo Hensley, CPC-A Herculaneum MOJoyce Ann Davis, CPC-A House Springs MOJanis W Smith, CPC-A Kansas City MOElizabeth Giocondi, CPC-A Raytown MOHeather L Blacksher, CPC-A Saint Louis MOAndrea D Whittier, CPC-A Saint Louis MOAmanda Dawn Croft, CPC-A St Louis MOPeggy A Fahrenkamp, CPC-A St Louis MOPenny K Hampton, CPC-A St Louis MOMyla Shamese Hogue, CPC-A St. Louis MOLynnette Gant, CPC-A Kansas City MOJennifer L Ayers, CPC-A Bessemer City NCSarina Jenkins, CPC-A Charlotte NCRoberta M Mazingo, CPC-A Charlotte NCTerry Smith, CPC-A Charlotte NCChristopher Reinhard, CPC-A Creedmoor NCDebra B Teer, CPC-A Haw River NCTerry Lynn Williams, CPC-A Monroe NC

Miranda Paige East, CPC-A Mooresville NCJennifer Killian, CPC-A Murphy NCLisa Gragson, CPC-A Waxhaw NCHemangi Gaitonde, CPC-A Cary NCCecilia Gorzkowski, CPC-A Charlotte NCJamie Dionne Harrell, CPC-A Charlotte NCSandra T Boyles, CPC-A Denton NCDiane Paulette Miller, CPC-A Mebane NCTami Albert, CPC-A Fargo NDMaria Ramos-Loza, CPC-A Derry NHKimberly Ann Dailey, CPC-A Rochester NHGeorge Mammen, CPC-A Swedesboro NJStacey Souders, CPC-A Lakewood NJLinda A Myhre, CPC-A Princeton NJGina Maria Foster, CPC-A Baldwinsville NYLisa M Smith, CPC-A Bloomingdale NYLisa M Vercillo, CPC-A Cicero NYAmanda Deleva, CPC-A Horseheads NYPatricia Hitchcock, CPC-A Horseheads NYMelissa M Carmona, CPC-A Mattydale NYGina Marie Alford, CPC-A Syracuse NYLeila R DeDominicis, CPC-A Syracuse NYTanisha C Martin, CPC-A Syracuse NYAnne Richard, CPC-A Holbrook NYDiana Scotto, CPC-A N Massapeque NYKaren Ann Kelley, CPC-A Ashland OHKimberly Ann Aberts, CPC-A Loudonville OHLaura Rene Opper, CPC-A Broken Arrow OKAmie Lynn Ratterree, CPC-A Skiatook OKAlberto Castillo, CPC-A Tulsa OKTammy Lynn Edwards, CPC-A Tulsa OKNatalya Yelchaninov, CPC-A Portland ORLaura Piperato, CPC-A Tatamy PADonna Jones, CPC-A Walnutport PARosemary E Millan, CPC-A Carlisle PAHae Young Eum, CPC-A Enola PAErin E Stellar, CPC-A Kulpmont PAAdrienne Heatley, CPC-A Columbia SCAnn A Doolittle, CPC-A Ft Mill SCJennifer Rodgers, CPC-A Gaston SCPatrick Abrams, CPC-A West Columbia SCPatricia May, CPC-A Spearfish SDRae Lynne Adkins, CPC-A Memphis TNVickie Wood, CPC-A Mt. Juliet TNCathy Bingham, CPC-A Murfreesboro TNBrandon Petty-Perry, CPC-A Nashville TNMegan Cadogan, CPC-A Portland TNRobi Love Fortune, CPC-A Springfield TNJoan W Johnson, CPC-A Springfield TNJoanna M Gott, CPC-A Eddy TXBhagya L Alloju, CPC-A Frisco TXChristy Samford, CPC-A Mckinney TXAnnie Tapiawala, CPC-A Plano TXVernon Selvidge, CPC-A Rowlett TXTrish Spaziani, CPC-A Waxahachie TXSandra Mireles, CPC-A El Paso TXSona Palankar, CPC-A, CPC-H-A Irving TX

