Your Opinion Matters

January 2011
Your Opinion
Matters
AAPC National Advisory Board
Plus:
Vertebroplasty • ED MDM • Hospital Work Plan • 2011 OPPS • COPD
contents
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[contents]
January 2011
In Every Issue
7Letter from the President and CEO
8 Coding News
10 Letters to the Editor
13 Letter from Member Leadership
Special Features
13
Features
14 Are You Aboard the EHR Revolution?
Stephen C. Spain, MD, FAAFP, CPC
16 Don’t Let PHI Become TMI
Robert A. Pelaia, Esq., CPC
20 Health Care Reform: The Assault on Waste, Fraud, and Abuse
David Behinfar, JD, LLM, CHC, CIPP
22 Accurately Score MDM in the ED
Sarah Todt, RN, CPC, CEDC
26 Vertebroplasty Is Not Vertebral Augmentation
G. John Verhovshek, MA, CPC
30 Prepare for 2011 OPPS Final Rule
Denise Williams, RN, CPC, CPC-H
42 Road Map to ICD-10: Get on Board for the Next 1000 Days
Angela “Annie” Boynton, BS, RHIT, CPC, CPC-P, CPC-H, CPC-I, CCS, CCS-P
44 COPD: Frequently Used, Frequently Misreported
Jill M. Young, CPC, CEDC, CIMC
Online Test Yourself – Earn 1 CEU
go to www.aapc.com/resources/
publications/coding-edge/archive.aspx
18AAPCCA: Make a Lasting First Impression
Melissa Brown, RHIA, CPC, CPC-I, CFPC
49Acquire Coding Instructor Skills
Geanetta Johnson Agbona, CPC
People
37Repair Relationships: Approach Providers
from Their Viewpoint
Lynn S. Berry, PT, CPC
38 Newly Credentialed Members
50 Minute with a Member
Coming Up
ENT
46 Evaluate Your Performance When ED Leveling
Sleep Medicine
Jim Strafford, CEDC, MCS-P
Subpoenas and Search Warrants
On the Cover: Every fall, AAPC’s National Advisory Board (NAB) meets in Salt Lake City to
represent members throughout the country. See the NAB president’s message for more.
Cover photo taken by Rachel Minson.
Vascular Surgery
Remote Billers
www.aapc.com
January 2011
3
Serving 100,000 Members – Including You
Serving AAPC Members
The membership of AAPC, and subsequently the readership of Coding Edge, is quite
varied. To ensure we are providing education to each segment of our audience, in
every issue we will publish at least one article on each of three levels: apprentice,
professional and expert. The articles will be identified with a small bar denoting
knowledge level:
APPRENTICE
Beginning coding with common technologies, basic anatomy and
physiology, and using standard code guidelines and regulations.
PROFESSIONAL
More sophisticated issues including code sequencing, modifier
use, and new technologies.
EXPERT
Advanced anatomy and physiology, procedures and disorders
for which codes or official rules do not exist, appeals, and payer
specific variables.
January 2011
Chairman
Reed E. Pew
reed.e.pew@aapc.com
President and CEO
Deborah Grider,
CPC, CPC-I, CPC-H, CPC-P, COBGC, CPMA, CEMC, CPCD, CCS-P
deb.grider@aapc.com
Vice President of Marketing
Bevan Erickson
bevan.erickson@aapc.com
Vice President, Business Development
Rhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTC
rhonda.buckholtz@aapc.com
Directors, Pre-Certification Education and Exams
advertising index
Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC
Raemarie.jimenez@aapc.com
Katherine Abel, CPC, CPMA, CPC-I, CMRS
Katherine.abel@aapc.com
American Medical Association .............p. 33
www.amabookstore.com
Vice President, Post Certification Education
American Society of Health
Informatics Managers . ....................... p. 5
http://ashim.org
Director of Editorial Development
David Maxwell, MBA
david.maxwell@aapc.com
John Verhovshek, MA, CPC
g.john.verhovshek@aapc.com
Directors, Member Services
Brad Ericson, MPC, CPC, COSC
brad.ericson@aapc.com
Danielle Montgomery
danielle.montgomery@aapc.com
The Coding Institute, LLC ................... p. 36
www.supercoder.com/guides
The Coding Institute, LLC ................... p. 41
www.SuperCoder.com
Senior Editors
Michelle A. Dick, BS
michelle.dick@aapc.com
Production Artist
CodingWebU . ...................................... p. 51
www.CodingWebU.com
Contexo Media .................................... p. 6
www.contexomedia.com
HeathcareBusinessOffice LLC ............ p. 25
www.HealthcareBusinessOffice.com
Ingenix . ............................................... p. 12
www.shopingenix.com
Medicare Learning Network® (MLN)...... p. 11
Official CMS Information for Medicare Fee-For-Service Providers
www.cms.gov/MLNGenInfo
NAMAS/DoctorsManagement ............ p. 52
www.NAMAS-auditing.com
ZHealth Publishing .............................. p. 2
www.zhealthpublishing.com
Renee Dustman, BS
renee.dustman@aapc.com
Tina M. Smith, AAS Graphics
tina.smith@aapc.com
Advertising/Exhibiting Sales Manager
Jamie Zayach, BS
jamie.zayach@aapc.com
Address all inquires, contributions and
change of address notices to:
Coding Edge
PO Box 704004
Salt Lake City, UT 84170
(800) 626-CODE (2633)
© 2010 AAPC, 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 AAPC. Statements of fact or opinion
are the responsibility of the authors alone and do not represent an opinion of AAPC,
or sponsoring organizations. Current Procedural Terminology (CPT®) is copyright 2010
American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
values or related listings are included in CPT®. The AMA assumes no liability for the data
contained herein.
CPC®, CPC-H®, CPC-P®, and CIRCC® are registered trademarks of AAPC.
Volume 22 Number 1
January 1, 2011
Coding Edge (ISSN: 1941-5036) is published monthly by AAPC, 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.
4
AAPC Coding Edge
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18271
letter from the president and CEO
Face ICD-10 Challenges Together
While watching my favorite football team,
the Indianapolis Colts, the other night, I
thought about how it’s important for teams
to follow their quarterback’s instructions
when playing the game. I watched Peyton
Manning call the plays and how the entire
team worked side by side with him—and,
of course, they won the game.
I’m confident that by Super Bowl XLVII,
we will be ready to block and tackle any
obstacles we face during the ICD-10 transition Oct. 1, 2013. All we have to do is
work together as a team—a very large team
with over 100,000 AAPC members—and
listen for when the plays are called.
Implementation Kick-off
It’s 2011, and it’s time to get serious about
the national implementation of ICD-10.
Providers, hospitals, health plans, and
anyone who is mandated under Health
Insurance Portability and Accountability
Act (HIPAA) must comply with the Oct.
1, 2013 implementation deadline.
For those of you who are involved in your
organization’s ICD-10 implementation process, now is the time to become familiar
with how the codes translate to documentation and how they map from ICD-9-CM
to ICD-10-CM. These are critical steps.
Learn these steps and incorporate them
into your practice so you will be ready for
this important transition.
Wait for the Final Code Set Release
As for learning the new code sets, AAPC
is recommending coders wait until the
fourth quarter of 2012 or the beginning of
2013. Why wait when other organizations
are saying the time is now? AAPC doesn’t
believe creating a sense of urgency to learn
ICD-10 code sets is a good play.
The ICD-10 code sets and guidelines are
still in draft format until the codes are
finalized and there is a code “freeze.” The
last regular update will be Oct. 1, 2011
for ICD-9-CM and ICD-10-CM code
sets. Only limited updates will be made to
capture new technology and diseases for
ICD-9-CM and ICD-10 in 2012. In 2013,
ICD-9-CM will not be updated and only
limited updates will be made to ICD-10.
Regular ICD-10 updates will resume Oct.
1, 2014, at which point ICD-9-CM will no
longer be used.
It simply doesn’t make sense to spend time,
effort, and money on learning codes and
guidelines that might change. If you only
need to learn the codes, be patient and
wait for the right time.
Here’s the Game Plan
AAPC plans to continue in 2011 to offer
on-site boot camps and distance learning modules for anyone involved in the
implementation process. These courses are
designed to help a medical practice and/
or health plan implement ICD-10 within
their organization. We also have 15-minute
webinars for providers and managers to
explain what elements go into ICD-10
planning and provide guidance on where
to begin.
In 2012, AAPC will begin to offer code set
training on both ICD-10 CM and ICD10-PCS (for inpatient coders) in various
venues including boot camps, workshops,
conferences, distance learning, and webinars. There will be general and specialtyspecific opportunities for education.
In 2013, boot camps, workshops, distance
learning, and webinars will continue and
there also will be up to 10 regional conferences across the country dedicated to
ICD-10 training. We think this will provide everyone with the training necessary
to move ahead.
Train for the Big Day
Don’t wait to learn about ICD-10. Visit
AAPC’s website at www.aapc.com/ICD-10
to read ICD-10 articles and information.
Start the implementation process in your
organization right away. You can log into
your member area and use the benchmark
tracker to track your organization’s imple-
mentation progress. Begin code set training in 2012-2013. Get the right training at
the right time so you will be ready to score
when the big day comes in 2013.
I hope you all had a wonderful holiday
season and that we all have a happy and
productive new year.
Until next month, my friends…
Sincerely,
Deborah Grider,
CPC, CPC-H, CPC-I, CPC-P, CPMA,
CEMC, COBGC, CPCD, CCS-P
AAPC President and CEO
www.aapc.com
January 2011
7
coding news
coding news
AMA Releases 2011 CPT® Errata
With your new 2011 CPT® in your hand,
you’re ready and anxious to start coding
this year’s procedures. Before you get
into the thick of coding claims, however,
update your book with new information
from the American Medical Association
(AMA).
Evaluation and Management (E/M)
Prolonged Services
The parenthetical note for add-on code
8
AAPC Coding Edge
99356 Prolonged physician service in the
inpatient setting, requiring unit/floor time
beyond the usual service; first hour (List
separately in addition to code for inpatient
Evaluation and Management service) splits
the 99221-99233 code range to no longer
include 99224-99226 as subsequent observation codes. Its parenthetical note now
reads “(Use 99356 in conjunction with
99221-99223, 99231-99233, 99251-99255,
99304-99310, 90822, 90829).”
Surgery
Bone Marrow or Stem Cell Services/Procedure codes 38205 and 38240 and parenthetical note following 38230 are corrected
to revise the erroneous term “allogenic,”
which now reads “allogeneic.”
In the Digestive System, Biliary Tract, surgery section, the parenthetical note, “(For
radiological supervision and interpretation,
use 75989),” following 47490 Cholecystostomy, percutaneous, complete procedure,
including imaging guidance, catheter placement, cholecystogram when performed, and
radiological supervision and interpretation, is
deleted because it is now a bundled service.
More Parenthetical Note Revisions
There are several other changes to CPT®
parenthetical notes. They are:
• Revise the parenthetical note following code 76513 referencing deleted
code 0187T and include 92132.
• Revise the parenthetical note following 82013 to “gastric acid” not “acid
gastric.”
• Delete the parenthetical note preceding code 90862 that references deleted
codes 0160T, 0161T.
• Delete the parenthetical note following the Neurology and Neuromuscular Procedures guidelines referencing
deleted codes 0160T, 0161T.
• Revise the third parenthetical note following 95806 to include the term “a
minimum.”
Appendix B
AMA has made a few changes to Appendix
B. Most notable is that 99365 has been
rescinded and is deleted from Appendix
B. Other changes to Appendix B are the
reference to deleted code 91000 should be
moved to follow code 90868 rather than
90670; and 93268 is revised to retain the
phrase “24-hour attended monitoring” in
the code descriptor.
Index
In the Index, under Atherectomy, add “or
Percuatenous” to the “Open” subheading
and delete duplicate references:
Femoral … 37225, 37227
Popliteal … 37225, 37227
Tibioperoneal … 37233, 37235
Other changes to the Index are:
Evaluation and Management
• Work-Related and/or Medical Disability - Delete reference code 99450 and
replace with 99455.
CT Scan/Guidance
• Visceral Tissue Ablation - Delete reference code 76362 and replace with
77013.
Urethra
• Pressure Profile - Delete reference
code 51772 and replace with 51727,
51729.
Short Descriptors
Short Descriptors 22900, 22901, 74176,
74177, 74178, and 99218 have been
revised. See the complete AMA errata
“Corrections Document—CPT® 2011”
located at www.ama-assn.org/ama1/pub/
upload/mm/362/cpt-2011-corrections.pdf
for details.
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letters to the editor
Letters to the Editor
More on Changing the Code
Complex Catheter Coding, Simplified
I would like to “put my two cents in” regarding the articles “Just
Change the Code” by Simone Tessitore, CPC, COBGC, (May
2010) and “Don’t Change the Code” by Pam Brooks, CPC,
PCS, (November 2010) on requests to change codes. From the
viewpoint of not only a coder but also a billing and reimbursement specialist, I can easily identify with the dilemma of dealing
with the treatment of coding discrepancies that result in claim
denials.
Frequently, our patient account managers would get angry calls
from patients telling us about receiving a bill because a claim was
coded incorrectly. As an off-site billing service, we did not have
professional coders on staff, and had to essentially rely on information entered by the provider on the encounter forms as we processed the data into our practice management system.
Altering codes with the sole intent to obtain or increase coverage or to benefit patients is clearly fraud. In fact, many billing
software programs have hooks in them to prevent code changes
when resubmitting the same claim. For example, our billing software allowed the changing of an ICD-9-CM code in the event of
a later confirmed disease, but it was programmed to not permit
changing of a CPT® code.
Besides getting requests from patients to change codes, we’d also
get requests from doctors, and yes, even suggestions from payers
to resubmit claims with different CPT® codes. I and my staff were
caught between a rock and a hard place with these situations, and
the conflict in client communication would sometimes cause the
relationship to be severed—for the better, in my opinion, especially when considering AAPC’s motto of “Upholding a Higher
Standard.”
Regarding medical bills being negotiable, this is only true from
the standpoint that if a doctor has a self-paying patient or one
who is on a non-contracted (fee-for-service) plan, the patient may
be able to do some research based on the CPT® or HCPCS Level
II code and see what the Medicare rate is for that service and
use that as a guideline in the attempt to get a balance reduced.
For example, if a physician’s fee is $900 for a service which the
payment schedule on the corresponding CPT® code indicates
$637.22, perhaps the patient could offer $650 as a settlement—
however, the code itself is not negotiable!
Thank you so much for publishing the article entitled “In the
Journey Through Vessels, Code Destinations, Not Waypoints,”
by Kimberly Engel, CPC, in the November 2010 edition of
Coding Edge. I have never had the pleasure of reading such a clear
explanation about how to assign codes for catheter placement.
Ms. Engel’s mention that there are 60,000 miles of vessels in
the human body (2.5 times around the equator) truly provides
a visual of just how complex coding catheter placements can be.
Thank you for publishing Ms. Engel’s article.
I also express my appreciation to AAPC staff and an author of
a recent Coding Snapshot article who helped me understand an
ICD-10-CM code assignment. As a coding instructor and textbook author, I just had to “get it” and everyone was so patient
with my persistence when attempting to understand. Thank you!
Ken Camilleis, CPC, CPC-I, CMRS
10 AAPC Coding Edge
Michelle A. Green, MPS, RHIA, FAHIMA, CPC
SUNY Distinguished Teaching Professor
Alfred State College, Alfred, N.Y.
Stay Current for Accurate Coding
I want to commend AAPC’s Coding Edge for the timeliness of
articles. On more than one occasion I have found and used articles for my clients exactly when I needed them. It is uncanny how
these articles seem to appear when I am in need of a reference.
Thank you for quality work.
Jules Enatsky, RT, BSN, CPC-H
J.A. Thomas & Associates
Please send your letters to the editor to:
letterstotheeditor@aapc.com.
R
Official CMS Information for
Medicare Fee-For-Service Providers
Get Accurate Answers
About Medicare Reimbursement.
You can find plenty of answers to your Medicare questions. Find the accurate ones from the
Centers for Medicare & Medicaid Services’ (CMS) Medicare Learning Network® (MLN). Get nationally
consistent, accurate, timely and free information that will help providers correctly submit claims
the first time. Please visit our website today.
http://www.cms.gov/MLNGenInfo
letter from member leadership
COVER
AAPC Is All About Members
This month’s Coding Edge cover photo of
AAPC’s National Advisory Board (NAB)
isn’t to glorify the NAB, it is to remind
you AAPC is here on your behalf, helping you and your profession chart a course
through the stormy seas of the future. As
the NAB—and as coders—we never forget
what we are here for. We’re here to represent you.
NAB includes 16 member coders serving
two years who are appointed by AAPC to
represent eight geographical regions of the
United States and four officers elected by
the NAB including president, presidentelect, member relations, and secretary.
Every fall, the NAB meets in Utah for several days to share what we’re hearing from
our colleagues, seeing in the field, and
perceiving about the future. This meeting is our annual culmination of monthly
phone meetings, dozens of phone calls, and
countless e-mail messages.
Coders are not shy, and the organization
not only learns from when you contact
AAPC, but from when we and the AAPC
Chapter Association (AAPCCA), an independent board, visit chapters. We learn
what each area faces and we consider what
is pertinent to coders’ success.
Look Ahead to the New Year
A new NAB will take the helm this year
at the AAPC National Conference, April
3-6, in Long Beach, Calif. The incoming
members work in the field, and they see
the daily ups and downs all members face.
They are aware of the inevitable changes
ICD-10, electronic health records (EHRs),
and health reform will bring; and they
know it’s essential to roll with the punches
and provide colleagues with the resources
to not only help make coding grow professionally, but be vital to the changes afoot.
Prepare for the Future
As 2011 starts, we all face an uncertain
future; but it is no more uncertain than
in the past. This upcoming year promises
to be exciting for AAPC. More ICD-10
training will be available, helping you
prepare for October 2013 when the nation
stops using ICD-9. ICD-10 will change
everything we do. Don’t wait until the last
minute to take advantage of this training,
as your practice or facility inevitably will
look to you for guidance once its clear new
software won’t solve all of the implementation problems.
AAPC promises more interesting and
applicable educational programs for various
facets of coding. Plus, we are expanding
our training and certification in compliance as health reform and federal budget
tightening means more scrutiny not only
by Medicare, but by state programs and
commercial payers. We need to keep looking forward without forgetting what is best
for coders.
The NAB and AAPC Is You
We see what you see. We hear what you
are telling us about your day-to-day victories, frustrations, and fears. We want you
to know that a group of coders is helping
to keep AAPC and the field of coding
forward-moving and afloat.
Best wishes,
Terrance C. Leone,
CPC, CPC-P, CPC-I, CIRCC
President, National Advisory Board
NAB on Front Cover:
Back row: Terri Scales, CPC, CCS-P; Janice G. Jacobs, CPA, CPC,
CCS; Linda Farrington, CPC, CPC-I; Trina Cuppett, CPC, CPC-H
Third row: David B. Dunn, MD, FACS, CIRCC, CPC-Cardio,
CPC-H, CCS, RCC; Cynthia Stahl, CPC, CPC-H, CCS-P; Robert
A. Pelaia, Esq., CPC; Julie A. Leu, BS, CPC, CPC-I; Julia Croly,
CPC, CPC-P, CPC-I; Jacqueline J. Stack, AAB, CPC, CPC-I, CEMC,
CFPC, CIMC, CPEDC, CCP-P
Second Row: Marge Carney, CPC, CGCS; Donna SanGiovanni,
CPC, CASCC, CHI; Stacie Hannah, LPN, CPC, CPC-I, CHCC;
Sandra Kunze, CPC, CPC-I, CHC-H; Kerin Draak, MS, RN, WHNPBC, CEMC; Corrie Alvarez, CPC, CPC-I, CEDC; Melody S. Irvine,
CPC, CEMC, CPC-I, CCS-P, CPMA, CMRS
Front Row: Beverly Welshans, CPC, CPC-I, CPC-H, CCS-P; Barbara Scott, BSN, RN, CPC, CFE; Terry Leone, CPC, CPC-P, CIC
www.aapc.com
January 2011
13
feature
By Stephen C. Spain, MD, FAAFP, CPC
Are You Aboard
the EHR Revolution?
Find out if you stand to benefit from adopting electronic health record technology.
APPRENTICE
H
ealth care providers are facing significant changes
in the years ahead, and the adoption of the electronic health record (EHR) is one change that
many providers have yet to embrace. For large practices and institutions, the move to electronic records
is a “no-brainer.” The need to share information and
patients within a group mandates that patient information be accessed easily and evaluated among members
of the provider group. Unfortunately, the benefits are
not as clear cut for small practices. Solo and two provider groups represent about one-third of all medical
providers in the United States, and so it is important
to address EHR concerns for this subset of health care
providers.
Because the adoption of the EHR is a difficult decision for small practices, it should not be undertaken
lightly. Several factors, besides the obvious incurred
expenses, will affect the final decision. Despite the costs
and difficulties associated with moving to the EHR,
most providers should be anticipating the conversion.
Depending on circumstances, however, certain practices may wish to forgo the EHR.
How Long Do You Plan on Sticking Around?
One of the first considerations is the age of the provider—or, more precisely, how long the provider
intends to keep practicing. Moving to an EHR system
is an arduous and labor-intensive process for even the
most computer-literate providers. Making that commitment may not be in the best interest of a doctor who
is only five or 10 years from retirement. Given that
these older providers often are less adept with computers, the move to the EHR may be more stressful and
result in greater productivity loss than for their younger
colleagues. For many doctors at the threshold of retirement, the financial incentives simply will not justify
14 AAPC Coding Edge
the emotional toll and the disruption to their practice
routine.
Conversely, for those providers with 10 or more practicing years in their future, the arguments in favor of
adopting the EHR are strong. Those advantages include
tracking of disease markers, measuring practice benchmarks, improved legibility, portable information that
is shared easily, electronic prescribing, drug interaction information, and allergy alerts. All Medicare and
Medicaid providers for whom retirement is not in the
foreseeable future should strongly consider embracing
an EHR. That decision should be made in the next two
years, to take full advantage of available government
subsidies.
The electronic revolution is clearly the way to the
future of medicine, and for many younger providers, it
makes little sense to delay reaping the benefits derived
from the EHR. The expenses and disruptions currently
associated with EHR adoption are improving with each
new generation of software.
Make a Calculated Decision
Cost is a frequently cited reason for not entering the
EHR arena. To help providers make this move, the
American Recovery and Reinvestment Act of 2009
(ARRA) has provided cash incentives to defray costs
associated with adopting EHR technology. These
incentives are only for health care providers who receive
a significant percentage of their income from participation in Medicare and/or Medicaid.
