Bone-up on Anatomy for Arthroscopy Procedures

Transcription

September 2010
Bone-up on Anatomy for
Arthroscopy Procedures
Denis Rodriguez, CPC, CIRCC, CCS, CASCC,
and Lisa Weston, CPC-H, CASCC, LHRM
Plus: ZPICs • Radiology • 2011 ICD-9-CM • Claim Scrubbers • Ob/Gyn • Meaningful Use
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Conference will provide a wide range of educational topics and a balanced program
CEUs
of new information and coding fundamentals. With more than 25 educational
sessions, attendees will take away an increased understanding of what it takes to
avoid the pitfalls of lost revenue.
TOPICS INCLUDE:
•
•
2011 ICD-9-CM Updates
Fraud and Abuse
•
Neurovascular Interventional
Coding
•
An Overview of RACs
•
Understanding ERISA
•
Effectively Communicate with
Payers
HITECH Act - HIPAA on Steroids
•
•
•
ICD-10-CM
Neurological Procedures
Auditing E/M Services
•
REGISTER TODAY!
•
•
Effective Collection Methods
Inpatient and Observation Hospital
Services: Physician Coding Rules
•
•
Coding for pulmonary and allergy
offices
Coding the Anesthesia Record
REGISTER AT WWW.AAPC.COM/SPRINGFIELD OR COMPLETE THE ATTACHED FORM
AAPC (www.aapc.com) is the nation’s largest medical coding training and certification association for medical
coders with over 96,000 members. AAPC provides credentials to medical coders in physician offices, outpatient
facilities and payer environments which represent the gold standard certifications for medical coding.
Membership | Training | Certification | Employment | Continuing Education
www.aapc.com/springfield
contents
22
34
36
[contents]
September 2010
In Every Issue
7 Letter from Member Leadership
8 Coding News
11 Letters to the Editor
13Letter from the President and CEO
26
Features
14 Seven Tips for Diagnostic Radiology Coding Success
Terry Leone, CPC, CPC-P, CPC-I, CIRCC, and G.J. Verhovshek, MA, CPC
18 ICD-9-CM for 2011 Aimed at Diagnostic Specificity
G.J. Verhovshek, MA, CPC
22 Wisely Choose Between Modifier 25 and Modifier 57
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC
Education
Online Test Yourself – Earn 1 CEU
go to www.aapc.com/resources/
publications/coding-edge/archive.aspx
10Test Your Specialty Expertise with
Code-A-Round
Michelle A. Dick
482010 G2KYLC
Freda Brinson, CPC, CPC-H, CEMC
26 Arthroscopic Gems: Hints for Accurate Coding
Denis Rodriguez, CPC, CCS, CIRCC, CASCC
32 Evaluate and Manage Medicare Teaching Physician Rules
Jenny Berkshire, CPC, CEMC, CGIC
34 Maximize Coding for Minimally Invasive Ob/Gyn Surgeries
Kerin Draak, MS, RN, WHNP-BC, CPC, CEMC, COBGC
People
38 Newly Credentialed Members
50 Minute With a Member
36 Claim Scrubbers Are Not Infallible
Dorothy Steed, CPC-H, CHCC, CPC-I, CPUM, CPUR, CPHM, CCS-P, CEMC, CFPC,
ACS-OP, RCC, RMC, PCS, FCS, CPAR, CPMA
Coming Up
42 Get the Most Out of EHR Meaningful Use
Salary Survey
Renée Dustman
44 ZPICs: Medicare Audits Expands
By Anna M. Grizzle, Esq., and Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC
On the Cover: Denis Rodriguez, CPC, CCS, CIRCC, CASCC, and Lisa Weston, CPC-H, CASCC,
LHRM, of The Coding Network, LLC bone-up on the importance of joint anatomy when coding
arthroscopic procedures at Pro Sports and Pro Spine, Vero Beach, Fla. Cover photo by Jon Pine
(772-778-5250).
EHR Final Rules
Transforaminal Injections
Procrastination
5010
www.aapc.com
September 2010
3
Serving 97,000 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.
September 2010
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. 17, 21
www.amabookstore.com
Vice President, Post Certification Education
David Maxwell, MBA
david.maxwell@aapc.com
American Society of Health
Informatics Managers . ....................... p. 6
http://ashim.org
Director of Editorial Development
John Verhovshek, MA, CPC
g.john.verhovshek@aapc.com
Directors, Member Services
The Coding Institute
CodingCert.com ............................ p. 9
www.CodingCert.com
Coding Conferences LLC
www.CodingConferences.com
CodingWebU . ...................................... p. 51
www.CodingWebU.com
Contexo Media .................................... p. 49
www.contexomedia.com
HeathcareBusinessOffice LLC ............ p. 28
www.healthcareBusinessOffice.com
Ingenix . ............................................... p. 5
www.shopingenix.com
Inhealthcare, LLC ............................... p. 47
www.supercoder.com
Medicare Learning Network® (MLN)...... p. 29
Official CMS Information for Medicare Fee-For-Service Providers
www.cms.gov/MLNGenInfo
NAMAS/DoctorsManagement ............ p. 52
www.drsmgmt.com
Navicure .............................................. p. 12
www.navicure.com
PMIC ................................................... p. 30
http://PmicOnline.com
Brad Ericson, MPC, CPC, COSC
brad.ericson@aapc.com
Danielle Montgomery
danielle.montgomery@aapc.com
Senior Editors
Michelle A. Dick, BS
michelle.dick@aapc.com
Renee Dustman, BS
renee.dustman@aapc.com
Production Artist
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 2009
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 21 Number 09
September 1, 2010
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
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61
letter from member leadership
Members:
The Backbone of AAPC
With more than 97,000 members, AAPC
membership has risen dramatically to
become the nation’s largest medical coding
training and certification organization. Our
membership consists of coders, billers, physicians, auditors, business owners, lawyers,
consultants, students, etc. We are a diverse
group at different stages in our careers.
We are a melting pot of individuals with a
common goal for coding excellence, which
creates a strong, credible presence in the
health care community.
Knowledge Gives Us Credibility
AAPC members are dedicated to providing
the highest standard of professional coding
and billing services to employers, clients,
and patients. In turn, physicians and their
staff see AAPC credentialed members as
exemplary employees.
Our certified members are the experts on
compliant coding, proper physician documentation, ICD-10-CM, EHRs, PQRI,
billing, auditing, etc., and we are gaining a
stronger foothold in our industry through
that knowledge. Physicians and other medical professionals look to us for guidance
because AAPC prepares us and provides
important current coding information to
membership. That readily available education is ours to share with others in the
industry.
If you’d like to see an example of how news
sources in the health care industry see us as
credible experts, go to http://news.aapc.com/
index.php/category/aapc-in-the-news/.
Members Bolsters Coding
Confidence
As members, we value each other’s expertise.
We form relationships through networking, teaching, and mentoring. Our members
and AAPC staff are the resources that are
tapped into to boost coding know-how and
confidence.
Sometimes student members feel overwhelmed by curriculum or are anxious
about finding their first coding job. Experienced members, chapter officers, and other
students help ease these worries because
they have been through it. Their guidance
prevents new members from getting lost in
the coding shuffle and feeling discouraged.
I encourage you to explore the huge resource
that AAPC membership offers by building relationships with other members. The
education and networking opportunities
are limitless if you see the worth of our
membership. The best way to realize this
is by attending chapter meetings, posting
questions on our forums, attending coding
conferences, and looking for ways to learn
and share your knowledge with the coding
community. Put yourself out there.
When we realize our membership’s worth as
a growing presence in the health care industry, we become its leaders.
Sincerely,
Terrance C. Leone,
CPC, CPC-P, CPC-I, CIRCC
President, National Advisory Board
www.aapc.com
September 2010
7
coding news
coding news
through Dec. 31, 2009 received after Dec.
31, 2010 will be past the timely filing
deadline and denied; and
Claims with service dates Jan. 1, 2010 and
later received more than one calendar year
beyond the service date will be past the
timely filing deadline and denied.
Key points of timely filing in CR 7080 are:
New Instruction
on Timely Claims Filing
The Centers for Medicare & Medicaid Services
(CMS) established basic standards for timely
filing as a result of Section 6404 of the Patient
Protection and Affordable Care Act of 2010
(ACA). These standards state claims with service dates on or after Jan. 1, 2010 received later
than one calendar year beyond the service date
will be denied by Medicare.
Change Request (CR) 7080 expands the
Medicare reimbursement instructions outlined in CR 6960, which specifies the basic
timely filing standards established for feefor-service (FFS) reimbursement. CR 6960
established that:
Claims with service dates prior to Oct. 1,
2009 are subject to pre-ACA timely filing
rules and associated edits;
Claims with service dates Oct. 1, 2009
8
AAPC Coding Edge
For institutional claims including span service
dates (i.e., a “From” and “Through” date
span on the claim), the “Through” date on
the claim will determine the service date
for claims filing timeliness.
For professional claims (CMS-1500 Form and
837P) submitted by physicians and other
suppliers including span service dates, the
line item “From” date is used to determine
the service date and filing timeliness. (This
includes supplies and rental items). Physicians and other suppliers billing span date
claims cannot exceed one month.
Warning: If a line item “From” date is
not timely, but the “To” date is, Medicare
contractors will split the line item and deny
untimely services as not timely filed.
As an example, you should fill out claims
with a Feb. 29 service date by Feb. 28
of the following year to be considered as
timely filed. If the service date is Feb.
29 of any year and is received on or after
March 1 of the following year, the claim
will not meet the timely filing requirement
and will be denied.
Make billing staff aware of these changes.
You can find CR 7080 at www.cms.gov/
Transmittals/downloads/R734OTN.pdf on
the CMS website.
New Rules for HHAs Providing
DME in Competitive Bidding Areas
If you are home health agency (HHA)
submitting claims to regional home health
intermediaries (RHHIs) for providing
durable medical equipment (DME)
to Medicare beneficiaries residing in
competitive bidding areas, CR 7014’s
(www.cms.gov/Transmittals/downloads/
R741OTN.pdf) information is for you.
Effective Jan. 1, 2011, edits will be in place
for HHAs who bill competitively bid DME
items in competitive bidding areas to pre-
vent the inappropriate payment of DME
items to HHAs. In a competitive bidding
area, a supplier must be awarded a contract
by Medicare to bill Medicare for competitively bid DME.
Here’s what you need to know:
Medicare contractors will return HHA
claims (types of bill 32x, 33x, and 34x) containing HCPCS Level II codes identified as
being for items or services subject to competitive bidding in a competitive bidding area.
For HHAs to bill competitively bid items they
must also be a contract supplier under Medicare’s DME competitive bidding program.
All suppliers of competitively bid DME
must bill the DME Medicare administrative contractors (MACs) for these items and
can no longer bill for competitive bid items
to Medicare contractors processing HHA
claims. HHA claims will be returned to
the provider (to remove the affected DME
line items) when submitted for HCPCS
Level II codes subject to a competitive bidding program.
Look for applicable HCPCS Level II codes
and ZIP codes for competitive bidding areas
on the “Supplier” page of the Competitive
Bid Implementation Contractor (CBIC)
website at www.dmecompetitivebid.com/
Palmetto/Cbic.nsf/DocsCat/Home.
DME claims furnished by HHAs not subject to competitive bidding may be submitted to appropriate HHA claims processing
contractors.
CMS Defines Ambulance Services
CMS issued CR 7058 which affects ambulance suppliers submitting claims to Medicare contractors for ambulance services
provided to Medicare patients. CR 7058
updates the Medicare Benefit Policy Manual
(chapter 10, section 30.1.1) by providing examples for application of Basic Life
Support (BLS)–Emergency, Advanced
Life Support Level 1 (ALS1), and Emergency and Advanced Life Support Level 2
(ALS2) information. Although there is no
new policy, CR 7058 updates the relevant
manual section to reflect current policy. The
updated manual section is attached to CR
7058 (www.cms.gov/transmittals/downloads/
R130BP.pdf).
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added edge
-A-Rou
7 6 54
8
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Experience real coding
simulation to go beyond learning
for continuing education units.
e
od
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Test Your Specialty
Expertise with
3
9 2
1
By Michelle A. Dick
C
ode-A-Round is an online coding simulation that
mimics the real world. The program was designed
and developed by in-house AAPC staff to bring low cost,
specialty-specific coding education to your computer.
AAPC’s Director of Education Raemarie Jimenez,
CPC, CPMA, CPC-I, CANPC, CRHC, said CodeA-Round is “extremely beneficial to members who hold
a specialty credential and need specialty CEUs and it is
beneficial to coders wanting more practice in a particular
specialty.”
Here’s how it works: You view actual, redacted patient
notes onscreen and code them, inputting correct ICD9-CM, CPT®, and HCPCS Level II codes for that note.
The answers are not multiple choice unlike most online
practice tests – and you can’t guess from multiple choice
answers. The correct codes must be typed in. Incorrect
answers are flagged for re-coding, but the answers and
rationales for those are not given. This most closely simulates the on-the-job environment.
Send in Your Reports
AAPC’s Vice President of Product Management David
Maxwell said that Code-A-Round is unique because the
program only operates through the willing participation
of AAPC members. Members contribute operative notes,
allowing AAPC to create the program. The good news
is: “When we send out a call for notes, our members are
eager to respond,” Maxwell said. “It’s a way for our members to ‘give back’ and to help each other grow and learn
in the profession.”
AAPC uses the submitted notes to help specialty credential holders obtain their required continuing education
units (CEUs) and to help students learn as part of their
classroom instruction.
Get Specialty Coding Experience
Code-A-Round provides a great specialty-specific edu10 AAPC Coding Edge
cational opportunity. Because Code-A-Round requires
you to answer all codes correctly before completing the
round, you have the opportunity to “learn by doing”
while working through the notes. Maxwell said, “We
receive calls at the national office from our members who
are stumped by a certain aspect of a note.” He continued, “After providing some hints to help them complete
the note, the comment we hear most often is ‘I’ve been
coding for 10 years and I can’t believe I missed that!’
This lets us know that Code-A-Round stretches both
experienced and beginner coders’ knowledge.”
For coders who don’t have specialty experience, Jimenez
said that Code-A-Round provides “the ability to practice
coding for a specialty that interests them that they may
not have experience in.”
Earn Specialty and Core CEUs
Each Code-A-Round contains five patient notes and is
approved for one AAPC CEU. Code-A-Round provides
members with the opportunity to earn CEUs in two ways:
1. By submitting five redacted op notes to AAPC,
members can receive one free round of Code-A-Round
(Submit notes to Kris Taylor, kris.taylor@aapc.
com). After the member codes the notes and finishes
the round, he or she is credited with one CEU.
2. Members can purchase Code-A-Round rounds
online. When the notes are coded, they receive one
CEU. Although Code-A-Round was conceived primarily for specialty credential holders, it also satisfies CEU requirements for the Certified Professional
Coder (CPC®), Certified Professional Coder-Hospital
(CPC-H®), and Certified Professional Coder-Payer
(CPC-P®) credentials.
Each five-note round is $9.95 and takes approximately
one hour to complete.
letters to the editor
Letters to the Editor
Add-on Codes Don’t Require Modifier 51
“We receive calls at the national
office from our members who are
stumped by a certain aspect of a
note … This lets us know that CodeA-Round stretches both experienced
and beginner coders’ knowledge.”
Code-A-Round for More than CEUs
The Code-A-Round concept goes beyond earning CEUs.
It is used also as an education tool for PMCC instructors
to teach students how to code. Maxwell said, “Students
receive homework assignments in Code-A-Round and
code the notes to complete the assignment. The instructor can then review the answers to see which students
need help in learning coding concepts.”