Jean Stellon, CPC-A Virginia Beach VALorraine G Paine, CPC-A Morrisville VTKenyon A Moshovetis, CPC-A Williston VTSherry Johnson, CPC-A Charlottesville VAGloria Evans, CPC-A Edinburg VACheryl Ann Hopkins, CPC-A Elkton VATamara Gordon, CPC-A Grottoes VAErin Patterson, CPC-A Lyndhurst VAKelly Washington, CPC-A Orange VARobin Hunley, CPC-A Rocky Mount VARuth L Jones, CPC-A Stanardsville VAScott Heynderickx, CPC-A Battle Ground WAScott Nicholson, CPC-A Bunker Hill WVValerie Jill Chapman, CPC-A Elkview WVKaila Monaghan, CPC-A Greenacres WALori Babcock, CPC-A Seattle WATeresa Greene, CPC-A Wenatchee WAMarcy Kemp, CPC-A Stoughton WIJessica Lee Chandler, CPC-A Dunbar WV

Stephanie L Timmons, CPC, CEMC Maricopa AZ

Schawn Anne Pedersen, CPC, CEMC Phoenix AZ

Judith A Hallas, CPC, CDERC Scottsdale AZ

Corie L Payne, CPC, CEMC Tucson AZ

Alex C Au-Yeung, CPC, CIRCC Santa Rosa CA

Brenda Ann Currie, CPC, CASCC, CGSC Broomfield CO

Tincy Von Atzingen, CPC, CASCC, CGSC Broomfield CO

Sheila Key, CPC, CPC-H, CASCC, CGSC Thornton CO

Betty Johnson, CPC, CPC-I, CDERC Homewood IL

Brenda K Kuhnert, CPC, CUC Lawrence KS

Laura Renee’ Valmont, CEDC Church Point LA

Sandra Foreman, CEDC Rayne LA

Connie Joy Murphy, CPC, CEMC Poplar Bluff MO

Rita C Weeks, CPC, CEMC Wake Forest NC

Andrea Beck, CASCC St Libory NE

Casey C Bzdak, CPC, CFPC, CGSC, COBGC Derry NH

Deborah Ann Wilson, CPC, CEDC Clifton Park NY

Christiana Oji, CPC, CCC, CCVTC Queens Village NY

Kathleen M Gasiewski, CPC, CEDC Selden NY

Sharee Luckeydoo, CPC, CPC-H, CANPC Bidwell OH

Tracey Christine Glenn, CPC, CPC-H, CEMC Harrisburg PA

Katrina M. Moultrie, CPC, CFPC North Richland Hills TX

Yolanda A. Stapleton, CFPC Robinson TX

Michael E Brown, CPC, CIRCC Houston TX

Vanessa Bryant, CCC Spokane WA

Kathleen Casey, CPC, CEMC Greenfield WISpecialties


40 AAPC Coding Edge

Erika Heiges, MPH, CHES, senior health educator with HealthEd in Clark, NJ recently asked Coding Edge, “Which CPT® code is appropriate when a provider instructs a patient how to inject a self-administered drug?”

Self-injection Training is…Self-injection training often is provided by a non-physician practitioner (NPP), and includes educating patients on injec-tion procedures, possible side effects, and other pertinent information. Face-to-face dialogue, classes, and/or video recordings may be used to provide instruction.

“Patients that may require self-injection training include those with chronic disease, such as rheumatoid arthritis—Humira and Enbrel are the drugs for these patients,” notes Linda Mar-tien, CPC, CPC-H, RCM education specialist at National Healing, Inc. Additional condi-tions that may require self-injection training include relapsing-remitting multiple sclerosis, hepatitis, erectile dysfunction, psoriasis, and migraine headaches, among others.

Report the Who, What, and Where“Code selection for self-injection training will depend on who is providing the service, and in what setting,” adds Nancy L. Read-ing, RN, BS, CPC, of Cedar Edge Medical Coding and Reimbursement. “An office nurse would be most likely to provide this service, although the provider would have to be in suite at the time. These are incident-to services, and you’d have to report 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.”

“From my understanding, when the self-injection training is provided by staff under the supervision of a credentialed pro-vider, rather than by the credentialed provider, the only coding option would be 99211,” confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, with MJH Consulting.

Note that self-injection training sessions may far exceed the typical 5 minute reference time for 99211. The practice simply has to absorb the cost of the NPP’s additional time.