ARRA stimulus payments, although not likely to offset
completely the costs associated with the transition, certainly will make the process more affordable. Depending on a provider’s Medicare/Medicaid practice mix,
subsidies of $44,000 (Medicare) to $63,000 (Medicaid)
are available (but not both). These subsidies are paid
feature
To discuss this
article or topic, go to
www.aapc.com
For many doctors at the threshold of retirement, the financial incentives simply will not
justify the emotional toll and the disruption to
their practice routine.
out over four to six years, and likely will not offset the
total purchase price of an EHR system with the first
incentive installment. Many EHR vendors are structuring their pricing creatively, to help customers minimize
the initial negative cash flow. There are a growing
number of web-based EHR alternatives that are priced
as a monthly service, thereby minimizing the need for a
large, initial cash outlay, as well.
EHR adoption also will avoid the looming penalties
for non compliance, which could be substantial over a
long career. ARRA establishes penalties for Medicare
and Medicaid providers who do not adopt the EHR,
beginning as a 1 percent Medicare or Medicaid payment reduction in 2015 and reaching a maximum of
3 percent in 2017. To add insult to injury, a penalty
for not using electronic prescribing, a common EHR
feature, begins in 2012, and reaches a maximum of 2
percent in 2014.
To illustrate the effect of these penalties, consider a
practice that generates $500,000 in annual revenues,
of which 30 percent of the total comes from Medicare
or Medicaid. In this case, $150,000 could be subjected
to penalties, for an annual loss in 2017 of 5 percent,
or $7,500.
As the penalties are phased in, for the 10-year period
from 2011 to 2020, a non adopter, using our example
practice, would be fined about $47,000 for the decade
(the “net expense’). An adopter paying $8,500 annually
for his or her system would pay $85,000 over that same
decade. Subtract the government incentive of $44,000
from the EHR expense, and the adopter has a net
expense of $41,000—$6,000 less than the penalty the
non-adopter in our example would pay.
The numbers change as individual circumstances
change, so every practice struggling with an EHR
decision should scrutinize its bottom line, weigh the
financial incentives and penalties, and plan accordingly.
For example, an adopting provider who qualifies for the
Medicaid (rather than Medicare) incentive could qualify for $63,750—which over our decade-long example
nets about $25,000 more than the non-adopter.
Purchase options and payment methods for EHR
systems vary widely, and the level of incentive funds
available will differ greatly between practices (several
vendors have online calculators that allow site visitors
to input their specific practice information to see what
their incentive could be). The actual cash outlay for a
given system also may vary widely from the examples
above. Likewise, penalties will vary widely because of
the differences in each practice’s level of Medicare and
Medicaid revenue.
Where Does Your Practice Stand?
Our country is in the midst of a health care revolution
that will have far reaching effects upon all aspects of
medical care. Change is at the heart of every revolution,
including our present health care overhaul. The EHR is
an integral part of these challenges that now confront
providers. While every participant cannot be expected
to embrace the changes that are forthcoming, certainly
each can, and should, evaluate and plan for these
changes. Preparing for this revolution is a vital step in
protecting the viability of small practices, as well as the
livelihood of these health care providers.
Stephen Spain, M.D., has been
engaged in the full-time practice of
family medicine for over 25 years.
In 1998 he founded Doc-U-Chart, a
practice management consulting firm
specializing in medical documentation. Dr. Spain can be reached at
sspain@docuchart.com.
www.aapc.com
January 2011
15
feature
Don’t Let PHI Become TMI
Know when protected health information (PHI) may be
too much information (TMI) in social media.
By Robert A. Pelaia, Esq., CPC
S
APPRENTICE
16 AAPC Coding Edge
ignificant progress in information technology
has brought social media in health care to the
mainstream. Consider these four examples:
1. According to its website, the Mayo Clinic
recently launched a Center for Social Media
with the intention of training physicians and
hospitals to use Facebook, Twitter, YouTube,
and other popular social media outlets. Mayo’s
Center for Social Media claims the Mayo
Clinic has “the most popular medical provider
channel on YouTube” and more than 80,000
followers on Twitter, as well as over 25,000
Facebook friends. The Mayo Clinic even offers
a special Twitter training camp, or “Tweetcamp,” where participants can be trained on
using social media tools to improve health
care, promote health, and fight disease.
2.Recently, physicians at Henry Ford Hospital in
Detroit broadcast live surgical procedures via
Twitter, a social-networking site, to give short,
real-time updates (of less than 140 text characters each) about certain complex or unique
procedures.
3. Nov. 8, 2010, the American Medical Association (AMA) adopted a new social media policy
designed to encourage physicians to better
manage their online presence while protecting
patient privacy and maintaining professionalism. AMA policy acknowledges that social
media outlets foster collegiality and camaraderie and provide opportunity to widely disseminate public health messages and other health
communication. AMA policy also stresses the
importance of appropriate conduct on social
networks, the use of strong privacy settings,
and the separation of personal and professional
content online to preserve the integrity of the
patient-physician relationship.
4.As an AAPC member, you have access to
AAPC’s website, where countless questions
are posted in discussion forums by coders
throughout the country. These informative
and educational postings often contain specific coding scenarios, diagnoses, and medical
information.
Popular Avenues for Sharing Knowledge
Social networks and websites such as Facebook,
Flickr, MySpace, Second Life, Twitter, and
YouTube are popular avenues through which
knowledge is shared, creativity is expressed, and
connections are made. In addition to the Internet,
cell phones frequently are used for text messaging
and taking photos and videos. Such use is considered a catalyst of “social media” because these
photos and video clips often are posted immediately on social media sites to share with others.
Although there are many benefits to the social
networking revolution and advantages to the use of
social media in the health care environment, social
media used in the health care world poses more
risk than when social media is used in other industries. If you participate in these social networks,
discussion forums, or blogs, it is important that
you—as a participant in the health care delivery
system—be careful to maintain the privacy and
confidentiality of your patients and co-workers.
Consider HIPAA Appropriateness
Patients also may use social media while receiving
services from a health care provider (e.g., a patient
“tweets” from the operating room or takes pictures
of the ultrasound monitor with a cell phone). To
further complicate the issue, there is a debate on
the appropriateness of health care providers using
social media to relate medical advice or information with their patients (e.g., physicians and
patients being Facebook friends).
Health care providers need to exercise extreme caution when giving patient-specific medical advice in
an online environment because sharing thoughts
feature
The social media world is moving at such a fast pace
that it’s impossible to address the many questions and
issues that arise when providers and patients use it in
the health care environment.
publicly about a patient can easily turn into a
Health Insurance Portability and Accountability
Act (HIPAA) privacy breach. Unlike informal
comments made at a casual dinner party, a tweet
or a Facebook message leaves a permanent record
of a potential privacy violation.
Privacy Policies Try to
Keep Up with Technology
Social media is moving at such a fast pace that
it’s impossible to address the many questions and
issues that arise when providers and patients use it
in the health care environment. Today, the trend
is for health care entities to move towards adopting policies that attempt to regulate employees’
social media use. Some health care employers ban
access to social media outlets or other personal
Internet use while at work. Although it is difficult
for health care employers to monitor employees’
activities on social media websites outside of work,
there are a few basic “common sense” ideas to keep
in mind when you enter the cyber world.
Protect Yourself and Patients
Use good judgment when participating in a blog or
discussion forum, or when submitting content to a
social media site. Embarrassing, obscene, or inappropriate material—including photos, videos, or
written comments—that you submit to these sites
may reflect poorly on you, your employer, or, worse
yet, violate patient confidentiality and privacy.
To protect yourself (and your patients and fellow
employees), remember that cell phones with camera
capabilities should not be used to take pictures
of patients, regardless of whether the pictures are
stored internally on a memory card or sent electronically to any social media or website. Taking
unauthorized pictures or videos of patients is a violation of patient confidentiality and privacy.
Any information about a patient’s medical history,
medical condition, demographics, diagnostic data
or finances always is considered confidential and
never should be shared in a social media outlet.
If you submit a question on an AAPC discussion
forum, make sure you do not disclose confidential
or protected patient information. Such information
should only be disclosed to authorized personnel
in a manner consistent with state and federal law.
Access and use of patient information and images
must be provided only on a “need to know” basis
to fulfill your professional job duties. Confidential
patient information never should be shared when
you submit content to any social media site.
You’ll Be Held Accountable for Your Actions
We have all heard horror stories about social media
posts that contain just enough information to
allow the reader to identify the patient’s identity. A
quick online search reveals that the media is full of
examples where health care employees were terminated or disciplined for using social media to post
personal discussions concerning patients. You do
not want to have this happen to you. The bottom
line: If you use social media at all, even when
you are not at work, always protect your patients’
privacy rights and always safeguard and manage
patient information and images appropriately.
Disclaimer: Information published in this article is the
personal view of the author and not that of the University of Florida. Information published in this article is
not intended to be, nor should it be considered, legal
advice. Readers should consult with an attorney to discuss specific situations in further detail.
Robert A. Pelaia, Esq., CPC, is senior
university counsel for health affairs at the
University of Florida College of Medicine,
Jacksonville, Fla. Pelaia is certified as a
Health Care Law Specialist by the Florida
Bar Board of Legal Specialization and
Education. He is also a member of the
AAPC National Advisory Board (NAB).
www.aapc.com
January 2011
17
AAPCCA
Make a Lasting First Impression
Chapters should initiate the first contact and make it positive.
By Melissa Brown, RHIA, CPC, CPC-I, CFPC
I
t’s been said, “You never get a second chance to
make a first impression.” The same may hold true
for local chapter meetings. We hear stories of chapters struggling for attendance numbers, even when
there are hundreds of members assigned to a particular
chapter. With the start of a new year, there’s renewed
opportunity for chapters to make a lasting impression.
Your First Chance Starts Online
The first chance to make a lasting impression for many
chapters is on AAPC’s website. When a member is new
to a city or new to the organization, one of the first
things they do is search the website for a local chapter.
When they pull up your chapter’s web page:
Are there officers in every slot?
Is there current contact information for each officer?
Are there upcoming events listed?
These are all important items that show a proactive
group of leaders. If you have numerous officers, this
gives the impression of a dynamic group of leaders with
involved members. Be sure to have current contact
information for each leader so prospective members can
get more information about your meetings, and have
several meetings listed to show you are actively addressing member needs.
You may feel you only have a limited amount of control
over what shows on the website, but in reality, what
isn’t posted may say as much about your chapter as
what is there. Make sure your meetings are planned
and posted online well in advance, and be sure to
submit continuing education unit (CEU) approval for
chapter meetings and exams as soon as you have all the
required information. When your year is planned in
advance, the chances of making a good first impression
are exponentially increased.
First Contact Is Critical
Remember how exciting it was when you first became
an AAPC member or moved to a new chapter? As an
officer, you can make a lasting impression on a new
member when you initiate the first contact. This lets
18 AAPC Coding Edge
the new member know you care about him or her, the
members of your chapter, and AAPC. When you are
notified of a member joining your chapter, or of newly
credentialed members, you have the perfect opportunity to make the members feel welcome by sending out
an e-mail or card that tells about the chapter meeting
dates and times, and that congratulates them on their
accomplishment (as appropriate). The impression you
make with the first contact is remembered, so make it a
great one.
There are times when a member contacts you first. If
the first contact is a phone conversation or e-mail initiated by the member, use the same rules of engagement.
Be friendly, courteous, informative, and welcoming
in your tone and be in-depth with information you
provide. Short “yes” and “no” answers may provide the
information sought but may send a negative impression about the concern you have for your chapter and
members. Anticipate follow-up questions and provide
helpful information to make the new member feel
valued. Respond to these contacts in a timely manner.
If it takes you more than a week to respond to a message, the member will have the impression that you are
too busy to care about their questions. A good rule of
thumb is to respond within 24 hours.
Despite your best efforts at having a proactive approach
to meeting members, the first contact is often face-toface at an actual meeting. Even in this setting, there are
many opportunities to make a positive impression that
encourage new members to return. Consider positioning the new member development officer and other
greeters throughout your meeting area, such as at the
doorway entrance, directing the way to the sign-in
table, near the refreshment area, and other areas where
your members may be before the meeting. A great way
to make someone feel welcome is to introduce yourself,
make eye contact and say something as simple as, “We
are glad you are here!” During opening remarks, it is
recommended for the president to recognize all firsttime members, visitors, and guests. Encourage everyone
to introduce themselves at some point during or after
the meeting.
AAPCCA
Short “yes” and “no” answers may provide the information
sought but may send a negative impression about the
concern you have for your chapter and members.
Keep Them Coming Back
Here’s Your Second Chance
Helpful hints for a great meeting and to make a great
lasting impression:
Have an agenda—and follow it
Start on time and end on time
Welcome everyone—all members should know
their presence is appreciated
Be aware of special needs and ensure those needs
are met (eg, hearing-impaired members)
Have a positive attitude
Be organized
Properly introduce speakers
Announce the next meeting time and subject
Have FUN!
This is a new day in a new year with excited new officers. What better time to “turn over a new leaf” and
make a positive impression on your new and existing
chapter members?
Melissa Brown, RHIA, CPC, CPC-I, CFPC, is vice-chair of
the AAPCCA board of directors and manager of education
and reimbursement at the University of Florida Jacksonville
Physicians, Inc. Melissa’s areas of expertise include budget
analysis, Physician Quality Reporting Initiative (PQRI), and
a wide variety of billing/coding-related topics—expertise
that has been shared with a wide audience through classes
and seminars. Melissa’s talents as a public speaker have
been honed through Toastmasters International, with which she holds the
highest status of Distinguished Toastmaster (DTM). After 18 years in the
health care industry, she still enjoys researching complex coding queries
and tackling difficult reimbursement issues.
Introducing AAPC’s newest credential…
Certified Professional Compliance Officer (CPCO)
Exam registration opens January 15.
Voluntary Today, Mandatory Tomorrow – while compliance programs
for individual and small group practices are not federally mandated today, the
Patient Protection and Affordable Care Act will require providers and suppliers
to adopt, as a condition of enrollment, compliance programs.
www.aapc.com/cpco
1-800-626-CODE (2633)
www.aapc.com
January 2011
19
coding compass
Health Care Reform:
The Assault on Waste, Fraud, and Abuse
Understand how Patient Protection and Affordable Care Act of
2010 effects your practice’s liability.
By David Behinfar, JD, LLM, CHC, CIPP
H
EXPERT
ealth care reform became a reality on March
23, 2010 when President Obama signed into
law the Patient Protection and Affordable
Care Act of 2010 (PPACA). A number of the law’s provisions are aimed at reducing and eliminating waste,
fraud, and abuse in health care. We’ll highlight several
of the law’s provisions that require thoughtful response
from the health care community.
Repay Government Overpayments Within 60-days
PPACA requires health care providers to report and
return overpayments from governmental payers within
60 days from the time the provider discovers the overpayment. If an overpayment is retained beyond 60
days, it becomes an “obligation” sufficient for reverse
false claims liability under the False Claims Act, and
may become subject to triple damages and penalties if
there is “knowing and improper” failure to return the
overpayment.
Health care entities that receive reimbursement from
government payers need to address this time-sensitive
reporting requirement by examining their current
process for auditing charges and returning overpayments. Although this sounds like a simple task, the
time pressure—combined with possible penalties—may
cause discomfort to those departments involved in the
revenue stream. Many parties must address the practical improvements necessary to identify, report, and
repay the government within the 60-day limit. Coding
specialists are likely to assume a key role in reviewing
claims to help avoid overpayments on the front end.
Whistleblowers Gain Incentives
To identify fraud, PPACA expands the class of potential
whistleblowers in false claims actions. Typically, whistleblowers are encouraged to come forward through an
opportunity to participate in the recovery of any fine
imposed upon a health care entity in violation of the
False Claims Act.
20 AAPC Coding Edge
Prior to PPACA, to qualify successfully as a whistleblower (or “relator,” as the term is defined in the False
Claims Act), the individual must be the original source
of information that implicated false claims activity.
This generally meant the whistleblower was an insider,
or someone with close ties to an organization and access
to their non-public documents, who stepped forward
with this information and exposed the fraud. The government did not allow an individual to share a portion
of the recovered amount if the whistleblower provided
publicly available information (information available
in media reports, state and federal civil administrative,
and criminal proceedings, etc.).
PPACA now allows whistleblowers to act based on
information disclosed publicly in a state or local proceeding. PPACA takes this small step to recognize that
it is more important to encourage people with fraud
knowledge to step forward, than to worry about how or
where they obtained the information. This is another
incremental move in favor of the government, which
potentially increases the prosecution of health care
fraud.
Stark Violation – Medicare Self-Referral Disclosure
Protocol for Providers
In March 2009, the Office of Inspector General (OIG)
announced it would focus on potential violations of the
anti-kickback statute. Because of this new priority, the
OIG no longer would accept provider self-disclosures of
Stark Law violations unless those violations also implicated a “colorable” violation of the anti-kickback statute. Consequently, since March 2009, providers have
been unable to self-report violations of the Stark Law.
PPACA fills this void and allows providers once again
to self-report Stark violation through a newly designed
protocol.
The new self-referral disclosure protocol for providers
was announced on the Centers for Medicare & Medic-
coding compass
The new self-referral disclosure protocol is a welcome
tool for providers to prove they mean well but sometimes make mistakes, and to demonstrate to the government they have an active compliance program and
own up to those mistakes.
aid Services (CMS) website Sept. 23, 2010 (www.cms.
gov/PhysicianSelfReferral/Downloads/6409_SRDP_
Protocol.pdf). The self-referral disclosure protocol presents an important opportunity for physicians to reduce
their risk exposure. By allowing physicians to report
Stark violations voluntarily, CMS expects (except in
extreme scenarios):
ll Payments made for designated health services
that violate Stark will be refunded to the government, but
ll punitive-based penalties to be unlikely, especially in cases of technical violations.
CMS Offsets Stark Violation Payments with SelfReferral Disclosure Protocol
As part of the aforementioned new self-referral disclosure
protocol, CMS has the option of recouping payments
made to a provider by reducing or offsetting any Medicare payments that otherwise would be made to the provider. The secretary must take the following into account
when determining the amount of any reduction:
ll The nature and extent of self-disclosed
improper or illegal conduct
ll The timeliness of the provider’s self-disclosure
ll Cooperation when CMS requests additional
information during the investigation/reporting
ll The litigation risk associated with the disclosed
matter
ll The disclosing party’s financial position
Self-reporting typically is viewed as a positive opportunity for providers to identify and admit to mistakes,
pay any resulting amounts owed for the mistake, and
move on without fear of further repercussions. The
new self-referral disclosure protocol is a welcome tool
for providers to prove they mean well but sometimes
make mistakes, and to demonstrate to the government
they have an active compliance program and own up to
those mistakes.
Anti-Kickback Statute and False Claims Liability
Implications Change
The federal anti-kickback statute provides civil and
criminal penalties to individuals who knowingly offer,
pay, solicit, or receive bribes or kickbacks or other
remuneration to induce business reimbursable by federal health care programs. PPACA has introduced a
provision to eliminate the well-recognized Hanlester
defense, which interpreted the statute as requiring proof
that the defendant:
(1) had specific knowledge of the anti-kickback statute;
and
(2) engaged in prohibited conduct with the specific
intent do disobey the law (Hanlester Network v.
Shalala, 51 F.3d 1390 (9th Circ. 1995)).
PPACA also contains a provision stating health care
claims for reimbursement that include items or services
in violation of the anti-kickback statute constitute false
claims for False Claims Act purposes.
Providers now face a lower threshold for anti-kickback
violations, and may incur possible False Claims Act liability with fewer defenses to avoid this liability. PPACA
has made it easier to prove an anti-kickback violation
and establish the carry-over effect as a false claims
violation. The PPACA may cause providers who have
legitimate errors in billing, or contractual deficiencies
with third party contractors or suppliers, to find themselves in violation of federal fraud statutes.
Address PPACA Initiatives
PPACA provides clear insight into the government’s
intent to tighten the reins on health care waste, fraud,
and abuse. Although the well meaning and law-abiding
segment of the health care community appreciates the
elimination of waste and fraud in health care, providers
who fail to recognize that the government can ensnare
those who make unintentional billing errors and other
compliance-related mistakes are caught in the middle
of this battle. Physicians and coders must be proactive in addressing the waste and fraud initiatives in the
PPACA, and work with their compliance, legal, and
revenue departments to help avoid liability associated
with these new provisions.
David Behinfar, JD, LLM, CHC, CIPP, has been
employed as privacy manager at the University of
Florida College of Medicine in Jacksonville for the past
eight years. David has worked in health care compliance both as an attorney and in his current role for
more than 14 years. He also has written a number of
articles on health care compliance and privacy and has
spoken at several national and state level conferences.
www.aapc.com
January 2011
21
facility
Accurately Score MDM in the ED
Make smart decisions about your physicians’ medical decision making (MDM).
By Sarah Todt, RN, CPC, CEDC
D
etermining MDM using the 1995 Documentation
Guidelines for Evaluation and Management Services
and directions from CPT® Evaluation and Management (E/M) Services Guidelines poses unique challenges when
coding emergency medicine E/M services.
The three key components used in the emergency department
(ED) for assigning E/M services include: history, exam, and
MDM. MDM dictates the highest service level that may be
reported and the history and physical exam documentation
needed to support the choice.
EXPERT
MDM: The Driving Force
There are four levels of MDM to support the five ED E/M
codes:
ll Straight forward (99281)
ll Low (99282)
ll Moderate (99283 and 99284)
ll High (99285)
Determine the MDM level by reviewing three distinct components. The entire record must be reviewed and all information
considered.
CPT® references the following three components for MDM:
1. Number of diagnosis and management options
2.Amount and complexity of data
3. Risk
Many coders or auditors reference MDM scoring modeled
after a Marshfield Clinic-type audit tool. The scoring is not
part of official documentation guidelines, with the exception
of the Table of Risk. The audit tool gives some components
a numerical value to help the coder or auditor determine the
appropriate level.
For more information on assigning E/M ED leveling, see the
article “Evaluate Your Performance When ED Leveling” by
Jim Strafford, CEDC, MCS-P, in this issue of Coding Edge.
Number of Diagnosis and Management Options
The “number of diagnosis and management options” component of MDM considers the range of diagnoses and the treatment that may be required. Audit tools score this component
based on if a patient is established or new, and if there is addi22 AAPC Coding Edge
tional work-up planned. CPT® does not distinguish between
new and established patients for ED E/M service codes. Most
ED patients are considered new.
Scoring for number of diagnosis or management options:
New patient no additional work-up planned
3 points
New patient with additional work-up planned
4 points
The definition of “additional work-up planned” has not been
defined clearly within the audit tool, and there are many interpretations available. Most audit tools reference (at a minimum)
admissions, transfers, and scheduled diagnostics or physician
follow-up for additional work-up planned.