“We will soon be launching a new hiring exam using
the submitted notes that will help hiring managers in
the decision-making process by placing applicants in a
real-world coding simulation,” Maxwell said. The objective is to “help hiring managers better evaluate potential
candidates and we are certain our AAPC credentialed
members will stand out from the crowd.”
For more information, visit AAPC’s website at www.aapc.
com/medical-coding-education/code-a-round.aspx.
Disclaimer: Code-A-Round notes and answers are intended
for educational purposes only, not as a reference standard for
coding. Each note has been coded twice by independent certified
coders and then quality checked for accuracy by a senior coder.
However, due to the nature of the coding process, answers should
not be considered definitive.
[
]
Michelle A. Dick is senior editor at AAPC.
I have a question about the article “Expose the Layers of
Abdominal Wall Reconstruction,” by John Bishop (July 2010
Coding Edge, pages 44-46). The table on page 46 depicts 14302
with modifier 51. Isn’t 14302 an add-on code exempt from
modifier 51?
Jeannie FG
You’re absolutely correct. All add-on codes, including 14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq
cm, or part thereof (List separately in addition to code for primary procedure), are exempt from the multiple procedure concept, according
to CPT® instructions. As such, you never would append modifier
51 Multiple procedures to a designated add-on code.
Other important points to remember about add-on codes
include:
They are denoted in CPT® with a “+” to the left of the code.
The CPT® code descriptor will include some variation of
the phrase, “list separately in addition to code for primary
procedure.”
Always use them with a “primary” procedure (parent) code.
Never list an add-on code as a primary procedure.
Payment for these services should not be lowered as a
multiple-surgery reduction.
A complete list of add-on codes may be found in CPT®
Appendix D, “Summary of CPT® Add-on Codes.”
Take Out the Mandibular in RME
“Sleep Apnea: The Not So Silent Bed Partner,” page 27, in the
August issue, should read “A subsequent sleep medicine consultation, sleep studies (if indicated), and appropriate treatment
(e.g., surgery, rapid maxillary expansion (RME), nasal continuous positive airway pressure (nCPAP), maxillomandibular
advancement (MMA), etc.), can help restore sleep, correct deficient growth patterns, eradicate bed wetting, eliminate reflux,
and improve school performance.” “Rapid maxillary, mandibular
expansion (RME)” was printed in error.
Please send your letters to the editor to:
letterstotheeditor@aapc.com.
www.aapc.com
September 2010
11
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letter from the president and CEO
When Compliance
Is No Longer an Option
Voluntary compliance programs are ending.
With the passage of the Patient Protection
and Affordable Care Act of 2010, amended
by the Health Care and Education Reconciliation Act of 2010 (Health Care Act),
Congress mandates compliance for providers
and suppliers, which includes physician services. According to this new law, providers
and suppliers must adopt a compliance program as a condition of Medicare enrollment.
Although regulations for the new mandatory compliance are not issued yet, I encourage every health care organization to ensure
a compliance plan is in place or in progress.
Your providers must be more diligent in the
compliance program effort. Failing to implement a compliance program will promote
further regulatory scrutiny in the health
care industry.
For the past several years, the U.S. Department of Health and Human Services (HHS)
and the Office of Inspector General (OIG)
have strongly encouraged but have not mandated compliance programs―even though
the OIG has provided guidance for many
entities including physician practices. The
OIG has settled thousands of cases involving
alleged fraud, abuse, and civil allegations in
the form of Corporate Integrity Agreements
(CIAs) and other similar settlements mandating compliance for those fined and penalized. Undoubtedly, HHS will consider these
elements when determining what compliance elements will be mandated. The Health
Care Act’s compliance programs are divided
into two categories: 1.) nursing facilities and
2.) other providers and suppliers.
When Will It Happen?
By Dec. 31, 2011 the secretary of HHS
will implement a quality assessment and
performance improvement program (QAPI)
for nursing facilities addressing best practices. By March 23, 2012 the secretary of
HHS working with the OIG will create
regulations for nursing facility compliance
that will vary depending on the size of the
organization and the facilities they own.
All skilled nursing facilities (SNFs) must
be in compliance by this date. There is not
a set date for compliance for physicians and
other suppliers; however, the law does state
“as a condition of enrollment” a compliance
program must be established with certain
core elements which will be established by
HHS and OIG. The requirements have not
been defined yet. Congress also has extended
the requirement for mandatory compliance
in the Medicaid program. Each state must
require providers and suppliers under a state
Medicaid plan to establish a compliance
program.
What Does This Mean for You and
Your Organization?
If you have a compliance program in place
now, review the plan, update it, and ensure
it is followed. If your organization or practice does not have a compliance program in
place, consider adopting one now.
What Are AAPC’s Plans
for Compliance?
Compliance is on the forefront of AAPC’s
radar in 2010 and beyond. In 2011, we plan
to add a compliance certification to our credentials and expand on existing credentials.
We want to make sure health care professionals, including auditors, coders, compliance officers, physicians, etc. are kept up to
date on the knowledge necessary to maintain compliance.
What Can You Do Now?
Proactively undertake compliant activities
by at least beginning to audit and monitor
for coding compliance. Review physician
documentation relative to coding, which
ultimately improves documentation. Review
and stay on top of Medicare national and
local coverage determinations (NCDs and
LCDs) as well as Medicaid policies. Carefully monitor coding and billing to ensure
services rendered are reported correctly.
Sincerely,
Deborah Grider,
CPC, CPC-H, CPC-I, CPC-P, CPMA,
CEMC, COBGC, CPCD, CCS-P
AAPC President and CEO
www.aapc.com
September 2010
13
1234
EXPERT
feature
5
6
7
Seven Tips for
Diagnostic Radiology
Coding Success
Follow AMA, CMS, ACR,
individual payer rules,
and these helpful tips
for surefire billing.
By Terry Leone,
CPC, CPC-P, CPC-I, CIRCC,
and G. J. Verhovshek, MA, CPC
D
iagnostic radiology encompasses a variety of services,
including diagnostic radiology (plain film), diagnostic
ultrasound, computed tomography (CT), magnetic resonance
imaging (MRI), diagnostic nuclear medicine, positron emission
tomography (PET), and mammography. The following seven
tips pertain to diagnostic radiology coding guidance as per
American Medical Association (AMA), Centers for Medicare
& Medicaid Services (CMS), and American College of Radiology (ACR) instructions, and are intended to help coders submit
accurate claims during a time when imaging services are being
avidly scrutinized by public and private payers. Remember that
individual payer rules take priority when billing that payer. Ask
for payer requirements in writing, and be sure that billing and
coding staff have access to, and are familiar with, all payer rules.
14 AAPC Coding Edge
feature
Tip 1: Be Sure Reports Meet Minimum
Requirements
To meet ACR guidelines, all dictated radiology reports must
contain:
ll Heading (study name)
ll Number of views or sequences (name of views – what
was done)
ll Clinical indication (reason for exam)
ll Body of report (findings)
ll Impression or conclusion (synopsis of findings)
ll Physician signature
ll Diagnostic studies (plain films)
Tip 2: Separate Professional
and Technical Components
Most radiology procedures include both a technical component
and a professional component. As a basic requirement of radiology coding, the coder must know whether to report a technical,
professional, or “global” service.
The technical component (TC) of a service includes the provision
of all equipment, supplies, personnel, and costs related to the
performance of the exam. To report only the technical portion of
a service, append modifier TC Technical component.
There is one important exception to this rule. For services performed in a hospital, it is assumed the hospital is billing for the
technical component of each study so hospitals are exempt from
reporting modifier TC.
The professional component of a service includes the physician work in providing a dictated report or dictated report and
supervision. To report only the physician work portion of a service, append modifier 26 Professional component. When applied,
modifier 26 should be placed in the first designated modifier
field because it affects how the claim will be paid.
A global service occurs when the physician both bears the
expense of equipment, supplies, etc., and provides supervision
and/or prepares the report. Global services generally take place
in an office setting, where the physician group owns the equipment and provides the dictated reports. When reporting global
services, modifiers TC and 26 are not required.
For example, if the radiologist reads a two-view chest X-ray in
the hospital, you would report 71020 Radiologic examination,
chest, 2 views, frontal and lateral with modifier 26. If the radiologist supplies, in his own office, the equipment on which the
X-ray is performed, report 71020 without modifiers.
If your department or office has a list of
“standard views,” or the number of views
to be imaged on a patient, you cannot use
it for coding purposes. The medical report
must state the number of views.
Tip 3: Report Only the
Number of Views Documented
The number of views claimed must meet the basic requirements of the CPT® code reported. If your department or office
has a list of “standard views,” or the number of views to be
imaged on a patient, you cannot use it for coding purposes.
The medical report must state the number of views. It is the
coder’s responsibility to count the number of views and select
the correct corresponding CPT® code.
For example, a knee exam may be reported using one of four
CPT® codes. To report 73564 Radiologic examination, knee; 4
or more views, documentation has to substantiate four or more
views. If the physician does not state “four views,” but rather
documents “AP, lateral, and both obliques,” that is also acceptable documentation. If, however, the physician uses the phrase
multiple views of the knee, the rules state you must report the
lowest-level corresponding CPT® code for the particular study
(73560 Radiologic examination, knee; 1 or 2 views).
This holds true for referring physician orders, too. If the views
or the number of views are not listed in the order, the radiology
office cannot impose their department standards of, for instance,
four views. Instead, the radiology department or office should
contact the referring physician and ask for a new order indicating the views he would like performed.
Note, however, that some diagnostic studies require specific
view names. For example, if the physician dictates the number
of abdomen views instead of the precise names of the views, you
must report the lowest-level code (74000 Radiologic examination,
abdomen; single anteroposterior view) for that service.
Tip 4: Distinguish Scout View and Contrast Studies
A scout view is a single supine view of the abdomen taken prior
to gastrointestinal (GI) examinations. It may be referred to as a
KUB (Kidney, Ureters, and Bladder). The physician must document that film was taken, and he must dictate any findings
from the film separately.
During a single contrast study, the patient ingests a thin liquid
barium sulfate contrast. A double contrast upper GI study uses
a thicker (heavy density) barium sulfate and effervescent crystals
taken with water. When mixed and swallowed, the patient’s
www.aapc.com
September 2010
15
feature
To discuss this
article or topic,
go to www.aapc.com
stomach fills with air or gas from the crystals. The thicker
barium coats the walls of the stomach so the physician can look
for ulcers, etc.
Note: A cervical (neck) esophagram study is bundled to single
and double upper GI studies; however, if there is documented
medical necessity to warrant a separate exam, the esophagus
study (74210-74230) may be reported with modifier 59 Distinct
procedural service, in addition to the upper GI studies.
When reporting barium enema (colon) study, determine if
the procedure used single or double contrast. Single contrast
study uses a thin mixture of barium sulfate and water instilled
through a tube in the patient’s rectum. When performing a
double contrast barium enema, the colon first is instilled with
heavy density barium and air. During the second contrast, air is
pumped into the colon to coat the walls of the bowel with the
barium. Whether a preliminary abdomen KUB is performed
does not change the code set.
Bonus Modifier Tip: Numerous GI study
code descriptors (e.g., 74328, 74329, and 74330) specify “supervision and interpretation.” These studies may be performed by
a physician and interpreted by a (different) radiologist, both of
which may bill the service by appending modifier 52 Reduced
services to the appropriate CPT® code. The modifier tells the
payer that neither billing physician solely performed/interpreted the entire study.
Tip 5: “Complete Exam”
Documentation Must Be Complete
All diagnostic ultrasound examinations require permanent
image documentation. Abdomen and retroperitoneal studies
have additional, strict documentation requirements to code for a
complete exam.
A complete abdomen study (76700 Ultrasound, abdominal, real
time with image documentation; complete) requires documentation
of the liver, gall bladder, common bile ducts, pancreas, spleen,
kidneys, and the upper abdominal aorta and inferior vena cava.
16 AAPC Coding Edge
If any one of the required anatomy is not documented, the
study must be down-coded to a limited exam (76705 Ultrasound,
abdominal, real time with image documentation; limited (eg, single
organ, quadrant, follow-up)).
A complete retroperitoneum study (76770 Ultrasound, retroperitoneal (eg., renal, aorta, nodes), real time with image documentation; complete) consists of documentation of the kidneys, abdominal aorta,
and common iliac artery origins. Alternatively, imaging of the
kidneys and urinary bladder also constitute a complete retroperitoneal study when the clinical indication for the exam consists of
urinary pathology.
Tip 6: Oral/Rectal Administration
Doesn’t Count as Contrast
Whether intravenous contrast was injected determines
coding for CT and MRI. Only intravenous administration of
contrast changes the code sets. Oral and/or rectal contrast is
not billable as a “with contrast” study. To report contrast, the
technique section of the dictated report must state, “with IV or
intravenous contrast.”
Tip 7: Don’t Forget Supplies
Diagnostic nuclear medicine studies and PET do not include
radiopharmaceuticals. Hospitals and privately-owned nuclear
medicine and PET departments/offices should report the
radiopharmaceutical kit separately utilizing the correct supply
code(s).
Terry Leone, CPC, CPC-P, CPC-I, CIRCC, is president of AAPC’s National
Advisory Board (NAB) and is a specialist in radiology coding, interventional
coding and consulting. His career spans over 30 years with experience in
various aspects of management, billing, and coding. Since 1996, Terry has
been the principal owner and president of Catamount Associates, LLC—a
physician billing company. He is the founder and past president of the
Western New York Chapter at Buffalo. He is a certified instructor at Bryant
& Stratton College, Rochester, N.Y. teaching Professional Medical Coding
Curriculum (PMCC).
G. John Verhovshek, MA, CPC, is director of editorial
development/managing editor at AAPC.
Radiology Coders:
There is a simple solution
to ensuring coding accuracy
The Clinical Examples in Radiology newsletter
is the easiest way to improve claims reporting
and reimbursement accuracy when it comes to
radiology coding. Published by the American
Medical Association and the American College
of Radiology, this newsletter was developed
to help coding professionals understand the
practical application of CPT® codes with regard
to radiology coding.
Each issue of this quarterly, 12-page newsletter
provides you with:
• Clinical Examples: Several carefully
selected procedure reports dissected and
annotated by nationally-recognized experts
in radiology coding
• Documentation Challenge: A real-life
radiology operative report, along with
insightful and detailed commentary, will
help you tackle difficult cases and provide
concrete suggestions to improve procedure
reporting and coding
• Radiology Coding Q&A: Answers to radiology coding questions
submitted by newsletter subscribers
• Self Quiz: Test your knowledge with each issue’s radiology
test case and compare your answer to the correct answer and
explanation provided
• Earn CEU credits toward AAPC, AHIMA and RCC with online,
interactive tests
Subscribers also receive two special report bulletins a year that cover
ongoing code changes, brief clarifications of existing CPT codes,
“hot” coding topics in radiology, and more.
Subscribe today!
Visit www.ama-assn.org/go/radiology-coding
to learn more.
hot topic
ICD-9-CM for 2011
Aimed at Diagnostic Specificity
New, expanded, and replaced codes
more precisely capture the diagnosis.
Co m p l
2011teIC
American
2480 Sou Academy of Pro
th 3850
fes
Salt Lak
West, Sui sional Coders
e Cit
800-626-C y, Utah 84120 te B
ODE (26
www.a
apc.com 33), Fax 801-23
6-2258
ISBN 978
Coding
-1-936095-
91-9
By G.J. Verhovshek, MA, CPC
PROFESSIONAL
T
he new year begins early for ICD-9-CM: Code revisions
for 2011 are released and go into effect Oct. 1, 2010.
Changes are relatively few and aim primarily to increase
diagnostic specificity.