Be aware of scope-of-practice issues when an NPP provides patient services. “In some states, for instance, an MA [medical assistant] must pass additional certification exams to be able to give injectables. So they may not always be the personnel to train,” Reading continues. Research the scope-of-practice

guidelines in your state to verify that the NPPs in your prac-tice are providing and reporting services appropriately.

Reading warns, “This issue really begs the incident-to criteria if self-injection training is done in place of service 11 [Office]. All other POS [place of service] would not bill or code for this service for Medicare Part B because the staff is not the physi-cian’s and the physician is seldom the person doing the train-ing. An in-depth analysis of where the service is performed and who owns the clinic and pays the staff is essential to determine prior to even discussing the service.”

In the Event of a Shared VisitOccasionally, injection training in the office may be part of a shared visit, in which the NPP provides the injection train-

ing and the physician sees the patient for additional, medically-necessary evalua-tion. This, too, is an incident-to service, for which the physician may report an appropriate evaluation and management (E/M) service level for the total work. The Medicare Claims Processing Manual, section 30.6.1.B, explains, “When an E/M service is a shared/split encounter between a physi-cian and a non-physician practitioner (NP, PA, CNS, or CNM [nurse practitioner, phy-sician assistant, clinical nurse specialist or

certified nurse midwife]), the service [in POS 11] is considered to have been performed ‘incident to’ if the requirements for ‘incident to’ are met and the patient is an established patient. If ‘incident to’ requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN [Unique Physician Identification Number/Provider Identification Number], and payment will be made at the appropriate physician fee schedule payment.”

In a hospital setting, when an E/M is shared between a physi-cian and an NPP from the same group practice, and the phy-sician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s UPIN/PIN number.

Document Each EncounterIn all cases, “documentation of patient education would be necessary,” Reading says. “As well, I would recommend docu-mentation of a return demonstration. This is crucial to ensure that the patient really can self-inject. You also might want to document support systems at home, such as a medical alert bracelet, in case the patient gets into trouble.”

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feature

Low-level E/M Defines Self-Injection Training


Note that self-injection training sessions may far exceed the

typical 5-minute reference time for 99211. The practice simply has to absorb the cost of the

NPP’s additional time.

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RHONDA BUCKHOLTZ, CPC®, CPC-I®

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06/17/09 THE CONFIDENT CODER: HOW TO ACCURATELY CODE FOR PROFESSIONAL SERVICES IN GI

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06/24/09 HOW TO AVOID TOP CODING AND BILLING MISTAKES BY ACSCS: THE FREE STANDING FREE FALL

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07/01/09 THE CONFIDENT CODER: HOW TO ACCURATELY CODE FOR PROFESSIONAL SERVICES IN ANESTHESIOLOGY

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SUSAN WARD, CPC®, CPC-H®, CPC-I®, CPC-E/M

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09/16/09 MODIFIERS KATHERINE ABEL, CPC®, CPC-I®

11/24/09 2010 COMPLETE CODE UPDATE FOR PROFESSIONAL SERVICES IN DIAGNOSTIC RADIOLOGY + OIG REPORT

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42 AAPC Coding Edge

feature

Question: What do the following procedures all have in common: Retropubic urethrolysis of a previously performed Burch colposuspension, laparoscopic distal pancreatectomy and splenectomy, electrosleep therapy, core decompression of the femoral head, thyroplasty, and endoscopic stapling of the diverticulum?

Answer: CPT® does not include codes for any of these services.

Question: What’s a coder to do when encountering one of these procedures in a physician’s notes?

Answer: Turn to the unlisted procedure codes in CPT®.

CPT® includes unlisted procedure codes allowing you to submit claims for services without specific CPT® descriptors assigned to them. You should never report a code that comes close to the procedure your physician performed but doesn’t quite fit. If no precise procedure or service code exists, you should report the service “using the appropriate unlisted pro-cedure or service code,” according to the CPT® Instructions for Use section in the CPT® manual.

Payment for such claims is not automatic. With carefully documented procedures, however, the information you include with your claim can make all the difference. You can stream-line your unlisted procedure code claims and ensure your physician gets reimbursed without using specific codes by fol-lowing these three pointers.