Amount and Complexity of Data
The “amount and complexity of data” component is referred
to as the “data point” component of MDM. This component
gives value to diagnostic tests and other information essential for determining the management of the patient’s illness.
Components to consider include: diagnostic tests, obtaining or
reviewing old records, discussion with other providers, independent visualization of image or tracing, and obtaining history from someone other than the patient.
The components have a numeric value of one or two points.
The points obtained are added for a final score in this area.
Amount and Complexity of Data
Points
Clinical labs test ordered or reviewed
CPT® Medicine section test—ordered/reviewed
CPT® Radiology section test—ordered/reviewed
Discuss patient results with performing physician
Decision obtain old records or additional hx other than pt
Review/summarize data old records/add hx other than pt
1
1
1
1
1
2
Independent interpretation of an image, tracing, specimen
2
Table of Risk
The Table of Risk is an official part of the 1995 Documentation Guidelines for Evaluation and Management Services and
is applicable to all specialties. Coders are instructed to assign
risk based on the highest intervention in any category of the
risk table. The three categories include:
facility
The “amount and complexity of data” component is
referred to as the “data point” component of MDM.
This component gives value to diagnostic tests and
other information essential for determining the management of the patient’s illness.
1. Presenting Problem
2.Diagnostic Procedure(s) Ordered
3. Management Options Selected
Generally, for ED coding, the interventions listed in the
“diagnostic procedure(s) ordered” will not lead to the highest
element for risk.
Example of risk elements typically used for ED MDM:
MINIMAL
LOW
MODERATE
HIGH
Suture removal
(placed at
other facility)
OTC med
only;
Rx management;
Abrupt neuro
change;
acute
uncomplicated injury
or illness
Acute illness with
systemic symptoms;
Acute complicated
injury;
Exacerbation of
chronic condition
Potential life
threatening
illness; Severe
exacerbation
of chronic illness; Medications requiring
monitoring;
Parenteral
controlled
medications
Overall Scoring of MDM
Each of the three MDM areas should be scored. The level is
determined by selecting the highest two of the three distinct
areas.
Number of Dx and
Mgt Options
Amount and
Complexity of
Data
Risk
Level of MDM
1
1
Minimal
Straight forward
2
2
Low
Low
3
3
Moderate
Moderate
4
4
High
High
Nature of Presenting Problem
The nature of the “presenting problem” is not considered a
key component of scoring MDM; however, it may provide
essential information needed to determine appropriate levels of
service. In the current environment of electronic health records
(EHRs) and templated records, documentation tools are engi-
neered to encourage optimal documentation. To ensure proper
code assignment, take the nature of the presenting problem
into consideration—especially with moderate MDM supporting both 99283 and 99284.
CPT® provides the following language:
99283Emergency department visit for the evaluation and
management of a patient, which requires these 3 key
components: An expanded problem focused history; An
expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or
coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and
the patient’s and/or family’s needs. Usually, the presenting
problem(s) are of moderate severity.
99284Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:
A detailed history; A detailed examination; and Medical
decision making of moderate complexity. Counseling and/
or coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and
the patient’s and/or family’s needs. Usually, the presenting
problem(s) are of high severity, and require urgent evaluation
by the physician but do not pose an immediate significant
threat to life or physiologic function.
Cases scoring as moderate MDM may range from an illness
that requires a prescription at discharge to an illness that
requires labs, X-rays, and parenteral medications. For example,
a patient diagnosed with conjunctivitis and discharged with a
prescription for eye drops, and a patient with abdominal pain
treated with parenteral medication after diagnostic evaluation
including a computed tomography (CT) scan and lab work,
would both support moderate MDM. If both cases are documented with a detailed history and exam, the coder will now
need to consider the nature of presenting problem to assign
the appropriate level: 99283 or 99284.
Final Level Assignment
As mentioned, MDM dictates the highest level that may be
assigned and the history and exam must support the assignment. With a good understanding of the components, you can
assign the MDM level accurately and appropriately. Consider
these two cases as examples:
www.aapc.com
January 2011
23
facility
Case History 1
History of Present Illness
The patient is a 9-year-old female who presents with dry
cough that started last night with low grade fever and malaise. Pt. also complains of right ear pain, duration lasting one
day(s). The course is constant.
Cough quality: moderate, dry and barking cough. Pt. otherwise active and talkative, and sounds happy. The degree of
severity is mild.
Tylenol® given for fever with relief.
Review of Systems
Genitourinary symptoms: Negative.
Musculoskeletal symptoms: Negative.
Neurologic symptoms: Negative.
Lymphatic symptoms: Negative.
Skin symptoms: Negative, but no rash.
Other review of systems: All systems reviewed as documented in chart.
Past medical history: Negative.
Physical Examination
General appearance: No acute distress, alert, smiling, interactive and body habitus is well-nourished.
Skin: Warm. Dry. No pallor.
Ears, nose, mouth, and throat: Oral mucosa moist. No pharyngeal erythema or exudate. Ear: Right tympanic membrane red.
Neck: Supple, no tenderness.
Heart: Regular rate and rhythm, no extra heart sounds.
Respiratory: Respirations non-labored. Lungs: Clear to auscultation. equal bilateral, no stridor no wheezes.
Chest wall: No tenderness.
Abdominal: Soft.
Neurological: Alert.
MDM
Differential diagnosis:
Wheezing, upper respiratory infection, otitis
Impression and Plan
Diagnosis:
URI, otitis media
Discharge plan
Condition: Stable.
Dispositioned: To home.
Prescriptions: Prescription order.
Pharmacy: amoxicillin 250 mg/5 mL oral liquid (Ordered): 5
mL, PO, BID, 7 day(s), 70 mL
MDM Scoring
Number of diagnosis and management options: New patient,
no additional work-up = 3 points
Amount and complexity of data: none = 0 points
24 AAPC Coding Edge
Risk: Prescription management = moderate
Total MDM: Moderate
History and exam: Detailed
This case could support either a 99283 or 99284 based on
moderate MDM. The coder needs to evaluate the nature of
the presenting problem. This case would be more consistent
with the moderate severity, supporting a 99283.
Case Example 2
History of Present Illness
The patient is a 4-year-old female who presents with dry
cough that started last night with fever of 104 and malaise.
She has not voided in 12 hours and parents report that she has
decrease in PO intake. Pt. also complaining of right ear pain,
duration lasting 1 day(s). The course is constant.
Cough quality: Moderate, dry and barking cough. The degree
of severity is mild.
Tylenol® given for fever with relief.
Review of Systems
Genitourinary symptoms: Negative.
Musculoskeletal symptoms: Negative.
Neurologic symptoms: Increased tiredness.
Lymphatic symptoms: Negative.
Skin symptoms: Negative, but no rash.
Other review of systems: AIl systems reviewed as documented in chart.
Past medical history: Negative.
Physical Examination
General appearance: No acute distress, slightly lethargic, and
body habitus well-nourished.
Skin: Warm. Dry. No pallor.
Ears, nose, mouth, and throat: Oral mucosa moist. No pharyngeal erythema or exudate. Ear: Right tympanic membrane
red.
Neck: Supple, no tenderness.
Heart: Regular rate and rhythm, no extra heart sounds.
Respiratory: Respirations non-labored. Lungs: Clear to auscultation. Equal bilateral, no stridor no wheezes.
Chest wall: No tenderness.
Abdominal: Soft.
Neurological: Alert.
MDM
Differential diagnosis:
Wheezing, upper respiratory infection, otitis
Orders
Labs: CBC, Chem 7, UA
Chest X-ray
IV NS 250 cc bolus
facility
Cases scoring as moderate MDM may range from an illness that requires a prescription at
discharge to an illness that requires labs, X-rays, and parenteral medications.
Reassessment
Pt. much improved after bolus. Afebrile. Parents agree to
discharge.
Impression and Plan
Diagnosis:
Bronchitis, otitis media, mild dehydration
Discharge plan
Condition: Stable.
Dispositioned: To home.
Prescriptions: Prescription order.
Pharmacy: Amoxicillin 250 mg/5 mL oral liquid (Ordered): 5
mL, PO, BID, 7 day(s), 70 mL
MDM Scoring
Number of diagnosis and management options: New patient,
no additional work-up = 3 points
Amount and complexity of data = 2 pts
Risk: Prescription management = moderate
Total MDM: Moderate
History and exam: Detailed
The nature of presenting problem for this case appears much
higher than in Case 1. Both cases would be scored with moderate MDM and detailed history and exam; however, Case
2 would support the higher code choice 99284, based on an
urgent nature of presenting problem.
Sarah Todt, RN, CPC, CEDC, is the director of
compliance and physician education for MRSI,
Inc., an industry leader in emergency medicine coding and reimbursement. Sarah has
served on AAPC’s National Advisory Board
(NAB) and Emergency Department Specialty
Exam Steering Committee and has published
several ED-related articles in Coding Edge.
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January 2011
25
feature
Vertebroplasty Is Not
Vertebral Augmentation
One difference helps you tell these procedures apart.
EXPERT
By G. John Verhovshek, MA, CPC
26 AAPC Coding Edge
Percutaneous vertebroplasty is a minimally-invasive
procedure during which a “bone cement” (methylmethacrylate) is injected into one or more fractured
vertebra(e) to fill fractures, treat pain associated
with fractures, and restore spinal integrity. CPT®
provides three codes to describe vertebroplasty:
22520Percutaneous vertebroplasty, one vertebral
body, unilateral or bilateral injection; thoracic
22521 lumbar
+22522each additional thoracic or lumbar vertebral
body (list separately in addition to code for
primary procedure)
When reporting vertebroplasty, select a single,
initial-level code based on location (thoracic or
lumbar). For each additional thoracic or lumbar
level treated during the same session, report one
unit with add-on code 22522.
For example, the patient has fractures of the
second, third, and fourth lumbar vertebrae (L2,
L3, and L4). The physician applies a local anesthetic, places the needle over L2, and injects methylmethacrylate to fill the fracture. He repeats the
process at L3 and again at L4.
In this case, report 22521 (for the initial lumbar
level) and 22522 x 2 (for each of the additional
lumbar levels). You need not append modifiers
(e.g., modifier 51 Multiple procedures or modifier
59 Distinct procedural service) to report the additional levels. Note also that 22520-22522 cover
unilateral or bilateral procedures. Do not append
modifier 50 Bilateral procedure or expect additional
reimbursement if the physician injects the same
vertebral body multiple times.
feature
Kyphoplasty includes the use of an inflatable balloon to jack up the damaged
vertebra(e) prior to injection of the bone cement.
Stick With a Single Primary Code for
Cross Region Injections
If the physician treats multiple spinal levels,
beginning in the thoracic region and crossing
into the lumbar region, you should select a single,
initial-level code. Code 22520 is assigned a greater
number of relative value units (RVUs) than 22521
under the Medicare Physician Fee Schedule
(MPFS). You should report the initial level using
the thoracic code.
For example, osteoporosis, a common condition for
which physicians use percutaneous vertebroplasty,
often occurs at the thoracic/lumbar junction. If
the surgeon treats the final thoracic vertebra (T12)
and the first lumbar vertebrae (L1), report 22520,
22522.
Turn to Temporary, Unlisted Codes
for Cervical Vertebroplasty
CPT® does not include codes to describe cervical
vertebroplasty. If your payer accepts HCPCS Level
II Temporary National Codes, you may report
S2360 Percutaneous vertebroplasty, one vertebral
body, unilateral or bilateral injection; cervical and
S2361 Percutaneous vertebroplasty, one vertebral
body, unilateral or bilateral injection; each additional
cervical vertebral body, as appropriate. For example,
for vertebroplasty at C5, C6, and C7, report
S2360, S2360 x 2.
For those payers who do not accept S codes (including Medicare payers), you must code cervical vertebroplasty using CPT® unlisted procedure code
22899 Unlisted procedure, spine. As always, when
reporting an unlisted procedure code, include a full
description of the procedure so the payer can make
an appropriate payment determination.
Kyphoplasty Is Vertebroplasty, With a Difference
Percutaneous vertebral augmentation, more commonly called kyphoplasty, resembles vertebroplasty
in every detail, but adds one very important step.
Kyphoplasty includes the use of an inflatable bal-
loon to jack up the damaged vertebra(e) prior to
injection of the bone cement. For this reason,
kyphoplasty sometimes may be referred to as “balloon-assisted percutaneous vertebroplasty.”
The physician first creates a working space within
the fractured vertebral body. She then places an
inflatable bone tamp (the balloon) in the enlarged
cavity. She inflates the bone tamp, further enlarging the cavity and restoring height to the damaged
vertebral body. She removes the balloon and fills
the remaining cavity with bone cement. You often
can identify kyphoplasty by searching the operative note for the words “ balloon,” “bone tamp,”
“KyphX” (a common brand name for the bone
tamp) or “IBT” (inflatable bone tamp).
CPT® includes three dedicated codes for kyphoplasty, which mirror the vertebroplasty codes:
22523Percutaneous vertebral augmentation, including cavity creation (fracture reduction and
bone biopsy included when performed) using
mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); thoracic
22524
lumbar
+22525each additional thoracic or lumbar vertebral body (list separately in addition to
code for primary procedure)
Like the vertebroplasty codes, the kyphoplasty
codes represent either unilateral or bilateral procedures. Select a single, initial-level code (using
22523 as the initial level if physician crosses from
the thoracic to lumbar regions). When appropriate, report one unit of add-on code 22525 for each
additional level beyond the first that the physician
treats.
For example, if the physician documents kyphoplasty at levels T10, T11, and L1, report 22523,
22525 x 2.
No CPT® or HCPCS Level II codes describe cervical kyphoplasty. To report cervical kyphoplasty,
turn to unlisted procedure code 22899.
www.aapc.com
January 2011
27
feature
To discuss this
article or topic,
go to www.aapc.com
Radiologic Supervision
and Interpretation Is Separate
Needle placement for both vertebroplasty and kyphoplasty often takes place under imaging guidance. If
the physician personally performs the service, you
may report it separately with either 72291 Radiological
supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation
(sacroplasty), including cavity creation, per vertebral body
or sacrum; under fluoroscopic guidance or 72292 Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation
(sacroplasty), including cavity creation, per vertebral body
or sacrum; under CT guidance), as appropriate. Append
modifier 26 Professional service to show that the physician provided only the professional component (supervision and interpretation) of the imaging service.
Bundle Same-Location Bone Biopsy
When reporting 22520-22522 or 22523-22525, do
not report separately bone biopsy (20225 Biopsy, bone,
trocar or needle; deep (e.g., vertebral body, femur) at the
same location(s). Kyphoplasty code descriptors specifically include bone biopsy, while National Correct
Coding Initiative (NCCI) edits bundle bone biopsy to
vertebroplasty and kyphoplasty codes.
If the physician performs bone biopsy at a level not
addressed by the vertebroplasty or kyphoplasty, you
may report the biopsy separately with modifier 59
Distinct procedural service appended to indicate the
unrelated nature and separate locations of the two
procedures. For instance, if the physician documents
kyphoplasty at L2 and performs vertebral bone biopsy
for a different reason at T5, report 22524, 20225-59.
[
G. John Verhovshek, MA, CPC, is director of
editorial development/managing editor at AAPC.
]
Category III Codes Describe Sacral Procedures
Vertebroplasty (22520-22522) and kyphoplasty (22523-22525) codes apply only to thoracic and lumbar regions of the
spine. As elsewhere described, cervical procedures may be reported using HCPCS Level II Temporary National Codes
S2360 and S2361 (vertebroplasty, for payers who accept S codes) and/or unlisted procedure code 22899 (vertebroplasty, for payers who do not accept S codes, and kyphoplasty for all payers).
As of July 2009, you may select two new Category III codes specifically for sacral procedures:
0200TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical
device, when used, 1 or more needles
0201TPercutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical
device, when used, 2 or more needles
These codes apply regardless of whether balloon-assist is used to support the bone prior to injection (that is, these
codes describe both sacral vertebroplasty and sacral kyphoplasty, with no distinction between the two). Unlike 2252022525, the sacral codes differentiate between unilateral (0200T) and bilateral (0201T) procedures.
If fluoroscopic or computed tomography (CT) guidance is performed with sacroplasty, additionally report 72291 or
72292, as appropriate (see below for more detail). CPT® allows you to report bone biopsy (20225) separately, when
performed.
When provided, moderate sedation is included with 0200T and 0201T.
28 AAPC Coding Edge
MARCH
WORKSHOP
AdvAnced SurgicAl chArt Auditing
Surgical Chart Auditing is a skill that requires practice. In addition to assuring the proper coding
was assigned, other legal aspects found in a surgical record must also be considered. Don’t find
your practice in the middle of a payer audit feeling unprepared and vulnerable. Learn how to
completely and accurately review and validate surgical services from a compliance perspective.
You’ll Learn To:
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Outline the process for correctly dissecting an operative note
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Design an auditing report and/or corrective action plan based on results
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uPcOMing wOrkShOPS
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Advanced E/M
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Modifiers – The Rest
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RACs, MRACs, MICs and ZPICs
What Codes Are
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www.aapc.com/surgicalaudits | 1-800-626-CODE (2633)
PHOTOS COURTESY OF DESTinaTiOnS MagazinE
EXPERT
facility
Fees,
observation,
number of
codes are
some of the
changes for
2011.
Prepare for
2011 OPPS Final Rule
By Denise Williams, RN, CPC, CPC-H
F
or the 2011 Outpatient Prospective Payment
System (OPPS) Final Rule, the Centers for
Medicare & Medicaid Services (CMS) based
payments on claims data submitted by hospital
providers during 2009. Let’s highlight some of
the rule to prepare you for the changes in the year
ahead.
You can download the CMS display copy of the
rule and all preamble tables and addenda at: www.
cms.hhs.gov/HospitalOutpatientPPS/HORD.
Select CMS-1504-FC to access the Final Changes
to the Hospital Outpatient Prospective Payment
System and CY 2011 Payment Rates files and final
rule documents.
2X Rule Violation Exceptions Increase
As in the past couple of years, CMS made changes
to the ambulatory payment classification (APC)
assignment this year based on the “2X rule violation.” Prospective payment involves an inherent
grouping of services requiring comparable resource
usage. A 2X rule violation happens when the highest cost item’s median cost is twice that of the
lowest cost item within the same APC. The secretary of Health and Human Services (HHS) has the
discretion to allow exceptions to this rule (such as
for low-volume procedures and services), and has
approved 22 APCs as exceptions to the 2X rule for
2011 (seven more than in 2010). These are listed in
Table 22 in the Final Rule.
Composite APCs Remain the Same
CMS made no changes to existing composite
APCs, nor did they create new composite APCs
for 2011. The Multiple Imaging composites were
implemented in 2009, and the first claims data for
monitoring the impact were available for this year’s
rate setting. The APC panel and rule commenters
recommended additional composites that could be
created in the future. CMS continues to “consider
the development and implementation of larger
30 AAPC Coding Edge
payment bundles, such as composite APCs (a longterm policy objective for the OPPS), and continues
to explore other areas” where this model could be
utilized, according to the Final Rule.
Outlier Fixed-Dollar Thresholds Updated
CMS annually updates the formula for calculating
outlier payments. Just like in 2010, an outlier payment is triggered in 2011 when costs for providing
a service or procedure exceed both:
ll 1.75 times the APC payment amount
ll The APC payment plus $2,025 fixed-dollar
threshold (decreased by $150 from 2010)
CMS made no changes to the outlier reconciliation
policy for outpatient services provided based on
cost reporting periods beginning in 2009.
Pass-through Payment Changes
There is one device that became eligible for passthrough payment in October 2010. Described by
HCPCS Level II code C1749 Endoscope, retrograde
imaging/illumination colonoscope device (implantable), this item will continue with pass-through
status for 2011. There are additional applications
for pass-through items under consideration. Drugs
and biologicals with pass-through status that
expired Dec. 31, 2010 are listed in Table 27 of the
Final Rule. The cost of 13 of these drugs is above
the packaging threshold, which is $70 for 2011,
and separate payment will continue.
Payment for separately-payable drugs without passthrough status will increase for 2011 to average sale
price (ASP) plus 5 percent. For the 42 drugs and
biologicals having pass-through status for 2011,
payment is ASP plus 6 percent. These drugs are
listed in Table 28. There are HCPCS Level II code
changes for several of these drugs.
New vs. Established Definitions Continue
CMS notes that 2009 claims data continues to
reflect a cost difference between new and estab-
facility
lished patient visits. The agency continues to
define “new” and “established” patients based on
whether the patient was an inpatient or outpatient
of the hospital within the past three years.
E/M Guidelines Are Passed By
No new national evaluation and management
(E/M) guidelines are established for 2011. Claims
data continues to reflect stable distribution of
billed visits. CMS instructs hospitals to keep using
their individual internal guidelines, being sure that
the guidelines meet the 11 criteria specified in the
2008 Final Rule. Fiscal intermediaries (FIs) and
Medicare administrative contractors (MACs) are
encouraged to use the individual hospital’s internal
E/M guidelines when an audit occurs.
New CPT® Instruction, New Edit
CMS instructs facilities to follow CPT® guidelines.
Beginning in 2009, this included the introductory
guidelines for services contained in critical care
services (CPT® 99291 Critical care, evaluation and
management of the critically ill or critically injured
patient; first 30-74 minutes and +99292 Critical
care, evaluation and management of the critically
ill or critically injured patient; each additional 30
minutes (list separately in addition to code for primary service). For 2011, the American Medical
Association (AMA) has added language to the
Critical Care instructions noting that, “Facilities
may report the above services separately.” CMS
has provided packaged payment for critical care
services based on the CPT® definition for the past
two years. CMS notes, “Beginning in CY 2011,
hospitals that report in accordance with the CPT®
guidelines will begin reporting all of the ancillary
services and their associated charges separately
when they are provided in conjunction with critical
care.”
In response to this change, CMS will institute a
new Outpatient Code Editor (OCE) edit that will
package the services for the separately-reported
procedures into the payment for critical care
services. Instituting “automatic packaging” via
the OCE will ease a huge operational burden on
facilities who have had to use an internal, usually
manual, process to remove the HCPCS Level II
codes from the claim and roll the charges into one
line item for critical care services.
Inpatient-only Procedures Shrink
The “Inpatient Only” list specifies procedures typically provided in an inpatient setting due to the
invasive nature of the procedure; the need for at
least 24 hours of post-procedure monitoring before
the patient can be safely discharged; or the underlying physical condition of the beneficiary; and
therefore, these procedures are not reimbursable
under the OPPS. For 2011, CMS removed three
procedures from the inpatient-only list, which
allows hospitals to be reimbursed when these procedures are performed on an outpatient basis.