For instance, “disorders of iron metabolism” (275.0) are
deleted and replaced by several new codes:
275.01 Hereditary hemochromatosis
275.02Hemochromotosis due to repeated red blood cell
transfusion
275.03 Other hemochromotosis
275.09 Other disorders of iron metabolism
Hemochromatosis is an iron metabolic disorder, which causes
the body to absorb and store too much iron. The excess iron
accumulates in the organs—most significantly the heart and
the liver—and damages them. New fifth-digit classifications
not only identify hemochromatosis specifically (rather than
classifying it generically as a “disorder of iron metabolism”),
but allow for distinction among hereditary hemochromatosis,
hemochromotosis due to repeated red blood cell (RBC) transfusion, or other hemochromotosis (for instance, hemochromatosis resulting from alcoholism).
Additional examples follow the same logic, whereby a fourdigit code is deleted and replaced by two or more, five-digit
codes that provide greater detail.
Secondary thrombocytopenia (287.4) is deleted and replaced by:
287.41 Post-transfusion purpura
287.49 Other secondary thrombocytopenia
Other anomalies of the uterus (752.3) is deleted and replaced by:
752.31 Agenesis of uterus
752.32 Hypoplasia of uterus
752.33 Unicornuate of uterus
752.34 Bicornate uterus
752.35 Septate uterus
18 AAPC Coding Edge
e
D-9-CM
U p d a te
s & Ra
tionale
s
752.36 Arcuate uterus
752.39 Other anomalies of the uterus
Encounter for insertion of intrauterine device (V25.1) is
deleted and replaced by:
V25.11Encounter for insertion of intrauterine
contraceptive device
V25.12Encounter for removal of intrauterine
V25.13Encounter for removal and reinsertion of intrauterine
Note: Previously, the routine checking, removing, and any
subsequent reinserting of an IUD was coded V25.42 Surveillance of intrauterine contraceptive device.
Categories for Body Mass Index (BMI) are refined with
the deletion of “BMI 40 and over, adult” (V85.4), which is
replaced by five new codes:
V85.41 Body Mass Index 40.0-44.9, adult
V85.45 Body Mass Index 70 and over, adult
Blood Incompatibility Categories Expand Significantly
Extensive additions now describe more precisely blood incompatibility reactions.
A hemolytic transfusion reaction (HTR) is a reaction of
increased destruction of red blood cells (RBCs) due to incompatibility between blood donor and recipient. Hemolytic
transfusion reactions can be either acute (an accelerated
destruction of RBCs immediately within 24 hours of a transfusion) or delayed (accelerated destruction of RBCs, usually
between 24 hours and 28 days after a transfusion), and can be
due to either ABO or non-ABO incompatibility.
hot topic
Previously, four-digit codes 999.6 ABO incompatibility reaction and 999.7 Rh incompatibility reaction did not distinguish
between ABO and non-ABO HTRs, and between acute
HTRs and delayed HTRs. These codes are deleted, to be
replaced by:
999.60 ABO incompatibility reaction, unspecified
999.61ABO incompatibility with hemolytic transfusion reaction
not specified as acute or delayed
999.62ABO incompatibility with acute hemolytic transfusion
reaction
999.63ABO incompatibility with delayed hemolytic transfusion
reaction
999.69 Other ABO incompatibility reaction
999.70 Rh incompatibility reaction, unspecified
999.71Rh incompatibility with hemolytic transfusion reaction
not specified as acute or delayed
999.72Rh incompatibility with acute hemolytic transfusion
reaction
999.73Rh incompatibility with delayed hemolytic transfusion
reaction
999.74 Other Rh incompatibility reaction
999.75 Non-ABO incompatibility reaction, unspecified
999.76Non-ABO incompatibility with hemolytic transfusion
reaction not specified as acute or delayed
999.77Non-ABO incompatibility with acute hemolytic transfusion reaction
999.78Non-ABO incompatibility with delayed hemolytic transfusion reaction
999.79 Other non-ABO incompatibility reaction
999.80 Transfusion reaction unspecified
999.83 Hemolytic transfusion reaction, incompatibility unspecified
999.84Acute hemolytic transfusion reaction, incompatibility
unspecified
999.85Delayed hemolytic transfusion reaction, incompatibility
unspecified
Revisions Encourage Better Documentation
Where codes undergo revision for 2011, code descriptors
become more specific, and one or more additional, related
codes are added to increase the diagnostic detail.
As an example, 724.02 is revised to specify Spinal stenosis,
lumbar region, without neurogenic claudication (new text is underlined). Neurogenic claudication describes a syndrome associated with significant lumbar spinal stenosis, which leads to
compression of the lumbar nerves (cauda equina). A new code,
724.03, has been added to report Spinal stenosis, lumbar region,
with neurogenic claudication.
Similarly, V13.69 is revised to describe Personal history of other
(corrected) congenital malformations (new text is underlined).
Due to medical advances, many congenital conditions may
be repaired and leave little or no residual condition. When a
congenital condition is corrected, Coding Guidelines directs, “a
personal history code should be used to identify the history of
the anomaly.” The descriptor revision recognizes and emphasizes this directive.
Whereas V13.69 previously was a catch-all category, however,
ICD-9-CM now includes seven location/system-specific codes
to describe personal history of corrected congenital malformations:
V13.62Personal history of other (corrected) congenital
malformations of genitourinary system
malformations of nervous system
malformations of eye, ear, face, and neck
malformations of heart and circulatory system
malformations of respiratory system
malformations of digestive system
V13.68Personal history of other (corrected) congenital malformations of integument, limbs, and musculoskeletal
system
Report “other” code V13.69 only if a more precise location/
system is unknown or not specified.
All-New Codes
Describe Multiple Gestation, Ectasia, and More
Among the “all new” changes for 2011, the most significant is
the creation of new category V91.
Birth defects and loss of fetuses is closely linked to the
number of placenta and amniotic sacs present during fetal
development (thus, the risk of complications is higher and the
treatment plan may differ depending on these same factors).
Category V91 allows tracking and reporting of the number of
placenta and amniotic sacs for multiple gestation pregnancies:
V91.00Twin gestation, unspecified number of placenta,
unspecified number of amniotic sacs
V91.01Twin gestation, monochorionic/monoamniotic
(one placenta, one amniotic sac)
V91.02Twin gestation, monochorionic/diamniotic
(one placenta, two amniotic sacs)
V91.03Twin gestation, dichorionic/ diamniotic (two placenta,
two amniotic sacs)
V91.09Twin gestation, unable to determine number of placenta
and number of amniotic sacs
V91.10Triplet gestation, unspecified number of placenta and
unspecified number of amniotic sacs
www.aapc.com
September 2010
19
hot topic
Where codes undergo revision for 2011, code
descriptors become more specific, and one or more
additional, related codes are added to increase the
diagnostic detail.
V91.11Triplet gestation, with two or more monochorionic
fetuses
V91.12Triplet gestation, with two or more monoamniotic
fetuses
V91.19Triplet gestation, unable to determine number of
placenta of placenta and amniotic sacs
V91.20Quadruplet gestation, unspecified number of placenta
and unspecified number of amniotic sacs
V91.21Quadruplet gestation, with two or more monochorionic
fetuses
V91.22Quadruplet gestation, with two or more monoamniotic
fetuses
V91.29Quadruplet gestation, unable to determine number of
placenta and number of amniotic sacs
V91.90Other specified multiple gestation, unspecified number
of placenta and unspecified number of amniotic sacs
V91.91Other specified multiple gestation, with two or more
monochorionic fetuses
V91.92Other specified multiple gestation, with two or more
monoamniotic fetuses
V91.99Other specified multiple gestation, unable to determine
number of placenta and number of amniotic sacs
All-new codes also are created to describe ectasia, a weakening
(with some dilation) of the aortic wall:
447.70 Aortic ectasia, unspecified site
447.71 Thoracic aortic ectasia
447.72 Abdominal aortic ectasia
447.73 Thoracoabdominal aortic ectasia
Although distinct from aneurysm, ectasia previously was
reported using 441.9 Aortic aneurysm, unspecified (thereby
explaining why the new codes were necessary).
Other new codes effective on Oct. 1 include:
560.32 Fecal impaction
(Previously reported with 560.39 Other impaction of intestine.)
784.92 Jaw pain
(Previously reported with 526.9 Unspecified disease of the jaws.)
E000.2 Volunteer activity
(Previously reported with E000.8 Other external cause status.)
Military Requests Drive Several Additions
The Department of Defense (DoD) proposed a new code for
history of combat and operational stress reaction (COSR) in
2008. For 2011, an inclusion term for combat and operational
stress reaction is added in category 308 Acute reaction to stress.
20 AAPC Coding Edge
With this change, V11.4 Personal history of combat and operational stress reaction is accommodated. The personal history
code provides the capability of tracking patients who later
have symptoms related to having had COSR.
The DoD also requested new codes for embedded fragment
status. Injuries from explosions often include fragments or
splinters from the explosive device, which become embedded
in the injured person. Sometimes these cannot be removed,
and noting them is important—for instance, because an
embedded magnetic object may contraindicate magnetic resonance imaging (MRI) exam, or because embedded fragment(s)
(such as those composed of lead) pose long-term health risks.
V90.01 Retained depleted uranium fragments
V90.09 Other retained radioactive materials
V90.10 Retained metal fragments, unspecified
V90.11 Retained magnetic metal fragments
V90.12 Retained nonmagnetic metal fragments
V90.2 Retained plastic fragments
V90.31 Retained animal quills or spines
V90.32 Retained tooth
V90.33 Retained wood fragments
V90.39 Other retained organic fragments
V90.81 Retained glass fragments
V90.83 Retained stone or crystalline fragments
V90.89 Other specified retained foreign body
Although this category is useful primarily for the military,
the codes are applicable to any injury resulting in embedded
fragments. The codes do not, however, apply to or overlap
with internal medical devices.
Go to the Source for More Information
The above covers many of the most significant changes to
ICD-9-CM for 2011, but is not an exhaustive listing. The
final addendum providing complete information on changes
to the diagnosis part of ICD-9-CM is posted on Centers for
Disease Control and Prevention’s (CDC’s) webpage at: www.
cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#addenda.
Scroll to the bottom of the page to find the 2010 Addenda,
which are available as downloadable PDF files, in either tabular or index form.
Additional ICD-9-CM changes subsequently released as
addenda or errata will be posted on the AAPC website: www.
aapc.com.
[
G. John Verhovshek, MA, CPC, is director of
editorial development/managing editor at AAPC.
]
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feature
Wisely Choose Between
Modifier 25 and Modifier 57
E/M coding can be difficult enough without
throwing a modifier monkey wrench into the mix.
By Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC
PROFESSIONAL
A
participant in an online coding discussion board to which I
belong recently posted a question regarding the appropriate
use of modifier 25 Significant, separately identifiable evaluation and
management service by the same physician on the same day of the procedure
or other service, versus that of modifier 57 Decision for surgery. After
years of taking part in such forums, attending coding conferences,
and serving as a coding consultant, I’ve heard the same question
dozens of times, and I always respond the same way.
22 AAPC Coding Edge
feature
Accessing the CMS Physician
Fee Schedule Relative Value File
Determine First: Major or Minor Procedure?
Both modifiers 25 and 57 apply to evaluation and management (E/M) service codes only, and both allow the
provider to report an E/M service separately with another
procedure or service. For most payers, the distinction
between the two modifiers depends on the nature of
other, non-E/M service(s) reported.

Modifier 57 applies when an E/M service results in
the initial decision to perform a major procedure,
which usually is defined as a procedure with a
90-day global surgical period.

Modifier 25 applies when the provider performs a
significant, separately identifiable E/M service on the
same date as a minor procedure/service. A minor
procedure/service has a global period of fewer than
90 days (for instance, 10 days or zero days).
The concept of major and minor procedures derives not
from CPT®, but from the Centers for Medicare & Medicaid Services’ (CMS’) Physician Fee Schedule Relative
Value File, which assigns a global period for all CPT®
and HCPCS Level II codes. CPT® (Appendix A – Modifiers) states only that modifier 25 applies when the significant, separately-identifiable E/M service occurs on the
day of a procedure or service; whereas modifier 57 applies
when an E/M service results in the “initial decision to
perform the surgery.” CPT® does not, however, precisely
define “procedure,” “service,” or “surgery,” or assign
global days for any of these categories.
If your payer isn’t Medicare, ask for further guidance.
The major and minor procedure designations apply
definitively only for Medicare and those payers who
follow CMS guidelines expressly. Third-party payers
often follow CMS in this regard, but may designate their
own rules. For example, in defiance of CMS (and CPT®)
instruction, Florida Medicaid does not recognize modifier 57 and instead calls for modifier 25 anytime an E/M
service and another procedure or service are reported
together. The advice I give here assumes a payer follows
CMS guidelines; for other payers, inquire specifically as
to the rules for applying modifiers 25 and 57 and get
those specific payer instructions in writing.
Modifier 57 Parameters
To apply modifier 57, the E/M service must have led to
the decision to perform the major procedure that follows.
For example, if surgery was scheduled June 17 and the
surgeon sees the patient again the day of the surgery,
June 25, do not report a separate E/M with modifier 57
for the encounter on June 25 because the decision for surgery was not made at that visit. Rather, the June 25 visit
is bundled into the surgical package.
The Physician Fee Schedule Relative Value File may be found on the CMS
website: www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4.
Download the most recent (last posted) file.
In the Relative Value File, the global period for each CPT®/HCPCS Level II
code may be found in the column listed “GLOB DAYS.” Only those procedures with a 90-day global period are major procedures. Global periods 0,
10, and XXX, designate minor procedures.
In contrast, if a patient presents with a burst appendix
and the decision for appendectomy is made immediately,
the E/M service (for example, 9928x) with modifier 57
appended may be billed separately with 44970 Laparoscopy, surgical, appendectomy.
Note that the global period for all major procedures begins
one day prior to the actual procedure; so, if the decision for
surgery occurs one day prior to the surgery, you may report
that E/M service separately with modifier 57.
For example, a surgeon is following an inpatient with an
obstructed colon. On day five, the surgeon decides that
if the obstruction does not resolve by the next day, the
patient will be brought to surgery for an exploratory laparotomy (and perhaps more extensive surgery). Based on
this, the day-five visit (9923x) may need to be reported
with modifier 57, if the surgeon decides to perform surgery on the following day. The surgeon should not report
the service until day six, when he’s certain whether the
laparotomy will occur. If the service is reported without
modifier 57, and surgery does occur on day six, the dayfive E/M service will be bundled inappropriately into the
laparotomy (or more extensive surgery).
If the obstruction begins to resolve on day six, and laparotomy is not required, the day-five visit (9923x) may be
reported without modifier 57, and the day-six evaluation
also may be reported.
Modifier 25 Parameters
Because all minor procedures include an E/M component,
you get paid separately for an E/M service with a minor
procedure only if the E/M service is “significant and
separately identifiable.” Here are three conditions when
this happens:
1. There is a different diagnosis for the E/M and
the procedure. The two diagnoses may be related (i.e.,
a sign or symptom diagnosis for the E/M and a definitive diagnosis for the procedure). The E/M results in a
decision to perform the procedure, either diagnostic or
therapeutic.
For example, a patient goes to an orthopedist complaining of shoulder pain. The orthopedist works up the
patient, performing a complete history, exam, and mediwww.aapc.com
September 2010
23
feature
If documentation indicates the physician was unable to
ascertain the condition of a “bullet,” but findings then
are documented via a diagnostic procedure, you can get
credit on both the E/M exam section and the procedure.