Tip 1: Describe the Procedure in Plain EnglishAny time you file a claim using an unlisted-procedure code (for example, 90779 Unlisted therapeutic, prophylactic or diagnos-tic intravenous or intra-arterial injection or infusion), you should include a separate report to explain in simple, straightforward language exactly what the physician did. Make sure to com-pare it to an existing procedure and give it a relative value to that existing procedure, as well as provide the operative or procedure note.

Keep in mind that insurers consider claims for unlisted pro-cedure codes on a case-by-case basis, and they determine pay-ment based on the documentation you provide.

It’s also a good idea to include diagrams or photographs to help the insurer fully understand the procedure. Some prac-tices recommend highlighting or making notes on the actual op report indicating where the provider describes the unlisted procedure. Some practices include copies of articles in medical journals supporting the reasonableness of the procedure, such as clinical trials and medical indications.

Don’t forget medical necessity documentation to back up the decision to perform the procedure. For instance, you can include details such as “electrosleep therapy was performed to treat chronic insomnia that has not responded to other treat-ments” to reinforce medical necessity.

For Medicare Administrative Contractors (MACs) or third-party payers that no longer accept paper claims or require an electronic claim to proof for timely filing, submit your unlisted CPT® code electronically with a short description of what was done in box 19 of the Centers for Medicare & Med-icaid Services’ CMS-1500 form or its electronic equivalent. Some MACs will then expect a faxed or mailed copy of your documentation after seven to 10 days, or will request docu-mentation after receiving the electronic submission.

When submitting an unlisted procedure claim, your docu-mentation should also include an explanatory cover letter.

For example, a young child requires a post-fistula tracheos-tomy tube change. The child is restless and unruly and will not submit to the procedure in the physician’s office. The doctor elects to perform the procedure in the operating room (OR) with the patient under anesthesia. In this case, your best code choice is 31899 Unlisted procedure, trachea, bronchi.

Your documentation should state, “The physician chose to perform the procedure under anesthesia in the OR rather than in the office because the patient was a young child who could not be safely restrained in the office setting. This was the best method to ensure a positive outcome and prevent any undue harm to the patient. CPT® does not contain a code to describe a procedure of this type, and we are submitting an unlisted procedure code.”

Tip 2: Compare the ProcedureAn insurer will decide to pay an unlisted procedure claim by comparing your procedure description to a similar, listed pro-cedure with an established reimbursement value.

Rather than leave it up to the insurer to determine which code is the “next closest,” you should explicitly make reference to the nearest equivalent listed procedure. After all, the treat-ing physician is best equipped to make this determination. You also should note the specific ways the unlisted procedure differs from the next-closest CPT® procedure listed. This explanation will help relate the procedure performed to an existing procedure as support for reimbursement. Make sure to explain how your procedure differs to show why you didn’t choose the existing code. Basing your fee on a similar proce-dure is helpful in claims processing, but is not mandatory.

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No Code? No Worries!Three tips for getting unlisted procedure CPT® codes to work for you.By Torrey Kim, MA, CPC


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feature

For example, the surgeon performs an arthroscopic bicep tenotomy, for which CPT® does not include a specific code. For this scenario, most coders recommend reporting 29999 Unlisted procedure, arthroscopy and requesting reimbursement at a level similar to 23405 Tenotomy, shoulder area; single tendon. The surgeon’s letter should explain the similarities and/or dif-ferences between the performed bicep tenotomy and a shoul-der tenotomy.

Tip 3: Solicit Outside Advice When You CanYour surgeon’s professional association might offer recom-mendations of when an unlisted code is warranted and, if so, which “compare” codes they recommend. The AMA often offers unlisted coding guidance in its CPT® Assistant and other publications.

If the physician uses equipment and techniques for which there is no dedicated CPT® code, you may ask for the manufacturer’s aid to receive appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician

practices on how to approach insurers regarding new technolo-gies. Use caution when applying manufacturers’ suggestions, however, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain payment.

If your practice performs a particular procedure often for which there is no specific code, consider meeting with the MAC’s or payer’s medical director to discuss how you can get paid for this service without having to jump through hoops every time it takes place. The payer may create a dummy code for the procedure, or set a fee for the unlisted code, facilitat-ing automatic adjudication.