21193Reconstruction of mandibular rami; horizontal,
vertical, C, or L osteotomy; without bone graft
21395Open treatment of orbital floor blowout fracture; periorbital approach with bone graft
(includes obtaining graft)
25909Amputation, forearm, through radius and ulna;
reamputation
These procedures, their corresponding CPT® codes,
and APC assignments are found in Table 46.
Direct Supervision for
Outpatient Therapeutic Services
In 2010, there was a lot of discussion regarding the
requirements under the conditions of participation
versus the definition requirements of direct physician supervision. CMS delayed enforcement of
direct supervision for therapeutic services provided
in critical access hospitals (CAHs) as of March
2010. In the Final Rule, CMS extended this nonwww.aapc.com
January 2011
31
facility
No new national evaluation and management (E/M) guidelines are established for 2011 … CMS instructs hospitals
to keep using their individual internal guidelines, being sure
that the guidelines meet the 11 criteria specified in the
2008 Final Rule.
enforcement period through 2011 and extended
the exception to small rural hospitals with 100
beds or fewer located in a rural area or paid under
OPPS with a rural wage index.
CMS listened to providers during the year and
made some changes to the definition of direct
supervision. The updated definition requires the
practitioner to be “immediately available” and
“interruptible,” but specific references to where
the practitioner must be physically located are
removed. The removal of reference to geographical location is applicable for both on-campus
and off-campus provider-based departments and
applies to cardiac rehab, pulmonary rehab, and
intensive cardiac rehab.
The agency created a list of 16 services, called
“non-surgical extended duration services,” for
which direct supervision is required at the initiation of the service. Once the patient is stable, general supervision may be provided for the duration
of the service. These services are identified in Table
48a. The included services must meet four criteria:
1. May last a significant time
2.Have a low risk of requiring direct supervision
once initiated
3. Have a significant monitoring component
typically provided by nursing/auxiliary staff
4.Are not surgical services that include recovery
time
Initiation of these services requires direct supervision; once the treating practitioner deems the
patient to be medically stable, general supervision
is acceptable. CMS expects the transition from
direct to general supervision to be documented in
the medical record, but does not specify what this
documentation must look like.
The agency acknowledges that “the statute does
not explicitly mandate direct supervision,” but
believes that direct supervision is the most appropriate level for services provided incident-to a
physician service. CMS proposes to establish a
committee and independent review process to
assess the appropriate supervision level for hospital
outpatient therapeutic procedures. For the 2012
rule-making cycle, CMS most likely will establish
32 AAPC Coding Edge
a timeframe for receiving requests, develop criteria
for evaluation of each service, and create or designate a committee. CMS has requested public comment on this proposal.
Additional Notable Changes
The Patient Protection and Affordable Care Act
(PPACA) waives the Part B deductible and coinsurance for certain preventive services payable
under the OPPS. Based on classification by the
U.S. Preventive Services Task Force (USPSTF),
covered preventive services graded as A or B mean
the beneficiary coinsurance is waived and, for
many of the services, the Part B deductible also is
waived. Table 48b contains specific information
regarding these services.
Changes to the 2011 Medicare Physician Fee
Schedule (MPFS) (CMS-1503-FC, found at: www.
cms.gov/PhysicianFeeSched/PFSFRN/list.asp) also
impact OPPS facilities related to laboratory requisitions and rehabilitation services with payment
based on the fee schedule. Beginning in 2011, requisitions for clinical laboratory services paid under
the laboratory fee schedule must be signed/authenticated by the physician/non-physician practitioner
(NPP). CMS discussed the history of lab requisitions vs. orders in the MPFS proposed rule.
CMS also is instituting a “multiple procedure payment reduction” for outpatient therapy services
paid under the MPFS. The reduction is 25 percent
of the second and subsequent “always therapy” services’ practice expense component. The first unit
of the highest valued service is payable at 100 percent; all additional units of the same service or different service are paid at 75 percent. The payment
reduction is based on services provided on a single
date of service, even if the services are provided by
different therapy disciplines. Table 21 in the 2011
MPFS Final Rule lists the services subject to this
policy.
Denise Williams, RN, CPC, CPC-H, is the director of revenue integrity services for Health
Revenue Assurance Associates, Inc. She has
been involved with APCs since their initiation.
She has worked as corporate chargemaster
manager for two health care systems, heavily
involved in compliance and coding/billing
edits and issues.
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nsure your practice is compliant with the updated
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with monetary penalties if not enforced, stricter accountability
for business associates, and use and disclosure of Protected
Health Information (PHI). HIPAA Plain & Simple, second edition,
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Updated from the bestselling 2003 first edition, this invaluable
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facility
PROFESSIONAL
Keep Your Hospital Compliant
with OIG’s Work Plan
Get a facility’s perspective of what’s in store for 2011.
By Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P
I
n December’s Coding Edge, we examined the 2011
OIG Work Plan from the perspective of the physician practice (“Center a Work Plan Around 2011
OIG Activities,” pages 44-45). This month, we’ll take a
look at items affecting the hospital setting.
There are several new items in the hospital section of
this year’s Work Plan, as well as returning items from
prior years. Although we won’t review these “returning
items” in depth, it is important for you to keep them
in mind. Determine if they are risk areas for your facility, and decide if you should include them in your own
compliance auditing and monitoring plan.
Most hospital-related reviews can be found within the
Centers for Medicare & Medicaid Services (CMS) portion of the Work Plan. You should focus most of your
effort in that section. If you are involved in academic or
research medicine, however, be sure to review the Public
Health Agencies section; the included information from
the National Institutes of Health (NIH) and the U.S.
Food and Drug Administration (FDA) usually is helpful
when developing your compliance audit plans.
Hospital Payments
for Nonphysician Outpatient Services
This item is specific to hospitals not paid under the
Prospective Payment System (PPS). Based on the appropriate regulations, all diagnostic services and other
admission services provided one day prior to the admission are considered part of that admission. The OIG
will review all outpatient claims paid for that one day
time period prior to admission to see if they meet these
criteria.
As a non-PPS facility, have edits built into your system
to check for these services before the claim goes to
the payer. If you do not have these types of edits currently built into your systems, adding this to your audit
plan for the year is a great start. Then, work with your
34 AAPC Coding Edge
software vendor and/or your clearinghouse to get these
edits built into your systems.
Although this is not an item for PPS hospitals, this
is a good reminder of the three day window, and the
recent changes there. Statutory changes were made to
the three day window in June 2010, and the Inpatient
Prospective Payment System (IPPS) rule for 2011 also
includes rules on those changes.
In basic terms, the payment window is now broken into
two separate time frames: the day of admission, and the
three days prior to admission. On the day of admission,
all services, diagnostic and non-diagnostic, provided
by the admitting hospital or any of its entities must be
bundled to, and billed as part of, the inpatient admission. Under the old rule, only diagnostic and related
non-diagnostic services had to be bundled into that
hospital bill. The definition of “related” now is redefined by CMS to include any outpatient service “clinically associated with the reason for a patient’s inpatient
admission.” There is an established item in the 2011
OIG Work Plan dealing with the three day window,
although it’s uncertain how these new rules will interact with this already established review. Be sure you’re
aware of what the current rules are, and that your systems are programmed to edit based on those guidelines.
Medicare Excessive Payments
In general, the biggest errors seen in HCPCS Level
II coding are units of service errors. The OIG is concerned that there are excessive payments being made
due to such coding errors. Hospitals wishing to review
for this easily can incorporate this into an existing
coding auditing plan. Because much of this coding is
charge master driven, hospitals not only should examine the individual claims, but also review the process of
how a claim is coded. This may provide insight on if,
and how, claims are being miscoded.
facility
… all deaths within 24 hours of when a patient is removed
from a restraint or seclusion, must be reported to CMS …
There is some concern by the OIG as to whether all deaths
are being reported, and that the reporting process might
somehow hinder the investigation process.
Hospital Occupational Mix Data
The federal government implemented an occupational
mix program to create more accuracy in the wage
index, due to a lack of confidence in those figures.
Now, there appears to be some concern about the accuracy of the data being submitted to CMS to create the
more accurate wage index data. Examine your process
for putting together your data for submission for the
occupational mix. Are you aware of this process? How
much effort is your facility putting into making sure
good quality data is submitted?
Hospital Reporting for
Restraint and Seclusion Related Deaths
Conditions of Participation state that all restraint- and
seclusion-related deaths, as well as all deaths within 24
hours of when a patient is removed from a restraint or
seclusion, must be reported to CMS. The agency then
will determine if an investigation is warranted. There is
some concern by the OIG as to whether all deaths are
being reported, and that the reporting process might
somehow hinder the investigation process.
Determine first who is currently handling this process
for your facility. The process needs to be reviewed to
verify that you are, in fact, reporting all appropriate
deaths to CMS. All deaths occurring within 24 hours
of the removal of the restraint or seclusion should be
reported as such.
Medicare Brachytherapy Reimbursement
This is a general review of brachytherapy services in
the hospital setting to determine whether services were
paid in accordance with Medicare requirements. Does
your facility perform the placement of these radioactive
sources? If so, your facility should conduct reviews to
verify that requirements as put forth under Medicare
Improvements for Patients and Providers Act (MIPAA)
are being met. MIPAA extended the cost to charge payment methodology for brachytherapy devices through
the beginning of 2010, thereby avoiding the planned
change in 2008 to the Outpatient Prospective Payment
System (OPPS) payment methodology. Although these
changes focused on the devices themselves, don’t focus
your review solely on the device. Make sure you review
the entire service to catch any potential errors because
the OIG surely will during its reviews.
Replacement of Medical Devices
There are many instances when a device is replaced in
a patient, and that device is received at a reduced cost,
or at no cost. This must be reflected in billing to the
program. This item from the Work Plan focuses on
that area, reviewing inpatient and outpatient claims
to determine if they were submitted properly when
the device was received at a reduced cost. Your facility
should have a process in place where your purchasing
(or appropriate) department works closely with your
billing staff to make sure billing is done properly when
the facility does not pay full price for any medical
device.
Hospital Inpatient Outlier Payments
Outliers have been an issue for years, showing up on
the Work Plan for a year or two and then going off.
They have shown up here again in 2011, with a specific
focus on the inpatient realm. There appears to be some
new concern because of an upswing in outlier payments
in 2009, as well as a large number of whistleblower
suits on the same topic. If you are a facility with a high
number of outlier payments, take a look at your processes. You also may wish to put a pre-submission process in place for any outlier claim to verify that coding
and charges are accurate.
www.aapc.com
January 2011
35
facility
To discuss this
article or topic,
go to www.aapc.com
Medicaid
The Medicaid section of the Work Plan does not have
any new hospital-related items, and the established hospital-related items seem to be related more to “controls”
than to items for which hospitals can prepare. As mentioned in December’s OIG article, your state Medicaid
integrity official may have released a work plan of its
own. Research your state to determine the status of the
Medicaid Integrity Program, and to determine whether
they’ve released a work plan. It could be a good companion to the OIG document.
Be Prepared
To avoid scrutiny from the OIG, be prepared. Have
an active compliance program, and not simply a written program that sits on a shelf. Audit and monitor
regularly throughout the year. Educate based on what
you find in that auditing. Review the OIG 2011 Work
Plan—and not simply the new aforementioned items,
but also the items that have appeared previously, such
as observation services, hospital re-admissions, and
provider based entities. Examine what types of services
are risk areas for your organization, and incorporate all
of these issues into your own work plan for the year. By
using the governments own roadmap to their work, you
can make your organization more compliant and, hopefully, a more efficient and effective facility.
Jillian Harrington serves as president and CEO
of ComplyCode, a health care compliance
consulting firm based in Binghamton, N.Y., and
has more than 17 years of experience in the
health care industry. She is the former chief
compliance officer and chief privacy official.
She teaches CPT® coding as an approved
AAPC instructor and is a member of AAPC’s
ICD-10 curriculum development team. She holds a bachelor’s
degree in health care administration from Empire State College
and a master’s degree in health systems administration from
the Rochester Institute of Technology (RIT).
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General Surgery Survival Guide
ICD-9 2010 Survival Guide
E/M Survival Guide
Modifier Survival Guide
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Ob-Gyn Coder’s Survival Guide
Otolaryngology Survival Guide
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36 AAPC Coding Edge
a coder's view
Repair Relationships:
Approach Providers from Their Viewpoint
By Lynn S. Berry, PT, CPC
Find out what a
typical day in the life
of a physician is like.
As a coder, you strive to help physicians
and other health care providers document
more clearly so you can code correctly and
ensure claims are paid. To that end, you
may need to query a provider regarding a
particular medical record entry. You may
be met with resistance or told there is no
time to talk at the moment. The encounter may be pleasant or it may not, depending on the physician and the day. Over
the years, I have heard many coders and
others complain about their “treatment”
by providers.
Perhaps it would help to see things from
their viewpoint. “The Vanishing Oath,”
a film from Crash Cart Productions,
LLC, does just that. In the documentary,
a physician and a social worker spend
several years going around the country
interviewing other physicians, economists,
professors, and average citizens. The physician tries to determine if the burnout he
feels personally is prevalent in the medical
community, and how it affects the practice of medicine and patient perceptions.
The film describes a typical day in the life
of an emergency department (ED) physician and the stresses he encounters as he
tries to provide quality patient care. It
brings out the emotions felt by physicians
as they meet administrative, government,
and other obstacles that prevent them
from caring for patients the way they
envisioned when they started their careers.
It even speaks about the coders’ role in
medicine.
This film is eye-opening for non-clinicians who think of physicians as highly
paid and revered individuals, when really
they are ordinary people who are feeling
economically, physically, and emotionally
pressured on a daily basis. Think about
the number of physicians who are looking
at changing their roles, getting away from
private practice, changing their hours, or
leaving medicine altogether. This film
explains why.
Watch this 90-minute documentary for
an uncommon educational presentation
at a local chapter meeting. Perhaps it will