Be able to identify these distinct parts in the chart.
cal decision-making (MDM) relative to the complaint
of shoulder pain. After this evaluation (and perhaps an
X-ray), the physician determines that the patient has
bursitis. He recommends and performs a joint injection.
As a minor procedure, the joint injection (20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg,
shoulder, hip, knee joint, subacromial bursa)) includes an E/M
component. To be paid separately for the E/M and the
minor procedure, the provider must show the payer that
the E/M was significant and separately identifiable from
the injection. Modifier 25 (supported by documentation)
alerts the payer to this fact.
2. A procedure lacks a specific, separate diagnosis.
Medicare guidelines state specifically there is no requirement for separate and distinct diagnoses for an E/M
with modifier 25 and a same-day procedure. See CMS
Transmittal 954, issued May 19, 2006 (Medlearn Matters
MM5025, Change Request (CR) 5025): “The E/M service
may be prompted by the symptom or condition for which
the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M
services on the same date.”
For instance, the E/M service may be linked to a sign or
symptom, and a same-day minor diagnostic procedure
results in no definitive finding. As such, the sign or
symptom also is linked to the procedure. Once again, the
E/M service led to the decision to perform the procedure.
As an example, a physician sees a patient who is complaining of recurring hoarseness. During the patient
workup (including a history, exam, and MDM for the
hoarseness), the physician finds he cannot visualize
adequately the larynx via mirror exam, due to gag reflex.
He then performs a flexible laryngoscopy (31575 Laryngoscopy, flexible fiberoptic; diagnostic), but ultimately finds
no reason for the hoarseness. In this case, both the E/M
(with modifier 25) and the flexible laryngoscopy should
be reported, and may be linked to the same sign and
symptom diagnosis (hoarseness).
3. An “Oh, by the way” scenario. This is when a
patient comes in for one problem for which the E/M is
performed and just before leaving the patient states,
“Oh, by the way, can you look at my …” This may
result in the performance of a minor procedure that is
totally unrelated to the original reason for the visit and
the diagnosis for the E/M service and the minor procedure is entirely unrelated.
24 AAPC Coding Edge
For example, a patient visits her primary care physician
to follow up on hypertension and diabetes. The internist
performs a history, exam, and MDM for the chronic conditions. After the E/M service has been completed, and
the care plan has been reviewed, the patient says to the
doctor, “Oh, by the way, can you look at this lump on my
back?” The physician examines the mass and decides to
perform a biopsy. The encounter for the day will include
an E/M with modifier 25 for hypertension and diabetes.
The minor procedure, 11100 Biopsy of skin, subcutaneous
tissue and/or mucous membrane (including simple closure), unless
otherwise listed; single lesion also is billed, with the diagnosis of 782.2 Localized superficial swelling, mass or lump.
Keep E/M, Procedure Notes Separate
Whenever modifier 25 is used, the documentation must
contain a separate history, exam, and MDM, apart from
the procedure note. If findings are indicated on the procedure note, you cannot count it towards the exam portion
of the E/M. If documentation indicates the physician was
unable to ascertain the condition of a “bullet,” but findings
then are documented via a diagnostic procedure, you can
get credit for both the E/M exam section and the procedure. Be able to identify these distinct parts in the chart.
Note, as well, that (unlike modifier 57) modifier 25
applies only if the E/M service and separate procedure
occur on the same day.
For example, a patient comes in on Monday and the
physician performs an E/M service. Because there is limited room in the schedule, the physician cannot excise
a lesion that is identified “of suspicious nature.” The
patient is scheduled to come back Tuesday to have the
lesion removed. Because the E/M took place on Monday,
and the lesion removal (a minor procedure that includes
an E/M on the day of the procedure only) took place on
Tuesday, there is no need to append modifier 25 to Monday’s E/M service code.
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H,
CPC-P, CPC-I, CHCC, is president of CRN Healthcare Solutions, performing consulting at a national
level. Barbara is a past member of the AAPC
National Advisory Board (NAB) and its Executive
Board. Barbara is a senior coder and auditor for
The Coding Network and a nationally-recognized
consultant in compliance, coding, and billing.
Making Sense of MAC E/M Rules
AAPC’s October Workshop | $189.95 $149.95 Member Price
Evaluation and Management coding can be challenging for all
coders. E/M is the most commonly coded professional service
and can often be the most confusing. There are so many hurdles
to overcome from documentation deficiencies, EMR overdocumentation, medical necessity and giving the appropriate
credit for the elements for the key components. Not only are there
two sets of guidelines to choose from, but coders also need to
know the variations of the documentation guidelines according to
the MAC in their region.
Coders need to know the resources available to them to make
confident decisions for the gray areas in E/M code selection.
Navigation of the online resources available from CMS and MACs
can provide the answers needed to select a code with confident
and know the E/M level will stand up to any audit.
This workshop will help you:
•
Translate the documentation requirements for the 1995 and 1997 E/M Documentation Guidelines
•
Maneuver through the variations of documentation requirements for E/M specific for your MAC
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•
Learn how to use E/M modifiers with confidence
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Register at www.aapc.com/complianceworkshop
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cover
Arthroscopic Gems:
Hints for Accurate Coding
Look at three general principles, your understanding
of anatomy, and AMA guidance for each joint.
PROFESSIONAL
By Denis Rodriguez, CPC, CCS, CIRCC, CASCC
Arthroscopy refers to less invasive procedures in which an
endoscope is placed within the joint for the performance
of diagnostic and therapeutic procedures. As technology advances, procedures previously performed through
large incisions are now performed arthroscopically. To
accommodate this emerging technology, new arthroscopy,
CPT® Category III codes, and HCPCS Level II codes,
have been added over the past few years.
There are three general principles of arthroscopic coding:
1. If a procedure is started arthroscopically and
finished open, it is coded using the open procedure
code only. In such a case, assign diagnosis code V64.43
Arthroscopic surgical procedure converted to open procedure to
report the arthroscopic component.
For example, a patient presents with intra-articular
fracture of the distal radius. The surgeon attempts
arthroscopic reduction of the fracture fragments after
synovial debridement for visualization. The surgeon finds
the fragments are not sufficiently mobile for arthroscopic
26 AAPC Coding Edge
reduction, and converts to an open reduction and internal fixation of the three distal radial fragments. CPT®
coding is 25609 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of
3 or more fragments. The arthroscopic attempt at reduction
and synovectomy for visualization is included in the open
completion of that procedure, as indicated by V64.43,
which also is reported.
2. Seven CPT® codes describe arthroscopically
aided procedures. This means that even though part of
the procedure is performed open, the arthroscopic procedure codes should be assigned. The codes are:
29850Arthroscopically aided treatment of intercodylar
spine(s) and/or tuberosity fracture(s) of the knee,
with or without manipulation; without internal or
external fixation (includes arthroscopy)
29851with internal or external fixation (includes
arthroscopy)
29855Arthroscopically aided treatment of tibial fracture,
proximal (plateau); unicondylar, includes internal
fixation, when performed (includes arthroscopy)
29856bicondylar, includes internal fixation, when performed (includes arthroscopy)
29888Arthroscopically aided anterior cruciate ligament
repair/augmentation or reconstruction
29889Arthroscopically aided posterior cruciate ligament
repair/augmentation or reconstruction
29892Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial
plafond fracture, with or without internal fixation
(includes arthroscopy)
3. Diagnostic procedures for each arthroscopic code
family are included in any surgical procedures performed from that same family. The families are:
 temporomandibular (29800-29804)
 shoulder (29805-29828)
 elbow (29830-29838)
 wrist (29840-29847)
 hip (29860-29863)
 metacarpophalangeal joints (29900-29902)
Within these families, the initial code describes the
diagnostic procedure and subsequent codes describe surgical procedures. The code families for the ankle (2989129899) and the subtalar joints (29904-29907) do not
contain diagnostic codes.
cover
The knee is a hinged joint and … is composed of three
compartments: medial, lateral, and patellofemoral. The
compartment coding concept is important for coding
arthroscopic procedures in the knee accurately.
Note: Two codes in this section (29848 Endoscopy, wrist,
surgical, with release of transverse carpal ligament and 29893
Endoscopic plantar fasciotomy) are not technically arthroscopies (that is, they are not endoscopies within a joint), but
rather are musculoskeletal endoscopies.
Although these general rules always apply, due to the
unique nature of the different joints, many arthroscopy
rules are specific to each joint, as shown here:
Shoulder
Shoulder arthroscopy codes encompass two joints in the
shoulder area: the glenohumeral joint (typically called
the shoulder joint) and the acromioclavicular joint. The
acromioclavicular joint is the smaller of the two and
there are arthroscopy codes specific to it; excision of the
distal clavicle, 29824 Arthroscopy, shoulder, surgical; distal
claviculectomy including distal articular surface (Mumford
procedure) and decompression of the subacromial space,
29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without
coracoacromial release, which includes partial excision of
the acromion or acromioplasty.
Arthroscopic debridement of the labrum and of the
undersurface of the rotator cuff (29822 Arthroscopy, shoulder, surgical; debridement, limited) may be reported separately when performed with subacromial decompression
(29826), according to the May 2001 CPT® Assistant. Per
the same edition, Subacromial decompression includes
acromioplasty, arch decompression, excision of bursa, and
coracoacromial ligament release.
Open procedures 23410, 23412, and 23420 differentiate between whether the tear is acute or chronic or how
many tendons are repaired. The arthroscopic code for
rotator cuff repair (29827 Arthroscopy, shoulder, surgical;
with rotator cuff repair) makes no such distinctions, and
can be reported whether the tear is acute or chronic;
whether one, two or three tendons are repaired, or;
whether one or more portals is required to repair the cuff
(February 2008 CPT® Assistant).
Often the surgeon will perform a biceps tenotomy (i.e.,
tendon release) via arthroscopy, and then perform a
tenodesis via an open procedure. In such cases, the code
for open biceps tenodesis (23430 Tenodesis of long tendon
of biceps) is most appropriate. Only assign the code for
arthroscopic biceps when the tenodesis portion of the
procedure is performed via arthroscope.
Arthroscopic capsular shrinkage (i.e., thermal capsulorrhaphy) is at times used to treat joint instability. For
payers recognizing HCPCS Level II S codes, S2300
Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy is appropriate for these procedures. For payers
who do not recognize S codes, CPT® 29999 Unlisted procedure, arthroscopy is appropriate. This procedure generally
is considered investigational and not payable by many
payers.
Knee
The knee is a hinged joint and, per the American
Medical Association (AMA), is composed of three compartments: medial, lateral, and patellofemoral. The
compartment coding concept is important for coding
arthroscopic procedures in the knee accurately.
The code for arthroscopic abrasion arthroplasty, multiple
drilling and/or microfracture (29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture) may be coded per
compartment so you should code microfracture of both
medial and lateral femoral condyles as 29879, 29879-59
Distinct procedural service.
As the descriptor states, chondroplasty (29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage
(chondroplasty)) is included in 29879 when chondroplasty
is performed in the same compartment. However, a
chondroplasty performed in a separate compartment may
be reported separately to 29877-59 (August 2001 CPT®
Assistant).
For Medicare, G0289 Arthroscopy, knee, surgical, for removal
of loose body, foreign body, debridement/shaving of articular
cartilage (chondroplasty) at the time of other surgical knee
arthroscopy in a different compartment of the same knee
may be reported once for a chondroplasty and/or loose
body removal performed in each compartment where it
is the only procedure performed. In contrast to 29879,
report code 29877 only once per knee, regardless of
the number of compartments in which it is performed
(December 2005 CPT® Assistant).
An often overlooked code is 29884 Arthroscopy, knee,
surgical; with lysis of adhesions, with or without manipulation (separate procedure), which may be assigned for excision of fibrosis/adhesions/scar due to previous procedures
or injuries. Debridement of cyclops lesions after total
knee replacement(s) is a common condition for which
arthroscopic lysis of adhesions is performed. Code
29884 is considered to be included in any other major
arthroscopic procedure performed in the knee, regardless
of whether it is performed in a separate compartment.
www.aapc.com
September 2010
27
cover
When synthetic plugs are used for osteochondral grafting
of the knee (i.e., mosaicplasty), 29867 Arthroscopy, knee,
surgical; osteochondral allograft (eg, mosaicplasty) may be
assigned, even though the descriptor refers to allograft,
per the December 2008 CPT® Assistant. The same, however, does not apply for the ankle. Rather than assign
code 29892 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond
fracture, with or without internal fixation (includes arthroscopy) for placement of synthetic material, report unlisted
code 28899 Unlisted procedure, foot or toes.
Wrist
Ankle
Note that CPT® does not have an arthroscopic complete
synovectomy code for the ankle. A total synovectomy is
not anatomically possible because it would cause dislocation of the joint. When synovium is debrided from the
medial and lateral aspects of the ankle, report a partial
arthroscopic synovectomy (29895 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial),
according to CPT® Assistant, December 2008.
Coding arthroscopies can be challenging; however, with a
good understanding of anatomy and with applying AMA’s
guidance for each joint, you can code with accuracy.
In contrast with knee arthroscopies, compartments do
not matter for wrist arthroscopies. For example, 29846
Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement includes a synovectomy (29845 Arthroscopy, wrist, surgical; synovectomy,
complete), regardless of whether the synovectomy was
performed in a separate compartment (CPT® Assistant,
December 2003).
Denis Rodriguez, CPC, CCS, CIRCC,
CASCC, is senior ambulatory surgery
center (ASC) coder and compliance
auditor for The Coding Network, LLC.
He has 20 years experience in the
medical field, the last eight of which
have been spent exclusively in ASC
coding, auditing, and education.
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facility
Evaluate and Manage Medicare
Teaching Physician Rules
Follow CMS teaching physician documentation guidelines
when billing collaborative services with a resident.
By Jenny Berkshire, CPC, CEMC, CGIC
PROFESSIONAL
T
eaching physicians provide a valuable service training resident physicians preparing to join the ranks of
practicing physicians. A physician who provides services
to Medicare patients as a teaching physician with residents in an academic setting must follow specific Centers
for Medicare & Medicaid Services (CMS) guidelines when
billing for these services.
According to guidelines published in the Medicare
Claims Processing Manual, internet-only manual, Pub.
100-04, chapter 12, section 100 (www.cms.gov/manuals/
downloads/clm104c12.pdf), a teaching physician may
receive Medicare payment if:
An evaluation and management (E/M) service is
provided by a resident with the teaching physician
physically present for the critical or key portion of
the service; or
Certain E/M services are provided by the resident in
a primary care exception clinic.
In the teaching setting, E/M services are typically provided to patients in one of the following scenarios:
1. The teaching physician performs the complete service without a resident. The resident may or may not
have provided the service independently;
2. The resident performs the service in the presence of
or jointly with the teaching physician; or
More About Residency Programs
To complete their education, students graduating from medical school must
spend three to seven years in residency. The residency program is a hands-on
learning process in which the resident physician works in approved training
programs with teaching physicians who have expertise in medical specialty care.
Residency programs at teaching hospitals are funded through a federal program.
The work of the resident is compensated through the hospital’s graduate medical
education (GME) funding, or through reasonable cost payments made to the hospital by Medicare contractors. The teaching physician’s work in providing services
to Medicare patients may be reimbursed through Medicare Part B.
32 AAPC Coding Edge
3. The resident performs the service without the teaching physician who later independently performs the
critical or key portion of the service.
Teaching Physicians Must Take Part in Care
For payment purposes, the teaching physician must document that he or she performed the service, or physically
was present during the key or critical portion of the service provided by the resident, and that he or she participated in the management of the patient. Documentation
must be dated and include a legible signature or identity.