Torrey Kim, MA, CPC, is the editor-in-chief of Part B Insider, a weekly publication that offers news and analysis on Medicare Part B issues. Visit the Part B Insider Web site at www.partbinsider.com.

44 AAPC Coding Edge

The Case of an Accessory OvaryEctopic ovarian tissue is extremely rare, occurring perhaps once per 500,000 (or more) gynecologic admissions. A precise esti-mate of occurrence is difficult due to a confusing (and still disputed) classification system, as well as the frequently asymptomatic nature of the condition. In this case, a morbidly obese 13-year-old girl is seen with a giant serous cystadenoma arising from an accessory ovary.

Indications: A 13-year-old girl presented with two bouts of abdominal and left flank pain during a six-month period, described as non-radiating and an 8 out of 10 in intensity. The pain was accompanied by nausea and one episode of vomiting. The patient also noticed a decrease in urinary frequency during the same interval. She denied fever, dysuria, hematuria, or bloody stools. Past medi-cal and family history was unremarkable. The patient had no history of hospitalizations, surgeries, or chronic illness. Menarche was at the age of 11, followed by irregular cycles occurring every 40 to 50 days with very heavy flow.

Physical examination revealed a morbidly obese (weight: 225 lbs., BMI: 40) adolescent girl. Her abdomen was soft and depressible and no masses were identified on palpation. Various imaging studies were performed including a pelvic ultrasound, which identified an 18.5 cm–10.0 cm–15.5 cm cystic lesion that extended into the abdomen approximately to the level of the umbilicus. MRI studies were ordered and identified a large cystic structure appearing to originate from the right adnexa, suggesting an ovarian tumor.

Due to the size and location of the cyst, a left salpingectomy was performed to remove it completely. The patient was left with two intact ovaries and her right fallopian tube. Due to the identification of two eutopic ovaries and the attachment to the mass to the left fallopian tube, a postoperative presumptive diagnosis of a left paratubal cyst was made. The final histopathological diagnosis was hemorrhagic serous cystadenoma arising from ovarian tissue.

Solution:The removal of the cyst would be reported with 58925 Ovarian cystectomy, unilateral or bilateral. Due the documented size and location of the cyst, however, another possible option—depending on the documentation in the op note—would be 49205 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter. In this scenario, 58700 Salpingectomy, complete or partial unilateral or bilateral (separate procedure) would also be reported.

Final diagnosis was hemorrhagic serous cystadenoma. In the ICD-9-CM Index, Cystadenoma/serous refers the reader to see Neo-plasm by site, benign. The histopathology identifies the cystadenoma source as ovarian. Report 220 Benign neoplasm of ovary.

The patient’s weight could also be reported with 278.01 Morbid obesity with V85.54 Body Mass Index, pediatric, greater than or equal to 95th percentile for age. Codes identifying specific BMI are for patients 20 years or older. For this patient, the pediatric percentile codes were used instead. Although the percentile was not provided in the medical documentation, by knowing the age, weight, and BMI of the patient, it could be computed on the Centers for Disease Control (CDC) Web site (http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx).


A 24-year-old roofer fell 12 feet from a one-story rooftop onto a tr

ee and was impaled by a

tree branch in his left flank at the level of the umbilicus. On arri

val at the ED, he had

a blood pressure of 136/110 mm Hg, pulse of 115 beats per minute, an

d a respiratory rate of

32 breaths per minute. Physical examination revealed equal breath so

unds on auscultation and

peritoneal signs on palpation.

The patient was resuscitated in the emergency department with crysta

lloids, which were admin-

istered through two large-bore venous catheters. He was transferred

to the operating room

conscious and supine. Extreme care was taken to avoid manipulating t

he branch, and rapid-se-

quence intubation was used to gain control of his airway.

The abdominal cavity was explored through a vertical midline incisio

n. During the operation,

bile-stained fluid was encountered in the right upper quadrant of t

he patient’s abdomen, and a

perforation of the lateral aspect of the second portion of the duode

num was noted. The gall-

bladder, pancreas, liver, and inferior vena cava were negative for in

jury. The tree branch was

removed under direct vision once the extent of the patient’s injurie

s had been assessed. A

Kocher maneuver was used to mobilize the patient’s duodenum and the

injury was repaired with

transverse closure in two layers. A distal feeding jejunostomy tube

was placed. The entrance

wound was debrided of dirt and splinters, lavaged, and allowed to he

al by secondary inten-

tion. The patient had a satisfactory recovery and was discharged to

home on postoperative day

seven. The jejunostomy was removed as an outpatient procedure on pos

toperative day 21.