help you better understand the physicians’
point of view and allow you to develop a
more empathetic approach to dealing with
the providers you encounter every day.
A copy of “The Vanishing Oath” may be
obtained at: www.crashcartproductions.
com/vanishing-oath/.
Lynn Berry, PT, CPC, had over 35 years
of clinical and management experience
before beginning a new career as a
coder and auditor and, later, a provider
representative for a Medicare carrier.
She now has her own consulting firm,
LSB HealthCare Consultants, LLC,
furnishing consulting and education to
diverse provider types. She has held a variety of AAPC
local chapter offices and continues as one of the
directors of the St. Louis West Chapter.
www.aapc.com
January 2011
37
newly credentialed members
newly credentialed members
Tonia Melissa Deacon, CPC Aniak AK
Angie Meade, CPMA Harvest AL
Monica Bragg, CPC Huntsville AL
Lee Horton, CPC, CPMA Huntsville AL
Gina Pieczynski, CPC Laceys Spring AL
Ashley Carr, CPC Montgomery AL
Sara Thomas, CPC Montgomery AL
Amanda Shaffer, CPC Prattville AL
Rebecca Hatcher, CPC Wetumpka AL
Nancy Spaulding, CPC Bella Vista AR
Lisa Deleta Davis, CPC Jonesboro AR
Donna Lou St. John, CPC Lonoke AR
Jana Phillips, CPC White Hall AR
Swee-Ai Milne, CPC Cottonwood AZ
Laura V Saldivar, CPC, CPC-H Gilbert AZ
Susan Swapp, CPC Gilbert AZ
Helena B Polk, CPC Pinon AZ
Catiria Isla, CPC Somerton AZ
Debra K Borden, CPC Tucson AZ
Stephanie D Encinas, CPC Tucson AZ
Eileen M Jacobson, CPC Tucson AZ
Kathleen J Lampert, CPC Tucson AZ
Annette Ramirez, CPC Tucson AZ
Susan Faye Vien, CPC Tucson AZ
Dana Hasten, CPC, CPC-H Winslow AZ
Henry Bonner, CPC Altadena CA
Linda Joyce Williams, CPC, CPC-H Canyon Country CA
Marynel Cruz, CPC Clovis CA
Rebecca Hill, CPC-H Clovis CA
Artemiss L Pourmand, CPC Glendale CA
Rena L Pacheco, CPC La Habra CA
Rosa Lazcano, CPC La Jolla CA
Regine Monfette, CPC Long Beach CA
Diana Peykar, CPC, CPC-H Northridge CA
Karen Amador, CPC Oakley CA
Diana Napolitano, CPC Pomona CA
Larry Impson, CPMA Rio Linda CA
Tashina Trimble, CPC Sacramento CA
Annabelle Perez Jaballa, CPC San Francisco CA
Yinna Zhou, CPC Santa Clara CA
Martin Rambaud, CPC Simi Valley CA
Sue Leamons, CPC, CPMA, CEMC Stanford CA
Jason Michaels Truitt, CPC Stockton CA
Marsha P McRorie, CPC, CPC-H, CIRCC Sunnyvale CA
Julie Papa, CPC Temple City CA
Lisa Wurzer, CPC Tustin CA
Sheh-Jiuan Tay, CPC, CPC-H Valencia CA
Marriym Lateefah Lofton, CPC Vallejo CA
Valerie Madison, CPC West Hills CA
Julia Lea Hatcher, CPC Aurora CO
Patricia J Abila, CPC Colorado Springs CO
Mindy Helm, CPC Colorado Springs CO
Kerry K Ochoa, CPC Colorado Springs CO
Naomi Pennington, CPC Colorado Springs CO
Kathryn A. Rountree, CPC Colorado Springs CO
Vicki L Faris, CPC, CPMA, CEMC Durango CO
Cynthia Kay Glefke, CPC Durango CO
Sherry E Holt, CPC, CPMA Durango CO
Linda K Peterson, CCS-P, CPMA Durango CO
Nancy Price, CPC Thornton CO
Michele Marie Krpata, CPC, CPMA East Hartford CT
Sharon S Donelli, CPC, CPC-H, CPMA Kensington CT
Jean Carusone, CPC Northford CT
Sandra Onate, CPC Norwich CT
Laura Brown-Johnston, CPC New Castle DE
Alice Ramey, CPC New Castle DE
Janice M Jones, CPC Townsend DE
Peggy Cauthen, CPC Bradenton FL
Efrain Duarte, CPC Bradenton FL
Erin Nigro, CPC-A, CPMA Clearwater FL
Sherrie Wilhelm, CIRCC Clearwater FL
Elizabeth Fuentes, CPC Coral Springs FL
Arleene Mahadeo, CPC Coral Springs FL
Leslie Beaman, CPC Crestview FL
Jan C Harris, CPC Dania FL
Philip R. DeLuca, CPC Deerfield Beach FL
Cynthia H Blanton, CPC Ft Lauderdale FL
Linda K Reid, CPC Ft Lauderdale FL
Rae Lynn Bailey, CPC Gainesville FL
Diane Barco, CPC Gainesville FL
Leticia A. Cohens, CPC Gainesville FL
Julian Dashan Smith, CPC Gainesville FL
38 AAPC Coding Edge
Linda M Beeman, CPC, CPMA Hampton FL
Natalie Hernandez, CPC Hialeah FL
Donna G O'Hern, CPC, CPMA, CEMC Lake Butler FL
Ann Marie Marks, CPC Lake Worth FL
Lois M Smith, CPC Lakeland FL
Maria Emily Guzman, CPC-H Largo Mar FL
Beverly A Greenidge, CPC Lauderhill FL
Amy Hendon, CPC Lutz FL
Ambreen Khan, CPC Miami FL
Katrina Lymon, CPC Miami FL
Eduardo Porras, CPC, CPMA Miami FL
Alexi Ruiz, CPC Miami FL
Guerda Louissaint, CPC Miramar FL
Patricia Dickenson, CPC Ocala FL
Jennifer Jean Ehlke-Jotch, CPC Odessa FL
Gredel Ann Buzbee, CPC Old Town FL
Lisa Ridgley, CPC Oldsmar FL
Nicole Newton, CPC Panama City FL
Heidi Philbrick, CPC Pembroke Pines FL
Richard Rohlehr, CPC Port Charlotte FL
Amanda Mullikin, CPC Port Saint Lucie FL
Christmarie Camacho, CPC Riverview FL
Lesley Dingman, CPC Sarasota FL
Simone Roberts, CPC Sunrise FL
Michael Bach, CPC Tampa FL
Keicia Tamara Cornwall, CPC, CPC-H, CPC-P
Tampa FL
Amy Diane Lawrence, CPC Tampa FL
James Pfeiffer, CPC Tampa FL
Joanne Long, CPC Titusville FL
Idolka Zoe Mesa, CPC, CPMA, CEMC West Palm
Beach FL
Jodi Mazzone, CPC, CPMA, CEMC Weston FL
Deborah Ann Eason, CPC, CPC-H Augusta GA
Karen Varnedoe, CPC Brunswick GA
Sherion Nettles, CPC Douglasville GA
Genieve R Nottage, CPC, CPMA, CPC-I Locust Grove GA
Henry Asemota, CPMA Marietta GA
Zadie Lee Pressley, CPC Newnan GA
Samantha Stensland, CPC Powder Springs GA
Elizabeth D Westbrooks-Steed, CPC Stockbridge GA
Rose Gibbs, CPC Suwanee GA
Janice Ann May, CPC Ankeny IA
Chelsey Storey, CPC Urbandale IA
Mariah Courtright, CPC Boise ID
Aimee Webb, CPC Boise ID
Tamie Chapman, CPC Donnelly ID
Carol J Gilbert, CPC, CPMA Downey ID
Kathy Arreola, CPC New Plymouth ID
Amy K Webster, CPC Rexburg ID
Cynthia Burley, CPC Twin Falls ID
Kristy L Verthein, CPC Beecher IL
Kathleen Ellingson, CPC-H Chicago IL
Maria Andrea Vega, CPC Chicago Heights IL
Brenda Wilson, CPC Chicago Heights IL
Sharon L Thompson, CPC Country Club Hills IL
Paige McWhorter, CPC Effingham IL
Angie Henson, CPC Highland IL
Mindi J Marcum, CPC, CIRCC Le Roy IL
Jessica Eccles, CPC Loves Park IL
Brenda Pichon, CPC-H Monticello IL
Angie M Craig, CPC Olympia Fields IL
Stephanie Annette Garland-Lloyd, CPC Robbins IL
Ciarra Montoya Davis, CPC Swansea IL
Heather O'Dell, CPC Toledo IL
Rhonda K Moegerle, CPC Brownsville IN
Sherri Brasher, CPC Chandler IN
Roy Arnold, CPC-P Evansville IN
Andrea R Winfield, CPC Evansville IN
Debbie Hight, CPC Franklin IN
Beth Ann Lahman, CPC Greens Fork IN
Nataya Austin, CPC Indianapolis IN
Sandra Chapman, CPC Indianapolis IN
Amy Jointer, CPC Indianapolis IN
Becky Ann Younger, CPC Indianapolis IN
Jacqueline Kay Baker, CPC Martinsville IN
Nicole Koehler, CPC Richmond IN
Kimberly Sue Schroeder, CPC Richmond IN
Melissa Ann Edwards, CPC, CPMA Shelburn IN
Cynthia Baumgardner, CPC Overbrook KS
Pat Ann Rentfro, CPC St Marys KS
Kari Deters, CPC Topeka KS
Tama Haggard, CPC Topeka KS
Tammy Lynn Poore, CPC Bowling Green KY
Julie Meiers, CPC Brandenburg KY
Amy Hyman, CIRCC Brooks KY
Julie Ann Rauch, CPC California KY
Carol Ann Walerius, CPC California KY
Anita C Sabelhaus, CPC Dayton KY
Kim Lynn Perry, CPC Ewing KY
Tonya Renee Mitchell, CPC Florence KY
Andrea G Quillen, CPC, CPC-H, CIRCC Florence KY
Marcia Lynn Waite, CPC Ft Thomas KY
Cathy Lynn Wise, CPC Glendale KY
Rhonda Robinson, CPC Hillsboro KY
Janice Gabbard, CPC London KY
Julie F Pope, CPC, CPC-H, CPMA, CPC-I Louisville KY
Teri Lynn Trail, CPC Louisville KY
Tammy Ann Smith, CPC Union KY
Lisa Jett, CPC Vanceburg KY
Donna R Duhon, CPC Abbeville LA
Ronada Shelton, CPC Baton Rouge LA
Tiffany Richard, CPC Bunkie LA
Marie Brown, CPC Andover MA
Michelle M Chmura, CPC Belchertown MA
Kerri Jo Rauschmier, CPC Belchertown MA
Stacey Robinson, CPC Franklin MA
Jennifer L Calkin, CPC Ludlow MA
Jodi Hermanski, CPC Pittsfield MA
Andrea Brown-Thomas, CPC Sandwich MA
Jo Ann Cabral, CPC Waltham MA
Sonja Fraser, CPC Columbia MD
Madhavi Surapaneni, CPC Gaithersburg MD
Angela Tablada, CPC Germantown MD
Blanche Missinga-Mahop, CPC Lanham MD
Laxmi Tankala, CPC N Potomac MD
Denise Huber, CPC Sykesville MD
Lisa D Nile, CPC Bowdoinham ME
Tina Ann Cook, CPC Brunswick ME
Faith H Poulin, CPC Portland ME
Erin Mann, CPC-H Battle Creek MI
Raquel M Saari, CPC Dollar Bay MI
Tracy Lynn Marschke, CPC Eau Claire MI
Nicole Payne, CPC Grosse Pointe Woods MI
Jodi Vaughn, CPC Williamsburg MI
Lucinda Lylan Suonvieri, CPC Floodwood MN
Faith Ellen Bauer, CPC, CPC-H, CPC-P Woodbury MN
Kelli LeAnn Thompson, CPC Camdenton MO
Danne Ryan, CPC Ozark MO
Todd G Beedy, CPC St Charles MO
Phyllis Britton, CPC Waynesville MO
Barbara James Newsome, CPC Jackson MS
Erica Whipps, CPC Jackson MS
La-Keisha Michelle White, CPC Raymond MS
Pamela Gabel, CPC Billings MT
Jewel Ann Lahr, CPC Browning MT
Dawna Raiser, CPC Butte MT
Alliz Parsons, CPC Kalispell MT
Melissa Horner, CPC Lolo MT
Karla Murphy, CPC Missoula MT
Sherry Simcox, CPC Boone NC
Robin Leguillow, CPC Cary NC
Justine Baker, CPC Charlotte NC
Loretta Robinson, CPC, CPC-H Charlotte NC
Amber Ayers, CPC Clemmons NC
Catherine H Erickson, CPC, CPC-H Durham NC
Kim Walsh, CPC Durham NC
Jennifer M S Edwards, CPC Fletcher NC
Tina Dixon, CPC Grimesland NC
Kelley Wade, CPC Henderson NC
Rhonda Walker, CPC High Point NC
Rebecca Woodward, CPC, CPMA, CEMC High Point NC
Brittany Branam, CPC Mooresville NC
Kristin Langley, CPC Morrisville NC
Lora Chamblin, CPC Mt Airy NC
Bill W Battershall, CPC Raleigh NC
Theresa Somerville, CPC Raleigh NC
Trikina Williams, CPC Raleigh NC
Ellen Grataski, CPC Snow Camp NC
Alberta Purvis, CPC Wagram NC
Jenny Ann Carver, CPMA Waynesville NC
Donna Helgeson, CPC, CPMA Bismarck ND
Stacey Slaymaker, CPC Albion NE
Anne Harvey, CPC Lincoln NE
Pamela Johnson, CIRCC Lincoln NE
Connie L Anderson, CPC Oakland NE
Becky Bellin, CPC Odell NE
Cynthia (Cindee) Ann Reichert, CPC Scottsbluff NE
Rhonda R Schafer, CPC Scottsbluff NE
Janine Crawley, CPC-H Alton Bay NH
Kathleen C Blanchard, CPC Ashland NH
Katie Sylvain, CPC Fremont NH
Carole Jutras, CPC Hookset NH
Gayle Edlund, CPC Portsmouth NH
Barbara Richer, CPC Berlin NJ
Gloria A Miller, CPC, CPMA Cherry Hill NJ
Lana Juskin, CPC East Hanover NJ
Anu Koshy, CPC East Windsor NJ
Samantha Nardolillo, CPC Freehold NJ
Maria P Sanchez, CPC, CPC-P Jackson NJ
Adelina Spektor, CPC-H Matawan NJ
Josephine Portis, CPC Morristown NJ
Shahita Baker, CPC Pennsauken NJ
Andrea Langston, CPC Pennsauken NJ
Deborah R Petrosky, CPC Ridgewood NJ
Steven Alan Wahl, CPC, CPMA Roseland NJ
Beverlyjean K Jenkin, CPC South Plainfield NJ
Olaya Delgado, CPC Artesia NM
Tammy D Baugh, CPC Farmington NM
Amy K Carlson, CPC, CPC-H, CPC-P Farmington NM
Sheryll J Turner, CPC-H Farmington NM
Maureen DeArmond, CPC Las Cruces NM
Yvonne Pina, CPC Las Vegas NM
Michelle Kimbrell, CPC Tucumcari NM
Betsy Priest, CPC, CPC-H Avon NY
Vyacheslav Kurdov, CPC Brooklyn NY
Anne Augustyn, CPC Depew NY
Sandra Verry, CPC Maine NY
Christopher Holder, CPC Poughkeepsie NY
Elizabeth Dimino, CPC Staten Island NY
Mercedes Rivera, CPC-H Wappingers NY
Aprille Marie O'Hara, CPC Westdale NY
Katy Elaine Davis, CPC, CPMA Amanda OH
Char Cihon, CPC Ashtabula OH
Elaine Gregory, CPC Avon Lake OH
Kathryn A Mayer, CPC Avon Lake OH
Yara G Roman, CPC Bedford OH
Marlene Harris, CPC Bedford Heights OH
Bonny J Kubicki, CPC Brook Park OH
Theresa Lynn Paukert, CPC Brunswick OH
Sara Davis, CPC Canal Winchester OH
Michelle Simpson, CPC Canton OH
Yvonne K Shaffer, CPC Chippewa Lake OH
Kim Hassard, CPC Cincinnati OH
Clara Yvonne Johnson, CPC Cincinnati OH
Jacqueline Kay Winslow Davis, CPC Cincinnati OH
Stephanie L Gross, CPC Cleveland OH
Barbara Joyce Stiner, CPC Cleveland OH
Joyce Thomas, CPC Cleveland OH
Barbara A Petro, CPC Columbia Station OH
Vicki Blawut, CIRCC Columbus OH
Cynthia Evans, CPC Delaware OH
William Haines, CPC Eastlake OH
Peggy Campbell, CPC Eaton OH
Kristie A Atkins, CPC Elyria OH
Clarissa Edwards-Wallace, CPC Euclid OH
Amy Dale, CPC Grafton OH
Melissa Huffman, CPC Harrison OH
Alice Yessayan, CPC Highland Heights OH
Cathy Ann Richman, CPC Liberty Township OH
Staci Booth, CPC Lockland OH
Melanie Rene Leonardi, CPC Medina OH
Danielle Lutz, CPC New Albany OH
Candy James, CIRCC Pataskala OH
Taylor McHale, CPC Powell OH
Diane Marie Moorman, CPC-H Spencerville OH
Nicole Kinney, CPC Vermilion OH
Katherine J Goodell, CPC Cleveland OK
Denice R Finch, CPC, CPC-H Hobart OK
Adrienne Brandenburg, CPC Oklahoma City OK
Bobbie Davis, CPC-H Oklahoma City OK
Arleen Moss, CPC Oologah OK
Francine Esche, CPC Tulsa OK
Lisa Souza, CPC Tulsa OK
Kimberly Boyd, CPC Tuttle OK
Penny Vaughn, CPC Wayne OK
Carley E Spangler, CPC Beaverton OR
Kimberly Smith, CPC Bend OR
Belinda C Baldwin, CPC, CPMA Eugene OR
Rebecca O'Dell, CPC Hillsboro OR
Keiva Bartel, CPC La Grande OR
Spring Cook, CPC Midland OR
Chanda Arscott, CPC-H, CPC-P Oakland OR
Lindi Moore, CPC-P Roseburg OR
Heather Kofoid, CPC Springfield OR
Connie Esther, CPC Tillamook OR
Tina Potter, CPC Veneta OR
Patricia McKinstry, CPC Warm Springs OR
Bernadette Potetz, CPC Allentown PA
Wendy Weigand, CPC Allentown PA
Lisa H Zamora, CPC Allentown PA
Jennifer Boyer, CPC Auburn PA
Cathie J Fruit, CPC Bloomsburg PA
Nicole Hammerly, CPC Breinigsville PA
Pamela Kunselman, CPC Brookville PA
Sandra Newstein, CPC, CPC-H, CPC-P, CPMA
Chadds Ford PA
Rhonda Kay Gayman, CPC Chambersburg PA
Danielle Louise Mills, CPC Chambersburg PA
Catherine Eileen Stobo, CPC Danville PA
Doris C Mulligan, CPC-H Erie PA
Kelly L Harmon, CPC Fayetteville PA
Linda A Johnston, CPC Folcroft PA
Karen S Sweesy, CPC, CPMA Freedom PA
Christine Powell, CPC Hanover PA
Diane Greco, CPC Hatboro PA
Lisa Crumling, CIRCC Hellam PA
Debra Zimnoch, CPC Hunlock Creek PA
Michelle Kreiser, CPC Jonestown PA
Christopher Valentino Reveron, CPC Kings of
Prussia PA
Bambi Lynne Cioffi, CPC Lancaster PA
Kristen Donovan, CPC Lansdale PA
Jasmine Leguillow, CPC Levittown PA
Betsy Miller, CPC Mertztown PA
Betsy I Dominick, CPC New Castle PA
Ann Marie Patsy, CPC New Castle PA
Robert Albert Phillips, CPC New Castle PA
Lucy Marie Sallmen, CPC New Castle PA
Rebecca Ann Sallmen, CPC New Castle PA
Pamela Jo Stoops, CPC New Castle PA
April Lea Miller, CPC Nicktown PA
Stephanie George, CPC Palmyra PA
Carol Furness, CPC Parkside PA
Adriene Bey-Brown, CPC-H Philadelphia PA
Shalina Brown, CPC Philadelphia PA
Carrie Beth Fisher, CPC, CIRCC Philadelphia PA
Rochelle Redding, CPC Philadelphia PA
Jacqueline Mehalich, RN, CPC, CPC-H Pittsburgh PA
Raynuld Reyna, CPC Secane PA
Pradnya Sathaye, CPC-H Whitehall PA
Jennifer Berlew, CPC Womelsdorf PA
Andrea Lynn Webster, CPC Adams Run SC
Tammy Strickland Bickerstaff, CPC Charleston SC
Tiffany Lee Cribb, CPC Charleston SC
Michelle Lee Hurt, CPC Charleston SC
Diane Meadows, CPC Charleston SC
DeeDee Murray, CPC Charleston SC
Patricia M Palmer, CPC Charleston SC
Roslyn S Peterson-Hale, CPC Charleston SC
Patricia Windham, CPC, CPMA Charleston SC
Sandra Annette Williams, CPC Darlington SC
Catherine Dudley, CPC Florence SC
Melisa C Hewitt, CPC Florence SC
Dena Robinson, CPC Florence SC
Timmi Caskey, CPC Fort Mill SC
Kimber A Bullington, CPC Goose Creek SC
Evelyn DeCastro, CPC Goose Creek SC
Angel Bice Cline, CPC Greenwood SC
Janice Carr, CPC Hilton Head Island SC
Tonya Plair, CPC Johnston SC
Nathan Edward Bartlett, CPC Mount Pleasant SC
Sharon Denise Davis, CPC North Charleston SC
Laura W Mayes, CPC North Charleston SC
Tamra Marie Stebbins, CPC North Charleston SC
Suzanne Brown, CPC Pawleys Island SC
Vonda Pickelsimer, CPC Piedmont SC
Katherine Maureen Melton, CPC Ravenel SC
newly credentialed members
Julie Lyn Davis, CPC Summerville SC
Sandra Marie Effler, CPC Summerville SC
Lindsy Gutierrez, CPC, CPMA Summerville SC
Lisa M Hair, CPC, CPMA Summerville SC
Cindy Lou Riscart, CPC Summerville SC
Angela Boyd, CPC West Columbia SC
Donna Marie Schenkel, CPC Brandon SD
Kathi Lynne Sorter, CPC Sioux Falls SD
Kanisha Williams, CPC Brentwood TN
Cynthia Herron, CPC Chattanooga TN
Lindsey D Vaughn, CPC, CPMA Hixson TN
Wendy Annette Rhodes, CPC, CPC-H, CPMA
Jefferson City TN
Theresa L Byrd, CPC Kingsport TN
Terri Fey McDonough, CPC Lebanon TN
Trina Ewing, CPC Memphis TN
Diana Hollis, CPC Murfreesboro TN
Jaime Sarten, CPC Murfreesboro TN
Peggy J Coleman, CPC-H Nashville TN
Amy Hixon, CPC Rutledge TN
Maureen E Foster, CPC, CPMA Signal Mountain TN
Priscilla Alfaro, MD, CPC Austin TX
Judy Devore, CPC Austin TX
Vicky C Foss, CPC Austin TX
Constance Stagman, CPC Austin TX
Sandra Lynn Keahey, CPC Benbrook TX
Christy A Miller, CPC Charlotte TX
Douglas Arrington, CPC, CPC-H, CPMA Dallas TX
Deirdra L Gaines, CPC Duncanville TX
Wathen Strong, CPC Frisco TX
Angelica Maria Martinez, CPC Ft Worth TX
Diann Kelley, CPC Garland TX
Guinnevere Stevens, CPC Garland TX
Dallia Jones, CPC Georgetown TX
Courtney Cofer, CPC, CPMA Kyle TX
Elaine Farias, CPC La Vernia TX
Theresa Vallery-McCoy, CPC Leander TX
Amy Pippin, CPC Lone Oak TX
Jessica Faircloth, CPC-H Longview TX
Leslie O'Neal, CPC McKinney TX
Senia Rascon, CPC McKinney TX
Nancy Barron, CPC Mesquite TX
Dale H Hill, CPC Nacogdoches TX
Roxanne Bazan, CPC Pleasanton TX
Stacy Williams, CPC Princeton TX
Cynthia Marie Funari, CPC Round Rock TX
Gloria Alaniz, CPC San Antonio TX
Nikki Lamberty, CPC San Antonio TX
Sarah Bueno, CPC Tyler TX
Froncel Burns, CPC Tyler TX
Kristal Rodriquez, CPC Tyler TX
Regina Karen Whitley, CPC Tyler TX
Pamela J Biffle, CPC, CPC-P, CPC-I Watauga TX
Vickie Quinn, CPC Windcrest TX
Becky J Wilson, CPC, CPMA Winona TX
Angela Miller, CPC Herriman UT
Stacie Tippetts, CPC Layton UT
Chelsey Marie Larson, CPC Roy UT
Valeria Jane Knotts, CPC Bentonville VA
Kathleen W Foster, CPC, CPMA Catlett VA
Amanda N Worlds, CPC Chesapeake VA
Mary Colleen Mescall, CPC, CPMA, CPC-I
Chesterfield VA
Robin Osler Hayes, CPC, CPMA Forest VA
Tamara A Phillips, CPC Richmond VA
Maire A Young, CPC, CPMA Stafford VA
Angela Frank Gagnon, CPC, CPC-H Virginia Beach VA
Nora Hodge, CPC Virginia Beach VA
Carol Suzan Tomala, CPC Virginia Beach VA
M LaNeice Watson, CPC-H Virginia Beach VA
Dawnelle R Sager, CPC, CPMA Weyers Cave VA
Debbie Robertson Tabb, CPC Newport VT
Tammy Cox, CPC Bremerton WA
Cecilia Maskell, CPC Fircrest WA