The teaching physician must document his or her physical presence and participation in the patient’s care; the
resident’s documentation may not be used to establish
the teaching physician’s presence and/or participation in
the patient’s care. For auditing purposes, the resident’s
documentation may be combined with the teaching
physician’s documentation to determine the care level for
billing and to establish medical necessity.
An example of minimally acceptable documentation
described in the CMS manual includes: “I saw the patient
with the resident and agree with the resident’s findings
and plan.” This statement clearly and concisely establishes
the presence of the teaching physician and links to and
confirms the information documented by the resident.
Examples from the manual of unacceptable documentation include these phrases: “Agree with above,” “Seen and
agree,” or even a resident note followed by the teaching
physician’s counter-signature. According to the manual,
none of these examples make it clear that the teaching physician was present, evaluated the patient, or had
involvement in the care plan.
Frequently, medical students are incorporated in patient
care in teaching settings. CMS does not allow any documentation by a medical student—except for a past,
family, and social history and a review of system (ROS)
(documentation anyone may document in a record)—to
be used for billing purposes. Although medical students’
feature
To discuss this
article or topic, go to
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Does IPPE Allow for Primary Care Exception?
documentation may be clinically appropriate, anything
(except for the above exclusions) documented by or referenced in a medical student’s note must be re-documented
for billing and auditing purposes.
Teaching physicians may bill for certain services provided
by residents in a setting granted as a primary-care exception. In this setting, the resident may see patients and
the teaching physician may bill for lower and mid-level
E/M services without the presence of the teaching physician. The specific CPT® codes appropriate for primary
care exception billing include new patient codes 99201,
99202, and 99203, and established patient codes 99211,
99212, and 99213 (see infobox “Does IPPE Allow for Primary Care Exception?”). For the primary care exception
to apply, the center must attest in writing that particular
criteria outlined in the Medicare Claims Processing Manual
are met.
Documentation to support the services of the teaching
physician may be dictated and typed, handwritten, or
computer-generated. CMS specifically allows the use of
macros with an electronic health record (EHR). A macro
is a command in a computer generating a pre-determined
text that is not edited by a user. This macro, when personally added in a secure, password-protected system
may serve as the required teaching physician’s personal
documentation. These macros should be developed by the
teaching physician in the presence of a compliance person
to assure that the macros satisfy Medicare’s teaching
physician documentation and attestation guidelines. Best
practice would be to design a macro statement mirroring
verbatim one of the acceptable examples provided in the
carrier’s manual.
Billing for services based on time (e.g., critical care or
prolonged care), must be based on the time the teaching
physician was present with the patient, either alone or
with the resident. Time the resident spent alone with the
patient is not billable for time-based codes.
Along with E/M services 99201- 99203 and 99211- 99213, Chapter 12, Section
100.1.1.C of the Medicare Claims Processing Manual allows that, effective
Jan. 1, 2005 an initial preventive physical exam (IPPE) as reported by G0344 is
included under the primary care exception (PCE). Code G0344 was deleted as
of Jan. 1, 2009 to be replaced by G0402 Initial preventive physical examination;
face-to-face visit, services limited to new beneficiary during the first 12 months of
Medicare enrollment. The most recent Medicare Manual reference does not reflect
the change, however, and I am awaiting a clarification from my carrier on the code
payable for the IPPE in a PCE clinic. Those readers who wish to report the IPPE as a
primary care exception also should seek clarification from their carrier.
Apply Modifiers GC, GE as Necessary
Medicare contractors may require services provided by
a teaching physician to be billed with an informational
HCPCS Level II modifier. Modifier GC This service has
been performed in part by a resident under the direction of a
teaching physician indicates the service was provided by
a teaching physician in collaboration with a resident.
Modifier GE This service has been performed by a resident
without the presence of a teaching physician under primary care
exception indicates the service was provided in a primary
care exception clinic.
Assure E/M Compliance for Teaching Physicians
Health care reform is focusing on fraud and abuse, and
audits are a necessary part of controlling it. Reimbursement for care teaching physicians provide to the Medicare
population is legitimate, but federal guidelines for documenting services must be followed to assure teaching
physicians are paid appropriately. As an auditor reviewing services provided by teaching physicians, I have seen
many variations of acceptable and unacceptable teaching
physician documentation and have also seen no teaching
physician statement. I have found the most common error
is the omission of a reference or link to the resident’s
documentation.
Jenny Berkshire, CPC, CEMC, CGIC,
is compliance manager with Wright
State Physicians, a universitybased, multi-specialty academic
medicine practice in Dayton, Ohio.
She has worked for 35 years in
medical practices, with 28 years in
a gastroenterology practice.
www.aapc.com
September 2010
33
featured coder
I
n recent years, minimally-invasive gynecological procedures
have become more widely available and increasingly popular
with surgeons and patients. Minimally-invasive techniques offer various advantages over traditional open surgery, including
faster recovery and fewer complications. Such techniques not
only differ clinically from their traditional equivalents, but also
require unique, dedicated CPT® coding.
Hysteroscopy
Maximize Coding
for Minimally Invasive
Ob/Gyn Surgeries
Keep coding current for the newest
gynecological surgery techniques.
By Kerin Draak,
MS, RN, WHNP-BC, CPC, CEMC, COBGC
34 AAPC Coding Edge
A hysteroscope is a thin, telescope-like device that contains a
small camera, which is inserted through the vagina and into the
cervical os (opening of the cervix) to gain entry into the uterine
cavity. Diagnostic hysteroscopy—for instance, to investigate
abnormal uterine bleeding—should be reported with CPT®
code 58555 Hysteroscopy, diagnostic (separate procedure).
Hysteroscopy also may be used to perform therapeutic procedures. For instance, if a biopsy is obtained or a polyp removed,
either with or without dilatation and curettage (D&C), during
a hysteroscopy, report 58558 Hysteroscopy, surgical; with sampling
(biopsy) of endometrium and/or polypectomy, with or without D & C.
Additional surgical hysteroscopy procedures include:
58559Hysteroscopy, surgical; with lysis of intrauterine adhesions
(any method)
58560Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
58561Hysteroscopy, surgical; with removal of leiomyomata
(fibroid)
58562Hysteroscopy, surgical; with removal of impacted foreign
body
Remember that surgical laparoscopy/hysteroscopy procedures
always include diagnostic laparoscopy/hysteroscopy so if it was
necessary to perform a surgical intervention during a diagnostic procedure, you would report only the surgical hysteroscopic
code. For instance, if during a diagnostic hysteroscopy for evaluation of abnormal or post menopausal bleeding, a polyp/submucous or grade 1 leiomyoma is identified and removed, you would
report only 58561.
Endometrial Ablation
Endometrial ablation is an alternative to hysterectomy to treat
irregular uterine bleeding. There are several methods available,
all performed via hysteroscope and with the common goal to
remove or ablate the uterine lining:
Gynecare Thermachoice® uses a small, silicone, fluid-filled
balloon inserted into the uterus, which is heated gently.
NovaSure® uses a slender surgical device inserted through
the cervix into the uterus to deliver electrical energy.
The Hydro ThermAblator® System (HTA® System) circulates a heated saline solution.
Regardless of which system the surgeon chooses, report endometrial ablation using 58563 Hysteroscopy, surgical; with endometrial
ablation (eg, endometrial resection, electrosurgical ablation and thermoablation).
featured coder
Hysteroscopic Sterilization
As an alternative to laparoscopy sterilization, two procedures
for fallopian tube cannulation—Essure® and Adiana®—now
are available. Using either method, inserts are placed via hysteroscope just inside the fallopian tube. This stimulates tissue
growth in the body, and scar tissue that is formed around the
inserts occludes the tube. This is reported 58565 Hysteroscopy,
surgical; with bilateral fallopian tube cannulation to induce occlusion
by placement of permanent implants, with ICD-9 code V25.2 Admission for interruption of fallopian tubes or vas deferens. If performed
in the office setting, the HCPCS Level II supply code is A4264
Permanent implantable contraceptive intratubal occlusion device(s) and
delivery system.
Laparoscopic Hysterectomy
Laparoscopic hysterectomy is a minimally-invasive alternative
to abdominal hysterectomy. Correct billing and coding depends
on knowing how these different procedures are performed. The
procedures may be classified as:
Total laparoscopic hysterectomy (TLH): When a total hysterectomy is performed with only the assistance of a laparoscope,
the uterus, adenexa, and cervix are morselized and removed
through endoscopic tools, and the vaginal cuff is repaired
endoscopically. This procedure is reported using CPT®
code range 58570-58573. Code selection depends on uterine
weight and if the tubes and ovaries were removed, as shown
in Table A.
Laparoscopy with vaginal hysterectomy (LAVH): If the provider
uses the laparoscope to perform the initial operative portion of a vaginal hysterectomy (where the uterus is detached
from surrounding upper supporting tissue) and then completes the hysterectomy vaginally, apply 58550-58554. Code
selection depends on uterine weight and if the tubes and
ovaries are removed, as shown in Table A.
Laparoscopic supracervical hysterectomy (LSH): A laparoscopic
hysterectomy where the cervix is preserved is called a
supracervical hysterectomy. The uterus, tubes, and ovaries
are removed using the laparoscope. Coding from 5854158544 depends on uterine weight and if the tube(s) and/or
ovary(s) are removed, as shown in Table A.
Laparoscopic hysterectomy is a minimallyinvasive alternative to abdominal
hysterectomy. Correct billing and coding
depends on knowing how these different
procedures are performed.
For example: During diagnostic laparoscopy for pain, a stage
four endometriosis is found in a patient who has completed
childbearing. The decision is made to eradicate the endometriosis by performing a TLH/BSO. The appropriate code would
be either 58571 (uterine weight of less than 250 g) or 58573
(more than 250 g). Modifier 22 Increased procedural service could
be appended for extensive lysing of adhesions, if documentation
supports significant additional time and/or effort.
Robotic Surgery
Robotic surgery represents the newest category of minimallyinvasive surgery. The daVinci® system lets a surgeon sit at a
computer console to control arms that move over the patient
according to the surgeon’s commands, thereby accomplishing a
laparoscopic procedure robotically.
No separate CPT® code describes robotic surgery. Rather, you
should code as if the physician were doing a standard laparoscopic procedure. For those payers who accept HCPCS Level
II codes, you additionally may report S2900 Surgical techniques
requiring use of robotic surgical system (list separately in addition to
code for primary procedure). There is no additional reimbursement
for the physician using a robotic system, by Medicare or the
majority of commercial carriers.
Kerin Draak, MS, RN, WHNP-BC, CPC, CEMC,
COBGC, has worked in health care for more than
18 years. She has more than 11 years of clinical
experience in women’s health, and was coding
educator for a 220-plus multispecialty clinic since
2004. She is the president for her local AAPC
chapter, and a member of AAPC’s National Advisory Board (NAB). She was a presenter for the Wisconsin Medical Society’s 2007 and 2008 Annual Symposiums, and
has conducted several audio and day seminars on its behalf. She
spoke at AAPC national conferences in 2008, 2009, and 2010.
Table A: Laparoscopic Hysterectomies Quick Coding Chart
TLH procedures
LAVH procedures
LSH procedures
Uterus 250 g or less
58570 Laparoscopy, surgical, with total
hysterectomy, for uterus 250 g or less;
58550 Laparoscopy, surgical, with vaginal
58541 Laparoscopy, surgical, supracervical
58571 … with removal of tube(s) and/or ovary(s)
58572 Laparoscopy, surgical, with total
hysterectomy, for uterus greater than 250 g;
58553 Laparoscopy, surgical, with vaginal
hysterectomy, for uterus greater than 250 g;
58543 Laparoscopy, surgical, supracervical
for uterus greater than 250 g;
Uterus 250 g or more
www.aapc.com
September 2010
35
feature
Claim Scrubbers
Are Not Infallible
APPRENTICE
Strong billing skills trump
computer-assisted functions.
By Dorothy Steed, CPC-H, CHCC, CPC-I, CPUM, CPUR, CPHM, CCS-P, CEMC, CFPC, ACS-OP, RCC,
RMC, PCS, FCS, CPAR, CPMA
Electronic billing systems usually have built-in claim scrubber edits that prompt the biller to enter information to the
claims. Although this can be helpful, these edits are computer-assisted functions and do not take the place of strong
billing skills.
How Claim Scrubbers Function
Various billing software vendors offer packages to providers.
These systems are designed to review the information on the
claim and search for inconsistencies and missing information.
Some systems are more sophisticated than others, but all usually function in a similar manner.
In most cases, each payer requires certain specific entries to
the claim to pass their internal claims processing edits. As
a result, it is very difficult for any one billing system to edit
entirely for all payers. Unless the biller is utilizing direct
data entry specific to that payer, such as the Fiscal Intermediary Standard System (FISS) for Medicare facility billing,
the system may not edit completely. Some electronic systems
allow the provider to implement certain payer edits, while
others may require the provider to request edits from the
vendor. Most systems connect with a clearinghouse that distributes the claims to the specific payers.
Resist Claim Scrubber Misconceptions
Several disturbing misconceptions have emerged regarding
electronic claims and scrubber software.
36 AAPC Coding Edge
ll Providers should not assume the scrubber will eliminate the need for quality billing skills. The biller
should be well trained and knowledgeable about
multiple payer requirements. Regardless of whether
the system prompts the biller for certain entries, it
is essential for the biller to recognize certain claims
requirements, such as number of units, appropriate
modifier usage, and suitable matches of information.
Claims submitted with inappropriate edits cause
claim rejection.
ll Successful resolution of rejected claims still requires
the biller to understand the reasons for the rejection,
and know what steps are necessary to correct the
claim. Most consultants and auditors have encountered multiple instances of rejected claims backlog
that are not being worked on due to inexperienced
billers and lack of knowledge about payer requirements. Staff members who do not possess adequate
billing and coding knowledge are not likely to resolve
these problems within the payer time limit for correction and/or appeal. Often, this involves very significant revenue dollars. When discussing this issue with
providers, it is not unusual to receive the response,
“We followed the system edits, but the payer still
rejected the claim.” Remember: Repeat submission of
erroneous information may be deemed billing abuse
and trigger a payer audit.
feature
ll Medical billing and coding is a hot industry attracting attention as a relatively stable market with significant growth potential. I have received a number of
inquiries from the general public about employment
opportunities. More than a few have said they were
advised by “someone already in the field that it is not
necessary to receive training because the computer
will tell you what to enter.” I always respond that
this is a gross misconception, and that most providers
would require training and demonstrated skills.
Common Problem Areas to Watch
Ineffective modifier reporting can result from lack of
understanding about payer processing edits. For example,
when two modifiers are required, some payers allow reporting of the service code one time, with both modifiers on the
same line. Other payers may want the service code reported
on two separate lines with the specific modifier appended to
each line.
As an example, when reporting left knee arthroscopy with
medial meniscectomy, professional component only, your
payer may allow 29881-26, LT Arthroscopy, knee, surgical; with
meniscectomy (medial OR lateral, including any meniscal shaving) –
Professional component, Left side on the same line, or may require
29881-26 on one line and 29881-LT on a second line.
As another example, bilateral services may be reported with
modifier 50 Bilateral procedure, or on two separate lines with
LT and RT Right side on each line. Both are correct; it is just
a matter of knowing your payer’s system edits.
Poor understanding of National Correct Coding Initiative (NCCI) edits may be another problem for billers
lacking fundamental experience. An effective claim scrubber should prompt for review of the services and whether both
should be reported—but the biller will need to determine
whether there is an unbundling issue or whether both can be
reported with a correct modifier.
There may be situations when two separate errors override each other and the claim scrubber may fail to edit
for either problem. A well-trained biller should review the
information on the claim and determine whether it is complete and error free.