The Case of the Impaled Roofer

Can You Code This Note?

Sometimes the circumstance can seem more extreme than the clinical reality, as in the case of this construction worker who was impaled on a tree branch when he fell from

a rooftop. But we all know, in coding, sometimes the devil is in the details. Code this scenario based on the operative services and diagnoses. Can you code this?

extreme coding

Have You Gone to Extremes?

Have you got a challenging scenario you’d like to see discussed in this forum? Send your op report to [email protected]. Before forwarding it to us, please safeguard the patient’s personal information by changing dates and removing unique identifiers.

46 AAPC Coding Edge

added edge

Certain services defined within CPT® contain separate professional and technical components. That is, the com-plete service, as reported by a single CPT® code, includes reimbursement for the physician’s work of the service—generally physician interpretation and report, or a diag-nostic test’s administration—and separate payment for necessary equipment usage and ancillary costs.

As a rule, codes with both a professional and techni-cal component describe equipment-intensive diagnostic services, including many services found in the radiology (70000 series) and medicine (90281-99607) sections of the CPT® manual. When reporting these codes, you may separate a service’s professional and technical components from one another with proper application of modifiers 26 Professional component and TC Technical component.

Identifying Qualifying CodesThe CPT® manual does not identify specifically codes with separate profes-sional and technical components. You may identify them readily, however: The Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (PFS) Relative Value File lists such codes on three separate lines, each with a different relative value unit (RVU) total. The first line describes the global service; the second line describes the service’s technical component (as indicated by “TC” in column B of the fee schedule), and; the third line describes the service’s professional component (as indicated by “26” in column B of the fee schedule).

Resource tip: You may download the CMS National PFS Relative Value File from the CMS Web site at: www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4. Be sure to select the most recent file.

Applying Modifiers 26 and TCMost often, you will append modifier 26 when the physi-cian does not own the equipment necessary to provide the service, such as when the physician provides the interpreta-tion and report for an X-ray taken in a facility setting.

When billing Medicare, physicians providing services in a facility setting cannot claim the procedure’s technical

portion regardless of whether they own the equipment. For instance, if a neurologist performs electromyography (EMG) (such as 95860 Needle electromyography; one extrem-ity with or without related paraspinal areas) for a Medicare inpatient using his own machine, he must append modi-fier 26. The hospital receives the payment for the technical component of any service provided in the facility as part of the diagnosis-related group (DRG) payment for Medicare inpatients. This is true even if the physician performs the service for a hospital patient in his or her office.

If, however, the physician provides the complete out-patient service in his office, using his own equipment, you may report the appropriate CPT® code without a modifier appended to receive reimbursement for the complete service.

For example, per the 2009 PFS Rela-tive Value file, the neurologist report-ing 95860 to Medicare in the facility setting recovers 0.96 RVUs for the professional portion of the service only. If the neurologist provides the same service for an outpatient in his own office, using his own equipment, he reports 95860 without a modifier, and receives a total of 2.16 RVUs for the complete service.

A physician practice may report a service with modifier TC only, but it would happen rarely. For example, sup-pose that several ophthalmology practices lease space within the same office complex. Practice A has had equip-ment difficulties, and arranges with Practice B to provide the technical portion of, for instance, visual field testing (92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination [eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) for Practice A’s patients. Practice B provides the printouts for Practice A, and Prac-tice A performs the interpretation and report. In this case, Practice A would report 92081-26, and Practice B would report 92081-TC.

SEPARATEProfessional & Technical

Components with 26 and TCBy G. John Verhovshek, MA, CPC


When billing Medicare, physicians providing services in a facility setting cannot claim

the procedure’s technical portion regardless of whether they own

the equipment.

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FTC Delays Red Flags RuleReady? Set? Stop!