Jennifer Busselle, CPC Lacey WA
Arcell Dungca, CPC McChord AFB WA
Gustavo Adolfo Aviles-Espinosa, CPC Olympia WA
Molly Miller, CPC Seattle WA
Yuliya Petrov, CPC, CPMA Seattle WA
Jessica R Pisca, CPMA Seattle WA
Frances Mauritson, CPC Shelton WA
Leanne Dukes, CPC Tacoma WA
Julie Schrag, CPC, CPC-H, CPMA Tukwila WA
Christine J Badora, CPC Green Bay WI
Jennifer L Fye, CPC Green Bay WI
Ellen Neibrand, CPC Waterford WI
Laura Kudronowicz, CPC Wausau WI
Kathy Williams deHaan, CPC Cody WY
Patricia Nicole Lawson, CPC Ft Washakie WY
Cindy Linton, CPC Powell WY
Vickie Prante, CPC Powell WY
Apprentices
Rosemary Bell, CPC-A APO AE
Clifton Edwards, CPC-A APO AE
Tracey-Ann Jackson, CPC-A APO AE
Shanna Vose, CPC-A APO AE
Nicole Zenke, CPC-A APO AE
Katherine Hill, CPC-A Bel Air AE
Michele Boucher, CPC-A Hooksett AE
Annette Fleming, CPC-A Mooresville AE
Donald R Page, CPC-A North Bend AE
Jennifer Lesley, CPC-A Rosedale AE
Charlene Kilinski, CPC-A Wall AE
Judith Marsh, CPC-A Wells AE
Nancy Lynn Brown, CPC-A Andalusia AL
Amy Thomas, CPC-H-A Dothan AL
Barbara Veneziano, CPC-A Enterprise AL
Ronda McLeod, CPC-A Fairhope AL
Teresa Haynes, CPC-A Hartselle AL
Venetia Langland, CPC-A Homewood AL
Jeannie Teague, CPC-A Starrett AL
Amanda Whitley, CPC-A Jonesboro AR
Tiffany Basha Williams, CPC-A Little Rock AR
Cheryl Moore, CPC-H-A Pine Bluff AR
Lynn Saenz, CPC-A Mesa AZ
Anne K Hoge, CPC-A Phoenix AZ
Dora Beltran, CPC-A San Luis AZ
Melissa Gonzalez, CPC-A Scottsdale AZ
Jaime Camacho, CPC-A Somerton AZ
Danielle Ernestine Beeaff, CPC-A Tucson AZ
Emmie S Gouvisis, CPC-A Tucson AZ
Elizabeth J Guerra, CPC-A Tucson AZ
Sucheta M Vyas, CPC-A Tucson AZ
Lauren G Marscher, CPC-A Apple Valley CA
Carey Cameron, CPC-A Ben Lomond CA
Eufrocinita Manalansan, CPC-A Buena Park CA
Ani Stepanian, CPC-A Burbank CA
David Howe, CPC-A Cerritos CA
Nallammai Vijayakumar, CPC-A Cerritos CA
Sonja Gil, CPC-A Clovis CA
Virginia Hillhouse, CPC-A Concord CA
Jeffrey Roth, CPC-A Cypress CA
Sarah Corpuz, CPC-A Daly City CA
Karen Jones, CPC-A El Cerrito CA
Jerry Hammond, CPC-A Fresno CA
Diane Tarifa, CPC-A Galt CA
Jody Mullen, CPC-A Garden Grove CA
Ronald Murphy, CPC-A Glendale CA
Ronald Murphy, CPC-A Glendale CA
Sara Jane Traylor, CPC-A Hesperia CA
Karen S Gilbert, CPC-A Irvine CA
Charles E Jones, CPC-A La Puente CA
Monica L Quesada, CPC-A Lake Forest CA
Theresa Beam, CPC-H-A Lincoln CA
Anthony E Mckee, CPC-A Long Beach CA
Colette A Dryden, CPC-A Los Angeles CA
Leticia Suniga, CPC-A Mission Hills CA
Givvenchy Viridiana Velazquez, CPC-A Murrieta CA
Timothy Walker, CPC-A Ontario CA
Bianca Gallegos, CPC-A Pittsburg CA
Cyndie Myers, CPC-A Pittsburg CA
Brenda Sinjem, CPC-A Placentia CA
Shirley L McGowen, CPC-A Redondo Beach CA
Michelle Mutuc, CPC-A Rosemead CA
Mercy Flora Ravi, CPC-A Sacramento CA
Jonathan Haile, CPC-A San Luis Obispo CA
Hao Phan, CPC-A San Mateo CA
Gay Sue Hemming, CPC-A San Pablo CA
Sherrie Chesnut, CPC-A Santa Clarita CA
Sepehr Samadani, CPC-A Tarzana CA
Lillian J. Galindo-Bryson, CPC-A Walnut Creek CA
Sandra Kim Bale, CPC-A Whittier CA
Farah Safaei, CPC-A Woodland Hills CA
Raquel Villalpando, CPC-A Yuba City CA
Teilene Bliss, CPC-A Aurora CO
Andrea Laca, CPC-A Castle Rock CO
Julie Joy Yashur, CPC-A Castle Rock CO
Dawn Barberot, CPC-A Colorado Springs CO
Shaun Cox, CPC-A Colorado Springs CO
Sonja V Hurtado, CPC-A Colorado Springs CO
Debbie Kindt, CPC-A Colorado Springs CO
Rhiannon Lee, CPC-A Colorado Springs CO
Edith Marie Nelson, CPC-A Colorado Springs CO
Christina Oran Nottoli, CPC-A Colorado Springs CO
Amanda Christine Toney, CPC-A Fountain CO
Stephanie DeRosa, CPC-A Branford CT
Joan Lang, CPC-A Branford CT
David Miller, CPC-A Branford CT
Meegan Sweeney, CPC-A Branford CT
Janet Frizell, CPC-A East Haven CT
Linda J Mastrangelo, CPC-A Lebanon CT
Catherine Perry, CPC-A Manchester CT
Tracy Kardas, CPC-A Middletown CT
Mary Roraback, CPC-A New Britain CT
Lori Ann Sheldon, CPC-A North Grosvenordale CT
Betty Allen, CPC-A Salem CT
John Stanley Budarz, CPC-A South Windsor CT
Paul J Grassel, CPC-A Stonington CT
Kathryn Haserick, CPC-A Tolland CT
Patricia Dobos, CPC-A Wethersfield CT
Carolyn Winton McNamara, CPC-A Windsor Locks CT
Viola Coleman, CPC-A New Castle DE
Donna F Bolte, CPC-A Neward DE
Jennifer Rowbottom, CPC-A Smyrna DE
Sarah Elizabeth Forbes, CPC-A Wilmington DE
Himabindu Kaza, CPC-A Wilmington DE
Hemi Patel, CPC-A Wilmington DE
Beyen Garcia, CPC-A Apopka FL
Kenneth Asch, CPC-A Boca Raton FL
Jillian Nichole McLaughlin, CPC-A Cantonment FL
Karen Norris, CPC-A Crestview FL
Karen Williams, CPC-A Dade City FL
Stacey Piccuito, CPC-A Ft Walton Beach FL
Rhoda Rhodes, CPC-A Gibsonton FL
Peter Frazier, CPC-A Green Cove Springs FL
Izabella Kurdian, CPC-A Green Cove Springs FL
Christine Sigmon, CPC-A Holiday FL
Ashley Miller, CPC-A Hollywood FL
Shaun Kunnmann, CPC-A Jacksonville FL
Nicavian Wilson, CPC-A Jacksonville FL
Jo-Ann Cassidy, CPC-A Lake City FL
Carol L Hart, CPC-A Lakeland FL
Lisa Diane Jacklin, CPC-A Lakeland FL
Cassandra Miller, CPC-A Lakeland FL
Teresa Nesmachnov, CPC-A Lakeland FL
Lynn Demos, CPC-A Lehigh Acres FL
Debora Lalor, CPC-A Mary Esther FL
Carrie Young, CPC-A Milton FL
Yudelkis Gil, CPC-A Miramar FL
Loreto Kaplan, CPC-A Naples FL
Aydee Molina, CPC-A North Miami Beach FL
Gail Michele Anscombe, CPC-A Orange Park FL
Suzanne Newman, CPC-A Orange Park FL
Payal J Bhatt, CPC-A Riverview FL
Annabel Caceres, CPC-A Royal Palm Beach FL
Kathleen C Gartland, CPC-A Spring Hill FL
Dawn May, CPC-A Spring Hill FL
Chad William Parrish, CPC-A St Petersburg FL
Nancy Talamonti, CPC-A St Petersburg FL
Nicole Cain, CPC-A Tampa FL
Adriana Crespo-Tanner, CPC-A Tampa FL
Sheryl Downs, CPC-A Tampa FL
Robin Gerdes, CPC-A Tampa FL
Elena Houle, CPC-A Tampa FL
Pashen Jackson, CPC-A Tampa FL
Robin Stephenson, CPC-A Tampa FL
Stacey Suggs, CPC-A Wesley Chapel FL
Jessica Brown, CPC-A Zephyrhills FL
Rose Kesanghe Udoumana, CPC-A Austell GA
Talia Kline, CPC-A Braselton GA
Julianne Tooher, CPC-A Buford GA
J Dillon, CPC-A Canton GA
Erin Gravitt, CPC-A Canton GA
Sangita Hazari, CPC-A Douglasville GA
Monica Kocjan, CPC-A Flowery Branch GA
Pamela Ramey, CPC-A Flowery Branch GA
Debra Whitley, CPC-A Flowery Branch GA
Iris Morales, CPC-A Gainesville GA
MaChanda Rush, CPC-A Jonesboro GA
Wendy Hayden, CPC-A Kennesaw GA
Colby McCulley, CPC-A Snellville GA
Nicole Roland, CPC-A Altoona IA
Sandra Lee McGrath, CPC-A Amana IA
Angela S Baker, CPC-A Belle Plaine IA
Linda A Campbell, CPC-A Cedar Rapids IA
Steven K Franks, CPC-A Cedar Rapids IA
Sheryl J Hansen, CPC-A Cedar Rapids IA
Debra R Linehan, CPC-A Cedar Rapids IA
Renee Mary Martin, CPC-A Cedar Rapids IA
Donna Lee Mullenix, CPC-A Cedar Rapids IA
Jeanne M Myers, CPC-A Cedar Rapids IA
Jeannine Kay Robinson, CPC-A Cedar Rapids IA
Laura J Ameling, CPC-A Clermont IA
Beth Moore, CPC-A Des Moines IA
Stephanie Jo Ranberger, CPC-A Fredericksburg IA
Julia Hanson, CPC-A Ft Dodge IA
Eileen Marie Wander, CPC-A Hawkeye IA
Holly K Auman, CPC-A Hiawatha IA
Jamie Blevins, CPC-A Lewiston IA
Roxanne Delany, CPC-H-A Marion IA
Brandy Marie Pingree, CPC-A Oelwein IA
Becky Sue Winkler, CPC-A Ossian IA
Justi R Steenhoek, CPC-A Prairie City IA
Kristi Jones, CPC-A Sioux City IA
Angela Mary Abernathey, CPC-A Swisher IA
Nancy M Steffen, CPC-A Waterloo IA
Kathy Sue Senner, CPC-A West Union IA
Teresa Kay Yauslin, CPC-A West Union IA
Deborah Atkeson, CPC-A Boise ID
Cindi Baker, CPC-A Boise ID
Linda Eastwood, CPC-H-A Boise ID
Julie Williams, CPC-A Boise ID
Yadira Bergstrom, CPC-A Caldwell ID
Michelle Villarreal, CPC-A Caldwell ID
Danielle Porritt, CPC-A Eagle ID
Patricia Larsen, CPC-A Lewiston ID
Melony Cade, CPC-A Meridian ID
D'rese Werry, CPC-A Meridian ID
Dorothy B Smith, CPC-A Nampa ID
Kathy Hardy, CPC-A Payette ID
Melanie Fahrner, CPC-A Belleville IL
Lorey Morton, CPC-A Bloomington IL
Alex Castle, CPC-A Chicago IL
Tyeisha Goree, CPC-A Chicago IL
Maritza Navedo, CPC-A Cicero IL
Emily Atkins, CPC-A Collinsville IL
Hal Blake, CPC-A Columbia IL
Christina Deutschendorf, CPC-H-A Geneva IL
Donna Dines-Huff, CPC-A Manteno IL
William Edward Huff, CPC-A Manteno IL
Karen Dauck, CPC-A Peru IL
Megan Reynolds, CPC-A Rockford IL
Angela Shaw, CPC-A Staunton IL
Christina Newnum, CPC-A Bloomingdale IN
Jennifer Sampson, CPC-A Carmel IN
Mary Upton, CPC-A Carmel IN
Jennifer Hollander, CPC-A Evansville IN
Amber Martin, CPC-A Evansville IN
Julie Basham, CPC-A Georgetown IN
Heather Robinson, CPC-A Greenville IN
Cynthia Parsley, CPC-A Greenwood IN
Jennifer Lynn Bolden, CPC-A Indianapolis IN
Joy Frakes, CPC-A New Albany IN
Pamela Riggs, CPC-A New Albany IN
Kelsey Stiles, CPC-A New Albany IN
Laura Mitchell, CPC-A Noblesville IN
Gregory S Ehlers, CPC-A Richmond IN
Danita Heiter, CPC-A South Bend IN
Cheryl Jean Bindel, CPC-A Baxter Springs KS
Danielle Wiggin, CPC-A Ft Scott KS
Jamie Renee Sterling, CPC-A Hays KS
Liana Alona Ayala, CPC-A Mayetta KS
Terra A Swor, CPC-A Pittsburg KS
Amanda Marie Whisenant, CPC-A Pittsburg KS
Erin McIntosh, CPC-A Roeland Park KS
Kamala D Smith, CPC-A Scranton KS
Traci Dawn Imes, CPC-A Topeka KS
Nancy Kloetzli, CPC-A Topeka KS
Jacqueline Kay Lytle, CPC-A Topeka KS
Megan McCarthy, CPC-A Topeka KS
Kimberley Nelle McCoy, CPC-A Topeka KS
Katie M Waters, CPC-A Wakarusa KS
Cindy Ann Painter, CPC-A Adolphus KY
Dustin Fugate, CPC-A Bowling Green KY
Paula Plummer, CPC-A Bowling Green KY
Sondra Schilke, CPC-A Bowling Green KY
Kassie Nicole Gibson, CPC-A Cave City KY
Michelle Kinsolving, CPC-A Cave City KY
Kathy June Luttrell, CPC-A Cub Run KY
Robin Lee Dotson, CPC-A Etoile KY
Lisa Donahoe, CPC-A Lexington KY
Kevin Wells, CPC-A Lexington KY
Ashley Hourigan, CPC-A Louisville KY
Stephanie Lynn Kinney, CPC-A Louisville KY
Christa Mercke, CPC-A Louisville KY
Kimberly Palmer, CPC-A Louisville KY
Chelsea Rougeux, CPC-A Louisville KY
Debra White, CPC-A Louisville KY
Kimberly Bramel, CPC-A Maysville KY
Kathy Tufano, CPC-A Mt Sterling KY
Jenny Jackson, CPC-A Owensboro KY
Melissa Johnson, CPC-A Richmond KY
Karen Denise Tucker, CPC-A Rockfield KY
Etta M Monhollen, CPC-A Scottsville KY
Rita Faye Parrish, CPC-A Scottsville KY
Betty Jo Short, CPC-A Scottsville KY
Lesa Spahr, CPC-A Scottsville KY
Shawn Curtis, CPC-A Winchester KY
Cheryl Reichel, CPC-A Winchester KY
Betsy Boudreaux, CPC-A Houma LA
Candace Riley Rockett, CPC-A LaFayette LA
Mary Ann Baldyga, CPC-A Belchertown MA
Debra Bassett, CPC-A Brewster MA
Kathleen Whittle, CPC-A Brewster MA
Jaclyn McNeil, CPC-A Burlington MA
Debra J Warren, CPC-A Chicopee MA
Thomas Heath, CPC-A Framingham MA
Martha Farnsworth, CPC-A Hampden MA
Manisha Kumar, CPC-A Hudson MA
Sandra Lee Nadeau, CPC-A Marlboro MA
Carole J Amore, CPC-A Mashpee MA
Lakeisha Clayton, CPC-A Milton MA
Sarah Moe, CPC-A North Andover MA
Shannon Decker, CPC-A North Chelmsford MA
Thomas Stoll, CPC-A Pocasset MA
Donna Degraide, CPC-A Sturbridge MA
Susan Hope Hines, CPC-A Taunton MA
Karen Correa, CPC-A Upton MA
Sharon L Nappi, CPC-A Westford MA
Benise Donahue, CPC-P-A Worcester MA
Lauren Techla Hill, CPC-A Worcester MA
Larraine Formica, CPC-A Abingdon MD
Kelly Naumann, CPC-A Baltimore MD
Randy Stapleton, CPC-A Belcamp MD
Kimann McHose, CPC-H-A Bowie MD
Jeanie Aydelotte, CPC-A Easton MD
Pamela Roth, CPC-A Ellicott City MD
Karen Campbell, CPC-A Forest Hill MD
Marlene Brown, CPC-A Laurel MD
Ranie Gopaul, CPC-A Laurel MD
Kamrul Hasan, CPC-A Laurel MD
Daniela Kantor, CPC-A, CPC-H-A Lutherville MD
Doralyn Osei, CPC-A Silver Spring MD
Lori Stauffer, CPC-A Taneytown MD
Laura McCann, CPC-A White Marsh MD
Amanda Worster, CPC-A Biddeford ME
Norma J Fritz, CPC-A Bowdoin ME
Doris J Marquis, CPC-A Bowdoin ME
Romney Davis, CPC-A Eliot ME
Merena R Daniel, CPC-A Freeport ME
Christy Griffin, CPC-A North Waterboro ME
Nicole Bechard, CPC-A Presque Isle ME
Linda A Dowd, CPC-A Richmond ME
Suzanne Holliday, CPC-A Sanford ME
Donna Kimball, CPC-A Shapleigh ME
Norman Roy, CPC-A Waterboro ME
Shannon Petty, CPC-A Belleville MI
Patricia Dale Rodgers, CPC-A Caledonia MI
www.aapc.com
January 2011
39
newly credentialed members
Kimberly Desjarlais, CPC-A Dearborn Heights MI
Lakisha Lampley, CPC-A Detroit MI
Tammie Marie Klump, CPC-A Dexter MI
Karen Berriman, CPC-A Flint MI
Rachel Adams, CPC-A Grand Rapids MI
Dana Sutton Garver, CPC-A Grand Rapids MI
Sherri Lewis, CPC-A Kimball Township MI
Shirley Owsiany, CPC-A Lawton MI
Suzanne Rodriguez, CPC-A Midland MI
Marcia Ramer, CPC-A Portage MI
Suzanne Duda, CPC-A Warren MI
Brenda Jenkins, CPC-A Warren MI
Toua Lee, CPC-A Brooklyn Park MN
Mary Frances Bjorn, CPC-A Minneapolis MN
Julie Zabel, CPC-A Minneapolis MN
Tannaz Ameli, CPC-A Roseville MN
Sherry Sue Powers, CPC-A Cape Girardeau MO
Sarah Jean Hester, CPC-A Chaffee MO
Teresa W Becker, CPC-A Columbia MO
Jennifer Renee Campbell, CPC-A Eldon MO
Margaret Jane Wilde, CPC-A Florissant MO
Ashley N Holt, CPC-A Fulton MO
Barbara Michele Sciacca, CPC-A Jasper MO
Lori M Curry, CPC-A Joplin MO
Annette Marie Murphy, CPC-A Joplin MO
Anita Salinas, CPC-A Joplin MO
Michele Leigh Lee, CPC-A Kansas City MO
Mary Lagergren, CPC-A Lake Waukomis MO
Teresa E. Hindrichs, CPC-A O'Fallon MO
Rebecca Ann Cox, CPC-A Oronogo MO
Kimberly Van de Riet, CPC-A St Charles MO
Mary Cooke-Dorhauer, CPC-A St Louis MO
Tatiana D Montgomery, CPC-A St Louis MO
Amanda McLaughlin, CPC-A Biloxi MS
Sandra W Berry, CPC-A Byhalia MS
Sherll Lynn Fry, CPC-A Jackson MS
LaTonya Surnette Hubbard, CPC-A Jackson MS
Nicole Diane Crouch, CPC-A Missoula MT
Teresa Gong, CPC-A Angier NC
Mary Byerly, CPC-A Archdale NC
Kathleen Hansen, CPC-A Asheville NC
Lucia Batchelder, CPC-A Chapel Hill NC
Renee Militante, CPC-A Chapel Hill NC
Aaron Elizabeth Bradley, CPC-A Charlotte NC
Lisa Ince, CPC-A Charlotte NC
Rhonda Granja, CPC-A Concord NC
Gail Stoycon, CPC-A Cornelius NC
Kathryn Abbott, CPC-A Durham NC
Shadonna Pierce, CPC-A Durham NC
Nanci-Ann Whitworth, CPC-A Durham NC
Marcia Cunningham, CPC-A Elizabeth City NC
Kenneth Earl Jordan, CPC-A Fayetteville NC
Frances Alexander, CPC-A Greensboro NC
Kathy Clark, CPC-A Greensboro NC
Pat Driver, CPC-A High Point NC
Alicia Cain, CPC-A Hubert NC
Hsiu Hsiang Elsa Gant, CPC-H-A Julian NC
Rhonda Goodman Travis, CPC-A Kannapolis NC
Kay L Hedrick, CPC-A Lexington NC
Berea Thomas, CPC-A Lexington NC
Lindsay M Willis, CPC-A Marshville NC
Donna M Craig, CPC-A Mooresville NC
Jan K Harris, CPC-A Mooresville NC
Sheri Lively, CPC-A Mooresville NC
Janice Williams, CPC-A Morrisville NC
Linda Planchon, CPC-A Olin NC
Jackie Watkins, CPC-A Olin NC
Mary Arnold, CPC-H-A Pittsboro NC
Angela Kelly, CPC-A Raleigh NC
Cindy Hodge, CPC-A Rolesville NC
Joseph Mullen, MD, CPC-A Shelby NC
Catherine Ann Baker, CPC-A Statesville NC
Christie Lee, CPC-A Statesville NC
Angela Harris, CPC-A Union Grove NC
Chantal Proulx, CPC-A Vale NC
Christine Crosby Taylor, CPC-A Wake Forest NC
Judith Cecilia Wicker, CPC-A Weddington NC
Laura Jean Barker, CPC-A Yanceyville NC
Tiffany M Larson, CPC-A Burlington ND
Regina Reynolds, CPC-A Bow NH
Debra Peck, CPC-A Center Ossipee NH
Cheryl A Aiken, CPC-A Claremont NH
Emilee Jane Minckler, CPC-A Claremont NH
Sheryl Scott, CPC-A Conway NH
Lynda Wright, CPC-A Derry NH
Michele Lise Becker, CPC-A Goffstown NH
Cheryl Morrissette, CPC-A Goffstown NH
Joseph Reopel, CPC-A Hillsboro NH
Marc Aldrich VonGeldern, CPC-A Lebanon NH
Teri Michael, CPC-A Litchfield NH
John Kelly, CPC-A Littleton NH
Nikki Bicchieri, CPC-A Londonderry NH
40 AAPC Coding Edge
Meaghan Donohue, CPC-A Londonderry NH
Doral Garon, CPC-A Manchester NH
Shawna Harper, CPC-A Manchester NH
Karen Hendershot, CPC-A Manchester NH
Lisa Reid, CPC-A Manchester NH
Milena Simon, CPC-A Manchester NH
Jessica Young, CPC-A Manchester NH
Ildiko Balogh, CPC-A Merrimack NH
Lisa Anne Oakes, CPC-A N Haverhill NH
Cheryl Wilson, CPC-A Ossipee NH
Elizabeth Ann Trussell, CPC-A Piermont NH
Lynn Zeltman, CPC-A Plainfield NH
Kelly Abbott, CPC-A Raymond NH
Diane Cardwell-Beland, CPC-A Weare NH
Tracey Lachance, CPC-A Weare NH
Laura Beth Boncek, CPC-A West Lebanon NH
Cynthia Schafer, CPC-A Belle Mead NJ
Lauren Earnest, CPC-A Bridgeton NJ
Annette Vanderhoff, CPC-A Butler NJ
Agnes Linder, CPC-A Cliffwood NJ
Jennifer J Sterner, CPC-A Colts Neck NJ
Kristeen Craig, CPC-A Eatontown NJ
Jill Mensch, CPC-A Egg Harbor Township NJ
Sherry Ann Driver, CPC-A Freehold NJ
Karen Giovetsis, CPC-A Gloucester City NJ
Evelyn Kaveski, CPC-A Hamilton NJ
Sherry McGuire, CPC-A Hamilton NJ
Susan Helmstetter, CPC-A Hazlet NJ
Marina Benoit, CPC-A Irvington NJ
William Lloyd, CPC-A Jackson NJ
Natalie Schaeffer, CPC-A Leonardo NJ
Jill Sandorse, CPC-A Little Silver NJ
Stephanie Dibble, CPC-A Marlboro NJ
Lois Weaver, CPC-A Middletown NJ
Jason Sobel, CPC-A Monroe Township NJ
Liqun Wang, CPC-A Morganville NJ
Paula Zumbana, CPC-A Piscataway NJ
Carol Linda Vermeulen, CPC-A Pompton Plains NJ
Nitya Iyer, CPC-A Princeton NJ
Ilene Janofsky, CPC-A Princeton Junction NJ
Randa Shetter, CPC-A Somers Point NJ
Janet Cleveland, CPC-A Vineland NJ
Ellen Giamboy, CPC-A Vineland NJ
Caroline Katz, CPC-A Westfield NJ
Bev Mayor, CPC-A Whippany NJ
Leslie Cruz, CPC-A Willingboro NJ
Sandra Evelyn Johnson, CPC-A Aztec NM
Megan Gabrielle Martinez, CPC-A Aztec NM
Darla S Monarco, CPC-A Kirtland NM
Wanda L Smith, CPC-A Kirtland NM
Audrey Dunn Leonard, CPC-A Sparks NV
Peter J Damico, CPC-A Apalachin NY
Kimberly Carey, CPC-A Bainbridge NY
Pamela R Snyder, CPC-A East Amherst NY
John Yesuratnam, CPC-A Jamaica NY
Natoshia Fraser, CPC-A Maryland NY
Denise Debra Wynter, CPC-A Middletown NY
Sharon Goodman, CPC-A Owego NY
Haimanti Mukherjee, CPC-A Rye NY
Laura Drozynski, CPC-A Sherrill NY
Karol Henderson, CPC-A Tonawanda NY
Jaime Decker, CPC-A Utica NY
Elizabeth Anne Schmeltz, CPC-A Wallkill NY
Charise N Owens, CPC-A Wappinger Falls NY
Lela Baker, CPC-A Akron OH
Mira Stojadinovic, CPC-A Akron OH
Crystal Jones, CPC-A Barberton OH
Matthew O'Malley, CPC-A Canton OH
Jillian Hendrickson, CPC-A Chardon OH
Debbie Matthews, CPC-A Cincinnati OH