Providers should never remove multiple edits from the claim
scrubber to “get claims out the door.” Edits will occur in the
payer’s processing system and result in multiple claims rejections.
There may be occasions when the claim scrubber will flag
for information changes when the claim is correct. These
issues should be resolved with the billing software vendor.
Training Trumps Computing
When training a new biller, it can be very advantageous to
have that person work rejected claims. He or she will see
the reasons why claims were not paid, how different payers
require data to be submitted, and how to avoid those same
errors on initial claims.
Some of the better skilled billers I’ve worked with have developed the ability to “think like the payer.” Does the claim
make sense as submitted? If not, why would it be paid? This
thought process can go a long way in avoiding claims rejections, delays, and requests for additional information.
The bottom line is this: You may use claims scrubbers for
their intended purpose, as a tool to provide assistance in
submitting clean claims. Understand they are not infallible
and are not to be substituted for adequate billing and coding
skills and strong physician documentation. “The system did
not flag for an error” will not be an acceptable argument in a
payer audit.
In today’s environment of fraud, abuse, recovery audit contractor (RAC) investigations and other payer monitoring activities
and penalty assessments, providers always should review closely
the skills of each person responsible for billing and coding.
Other solutions include the following:
ll Make periodic internal review of adequate physician
documentation standard practice.
ll Consider at least annually external review by a trusted
source.
ll Quickly work rejected claims. Issues that appear to
involve payer processing edits should be discussed
with that payer and inconsistencies between the practice billing software and payer requirements should
be resolved quickly.
ll Take advantage of any training your payers provide.
Many payers schedule periodic webinars, teleconferences, and occasional live workshops to educate their
providers in claim requirements.
ll Know your provider representative at each of your
payers and request assistance and clarification from
that person for claims problems. Ideally, you will use
that source and your billing software vendor representative to resolve system issues.
ll Invest in scheduled training for your billers and
coders. The key word in this industry is change.
Ensure your staff is ready for the challenge.
Dorothy Steed, CPC-H, CHCC, CPC-I, CPUM, CPUR,
CPHM, CCS-P, CEMC, CFPC, ACS-OP, RCC, RMC, PCS,
FCS, CPA, CPMA, is an independent consultant and
educator in Atlanta, Ga. Formerly a Medicare specialist
for a large hospital system with 33 years of experience in health care, she now works as a technical
college instructor in Atlanta, performs coding reviews
for the Quality Improvement Organization in Georgia,
and performs physician audits and education. She has been a technical
contributor for several medical publications, presented at several health
care conferences, and has developed training classes focusing on facility
billing, coding, and reimbursement.
www.aapc.com
September 2010
37
newly credentialed members
Padma Venkatachalam, CPC Redmond AE
Kendra Ruth Booth, CPC Anchorage AK
Linda Bulkley, CPC Anchorage AK
Kristel Kari Clark, CPC Anchorage AK
Melissa Jean Eastman, CPC Anchorage AK
Kathryn Alice Russell, CPC Anchorage AK
Lori Vickery, CPC Anchorage AK
Heather Juanita Whitaker, CPC Anchorage AK
Marian Maroney, CPC Eagle River AK
Chanleakhena Sovan Holder, CPC Birmingham AL
Karen L Barnett, CPC Ft Payne AL
Robin B Higgins, CPC Pinson AL
Misty Cantrell, CPC-H Trumann AR
Dellie Jane Nollen, CPC White Hall AR
Jessica R Burnett, CPC Buckeye AZ
Annette Chapman, CPC Fountain Hills AZ
Aide Barajas, CPC Glendale AZ
Lorraine Clark, CPC Glendale AZ
Kolleen J Geiger, CPC Mesa AZ
Stephanie Woods, CPC, CPC-H Mesa AZ
Lisa A Conley, CPC Payson AZ
Jeanne M Cronover, CPC Peoria AZ
Diane M Eastman, CPC Peoria AZ
Dena Newcomb, CPC Peoria AZ
Ruth E Borbon, CPC Phoenix AZ
Brandi Bowman, CPC Phoenix AZ
Kara Tiffany, CPC Phoenix AZ
Christina M Wendorf, CPC Phoenix AZ
Ericka Devon Jackson, CPC Queen Creek AZ
Nina D Batie, CPC Sun City AZ
Robert Franco, CPC Tucson AZ
Natalie Jividen, CPC Tucson AZ
Renee Munoz, CPC Tucson AZ
LeAnn M Vanier, CPC, CIRCC Alhambra CA
Amy Louise Lanoue, CPC American Canyon CA
Kimberly Alexander, CPC Antioch CA
Cynthia Granados, CPC Bakersfield CA
Ashley Lynch, CPC Bakersfield CA
Erika Rich, CPC Bakersfield CA
Linda Joyce Williams, CPC Canyon Country CA
Claynika Bruce, CPC Compton CA
Kim L Kelly, CPC Cupertino CA
Svetlana Litvinsky, CPC Foster City CA
Julieta Londono, CPC Hesperia CA
Cheryl Souza, CPC Hughson CA
Charlette Y Walker, CPC Inglewood CA
Reyna Lopez, CPC Lakeside CA
Natalya Zvereva, CPC Los Angeles CA
Sharman Hughart, CPC Modesto CA
Kerri Warren, CPC Moorpark CA
Adriana Rodriguez, CPC Oceanside CA
Bruce Tarzy, CPC Poway CA
Dina Hernandez, CPC Riverside CA
Gina Guillaume-Holleman, CPC Sacramento CA
John Hailes, CPC, CPC-H, CIRCC, CPMA, CPC-I,
CEMC, CFPC Sacramento CA
LaSha Hinton, CPC Sacramento CA
Mikaela Medina, CPC Sacramento CA
Marva Annette Garcia, CPC San Diego CA
Janeth P Paris, CPC San Diego CA
Nicole Louise Heuga, CPC Santa Cruz CA
Melissa Lucero Lombardi, CPC Sunnyvale CA
Gwen Carlson, CPC Thousand Oaks CA
Vicky Mahan, CPC Thousand Oaks CA
Kathy Campbell, CPC Aurora CO
Kala R Mazzadi, CPC Aurora CO
Louis Kallsen, CPC Ft Morgan CO
Kelly Kornelson, CPC Grand Junction CO
Elizabeth Mullin, CPC Grand Junction CO
Cynthia LeMaire, CPC Thornton CO
Leann Torre, CPC Ansonia CT
Patricia J Davis, CPC, CPMA, CPC-I Cromwell CT
Jacqueline M Roncinske, CPC Danbury CT
Rosangel Colon, CPC Hamden CT
April L Riley, CPC Hamden CT
Marianne Goodwin, CPC Jewett City CT
Melissa Martin, CPC Plainville CT
Judith DaCunto, CPC West Haven CT
Kate J Becker, CPC Newark DE
Joyce Flanagan, CPC Townsend DE
38 AAPC Coding Edge
Vicky Henry, CPC Auburndale FL
Phebee Abdou, CPC Boca Raton FL
Jane Marie Dellwo, CPC Bonifay FL
Laura Boles, CPC Bryceville FL
Gisela Garcia, CPC-H Cutler Bay FL
Camille Washington, CPC Davie FL
Jeanne C Fox, CPC Deland FL
Judy Mathews, CPC Frostproof FL
Tammy F Thompson, CPC Ft Lauderdale FL
Susan Horvath, CPC Ft Myers FL
Andra Booth, CPC Hilliard FL
Josietta Green, CPC Jacksonville FL
Angela Grover, CPC Jacksonville FL
Toshanda Nicole Mann, CPC Jacksonville FL
Michelle L Sawyer, CPC Jacksonville FL
Sumana Shashidhara, CPC Jacksonville FL
Priscilla Calderon, CPC Kissimmee FL
Anne E Purpura, CPC Largo FL
Benita Mobley, CPC Lauderhill FL
Dunia Aljure, CPC-H Miami FL
Odalys Garcia, CPC Miami FL
Norge Hernandez, CPC-H Miami FL
Leiza Rodriguez, CPC-H Miami FL
Habibah Urbina, CPC Miami FL
Latanya Brickley, CPC Miami Gardens FL
Lee Ann Atkinson, CPC Orlando FL
Domineack Guion, CPC Orlando FL
Susan M Maret, CPC Orlando FL
Crystal Wilhelm, CPC Orlando FL
Falesto Joseph, CPC Palm Bay FL
Chasity Hoffman, CPC Palm City FL
Subrina Etienne, CPC Pembroke Pines FL
Dana Duncan, CPC Ridge Manor FL
Nicoise De' Shong-Ault, CPC Sanford FL
Farah Pryor, CPC Sanford FL
Devyn Dyal, CPC Springhill FL
Julie Ann Morris, CPC, CIRCC Starke FL
Kellie L Caswell, CPC Tallahassee FL
Judith Gutierrez, CPC-P Tallahassee FL
Sherry Lange, CPC Tallahassee FL
Mary Catherine Palacios, CPC, CPC-H Tampa FL
Jodi Mazzone, CPC Weston FL
Bernice Haderthauer, CPC Zephyrhills FL
Deborah S Garcia, CPC Albany GA
Lakasha Coates, CPC Austell GA
Grace Mason, CPC Buford GA
Kindra Gray Redmond, CPC Carrollton GA
Deborah Suzanne McNeal, CPC Cleveland GA
Deborah Kubida, CPC Dallas GA
Linda Lee Leeson, CPC Dawson GA
Kristy Ann Jones, CPC Dawsonville GA
Karen Nix Hawkins, CPC Demorest GA
Theresa Morris, CPC Euharlee GA
Miriam G Ethridge, CPC Fitzgerald GA
Mary Claus, CPC Gainesville GA
Denise Cowart, CPC Gainesville GA
Haley Ellenburg, CPC Gainesville GA
Joyce Gayla Powers, CPC Gainesville GA
Carole Womack, CPC Jasper GA
Sherri Farmer, CPC Toccoa GA
Sheila Carlin, CPC Woodstock GA
Deborah-Ann Chan, CPC Kaneohe HI
Jennifer Langenfeld, CPC Boise ID
Jane Crane Johnson, CPC Eagle ID
Diana M Daum, CPC, CIRCC Hayden Lake ID
Sheryl Hopkins, CPC Meridian ID
Kristy Torrez, CPC Meridian ID
Michele G Esposito, CPC Chicago IL
Stephanie Figueroa, CPC Chicago IL
Athena Flores, CPC Chicago IL
Dulce Flores, CPC Chicago IL
Angela Giannese, CPC Chicago IL
Penny Kyriakopoulos-Lembesis, CPC Chicago IL
Arturo H Quipse, CPC Chicago IL
Castolina Solis, CPC Cicero IL
Lynn Marie Musser, CPC Dixon IL
Roshan Jaffer, CPC Downers Grove IL
Julie Ebeling, CPC Effingham IL
Ashley Probst, CPC Effingham IL
Evgenia Vantcheva, CPC Elmwood Park IL
Carol Sue Moynahan, CPC Granite City IL
Dana M Thornton, CPC Hillside IL
Maria Araceli Ortiz, CPC Melrose Park IL
Kathryn E. Marconi, CPC Monee IL
Mayada Fahoum, CPC Naperville IL
Minerva Zavala, CPC Oak Lawn IL
Marriya Rice, CPC Park Forest IL
Debbie D Bates, CPC Richton Park IL
Andrea L Kuntz, CPC Rockford IL
Patricia H Stade, CPC Schaumburg IL
Melissa Chism, CPC Sheridan IL
Virginia M Vaklin, CPC, CIRCC Skokie IL
Brenda Wobbe, CPC Trenton IL
Joyce C Neumann, CPC Winfield IL
Lindsay A Hollenbaugh, CPC Columbia City IN
Christine Carol Smith Stetler, RN, CPC Decatur IN
Betsy Christine Anderson, CPC Fishers IN
Elizabeth McAdams, CPC Franklin IN
Stacy Perrine, CPC Ft Wayne IN
Haley Galvin, CPC Indianapolis IN
Madelyn Moore, CPC Indianapolis IN
Raeann M Spurgeon, CPC Indianapolis IN
Linda Vinciguerra, CPC-P Lafayette IN
Shannon Lynn Burkhart, CPC Martinsville IN
Cheri Ann Hayden, CPC Martinsville IN
Kimberly Dawn Nix, CPC Martinsville IN
Kristine Renee Zupancic, CPC Morgantown IN
Sammye Wright, CPC New Albany IN
Licia Dunder, CPC Noblesville IN
David Walorski, CIRCC Osceola IN
Trisha Ann French, CPC Osgood IN
Beverly Chapman, CPC South Bend IN
Naghma Shahzada, CPC Arkansas City KS
Teresa Collier, CPC De Soto KS
Janice Price, CPC Emporia KS
Kimberly D Sampson, CPC Galena KS
Shirley Rosena Ferris, CPC Wellington KS
Lisa M Gasho, CPC, CPC-H Wichita KS
Barbara Guengerich, CPC Wichita KS
Sandra Guzman, CPC-H Wichita KS
Darrell Moore, CPC Wichita KS
Leah Watkins, CPC-H Wichita KS
Kelly Devilbiss, CPC Burlington KY
Julie A Bell, CPC Fairdale KY
Evette Rhodes, CPC Frankfort KY
Sandra Williams, CPC Independence KY
Kamlesh Dave, CPC LaGrange KY
Dorothea Soward, CPC Lexington KY
Stephanie Hudson, CPC Louisville KY
Kathy Judd, CPC Louisville KY
Jessica Ann Litsey, CPC Louisville KY
Shannon Mahoney, CPC Louisville KY
Carrie Zelch, CPC Louisville KY
Shirley Lisanby, CPC Madisonville KY
Janet Mattingly, CPC Pewee Valley KY
Robin Bush, CPC Winchester KY
Jackie G Boudreaux, LPN, CPC Ama LA
Cherie Mullooly, CPC Houma LA
Cynthia A Nelson, CPC Leesville LA
Debbie Nicholson Smith, CPC Shreveport LA