Physicians have a bit more time to develop and implement a written identify theft pre-vention program in accordance with the Red Flags Rule. The Federal Trade Commission (FTC) extended the compliance deadline for creditors and financial institutions covered under the rule to Aug. 1—three months later than the May 1 extension and nine months later than the original Nov. 1, 2008 enforcement date. The latest extension was announced April 30.

In addition, the FTC is creating a template designed to help entities that have a low risk of identity theft, such as physicians who know their customers personally, comply with the law.

“Given the ongoing debate about whether Congress wrote this provision too broadly, delaying enforcement of the Red Flags Rule will allow industries and associations to share guidance with their members, provide low-risk entities an opportunity to use the template in developing their programs, and give Congress time to consider the issue fur-ther,” FTC Chairman Jon Leibowitz said in an April 30 press release.

As stated in an American Medical Associa-tion (AMA) press release, issued May 1, “The AMA will utilize this time to convince the FTC and Congress that physicians are not “creditors” and should not be subject to this rule.”

The Fair and Accurate Credit Transactions Act of 2003 (FACTA)—the impetus of the Red Flags Rule—applies the term “credi-tor” to any entity that regularly extends or renews credit, or arranges others to do so, and includes all entities that regularly permit deferred payments for goods and services.

Realizing that several industries, such as health care, were uncertain about their par-ticipation in the effort, the FTC has prepared a number of training materials to help busi-nesses develop their identify theft prevention programs.

For more information regarding the Rule’s requirements, read an alert at www.ftc.gov/bcp/edu/pubs/business/alerts/alt050.shtm. For resources on how to design and imple-ment identity theft prevention programs, and for the FTC compliance template, go to ftc.gov/redflagsrule. The AMA has also prepared a sample policy template, avail-able at www.ama-assn.org/ama1/pub/upload/mm/368/red-flags-rule-policy.pdf.

Coding Edge will continue coverage of the Red Flags Rule as details develop. Articles in February and April issues are excellent resources.

coding newsBy Renee Dustman

coding news

48 AAPC Coding Edge

minute with a member

Coding Edge (CE): Tell us a little bit about your career—how you got into coding, what you’ve done during your coding career, what you’re doing now?Kenneth: My work experience in allied health goes back to my childhood. When I was 8 years old, I filed and pulled records at a clinic where my mother worked. I took note of strange numbers on the charts, which I later learned were ICD codes. As a teen, I worked in an ophthalmologist’s office where I prepared insurance claims and patient statements, filled contact lens orders, maintained the postage meter, stuffed envelopes, pulled charts, and typed schedules. This is where I was introduced to ICD coding. In 1989, I joined a practice management business serving a multitude of specialties, where I was senior biller for many years.

In the spring of 2006, I received a call from a career school’s regional director in need of a billing and coding instructor. I seized the opportunity to bring my knowledge into the classroom. Besides billing and coding, I teach a variety of subjects, such as front office skills, practice management software, and electronic health records. I joined the AAPC last summer; and completed the PMCC program in December 2008.

CE: What is your involvement level with your local AAPC chapter?Ken: I am a member of the Quincy Bay Coders; the chapter is based in Quincy, which is just south of Boston. Although I’ve only been a member for a few months, I partake in as many of their activities as time allows. To further expand my knowledge as a coder, I also attend seminars at other nearby chapters.

CE: What has been your biggest chal-lenge as a coder?Ken: Coding seems to be one of the more taxing subjects for some students. My objec-tive is to have them not only learn their basic way around a CPT® book, but also pay close attention to coding conventions, key words, and nuances such as the location of a semico-

lon. Students need to become familiar with coding guidelines and to understand when certain codes are not separately reportable.

In the hospital/clinical setting, I still see some challenges in consistently bridging the communication gap between coders and doctors. It all comes down to whether the physician is responsive and compliant.

CE: What do you advise other coders to do if they disagree with the way a physician has coded his chart? Do you approach the physician, or have a monthly meeting?Ken: If the discrepancy was an isolated situ-ation, I’d suggest the coder approach the physician directly, and focus on whether the error was a wrong code choice based on a properly documented chart or one of under-documentation for the services provided. Periodic meetings with the physician(s) may be necessary if the problem is ongoing.