Sheila Gooch, CPC-A Columbus OH
Therese A Nicholas, CPC-A Dayton OH
Marsi Williams, CPC-A Delaware OH
Elizabeth Quinn, CPC-H-A Dover OH
Tracy Ann Martin, CPC-A Eaton OH
Heather Michelle Mortellite, CPC-A Liberty Township OH
Michelle Layette Scott-Dickens, CPC-A Mayfield
Heights OH
Deidre Hann, CPC-A McConnelsville OH
Kirstie Sword, CPC-H-A Navarre OH
Karrie Abruzzino, CPC-A Newbury OH
Colleen Baxter, CPC-A North Canton OH
Michelle Dechiara, CPC-A North Canton OH
Randi Hendrickson, CPC-A North Olmsted OH
Lori H Lauver, CPC-A North Olmsted OH
Diane Salsburey, CPC-A Orrville OH
Angela Ziccardi, CPC-A Ravenna OH
Janet Ward, CPC-A Seville OH
Mandie Jo McCort, CPC-A Sherrodsville OH
Susan Neumaier, CPC-A Vandalia OH
Joyce A Cook, CPC-A West Chester OH
Laura Krupka, CPC-A Wickliffe OH
Gwendolyn Sexton, CPC-A Youngstown OH
Jan Toomey, CPC-A Broken Arrow OK
Carolyn Purcell, CPC-A Cameron OK
Deanna Blalock-Polley, CPC-A Jones OK
Darcy Jones, CPC-A Moore OK
Corie Bottoms, CPC-A Tulsa OK
Jennifer Boysel, CPC-A Tulsa OK
Debbi Lee Fussell, CPC-A Beaverton OR
Jessica Gustafson, CPC-A Beaverton OR
Thomas James Nguyen, CPC-A Beaverton OR
Mary Pham Tran, CPC-A Beaverton OR
Julie Watkins, CPC-A Boring OR
Edith A Adair, CPC-A Eugene OR
Marie Hoots, CPC-A Hillsboro OR
Linnell York, CPC-A Hillsboro OR
Linda Anderson, CPC-A Keizer OR
Roberta Holman, CPC-A Portland OR
Martin Vodka, CPC-A Portland OR
Susan Huhn, CPC-A Alburtis PA
Monica Suchdeo, CPC-A Allentown PA
Ahmi Kim, CPC-A Ambler PA
Jessica Viguers, CPC-A Aston PA
Joy Noecker, CPC-A Auburn PA
Mary Sieffert, CPC-A Barto PA
Melissa Ashburner, CPC-A Bethlehem PA
Doreen Baranowski, CPC-A Bethlehem PA
Linda Lou Peck, CPC-A Carlisle PA
Renee Warren, CPC-A Carlisle PA
Cherie Kraynick, CPC-A Catasauqua PA
Traci Hood, CPC-A Chadds Ford PA
Sara Elizabeth Curry, CPC-A Danville PA
Colette Robbins, CPC-A Danville PA
Karen L Curto, CPC-A Easton PA
Barbara Mulik, CPC-A Emmaus PA
Trisha Christine Mattis, CPC-A Erie PA
Jessica Marie Sanchez, CPC-A Erie PA
Christine Anne Satur, CPC-A Erie PA
Christa Keren DeVelde, CPC-A Franklin PA
Michael Alan Marquardt, Sr, CPC-A Gettysburg PA
Pamela Jeanne Heilman, CPC-A Grantville PA
Beverly Andrews, CPC-A Greensburg PA
Martha J Lawrence, CPC-A Hanover PA
Suzanne Hedrick, CPC-A Havertown PA
Brenda Cooper, CPC-A Jenkintown PA
Rebecca Wolfe, CPC-A Kempton PA
Christine M Shannon, CPC-A King of Prussia PA
Laurel Elizabeth Heinley, CPC-A Lancaster PA
Carol Stank, CPC-A Lancaster PA
Catherine Ward, CPC-A Lancaster PA
Jessica Kalinski, CPC-A Langhorne PA
Wanda Ambrose, CPC-A Lebanon PA
Debra Hoover, CPC-A Lebanon PA
Morgan Mellott, CPC-A Lebanon PA
Robert Bartlett, CPC-A Lehighton PA
Elizabeth Stewart, CPC-A Mechanicsburg PA
Deborah Cohen, CPC-A Melrose Park PA
Megan Szychowski, CPC-A Nanticoke PA
Sherry Lee Chaklos, CPC-A Nazareth PA
Nupur Pant, CPC-A Orefield PA
Marylee E Zart, CPC-A Orefield PA
Marie P Schoch, CPC-A Palmerton PA
Jodi R Freed, CPC-A Philadelphia PA
Kathy Kramer, CPC-A Ronks PA
Crystal A Nutall, CPC-A Smithton PA
Andrea Di Paulo, CPC-A Springfield PA
Marcella M Reynolds, CPC-A Terre Hill PA
Rosemary LoCastro-Talbert, CPC-A Washington
Crossing PA
Debbie J Brunner, CPC-A Wellsville PA
Sharon Lanzos, CPC-A Whitehall PA
Kelci Howard, CPC-A York PA
Denise Pazdan, CPC-A York PA
Lisa Curless, CPC-A York Haven PA
Diana Lynne Krehling, CPC-A York Haven PA
Rebecca Quinones, CPC-A Cayey PR
Pam Ziegenhorn, CPC-A Andrews SC
Ashley B Metcalfe, CPC-A Charleston SC
Ann E Williams, CPC-A Charleston SC
Marsha A Davis, CPC-A Clinton SC
Sarida N Davis, CPC-A Columbia SC
Mary Johnson, CPC-A Columbia SC
Tamara McKeithan, CPC-A Columbia SC
Linda Sanford, CPC-A Florence SC
Ariel LaGoldia Rice, CPC-A Fountain Inn SC
Elizabeth Lauren McRainey, CPC-A Greenville SC
Jessica Moore Reynolds, CPC-A Greenville SC
Donna Marie Brown, CPC-A Laurens SC
Sharniece Martrice Robinson, CPC-A North
Charleston SC
Aletha L Ellis, CPC-A Roebuck SC
Latoya V Glenn, CPC-A Summerville SC
Elizabeth R LeBlanc, CPC-A Summerville SC
Andrea DeRuntz-Walker, CPC-A Williamston SC
Lorraine Higgins, CPC-A Williamston SC
Jade Ariel Reeves, CPC-A Williamston SC
Sally Hines, CPC-A Salem SD
Teneka Clemese Taylor, CPC-A Chattanooga TN
Sangeetha Hemaraj, CPC-A Chennai TN
Debbie Kester, CPC-A Clarksville TN
Jennifer Lynn Baxter, CPC-A Hillsboro TN
Kara Ferguson, CPC-A Hixson TN
Kelly Raymond, CPC-A Kimball TN
Jane Andreaco, CPC-A Knoxville TN
Scarlet M Haynes, CPC-A Knoxville TN
Kelli A Jones, CPC-A LaVergne TN
Lorie Watson, CPC-A Lebanon TN
Loraine Sizemore, CPC-A Manchester TN
Rebecca Questell, CPC-A McMinnville TN
Ashley Lynn Carr, CPC-A Murfreesboro TN
Josie Collier, CPC-A Murfreesboro TN
Tetanishia Gooch, CPC-A Murfreesboro TN
David C Bowlin, CPC-A Nashville TN
Sharon Marcia Gardner, CPC-A Nashville TN
Iris Kontente Hearn, CPC-H-A Nashville TN
Anne Moorman, CPC-A Nashville TN
Jessica Williams, CPC-A Nashville TN
Kay G Allgood, CPC-A Pegram TN
Heather Rey Zaffis, CPC-A Portland TN
Holley R Reffue, CPC-A Smithville TN
Brandie King, CPC-A Addison TX
Marily Salinas, CPC-A Arlington TX
Roxanna Menger, CPC-A Austin TX
Laura Salazar, CPC-A Austin TX
Lorena Rivas, CPC-A Canutillo TX
Trenna Lynn Gillett, CPC-A Edgewood TX
Daniel Parra, CPC-A El Paso TX
Marlenna R Crowe, CPC-A Ft Worth TX
Tricia Williams, CPC-A Haslet TX
Laura Hanson, CPC-A Lancaster TX
Nadia Pullin, CPC-A Leander TX
Sheryl Therriault, CPC-A McKinney TX
Tonya Brogdon, CPC-A Mineral Wells TX
Cheabon Altwein, CPC-H-A New Braunfels TX
Lauren Shapard, CPC-A North Richland Hills TX
Florine Sanchez, CPC-A Plano TX
Rachel Arcos, CPC-A San Antonio TX
Rosario Barrientes, CPC-A San Antonio TX
William Liles, CPC-A San Antonio TX
Arpita Maloo, CPC-A San Antonio TX
Lanaea Galindez, CPC-A Draper UT
Heidi Daines, CPC-A Harrisville UT
Kristine Dalton, CPC-A Harrisville UT
Lori Strong, CPC-A Herriman UT
Michelle Sawley, CPC-A Ogden UT
Katie Spangenberg, CPC-A Ogden UT
Terree Brough, CPC-A Plain City UT
Michelle Herbert, CPC-A Springville UT
Nancy Pontzer, CPC-A Alexandria VA
Helen Martin, CPC-A Chesapeake VA
Rochelle A Owens, CPC-A Chesapeake VA
Angela Chamberlain, CPC-A Chester VA
Sharon L Moncrief, CPC-A Colonial Heights VA
LaPhandra Hoyes, CPC-H-A Hampton VA
Stacy M Quarles, CPC-A King William VA
Mary H Kellner, CPC-A Midlothian VA
Dorothy McFadden, CPC-A Midlothian VA
Virginia Marston, CPC-A Red House VA
MarQuetta Blakey, CPC-A Richmond VA
Kathryn M Deal, CPC-A Suffolk VA
Charles Aloisa, CPC-A Virginia Beach VA
Metina Baucom, CPC-A Virginia Beach VA
Janelle Elizabeth Grandison, CPC-A Virginia Beach VA
Mary Ellen McCann, CPC-A Virginia Beach VA
Victoria Anne Paur, CPC-A Virginia Beach VA
Lisa Michelle Lawrence, CPC-A Warrenton VA
Lisa Marie Hoskins, CPC-A Winchester VA
Dominique Veitch, CPC-A Chester VT
Annie Malloy, CPC-H-A Grand Isle VT
Angelia Marie Russell, CPC-A White River Junction VT
Lyn K Kolb, CPC-A Woodstock VT
James VanLiew, CPC-A Bellingham WA
Nicolette Doyle, CPC-A Bothell WA
Nicolette Wolfe, CPC-A Burlington WA
Holland Wood, CPC-A Camano Island WA
Kamalpreet Dhillon, CPC-A Everett WA
Peggy Jean Hagglund, CPC-A Everett WA
Kelly Lyn McCoy, CPC-A Federal Way WA
Ronald Weightman, CPC-A Federal Way WA
Sidney Faas, CPC-A Kent WA
Damika Rodrigue, CPC-A Kent WA
Tracey Lynne Jones, CPC-A Kirkland WA
Janet Eulene Ramynke, CPC-A Moxee WA
Daniela Wever, CPC-A Orting WA
Candace Drollinger, CPC-A Port Townsend WA
Patricia Langhans, CPC-A Redmond WA
Dena Bailey, CPC-A Renton WA
Denise Annette Brennan, CPC-A Renton WA
Roman R Gatalyak, CPC-A Renton WA
Jamie Robin Hallmark, CPC-A Renton WA
Alicyn Westerfield, CPC-A Selah WA
Rosandra Fedorko, CPC-A Silverdale WA
Anna-Louise Amiscua, CPC-A Stanwood WA
Maureen Strickland, CPC-A Tacoma WA
Vernon Eugene Brand, CPC-A Yakima WA
Patricia Kingsborough, CPC-A Yakima WA
Charlotte Werthmann, CPC-A Appleton WI
Keli M Westphal, CPC-A Appleton WI
Robyn Theresa Plompen, CPC-A Depere WI
Sara A Levendusky, CPC-A Manitowoc WI
Susan Milliron, CPC-A New Richmond WI
Specialties
Mary F Greenleaf,
CPC, CEMC APO AE
Selina Maria Thomson,
CEMC APO AE
Julia Ann Holt,
CPC, CPCD Fresno CA
Cheryl Tubig,
CPC, CPC-H, CEMC Oakland CA
Ashley Nicole Pickerill,
CPC, CANPC, CEMC Santa Cruz CA
Pallas Buckley,
CPC, COSC South Lake Tahoe CA
Kimberly Seegan,
COBGC Westlake Village CA
Alexis M Pyatt,
CPC, CEMC Fountain CO
Nancy D Weed,
CPC, CPC-H, CEDC, CEMC, CUC Wilmington DE
Kim Jones,
CPC-A, CHONC Jacksonville FL
Jamie Smith,
CPC, CEDC Jacksonville FL
Theresa Borsch,
CASCC Lake Worth FL
Paula Buckingham,
CPC, CEMC Orange Park FL
Jennifer Leigh Hestle,
CPC, CHONC Pensacola FL
Karen D Renner,
CPC, CEMC Buford GA
Adrien Leigh Peterson,
CPC, CEMC Clayton GA
Christy D Payne,
CPC, CEMC Clermont GA
Jennifer Michelle Kastner,
CPC, CEMC Cleveland GA
Sandra D Hicks,
CPC, CEMC Gainesville GA
Angela Odom,
CPC, COBGC Gainesville GA
Cathy M Stover,
CPC, CPC-H, CEDC Richmond Hill GA
Patricia Peaslee,
CPC-A, CUC Valdosta GA
Valerie Gene Westbrook,
CPC, CEDC Bethalto IL
Barbara Myers,
CGIC Charleston IL
Valerie N. Ramirez,
CPC, COSC Hanover Park IL
Charissa Hill,
CEMC Mascoutah IL
Cindy L Ward,
CPC, CPC-H, CPMA, CCC, CEMC Indianapolis IN
Marcia S Moore,
CPC, CASCC South Bend IN
Alanna Denae Jefferson,
CPC, CPC-I, CEMC, COBGC Gardner KS
Jason W Donnelly,
CPC, CASCC Richmond KY
Tammy Birdsong,
CHONC Shreveport LA
Ellen Rostron,
CPC, CASCC Peabody MA
David A Foster,
CPC, CIMC Sanford ME
newly credentialed members
Robin Thompson,
CCVTC Coon Rapids MN
Debra Mauer,
CCC St Paul MN
Wendy Anderson,
COBGC, CUC St Paul MN
Susan Falbo,
CFPC Kansas City MO
Rebecca Tucker,
COBGC Owensville MO
Renee Carlton,
CPC, CGIC Havelock NC
Laura Heffner Stearns,
CPC, CEMC Shelby NC
Staci L Murillo,
CPC, CEMC Gering NE
Linda A Elley,
CPC, CPMA, CEMC Scottsbluff NE
Bing Valencia Montoya,
CPC, CPEDC Teaneck NJ
Allison Beth Parnell,
CPC, CPC-H, CEDC Tijeras NM
Jill Barron,
CGIC Beachwood OH
Mandy Lynn Fowler,
CPC, CGIC, CGSC Chillicothe OH
Charity Jane Smith,
CPC, CFPC Jackson OH
Lisa M Shafer,
CPC, CUC Midwest City OK
Valerie Albert,
CPC, CUC Norman OK
Sheila English,
CPC, CPEDC Tulsa OK
Deborah Jeanne Phillips,
CPC, CGSC, COSC Springfield OR
Kelly J Steele,
CPC, CPC-H, CHONC Elizabethtown PA
Bethany Hess,
CPC, CGIC Ephrata PA
Amanda M Counasse,
CPC, CPEDC, CPRC Girard PA
LeeAnne Doman,
CUC Lancaster PA
Susan M Dietterick,
CPC, CASCC North Wales PA
Pamela L Nealy,
CPC, CEDC Pottstown PA
Tracey Zokuskie,
CPC, CPEDC St Clair PA
Katherine M Huss,
CGIC West Chester PA
Gabriel Rafael Aponte,
MBA, CPC, CPC-H, CCC San Juan PR
Deana K Middlesworth,
CPC, COSC Fort Mill SC
Patricia R Goodson,
CPC, CGSC Moore SC
Dorothy Ann DeWees,
CPC, CPCD Travelers Rest SC
Holly McGrew Barnes,
CPC, CEMC Dickson TN
Heather E Neal,
CPC, CPC-H, CCVTC, CGIC, CGSC, COBGC
Mansfield TX
Cindi Jane Jacobs,
CEDC Appomattox VA
Ruth N Egipciaco,
CPC, CPC-H, CEMC Hampton VA
Rebecca T Elmendorf,
CPC, CEMC Midlothian VA
Sarah Chapman Luchard,
CPC, CEDC West Point VA
Philip G Brown,
CPC, CASCC Seattle WA
Kelli Lynn Kahlenberg,
CPC, CEMC Manitowoc WI
Andrew Borden,
CPC, CENTC Milwaukee WI
Magna Cum Laude
Adrienne Diane Bowers,
CPC-A Tempe AZ
Ellen Lamel,
CPC-A Pasadena CA
Clint Hoffman,
CPC-A Salinas CA
Leigh Anne Odom,
CPC-A Lake Butler FL
Nancy O'quin,
CPC-A Land O' Lakes FL
Silvia Sanchez,
CPC-H Miami FL
Linda Carol Hilke,
CPC-A Palm Harbor FL
Mary Klein,
CPC Pensacola FL
Melissa McGuire,
CPC-A Ruskin FL
Susan M Grayson,
CPC-A South Pasadena FL
Ashley Beachum,
CPC St Petersburg FL
Monica Marcone,
CPC St Petersburg FL
Kimberly D Pillard,
CPC-A Vinton IA
Carla Kipen,
CPC-A Chicago IL
Sandra Lee Camargo,
CPC Olympia Fields IL
Darla Ratcliff,
CPC Baton Rouge LA
Elizabeth F Hamilton,
CPC Chicopee MA
Wanpijid Wang-itti,
CPC-A, CPC-H-A Odenton MD
Jerrilyn Schmitz,
CPC-A Absarokee MT
Patti Forest,
CPC Durham NC
Tracy Seaman,
CPC-A Endicott NY
Erik Lichtenberger,
CPC-A Akron OH
Jean Hallet,
CPC-A Cincinnati OH
Karen A Klepaski,
CPC Coldwater OH
Christine Corrigan,
CPC Westlake OH
Susan Elizabeth Sturgill,
CPC Oregon City OR
Michelle Elizabeth Moyer,
CPC-A Allentown PA
Cynthia Wellborn,
CPC-A Lexington SC
Anamika Saravanan,
CPC Chennai Tamil Nadu
Desiree Dy,
CPC-A Goodlettsville TN
Sara Mickelsen,
CPC-A Nashville TN
Jill Hill,
CPC-H-A Allen TX
Terry Latimer,
CPC Frisco TX
Christina Jenkins,
CPC Richardson TX
Lisa Ann Elswick,
CPC, CPC-H Tyler TX
Robyn Parker,
CPC-A Draper UT
Michelle Akers,
CPC-A Lakebay WA
Ricardo Jose Perez,
CPC Seattle WA
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January 2011
41
road map to ICD-10-CM
Get on Board for the Next 1000 Days
Road Map to ICD-10-CM
Get on Board
for the Next 1000 Days
42 AAPC Coding Edge
Time is ticking and ICD-10
won't stop to let you on the bus.
By Angela “Annie” Boynton, BS, RHIT, CPC, CPC-P, CPC-H, CPC-I, CCS, CCS-P
As I write this, there are just over 1,000 days until
ICD-10 becomes the new standard for disease classification in the United States. The Centers for
Medicare & Medicaid Services (CMS) will reject
any claim using ICD-9-CM codes with a date of
service on or after Oct. 1, 2013. Lack of preparation could be devastating.
Ignoring ICD-10
Will Not Make It Go Away
Although there are many competing priorities
right now (ARRA, HITECH, and Meaningful Use—to name a few), the longer you put off
ICD-10 implementation, the harder it will be to
comply with this deadline. Those who wait until
the last minute to prepare for ICD-10 are risking
their revenue in 2013 and beyond. The only way
to mitigate these risks is to be fully compliant with
ICD-10 by Oct. 1, 2013. Let’s discuss a few things
you can do to get the ball rolling toward ICD-10
compliance.
Ask Not What
ICD-10 Can Do for You …
By now, organizations should be finalizing impact
assessments. This means that steering committees have been formed; executive buy-in has been
obtained; basic education has been delivered to
project teams, stakeholders, and executives; and
5010 implementation is on track.
If reading this paragraph has made you reach for
the antacid (or worse), you are not alone. Recent
industry surveys have suggested that as many as
52 percent of health care organizations have not
begun their ICD-10 implementation planning
efforts. If your organization is one of them, you
need to get going—now.
Steering Committee—
Who’s Driving Implementation?
Although physicians will play a crucial role in
ICD-10 implementation, steering committees
should include members across the breadth and
depth of an organization. The steering committee
should be an interdisciplinary team representing
many areas of the organization. Some examples
include:
• Project managers
•Information technology (IT)/Information
systems (IS)
• Health information management (HIM)
• Physicians
• Revenue cycle staff
• Training
• Communication
• Vendors
• Management
• Coding professionals (of course)
ICD-10 Awareness:
If You Build It, They Will Come
Awareness develops over time and is critical to
ICD-10 implementation success. Rather than
spending precious dollars creating an ICD-10
campaign, organizations would do better to build
ICD-10 awareness by leveraging available resources.
Within larger organizations, these resources may
include existing newsletters, internal websites,
and even memos. Smaller organizations can place
ICD-10 information by the water cooler, or in the
lunchroom. Any size organization may conduct
lunchtime learning sessions. Many vendors, payers,
facility
specialty societies, and industry organizations are
providing free materials and webinars regarding
ICD-10.
All entry-level communications should give
basic information regarding the ICD-10 code set
changes, why we must transition, a general timeframe, and potential impacts to the organization.
Medical staff, coding professionals, and revenue
cycle staff may require additional communication
and increased training—but everyone should be
aware of the basics.
Impact Assessment:
An Organizational Crystal Ball
An impact assessment helps to provide an accurate picture of costs, scope, timelines, and other
resources required for ICD-10 implementation. It
involves careful analysis and budgetary consideration for the project’s life. In its simplest form, an
impact assessment can be started by addressing a
few questions: analyzing where, when, by whom,
and how ICD-9 codes currently are used across the
organization. More time spent conducting impact
assessment equates to greater budgetary accuracy
over the life of the implementation project.
ICD-10 Revolution: Change is Good!
ICD-10 is a revolutionary change to our disease
classification system in the United States. Revolutions in general tend to be painful, and projects
that carry the size and scope of the ICD-10 transition can cause anxiety. Open and maintain clear
communication channels to help mitigate fear.
Clearly define changes and expectations associated
with ICD-10 implementation as early as possible.
Provide constant updates when milestones are
formulated and overall project plans become clear.
With less than 1,000 days left, there is no time left
to lose.
Annie Boynton is the director of
5010/ICD-10 communication/
adoption and training at UnitedHealth Group. She also teaches
at Massachusetts Bay Community
College and is a developer and
member of AAPC’s ICD-10 Curriculum Development Team.
2011 Webinar SubScription
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10. Up to 80 CEUs — earn up to 2 CEUs per presentation (per attendee)
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7. Includes all 2011 webinars (live and on-demand)
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January 2011
43
feature
COPD:
Frequently Used,
Frequently Misreported
Giving essential details about the patient’s
condition can eliminate coding quandaries.