Ashley Broussard, CPC St Francisville LA
Suzanne Bourque, CPC Ashburnham MA
Rolando Montalvo, CPC Attleboro MA
Jane Ellen Pyche, CPC Auburn MA
Paige E Harris, CPC, CPC-H, CIRCC Beverly MA
Matthew Dryden Outten, CPC Boston MA
Mary Fitzgerald, CPC Braintree MA
Nancy Marie Stover, CPC Brockton MA
Melinda Bromberg, CPC, CPC-P Framingham MA
Lora Belknap, CPC Franklin MA
Kathie Ann Grupposo, CPC Franklin MA
Mary T Flagg, CPC Plymouth MA
Lee Ann Wielhouwer, CPC South Weymouth MA
Tami M Barna, CPC-H, CIRCC Springfield MA
Patricia A Hill, CPC Winchendon MA
Deborah Miller, CPC Baltimore MD
Mildred S Pessaro, CPC, CPC-H Bel Air MD
Brian Goldsberry, CPC Catonsville MD
Gretchen Chrisman, CPC Frederick MD
Jennie Masser Slifer, CPC Frederick MD
Pamela Woodard-Luallen, CPC Parkville MD
Jessica Nicole McCarson, CPC Rockville MD
Michelle Pyatt, CPC Portland ME
Sarah Lynn Faix, CPC Ann Arbor MI
Luci Hochrein, CPC Ann Arbor MI
Michelle Ann Kaikkonen, CPC Ann Arbor MI
Cheryl Ann Berney, CPC Barton City MI
Tammy Shephard, CPC Birch Run MI
Yvonne Nicole Cadoret, CPC Canton MI
Susan Renee Tews, CPC Canton MI
Christine Hillman, CPC Davisburg MI
Kimberly Ann Conrad, CPC Dexter MI
Jennifer Denison, CPC Goodrich MI
Andrea McKinzie, CIRCC Goodrich MI
Douglas Stephen Nagy, CPC Grand Rapids MI
Sally Wilkins, CPC Hickory Corners MI
Kaneshia K Fowler, CPC Jackson MI
Tammy Ann Stoker, CPC Jackson MI
Sherry Lynn Johnson, CPC Lawton MI
Mary Thomas, CPC Metamora MI
Cynthia Ann McLaughlan, CPC Milford MI
Danielle Mae Kalbarczyk, CPC Pleasant Lake MI
Jody Conn, CPC Pontiac MI
Melissa M Green, CPC, CPC-H Pontiac MI
Lori Meier, CPC Portage MI
Kelly Lynn Williams, CPC Rochester Hills MI
Maureen Smathers, CPC South Lyon MI
Kristina Lawrence, CPC Vicksburg MI
Denise Rogers, CPC Waterford MI
Michelle Blau, CPC West Bloomfield MI
Samika Boyd, CPC-H Westland MI
Jennifer Ann Cain, CPC Albertville MN
Theresa Jean Matthews, CPC Brooklyn Center MN
Jayne Marie Anderson, CPC, CPC-H Crookston MN
Debbie Miller, CPC Duluth MN
Jill Maruska, CPC Fosston MN
Lindsey Marie White, CPC Hibbing MN
Betsy Farrier, CPC Howard Lake MN
Katherine L Sijan, CPC, CPC-H, CPC-P
Inver Grove Heights MN
Brenda Ehalt, CPC Minnetrista MN
Sheryl L Toop, CPC Ramsey MN
Sharon Anderson, CPC-P St Louis Park MN
Carey E Shelton, CPC, CPC-P Columbia MO
Debra Ramey, CPC Raytown MO
Michelle LeAnn Holloway, CPC Rolla MO
Wendy Mattucks, CPC Saint Joseph MO
Catherine S Mohapp, CPC St Charles MO
Cynthia Day, CPC Strafford MO
Tina Howerton, CPC Webb City MO
Tammy Howell, CPC Amory MS
Stacia Nicole Gibson, CPC Brandon MS
Evana R Peterson, CPC Horn Lake MS
Ashley Marie Bullock, CPC Jackson MS
Sabrina L Saunders, CPC Jackson MS
Tanya Latricia Ward, CPC Lumberton MS
Angela D Brown, CPC Pearl MS
Jennifer Smith, CPC Vicksburg MS
Brandy Lee Hahn, CPC Great Falls MT
Dawn R Peterson, CPC Great Falls MT
Jean Randy Burback, CPC Helena MT
Brenda L Huston, CPC Missoula MT
Julie Kirasich, CPC Asheville NC
Crystal Patterson, CPC Dunn NC
Charlotte Louise Miles, CPC, CPC-P Greenville NC
Sophia Irvin, CPC Hope Mills NC
Shelia Atkins, CPC Oxford NC
Takisha Word, CPC Raleigh NC
Tomeka Phifer, CPC Troutman NC
Debbie D Matheson, CPC Valle Crucis NC
Crystal Smith Edwards, CPC Winterville NC
Mary Conyne, CPC Bismarck ND
Ronnell J Kulish, CPC Bismarck ND
Carol A Morast, CPC Bismarck ND
Melissa Okerson, CPC Bismarck ND
Sara Backman, CPC Fargo ND
Joleen R Splichal, CPC Garrison ND
Tami J Lantis, CPC Omaha NE
Allison K Williams, CPC Omaha NE
Dimple Patel, CPC Bradley NJ
Jaimini Patel, CPC Cliffside Park NJ
Angela M Janish, CPC Clifton NJ
Jasmin G Cachuela, CPC Dumont NJ
Roman Gontmakher, CPC-H Leonia NJ
Tammy Luttenberger, CPC Rockaway NJ
Michelle Caryn Grossguth, CPC Toms River NJ
Donna Pino, CPC Toms River NJ
Jennifer Hakala, CPC Las Vegas NV
Cissel Jaquez Viniegra, CPC Las vegas NV
Cynthia Pearson, CPC Las Vegas NV
Isabel Quinones, CPC Las Vegas NV
Sandi Rice, CPC-H Las Vegas NV
Pamela K R Makaea, CPC Atlantic Beach NY
Jane C Lee, CPC Brewster NY
Persis Christy, CPC Brooklyn NY
Alana Saunders, CPC Brooklyn NY
Nerine R Webb, CPC Brooklyn NY
Allison Ann Clement, CPC Carthage NY
Donna J Mills, CPC Catskill NY
Yusimil Perez, CPC East Elmhurst NY
Sreeja Karim, CPC Floral Park NY
Meiyi Zhao, CPC Flushing NY
Elaina Gonatas, CPC Forest Hills NY
Janelle Trenchfield, CPC Freeport NY
Leana Maks, CPC Fresh Meadows NY
Sonia Santoro, CPC Island Park NY
Ira Spector, CPC Jericho NY
Elsa M Zevallos, CPC Mount Kisco NY
Irene A Pecson, CPC Oakland Gardens NY
Jennifer Quic, CIRCC Richmond Hill NY
Donna Marie Lennox, CPC Sackets Harbor NY
Christopher W Schenk, CPC Sackets Harbor NY
Susan B Daley, CPC-H Walden NY
Susan Jane Hammond, CPC Watertown NY
Therese Warren, CPC Avon OH
Jodi Soeder, CPC Avon Lake OH
Melissa Ann Skaggs, CPC Bainbridge OH
Denise R Heckathorn, CPC Canton OH
Tina G Lewis, CPC Canton OH
Karen Sue Miller, CPC Canton OH
Deborah L Mayle, CPC Carrollton OH
Shannon Marie Clark, CPC Cincinnati OH
Marcella Melaragno, CPC Columbus OH
Angelina M Freiberger, CPC Dayton OH
Katherine Leff, CPC Dayton OH
Kathy Conley, CPC-H Delaware OH
Deena T Mayle, CPC E Canton OH
Molly Ann Backus, CPC Elyria OH
Keith E Scalli, CPC Elyria OH
Ashley Dawn Guinther, CPC Grove City OH
Thera Lee White, CPC Grove City OH
Leah Renee Hartman, CPC LaGrange OH
Lisa A Binkley, CPC Lima OH
Christine Krol, CPC Macedonia OH
Kimberly A Farley, CPC Marietta OH
Rebecca Anna Crookston, CPC Massillon OH
Teresa Wollett, CPC Nelsonville OH
Cheryl Lyn O'Toole, CPC New Richmond OH
Emily Bok, CPC North Ridgeville OH
Barbara Ganig, CPC North Ridgeville OH
Lisa McGrew, CPC Orient OH
Victoria Lynn Tankersley, CPC Pataskola OH
Jennifer Sue Cossin, CPC Reynoldsburg OH
Melanie D. Rideout, CPC, CPC-H Reynoldsburg OH
Angela LLoyd-King, CPC Solon OH
Cindy M Hoyt, CPC Uniontown OH
Jean Bruening, CPC Wadsworth OH
Karen S Giacomo, CPC Wadsworth OH
Kristie L Broadwater, CPC Wellington OH
Paula Andrysco, CPC-H Worthington OH
David L Moiel, CPC Clackamas OR
Jeffrey Todd Swanson, CPC Happy Valley OR
John J Kang, CPC Lake Oswego OR
Marilyn A Fay, CPC Milwaukie OR
Nazanin Sharifi, CPC Milwaukie OR
Neil Frederick Blair, CPC Portland OR
Wiley Vernon Chan, CPC Portland OR
Jane Y Chung, CPC Portland OR
Stephanie Detlefsen, CPC Portland OR
Joanne M Dierickx, CPC Portland OR
Susan Houseman, CPC Portland OR
Susan Kauffman, CPC Portland OR
Janet Diane Loewen, CPC Portland OR
Robert J Shneidman, CPC Portland OR
Jayne Weinmann, CPC Portland OR
Michael Peter McNamara, CPC Tualatin OR
Diana Kay Saddison, CPC West Linn OR
Jeanne Nicolle Burston, CPC Camp Hill PA
Elizabeth Anne Mathias, CPC Camp Hill PA
Catherine Cooney, CPC Collegeville PA
MaryJane Allegretto, CPC Erie PA
Judy Covatto, CPC Erie PA
Deborah Jean Czekai, CPC Erie PA
Virginia A Vommaro, CPC Erie PA
Laura Ann Wasielewski, CPC Erie PA
Jill Ann Bebout, CPC Glenshaw PA
Brittany Delgado, CPC Glenside PA
Marianne Shaffer, CPC Harrisburg PA
Heather Bennett, CPC Liverpool PA
Christa Lynn Champagne, CPC-H Monongahela PA
Peggy Rising, CPC Mt Bethel PA
Beth Ann Buckham, CPC Pittsburgh PA
Kim Wise, CPC Pittsburgh PA
Mariela Hachem, CPC East Providence RI
Dianne Marie McCarthy, CPC Wyoming RI
Heather Lynn Everhart, CPC Easley SC
Emily Drake Williams, CPC Easley SC
Kathleen L Depew, CPC Greer SC
Megan Thrift, CPC Mauldin SC
Sherri Lynn Clark, CPC Moncks Corner SC
Corrina Elaine Wyatt, CPC Pauline SC
Claressa Mandelle Craig, CPC Piedmont SC
Joanna Lynn Beckert, CPC Simpsonville SC
Jessica Keasler Hansen, CPC Simpsonville SC
Shawanda Brown, CPC Walterboro SC
Susan Worley, CPC-H Bon Aqua TN
Debra L Shrewsbury, CPC Bristol TN
Sarah Day, CPC Celina TN
Michelle Morton, CPC Gallatin TN
Karen E Lusk, CPC Johnson City TN
Kimberly A Tucker, CPC Johnson City TN
Lorie Chasteen, CPC Knoxville TN
Misti Miller, CPC Memphis TN
LaTisha Nash, CPC Amarillo TX
Catherine K Bond, CPC Arlington TX
Robyn Enbysk, CPC Austin TX
Loretta Lanell Harvey, CPC Austin TX
Barbara Kelly-Mahaffey, CPC-H, CPC-P Austin TX
Zenia Zenetta Gonzalez, CPC Cypress TX
Vanessa Yvette Margenau, CPC Deer Park TX
Susana Cadena, CPC El Paso TX
Yolanda Lynette Lewis, CPC Fort Worth TX
April Verret, CPC Fort Worth TX
Linda G Benoit, CPC Houston TX
Karin M Rockey, CPC Hurst TX
Karen Sliva, CPC Hutto TX
Karen Kay Baker, CPC Keller TX
Alice Janelle Escobar, CPC Lubbock TX
Shelene Christine Doss, CPC Royse City TX
Barbara Wampler, CPC Smithville TX
Cheri Hines, CPC Tuscola TX
Alaina Hoisington, CPC Elk Ridge UT
Earleen A Hilde, CPC, CPC-P Leeds UT
Amanda R Minor, CPC Carrollton VA
Cynthia Gail Mims, CPC-H Catawba VA
Melissa Christine Donafrio, CPC Chesapeake VA
Pamela Jeffreys, CPC Goochland VA
Kimberly R Davis, CPC Hampton VA
Djuanna Horne Mason, CPC Hampton VA
Jamie Ava Moss, CPC Hampton VA
Robin Lane Zuppa, CPC Mechanicsville VA
Tiffany Dawn Wilson, CPC Middletown VA
Susan Evelyn Davis, CPC Midlothian VA
Aspacia Anagianis, CPC Newport News VA
Terrie Cooper, CPC-H Newport News VA
Lindsay Nicole Hinton, CPC Newport News VA
Minerva Smith, CPC Newport News VA
Keshia Nicole Henderson, CPC Norfolk VA
Matthew Woodward, CPC Orange VA
Anita Tringle, CPC Portsmouth VA
Heather Michele Campbell, CPC Powhatan VA
Melissa Renee Childress, CPC Richmond VA
Kristin Michelle Edwards, CPC Richmond VA
Tina Lester, CPC Richmond VA
Lindsey Rice Rutledge, CPC Richmond VA
Deidre Allison Wason, CPC Richmond VA
Masae Iwasa Wetzler, CPC Richmond VA
Kelly Bayrer, CPC Roanoke VA
Angela Holland, CPC Roanoke VA
Angela Jackson, CPC Roanoke VA
Andrea Martin Lester, CPC Roanoke VA
Lindsey Webb Lyle, CPC, CPC-H Roanoke VA
E Juanita Wilhelm, CPC-H Roanoke VA
Lori R Wright, CPC Roanoke VA
Jan S Etter, CPC Staunton VA
Gemma Lyn Trahan, CPC Suffolk VA
Judy Bowyer, CPC Virginia Beach VA
Deborah L Liverman, CPC Virginia Beach VA
Tandra Lynn Napisa, CPC Virginia Beach VA
Frances Allen, CPC Wicomico Church VA
Julie C Smith, CPC Winchester VA
Nicole Marie Labell, CPC Bristol VT
Dana C Willette, CPC Burlington VT
Samantha Lynn Prince, CPC South Burlington VT
Sherry A Dion, CPC Winooski VT
Micki Martin, CPC Everett WA
Debi Bonner, CPC Kent WA
Caryn Smith, CPC Maple Valley WA
Laura Erickson, CPC-P Mountlake Terrace WA
Megan Jeann Mohler, CPC Puyallup WA
Kelly Marie Alden, CPC, CIRCC, CEMC, CGSC
Seattle WA
Margaret Louise Chambers, CPC, CPC-P Seattle WA
Gina L Rothrock, CPC Spanaway WA
Mike Geng-Li Lin, CPC Vancouver WA
Paurin Sangpatson, CPC Vancouver WA
Siu C Lee, CPC Woodinville WA
Wendy A Miller, CPC Appleton WI
Patrick T O'Reilly, CPC Appleton WI
Sandra Brunner, CPC Green Bay WI
Sara L Burrall, CPC Green Bay WI
Laura J Moeller, CPC Madison WI
Sherri Domres, CPC Marshfield WI
Bev Ott, CPC Marshfield WI
Charlene M Wienke, CPC Marshfield WI
Andrea Barick, CPC Mosinee WI
Carolyn Meyer, CPC New Richmond WI
Karen Benson, CPC Osceola WI
April Olson, CPC Schofield WI
Jodi R Larocque, CPC Spencer WI
Michelle Larsen, CPC Spencer WI