CE: If you could have any other job, what would it be?Ken: I picture myself playing an integral role in ICD-10-CM implementation consult-ing activities. I’d also enjoy being a PMCC instructor—mentoring students, shaping more certified coders, and encouraging students to continue their coding education after they’re certified.

CE: How do you spend your spare time? Tell us about your hobbies, family, etc.Ken: I am married with two daughters. We like to travel, but due to local business demands, I’ve had to stay put for awhile. I am also a historian, mainly focused on the second quarter of the 19th century. I dis-cover sites where people hung out during this era, and use a metal detector to find coins of styles and denominations that were discontinued about 150 years ago. I collect coins from 1821 to 1856. I find pieces as old as the late 1700s at research sites. Because of inconsistency in minting technology, studying these items requires attention to detail—just as with coding!

Kenneth Cable Camilleis, CPCAllied Health Instructor, Lincoln Technical Institute, Boston, Mass.

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50 AAPC Coding Edge

test yourself

Coding Edge Tests Your KnowledgeJune 2009

Get One CEUThese questions are answered in articles throughout this news magazine. For answer-ing all questions correctly, you will receive one CEU at the time of your renewal.

Test Yourself OnlineThese same questions can be accessed online at www.aapc.com/testyourself/. Once you go there and take the test, you can automatically grade your answers, correct any mistake, and have your CEUs automatically added to your CEU Tracker for submission. Starting the July issue, Test Yourself will only be accessible online.

1. Which E/M service component is the overarching criterion for E/M level selection?a. historyb. examc. medical decision-makingd. time

2. What is the “reference time” for a level III outpatient consultation service (99243)?a. 10 minutesb. 20 minutesc. 30 minutesd. 40 minutes

3. The coding rules/regulations as published in which of the following take precedence above all others?a. HIPAAb. CPT® Manualc. CPT® Assistantd. Payer-specific instructions, such as CMS/Medicare and national Correct Coding Initiative guidelines

4. Which of the following statements is NOT true?a. When reporting inpatient prolonged services for payers who follow CPT® guidelines, you may count only face-to-

face timeb. When reporting inpatient prolonged services for Medicare payers and others who follow Medicare guidelines, you

may count only face-to-face timec. When reporting outpatient prolonged services for payers who follow CPT® guidelines, you may count only face-to-

face timed. When reporting outpatient prolonged services for Medicare payers and others who follow Medicare guidelines, you

may count only face-to-face time

5. How many minutes beyond the “reference time” for a given level of E/M service must the physician document to report prolonged services?a. 15 minutesb. 30 minutesc. 45 minutesd. 60 minutes

6. The physician documents an expanded-problem focused history, a detailed exam and MDM of moderate complexity for an established patient in the outpatient setting. The visit lasts 90 minutes with well-documented medical necessity for that time. What is the appropriate coding?a. 99213, 99354b. 99213, 99354, 99355c. 99214, 99354d. 99214, 99354, 99355

7. The physician documents a brief history of present illness, an extended review of systems, and a pertinent past, family, and social history. What is the overall “level” of the history component in this example?a. Problem Focusedb. Expanded Problem Focusedc. Detailedd. Comprehensive

8. The physician documents, “Patient experiences a ‘popping’ or ‘clicking’ sensation of the jaw while chewing. This often leads to headaches and neck pain of mild to moderate severity, as well as discomfort when eating or yawning. Pain subsides after sleep, but increases as the day progresses. Symptoms began approx. two weeks ago. No swelling or bruising is apparent.” This qualifies as:a. A problem-focused HPIb. An extended HPIc. A pertinent PFSHd. A complete PFSH

9. True or False. When a physician performs a diagnostic test with both a technical and professional compo-nent, for a Medicare patient in a hospital, using his own equipment and/or staff, the physician can report the “global” service using the appropriate CPT® code, without a modifier appended.a. Trueb. False

10. When reporting an unlisted procedure code, upon initial claims submission, which of the following should you NOT do?a. Include a short description of the procedure in box 19 of the electronic claims formb. Prepare additional documentation for submission, if requestedc. Provide the payer with a suggested payment based on a comparison with an already-valued procedure of similar

intensity/resource utilizationd. Append modifier 22 Increased procedural service to the claim to identify it as unusual

Index: CE06002009A

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