By Jill M. Young, CPC, CEDC, CIMC
PROFESSIONAL
C
hronic obstructive pulmonary disease (COPD)
is a progressive disease that causes coughing,
wheezing, shortness of breath, chest tightness,
and other symptoms. The leading cause of COPD is
smoking; most people who smoke, or have smoked,
have some form of COPD. In 2007, an estimated 12.1
million Americans had the disease, which is not only
a major cause of disability but also the fourth leading
cause of death in America.
Coders will encounter COPD frequently in medical documentation, but often without the specificity
required to code the condition appropriately. A little
physician education will go a long way to solve this
problem.
Be Cautious of Shortcuts
As coders, we become so familiar with certain anagrams that we memorize the corresponding diagnosis
code—HTN for hypertension (401.9 Essential hypertension; Unspecified), DM for diabetes mellitus (250.00
Diabetes mellitus without mention of complication; type
II or unspecified type, not state as uncontrolled), and
OA for osteoarthritis (715.98 Osteoarthritis, unspecified
whether generalized or localized; Other specified sites), to
name just a few. Although you may know what ICD9-CM codes to assign in such cases, you do a disservice
to providers if you allow them to document with such
nonspecific code assignments. Ensure accurate representation of the patient’s illness by looking at the specificity available to diseases such as COPD.
“COPD” may be written in the record, but that does
not give essential details about the patient’s condition,
and this leads to coding quandaries. Was the patient
ill at this encounter with another respiratory process?
Was this illness and its severity included in the record
documentation? This information is necessary if you
44 AAPC Coding Edge
are to select codes that accurately identify the patient’s
condition.
COPD 496 Is a Non-Specific Code
Code 496 Chronic airway obstruction not elsewhere classified is one of the few valid three-digit codes in the
ICD-9-CM manual. The code includes a subcategory
listing of “chronic obstructive pulmonary disease
(COPD) NOS,” and is both a not otherwise specified
(NOS) and not elsewhere classified (NEC) diagnosis.
In other words, 496 is a legitimate diagnosis, but it
lacks specificity. Providers like to write the short anagram “COPD” when there may be (and perhaps should
be) a more specific code for a patient encounter.
Fold COPD into 491-493, When Present
You should not report 496 with chronic bronchitis (491.
xx), emphysema (492.x), or asthma (493.xx), according
to ICD-9-CM instructions. Just as shortness of breath
normally should be integrated in the coding for pneumonia, COPD should be incorporated into categories
491-493 for the other lung diseases listed.
For example, when COPD is documented with other
specified conditions, such as an acute exacerbation
(491.21 Obstructive chronic bronchitis) or asthma
(493.2x), per coding guidelines, code 496 is not used.
In such a case, COPD should not be documented
separately because it is redundant to the more-inclusive
diagnosis. Nor should you report 496 with 491.0 Simple
chronic bronchitis, 492.8 Other emphysemia, or asthma
of any kind (493.xx).
A tip in ICD-9-CM 2011 reminds, “COPD is a nonspecific term that encompasses many different respiratory conditions. Review medical record and query
physician for more specific documentation of emphysema, bronchitis, asthma, etc.”
feature
Figure A: Venn Diagram
Just as shortness of breath normally should be integrated
in the coding for pneumonia, COPD should be incorporated
into categories 491-493 for the other lung diseases listed.
One useful tool is the Venn diagram, as shown in
Figure A. Similar to what appears in the ICD-9-CM
manual, this diagram shows the interrelationship
between chronic bronchitis (491.xx), asthma (493.
xx), and emphysema (492). The overlapping areas are
indicative of diagnoses with shared qualities of two or
all three of the major disease processes. As you can see,
COPD has attributes of both chronic bronchitis and
emphysema; how much of each changes with every
patient, and potentially with each encounter.
Tip: As a note of caution, not all physicians agree with
the classifications this diagram offers, so you may want
to have a discussion with your provider to avoid any
confusion.
The Venn diagram helps us to understand that these
are three different and distinct diagnoses, but there are
related disease processes that must be considered. Your
code book may have definitions listed in several of the
subsections that are very helpful in differentiating codes
with common characteristics. Coding tips from the
2011 ICD-9-CM book specifically state, “Due to the
overlapping nature of conditions that make up COPD,
it is essential that the coder review all instructional
notes carefully.”
For example, documentation of a patient visit may
end with the physician listing COPD and chronic
bronchitis. This should be coded to 491.0; the chronic
bronchitis is the more specific code to the COPD,
according to ICD-9-CM guidelines. The same guidelines are applied if the documentation was COPD and
asthma. In this example, it is particularly difficult to
omit the 496 COPD code because an unspecified code
for the asthma is indicated with an unspecified subclassification, which codes to 493.90 Asthma, unspecified;
unspecified.
ICD-10 Raises the Stakes
COPD documentation and specificity will become even
more important with ICD-10-CM. COPD is classified
with acute lower respiratory infections (also identify-
ing the infection), and with exacerbation. You also are
instructed, where applicable, to use additional codes to
identify exposure to tobacco. This exposure is identified in codes representative of environmental tobacco
smoke, history of tobacco use, occupational exposure
to environmental tobacco smoke, tobacco dependence,
and tobacco use.
Help Providers, Help You
How can coders educate providers to document all the
necessary information to code COPD accurately? I
recommend you take your code book to providers (or,
copy and send them the relevant pages) to show them
firsthand the ICD-9-CM guidelines. If a physician sees,
for example, there are separate codes for a patient with
or without COPD and acute bronchitis, chronic bronchitis, or acute and chronic bronchitis together, they
will better understand why you are asking for more
specificity. Remind the provider that you cannot code
what is not documented. Any dialog between coders
and providers is invaluable to producing detailed documentation that leads to code selection with the bestpossible specificity.
The next time you see COPD (or 496) listed as a
diagnosis, think of the prevalence of patients with this
disease process, and remember that this code lacks
specificity. Don’t forget there are 24 distinct ICD9-CM code listings for which COPD should not be
listed separately as a diagnosis, according to guidelines.
Look to the documentation and your provider for the
data needed to represent the patient encounter accurately, with the greatest specificity that the ICD-9-CM
system offers.
Jill M. Young, CPC, CEDC, CIMC, has
more than 30 years of medical experience working in all areas of the medical
practice including clinical, billing, and
rounding with physicians. She is the
principal of Young Medical Consulting,
LLC, and is the current chair of the AAPC
Chapter Association (AAPCCA).
www.aapc.com
January 2011
45
featured coder
Evaluate Your Performance
When ED Leveling
Hospitals must develop internal guidelines,
based on general Medicare principles.
By Jim Strafford, CEDC, MCS-P
H
ow well does your emergency department (ED)
assign evaluation and management (E/M) levels
based on the resources used? How does your facility compare to other, similar facilities? If you don’t know
the answers, it’s time to take a closer look at your facility
E/M leveling.
Review Guidelines
The Centers for Medicare & Medicaid Services (CMS)
requires hospitals to report ED facility resources using
CPT® E/M services codes. But, whereas the 1995 and
1997 Documentation Guidelines for Evaluation and
Management Services direct E/M leveling for physician
services, there are no standard leveling guidelines
when reporting facility resources (see Medicare Claims
Processing Manual, chapter 4, section 160: www.cms.
gov/manuals/downloads/clm104c04.pdf). Instead, each
hospital must develop its own, internal guidelines,
based on 11 general principles that CMS outlined
in the 2008 Outpatient Prospective Payment System
(OPPS) Final Rule (see Federal Register, Nov. 27, 2007,
page 66805: http://edocket.access.gpo.gov/2007/pdf/075507.pdf).
Among other requirements, CMS expects each hospital’s internal guidelines to:
Follow the intent of the CPT® code descriptor (the
guidelines should relate reasonably to the hospital
resources used)
Be based on hospital facility resources, not physician resources
 Be clear to facilitate accurate payments
 Not facilitate upcoding
Be written or recorded, be well documented, and
provide the basis for selection of a specific code
As long as these general guidelines (and seven others)
are met, CMS allows the hospital (or, more precisely, its
coders) to decide how ED services should be documented
to support a given service level. The result has been a
hodgepodge of methodologies, including point systems,
matrixes, and hybrids of both (look to future articles for
a discussion of these differing methodologies).
Table A:
2009 Medicare Leveling Data for Four EDs in East Coast Suburban Areas Close to Large Urban Areas
46 AAPC Coding Edge
Level
99281
99282
99283
99284
99285
ED 1
2.54%
56.21%
28.27%
9.05%
3.92%
ED 2
1.39%
27.97%
37.17%
22.70%
10.77%
ED 3
1.81%
24.73%
69.01%
3.80%
0.66%
ED 4
12.08%
16.65%
15.04%
16.08%
40.16%
Medicare Average
5%
16%
33%
31%
16%
featured coder
How Do You Compare?
CMS states in the 2010 OPPS Final Rule, “CMS continues their belief that based on the use of their own
internal guidelines, hospitals are generally billing in an
appropriate and consistent manner that distinguishes
among different levels of visits based on their required
hospital resources.” (See Federal Register, Nov. 20,
2009, page 60552: http://edocket.access.gpo.gov/2009/
pdf/E9-26499.pdf.) At Strafford Consulting, review of
Medicare data indicates (in a very general way) CMS’s
statement may be true; however, many hospitals are
well below or well above national averages.
Table A gives Medicare acuity levels for four EDs in a
densely-populated Northeast state. The EDs are similar
in payer mix, volume, and patient mix. So why is there
such a variance in leveling among these hospitals?
Table A illustrates:
• EDs 1 and 2, which have visits in the 30-40K per
annum range, are moderate size EDs.
• EDs 3 and 4, which have visits in the 70-80K per
annum, are moderately large EDs.
• EDs 1-3 are well above national averages for 99282
Emergency department visit for the evaluation and
management of a patient, which requires these 3 key
components: An expanded problem focused history; An
expanded problem focused examination; and Medical
decision making of low complexity.
 ED 1 shows over three times the national
average for 99282. This could indicate a
leveling issue that is affecting revenue.
 Only ED 4 is in line with national averages
for 99282.
• A ll of the EDs are well below the national averages
for 99284 Emergency department visit for the evaluation and management of a patient, which requires
these 3 key components: A detailed history; A detailed
examination; and medical decision making of moderate complexity. This could represent a very significant revenue loss.
• ED 4 is well above the national average for 99285
Emergency department visit for the evaluation and
management of a patient, which requires these 3
key components within the constraints imposed by
the urgency of the patient’s clinical condition and/
or mental status: A comprehensive history; A comprehensive examination; and medical decision making
of high complexity. If the coding is not supported
by documentation and medical necessity, this ED
could be vulnerable to negative audit findings and
major paybacks.
Different practice patterns and resource use may affect
acuity levels. For example, a given hospital might have
a very robust walk-in clinic in the ED. But this report
tracks Medicare patients who typically are sicker than
the general population when visiting the ED. Because
CMS and CPT® do not provide guidelines for leveling,
the major reason for the leveling differences likely is the
leveling method each hospital uses, and the quality of
documentation at these EDs.
This example shows why you should examine E/M leveling in your facility.
Be Sure Used Guidelines Are Complete and
Capture All Supported Services
As a first step, review your reports and work-up percentages based on ED acuity levels. If your ED is
coding 99281 Emergency department visit for the evaluation and management of a patient, which requires these
3 key components: A problem focused history; A problem
focused examination; and Straightforward medical decision making and 99282 over 50 percent of the time, you
could be undercoding ED levels. If the majority (60-70
percent) of your levels are 99283 Emergency department
visit for the evaluation and management of a patient,
which requires these 3 key components: An expanded
problem focused history; An expanded problem focused
examination; and Medical decision making of moderate
complexity, you might be suffering from “Level-3-itis.”
This is still a common issue with physicians who do
their own coding (such as hospitalists). On the other
hand, if your ED is coding 99285 more than 40-45
percent of the time, there could be a compliance issue.
If your ED leveling percentages are way out of line, it
is likely that the guidelines you use for leveling are not
complete in capturing all elements that can support the
services. Or, the personnel who do the leveling are not
identifying all of the elements that would support an
ED level. In the later case, the problem may relate to
who does the leveling at your hospital. ED nurses are
responsible for leveling at some hospitals; and they are
most familiar with resources utilized in the ED to support levels. Like physicians, though, nurses often do not
have the time or inclination to focus on leveling.
Recognize also that atypical leveling patterns may
attract CMS’ attention. The 2010 OPPS Final Rule
(referenced above) states, “In the absence of national
guidelines, we [CMS] will continue to regularly reevaluate patterns of hospital outpatient visit reporting at
varying levels of disaggregation below the national level
to ensure that hospitals continue to bill appropriately
and differentially for these services.”
www.aapc.com
January 2011
47
featured coder
To discuss this
article or topic,
go to www.aapc.com
If your ED leveling percentages
are way out of line, it is likely
that the guidelines you use for
leveling are not complete in
capturing all elements that can
support the services.
Who Is Responsible for Leveling?
Many hospitals use medical records, or a coder/leveler
who is based in the ED (a very good choice for ongoing
interaction with ED personnel), to do some combination of the leveling, procedure coding, and ICD-9
coding. This is a great approach if the coder/leveler is
trained properly, with complete guidelines and ongoing
review and feedback. Some hospitals outsource the ED
facility coding to firms that specialize in ED coding.
This also can be a good choice.
Hospitals often seek hospital-side certification for
ED leveling positions. Presently, there is no specific
certification for facility-side ED coding. AAPC, however, offers a Certified Emergency Department Coder
(CDEC™) certification for reporting physician services.
CEDCs must pass a demanding exam that consists
entirely of ED chart reviews. CEDC certification
assures the hospital that the coder has familiarity with
ED procedure and ICD-9 coding, and should learn a
given hospital’s leveling methodology quickly.
Just remember: Expertise in ED physician coding does not
equate automatically to expertise in facility leveling.
Jim Strafford, CEDC, MCS-P, principal of Strafford
Consulting Inc., has over 30 years experience as a
consultant, manager, and educator in all phases of
medical coding, billing, compliance, and reimbursement. He is a published, nationally recognized expert
on emergency department revenue cycle and coding
issues. He can be reached at straffcon@aol.com and
www.StraffordConsulting.com.
48 AAPC Coding Edge
Take Steps to Track Your ED Leveling
Based on an analysis conducted by Strafford
Consulting, many EDs fall close to national
E/M leveling averages. But, in over 200 EDs,
codes 99281 and 99282 represent the majority of services for sicker and older Medicare
patients. Conversely, there are close to 100
EDs with 99284 levels well below national
averages. If your ED is falling well below or
above national averages, Strafford Consulting
recommends:
• Thoroughly reviewing your leveling tool
and procedures. Are all elements that can
be counted toward levels included in the
tool? Are services given proper weight
toward determining ED Levels?
• Using available research tools from American College of Emergency Physicians
(ACEP) to various point systems. Identify
the tool that works best for your ED.
• Auditing a significant sample of your ED
charts.
 Review documentation and levels
that were coded.
 Analyze data to determine
whether the issue is chart documentation, your leveling tool, or
coder error.
• Determining if personnel doing leveling
are best suited for the job.
• Educating your staff on audit findings.
• Scheduling reviews at least twice a year.
• Seeking advice from an outside consultant, when in doubt.
feature
Acquire Coding Instructor Skills
that Motivate Students
By Geanetta Johnson Agbona, CPC
A
s I sit and observe my students intently
reading their evaluation and management
(E/M) packages, a smile comes across my
face. I can see them processing the information:
Some stretch their eyes, others rub their hands
against their foreheads while breathing deeply,
some guide their eyes by putting a pen, pencil, or
finger under each word, and still others highlight
in multiple colors. I grade each package carefully
and feel a sense of pride when I discover each student has learned the material. After the test when
the students are leaving, some tell me, “Thanks
Mrs. G.—I got it! I am so glad that I passed my
test. I will see you tomorrow.”
Why are students motivated to return? A student’s
desire to learn is a powerful motivator—but to
keep students involved teachers should master
three skills: audience contact, the use of illustrations, and enthusiasm.
Eyes communicate feelings and thoughts. A
droopy eye communicates fatigue, while stretched
eyes could communicate anger, surprise, or even
fear. When addressing students, face them and
pause before you speak. This will encourage your
students to focus their attention on you. Look at
every student in your classroom. Do not stare at
each student and force them to feel uncomfortable. Address a student via eye contact, and then
move on to another.
Take a tip from the book “Benefit from the Theocratic Ministry School,” which advises, “When
you throw a ball to someone, you look to see if
it is caught. Each thought in your lecture is a
separate throw to the student. A catch may be
indicated by their response, a nod, a smile, an
attentive look. If you maintain good visual contact, this can help you to make sure that your
ideas are being caught.”
Notes can prevent a teacher from having good
audience contact. Use an outline, instead of reading directly from notes. Glance at the outline
instead of stopping to read a document verbatim.
This requires thorough preparation.
One of the best ways to teach is by using illustrations, including examples, comparisons, and
dramatizations. You can use words such as “like”
or “as” when giving an illustration. Similes and
metaphors provide excellent illustrations.
How would you teach your students the importance of coding correctly and avoiding fraud?
You could be dramatic and wear black and
white stripes with your ankles and hands bound
together using a set of chains. For the less adventurous, you could tell a story about a practice
that committed fraud and the consequences the
practice faced. In the case of the latter, verify the
information.
Whatever form of illustration you decide to use,
be sure it is understood by your audience and
your idea is “caught” and not offensive. This is
very easy to do if you are enthusiastic about your
material.
Hone in on
three teaching
techniques
that speak
volumes to
students.
PROFESSIONAL
Make Audience Contact
Use Illustrations
Be Enthusiastic
Even if you make eye contact and use illustrations, students won’t learn if their teacher sounds
depressed, unhappy, and bored.
If you are excited, your students will be excited.
Always think about why your students need the
material. Prepare the material in a way that it is
exciting to present. Learn to read with feeling.
Put life into your material. Sound as if you are
convinced about what you teach. Do not SHOUT
EVERY WORD, but spread excitement throughout the classroom. Enthusiasm is contagious.
Teaching is an art. If you have been entrusted
with the responsibility to mentor or guide someone, you can be effective. Audience contact makes
it personal, illustrations make students understand, and enthusiasm motivates them to keep
learning. Cultivating these skills will have your
students saying, “I’ll see you tomorrow!”
Geanetta Johnson Agbona, CPC, is a medical
billing and coding instructor at Southeastern
Institute, Charlotte, NC. She was recognized
as “Instructor of Distinction” in 2010. She
co-owns CGS Billing Service with her spouse,
Charles Agbona. She can be contacted at
geanettajohnson@hotmail.com
www.aapc.com
January 2011
49
minute with a member
Kristy Johnston, CPC
Biller for Advanced Medical Consulting and Billing, Southwick, Mass.
and are planning to take our next exams
together. Without my mother, I wouldn’t
be a coder and where I am today. We code
together as a team.
We use our coding knowledge to educate
our doctors on proper billing and documentation. We take great pride in ensuring our billing methods reflect proper
coding. I know not to just add a modifier
or change a code. I take the time to request
notes, and then educate the doctor if there
is anything wrong. I would rather have my
doctors prepared because, in today’s world
of insurance audits, no one is safe.
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, etc.
Kristy: I am a coder because of my mother,
Patti Wood, CPC. She owns a small medical billing company that provides services
for a variety of providers. Through the
years, I have helped my mom when I could
and four years ago, after the birth of my
first daughter, I finally joined her company
full time. I was intrigued by all the diagnostic and CPT® codes. The more accounts I
worked with, the more diagnostic and CPT®
codes I was exposed to on a regular basis.
My mother has been an AAPC member for
many years. She told me about the Certified Professional Coding (CPC®) exam
and how she always wanted to take it. I
asked her to take it with me, and after a
lot of convincing, she agreed. Since then,
our journey these past two years has been
amazing. To begin with, we attended a
coding boot camp. For three full days we
ate, breathed, and slept coding. We were
together and loved every minute of it. After
completing the course, we studied every
weekend and tested each other during
lunch. Finally, we both sat for the exam
and passed in June 2009.
Mom and I often discuss hot topics, new
codes, ICD-10, and other health care
issues. We push and inspire each other
50 AAPC Coding Edge
CE: What is your involvement level with
your local AAPC chapter?
Kristy: Mom and I attend local chapter
meetings together and we recently attended
the AAPC Regional Conference in Springfield, Mass. I try to attend local chapter
meetings regularly; however, for a mother
of two young children who works full
time, that can sometimes be a challenge. I
enjoy attending meetings when I can, and I
look forward to volunteering for an officer
position in the future.
CE: What AAPC benefits do you like the
most?
Kristy: I utilize the AAPC webinars often.
I really enjoy them. I usually take information from them to incorporate into everyday
billing and coding practices. I find AAPC’s
website informative, specifically the ICD-10
section. I enjoy the AAPC e-mails on
ICD-10 and the new one on billing.
CE: What has been your biggest
challenge as a coder?
Kristy: Confidence! Even though I have
learned so much about coding, I still
sometimes lack the self-confidence in
determining a code. I am studying for
the Certified Evaluation and Management Coder (CEMC™) credential. My
goal is to properly determine the level
of service based on the documentation
provided. Fortunately, I can turn to my
mom for a second opinion. I also am
challenged by anatomy and physiology.
Sometimes I am overwhelmed by the big
words I can’t even pronounce.
CE: How are you preparing for ICD-10?
Kristy: Mom and I read articles and attend
webinars or local meetings about ICD-10
whenever possible. We plan to take the
ICD-10 proficiency test as soon as it is
available. I took a general poll of our doctors and asked them about ICD-10. Almost
all of our doctors replied, “You’re my billing service. It is going to affect you (the
biller) more than me (the doctor)”. Huh?!
So, our office is gearing up for ICD-10 to
make sure all our practices have an implementation plan started by the beginning of
next year. It seriously could impact productivity and claims payments if our providers
aren’t ready, so I feel obligated to make
sure they are.
CE: If you could have any other job,
what would it be?
Kristy: That is difficult. I have done many
jobs before settling on this career and I
really enjoy being a biller and coder. The
physician’s job is to provide the patient
with quality care and services. Mine is to
make sure they are getting paid correctly
for their services. Honestly, I’d like to be a
consultant for providers. In a dream world,
perhaps I’d be a nurse or doctor..
CE: How do you spend your spare time?
Tell us about your hobbies, family, etc.
Kristy: Most of my time is spent with my
supportive husband, Christopher, and my
two beautiful and active daughters, Ezri,
4, and Rylee, 1. I hope someday one of
my daughters pursues a coding career and
we have the same opportunity to work
together as my mom and I do.
I also am an educational consultant with
Discovery Toys, where I do home shows and
sell children’s toys, books, and games.
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