Carol Veers, CPC Stratford WI
Doris Wriston, CPC Glasgow WV
Apprentices
Veronica Bisbal, CPC-A APO AE
Dave K Lopez, CPC-A APO AE
Kay Michele Andrews, CPC-A Aleknagik AK
Michelle Annette Bottoms, CPC-A Anchorage AK
Michelle Murrills, CPC-A Anchorage AK
Sabina Virginia Seeberger, CPC-A Anchorage AK
Samantha Erin Georges, CPC-A Kenai AK
Suzanne Jeanine Jackson, CPC-A Kenai AK
Tess Ellen Welch, CPC-A North Pole AK
Melissa Blake, CPC-A Soldotna AK
Charlene Mae Tautfest, CPC-A Soldotna AK
Karen L Le Bon, CPC-A Wasilla AK
Lola Allen Griffith, CPC-A Dothan AL
Renea Simpson Mears, CPC-A Dothan AL
Sharon W Hunt, CPC-A Enterprise AL
Kristina Siegrist, CPC-A Fort Rucker AL
Brandy N Maddox, CPC-A Geneva AL
Deborah Lynn Falk, CPC-A Headland AL
Betty Nevin, CPC-A Bullhead City AZ
Marie E Gibbens, CPC-A Gilbert AZ
Jeffrey Myers, CPC-A Gilbert AZ
Gwen Christina Anthis, CPC-A Glendale AZ
Jody Walsh, CPC-A Litchfield Park AZ
Ellene K Eisentraut, CPC-A Mesa AZ
Malyssa Raye Everhart, CPC-A Mesa AZ
Elizabeth K Olson, CPC-A Overgaard AZ
Martha Meadows, CPC-A Payson AZ
Brittany N Byrley, CPC-A Peoria AZ
Wendy Sue Quamme, CPC-A Peoria AZ
Margaret M DeBorhegyi, CPC-A Phoenix AZ
Jennifer L Hall, CPC-A Phoenix AZ
James W Smith, CPC-A Phoenix AZ
Sandra Castro, CPC-A San Tan Valley AZ
Katherine Joy McDaniel, CPC-A Scottsdale AZ
Glenn Hommes, CPC-A Surprise AZ
Rebekka Begay, CPC-A Tempe AZ
Denise DeRose Coetzee, CPC-A Tucson AZ
Marisa Ramsey, CPC-A Tucson AZ
Christine A Schack, CPC-A Tucson AZ
Mary Case-Krupski, CPC-A Williams AZ
Patricia P Gonzalez, CPC-A Adelanto CA
Pooja W Yong, CPC-A Alviso CA
Genevieve E Francisco, CPC-A Antioch CA
Christian L Gilbert, CPC-A Apple Valley CA
Deepika Reddem, CPC-A Apple Valley CA
Charity King, CPC-A Bellflower CA
Caroline Kashani, CPC-A Beverly Hills CA
Pouneh Noroozian, CPC-A Beverly Hills CA
Rosa Kendall, CPC-A Burbank CA
Pamela Brenner, CPC-A Burlingame CA
Gail M Calderon, CPC-A Claremont CA
Kathleen West, CPC-A Corona CA
Marsha Cook, CPC-A Downey CA
Bonnie Yates, CPC-A Downey CA
Denise T Kraensel, CPC-A El Segundo CA
Zlata Kushnir, CPC-A Encino CA
Beverly Kay Ferris, CPC-A Fairfield CA
Mary L Visco, CPC-A Fremont CA
Guadalupe Guzman, CPC-A Huntington Park CA
Donna Bixler, CPC-A La Mesa CA
Marie Madeleine Lokula-Eongo, CPC-A Livermore CA
Steve Munoz, CPC-A Los Angeles CA
Maria Leticia Rubalcava, CPC-A Los Angeles CA
Delia Rosales, CPC-A Lynwood CA
Shari Crader, CPC-A Martinez CA
Evan Sokol, CPC-A Modesto CA
Nancy Singh, CPC-A Modesto CA
Jerri Clemons, CPC-A Mountain View CA
Elizabeth V Hsieh, CPC-A Mountain View CA
Margaret Nusbaum, CPC-A Northridge CA
Elvis Alarcon, CPC-A Norwalk CA
Charmaine Mae Gasit, CPC-A Norwalk CA
Deborah Lynn Roberts, CPC-A Oakland CA
Giselle Curatolo, CPC-A Phelan CA
Elisabet Gomez, CPC-A Pico Rivera CA
Monica Cutino, CPC-A Pittsburg CA
Vanessa Vigil, CPC-A Pomona CA
Mayra Cuevas, CPC-A Riverside CA
Loralie Lambert, CPC-A Riverside CA
Gwenda Van Hofwegen, CPC-A Riverside CA
Connie Lynn Smith, CPC-A San Bernardino CA
Leticia Ortiz, CPC-A San Diego CA
Christina Garcia, CPC-A San Francisco CA
Paris Hill, CPC-A San Francisco CA
Faye Marie Manalili, CPC-A San Francisco CA
Sri Warti, CPC-A San Francisco CA
Andre Anderson, CPC-A San Jose CA
John Carl Lammers, CPC-H-A San Mateo CA
Richard Chesnut, CPC-A Santa Clarita CA
Peter Bueschen Jr, CPC-A Simi Valley CA
Kathy Gomez, CPC-A South Gate CA
Sara A Guevara-Coronado, CPC-A South Gate CA
Elizabeth Ramirez, CPC-A South Gate CA
Margaret Chan, CPC-A Tiburon CA
Criselda M Hurtado, CPC-A Vacaville CA
Jose Raul Ramirez, CPC-A Ventura CA
Usha M Reddy, CPC-A Victorville CA
Seema Puri Regalado, CPC-A Whittier CA
Susan Regina Watkins, CPC-A Aurora CO
Staci Leigh, CPC-A Canon City CO
Lee Ann Fox, CPC-A Castle Rock CO
Rod Dominguez, CPC-A Denver CO
Jocelyn Murray, CPC-A Denver CO
Valerie Jean Oliva, CPC-A Denver CO
Barbara Ellen York, CPC-A Denver CO
Timothy J Otteman, CPC-A Lakewood CO
Jennifer Near, CPC-A Windsor CO
Daisy Sims Clay, CPC-A Bloomfield CT
Troy L Chapman, CPC-A Bridgeport CT
Dorota Chmielewska, CPC-A Bridgeport CT
Monica C Muncaciu, CPC-A Bridgeport CT
Linda Louise Smitas, CPC-A Brookfield CT
Donna Reed, CPC-A Clinton CT
Gail E Lechowicz, CPC-A Coventry CT
Bertha Ann Ewell, CPC-A Danbury CT
Brenda Griffin, CPC-A Danielson CT
Diane Morishige, CPC-A Deep River CT
Sumathi Somaiah, CPC-A East Hartford CT
Damon D Lucibello, CPC-A East Haven CT
Lina Monterroso, CPC-A East Haven CT
Christina M Rotharmel, CPC-A Groton CT
Ashley Weber, CPC-A Groton CT
Tonika Rhodes, CPC-A Meriden CT
Margaret A Bogart, CPC-A Mystic CT
Carmel DePino, CPC-A New Haven CT
Maria Klingel, CPC-A North Branford CT
Barbara L. Elmore, CPC-A Southburg CT
Christine Nobile, CPC-A Storrs CT
Coleen M French, CPC-A Thomaston CT
Elizabeth Cote, CPC-A Torrington CT
Eileen Shiu, CPC-A Wallingford CT
Dawn Dicrosta, CPC-A Waterbury CT
Karen Ortiz, CPC-A Waterford CT
Audra J Shiffer, CPC-A Watertown CT
Jason Carey, CPC-A West Haven CT
Valerie Allard, CPC-A Woodstock CT
Terri Warren, CPC-A Washington DC
Jennifer Offutt, CPC-A Harrington DE
Kathy D Quinn, CPC-A Hockessin DE
Hongping Tang, CPC-A Hockessin DE
Deborah Marie Mooney, CPC-A Middletown DE
Paul W Archer, CPC-A New Castle DE
Trinh Tri Luu, CPC-A Newark DE
Laurie Lynn Patton, CPC-A Newark DE
Marion A Gallo, CPC-A Wilmington DE
Patricia J Turner, CPC-H-A Wilmington DE
Martha Ann Love, CPC-A Apopka FL
Jody Sapolsky, CPC-A Boca Raton FL
Ashley Reardon, CPC-A Bonita Springs FL
Paul L Jenkins, CPC-A Bradenton FL
Cristina Picerno, CPC-A Brandon FL
Michell Tse, CPC-A Brandon FL
Allyson Rose Cohan, CPC-A Cape Coral FL
Laura A LaGuardia, CPC-A Cape Coral FL
Mercedes Lara, CPC-A Cape Coral FL
Renee Raynor, CPC-A, CPC-H-A Cape Coral FL
Elizabeth M Stoops, CPC-A Cape Coral FL
Shannon Wegmann, CPC-A, CPC-P-A Cape Coral FL
Antonia Yount-Iverson, CPC-A Cape Coral FL
Roberta Verville, CPC-A Ft Lauderdale FL
Harriet Jo Kotlar, CPC-A Ft Myers FL
Holly Lynn Mather, CPC-A Ft Myers FL
Mary Elizabeth Garcia, CPC-A Gulf Breeze FL
Gary Reed, CPC-A Jensen Beach FL
MaryLou A Layeni, CPC-A Lake Mary FL
Faye Couey, CPC-A Margate FL
Anette Delgado, CPC-A Miami Lakes FL
Linda Murphy, CPC-A Naples FL
Jennifer Wedge, CPC-A New Port Richey FL
Robin Link, CPC-A North Fort Myers FL
Mariann Puszkar, CPC-A North Port FL
LaTonya Anderson, CPC-A Ocoee FL
John Joseph Howley, CPC-A Orlando FL
Susan Marie Kruse, CPC-A Orlando FL
Kimberly Levy, CPC-A Orlando FL
Diana Patricia Smith, CPC-A Ormond Beach FL
Patricia Turovsky, CPC-A Oviedo FL
Shannon Marie Brown, CPC-A Pinellas Park FL
Thomas Guido, CPC-A Port St Lucie FL
Leni Haekler, CPC-A Port St Lucie FL
Judy Ann Hauser, CPC-A Port St Lucie FL
Jonathan Matthew Hutchinson, CPC-A Port St Lucie FL
Tammy Howe, CPC-A Port St Lucie FL
Mary Milmore, CPC-A Port St Lucie FL
Karen J Smith, CPC-A Port St Lucie FL
Jeanette J Coniglio, CPC-A Port St Lucie FL
Diane Bomba, CPC-A Riverview FL
Thomas Hainsworth, CPC-A Spring Hill FL
Brenda L Hawkins, CPC-A St Petersburg FL
Karla Abbott, CPC-A Stuart FL
Donna M Foster, CPC-A Stuart FL
Laurette Rae Howard, CPC-A Stuart FL
Sandra A Mieloch, CPC-A Stuart FL
Eileen Minaya, CPC-A Sunrise FL
Tevieca Johnson, CPC-A Tallahassee FL
Sandra Thomas, CPC-A Tampa FL
Kimberly Ann Waidler, CPC-A Tampa FL
Maureen Soliman, CPC-A Weeki Wachee FL
Catlin J Pollett, CPC-A Winter Garden FL
Elizabeth Heil, CPC-A Zephyrhills FL
Cynthia Reeves, CPC-A Alpharetta GA
Ivette Laseria, CPC-A Cataula GA
Devina Collier, CPC-A Cumming GA
Suzanne H Fletcher, CPC-A Cumming GA
Renita Fae Burnett-Grayson, CPC-A Decatur GA
Debra Bethel, CPC-A East Dublin GA
Leslie Kirkland, CPC-A Grayson GA
Gilbert F White, CPC-A Lithonia GA
Sara Gail Burkhalter, CPC-A Silver Creek GA
Doni Crisolo, CPC-A Honolulu HI
Jodie Fujimoto, CPC-A Honolulu HI
Grata Koo, CPC-A Honolulu HI
Lori Lilly, CPC-A Honolulu HI
Corinne Tasake, CPC-A Honolulu HI
Nicole Melton, CPC-A Kailua HI
Stephanie Nohealani Gaea, CPC-A Waianae HI
Amy VanBuskirk, CPC-A Akron IA
Melinda Sue Bird, CPC-A Council Bluffs IA
Kelly A Snitker, CPC-A Des Moines IA
Melissa Mary Scott, CPC-A Missouri Valley IA
LuAnn K Boehm, CPC-A Treynor IA
Nicole Abajian, CPC-A Boise ID
Cynthia Gagnon, CPC-A Boise ID
Paula Hansen, CPC-A Boise ID
Jacque Kluck, CPC-A Boise ID
Levi LaSarte, CPC-A Boise ID
Jennifer Lober, CPC-A Boise ID
Eve Marostica, CPC-A Boise ID
Jennifer Miller, CPC-A Boise ID
Amy Poe, CPC-A Boise ID
Richard Rubert, CPC-A Boise ID
Joseph K Yaeger, CPC-A Caldwell ID
Patricia Van Quaethem, CPC-A Kuna ID
Lisa Petsche, CPC-A Meridian ID
Shannon Zapata, CPC-A Meridian ID
Nicole Cox, CPC-A Alton IL
Ana Dukic, CPC-A Bolingbrook IL
Donna Jean Judge, CPC-A Bolingbrook IL
Candace Anne Douglass, CPC-A Byron IL
Samantha Rene Geeseman, CPC-A Canton IL
Laura Ann Howard, CPC-A Canton IL
Courtney Hinds, CPC-A Chicago IL
Marlyn Martinez, CPC-A Chicago IL
Damaris Pacheco, CPC-A Chicago IL
Lillian Roberta Perry, CPC-A Chicago IL
Brenda Sue Butler, CPC-A Columbia IL
Kathryn Fraher, CPC-A Custer Park IL
Sarah Martins, CPC-A Dakota IL
Hannah M.K. Zimmerman, CPC-A Dakota IL
Ida Mae Eddington, CPC-A Dawson IL
Julie Andrea Floray, CPC-A Dixon IL
Melissa M Stowell, CPC-A Dixon IL
Patti K Susan, CPC-A Dixon IL
Janice Louise Wagner, CPC-A Dixon IL
Michelle Lynn Wolf, CPC-A Dixon IL
Courtney Nicole Pruitt, CPC-A Forreston IL
Dionis R Fleischer, CPC-A Freeport IL
Rebecca Jean Meinert, CPC-A Freeport IL
Jessica Gail Robertson, CPC-A Freeport IL
Kristi Lea Smith, CPC-A Freeport IL
Jeannine C Frye, CPC-A German Valley IL
Marjorie M Payne, CPC-A Green Valley IL
Carla L Case, CPC-A Havana IL
Kristy Ann Payton, CPC-A Havana IL
www.aapc.com
September 2010
39
Dianna M Budde, CPC-A Jacksonville IL
Susan A Stevenson, CPC-A Kankakee IL
Sandra D Pierson, CPC-A Knoxville IL
Angela Marie Weber, CPC-A Lacon IL
Lori A Meyers, CPC-A Lena IL
Sarrah Cathleen Terhune, CPC-A Lena IL
Herbert Turner, CPC-A Lombard IL
Cheryl L Lignell, CPC-A Loves Park IL
Ashley Lissetta Edwards, CPC-A Macomb IL
Elizabeth M Morris, CPC-A Manito IL
Tauni Carter, CPC-A Mazon IL
Janice G Staley, CPC-A Milledgeville IL
Terri L Raisbeck, CPC-A Mount Carroll IL
Debbie Platou, CPC-A Naperville IL
Kimberly Victoria, CPC-A New Lenox IL
Denise Renee Slager, CPC-A Oregon IL
Karen Alfano, CPC-A Orland Park IL
Tina Swenny, CPC-A Pana IL
Jason Samuel Wrigley, CPC-A Pekin IL
Jeanne Rozanski, CPC-A Plainfield IL
Jennifer A Diehl, CPC-A Polo IL
Robin Dee Imel, CPC-A Polo IL
Linda L Sutton, CPC-A Polo IL
Brittany Nicole McClure, CPC-A Princeton IL
Tiffany R Flack, CPC-A Rock City IL
Lisa Marie Schwab, CPC-A Rock Falls IL
Robyn Alford, CPC-A Schaumburg IL
Trisha L Pannkuk, CPC-A Shannon IL
Autumn Joy Sheetz, CPC-A Spring Bay IL
Jeremy A Izzard, CPC-A Springfield IL
Jean Termini, CPC-A Steger IL
Heather R Crofts, CPC-A Sterling IL
Kate A Gillespie, CPC-A Sterling IL
Jennifer Mae Rogers, CPC-A Sterling IL
Angie Rae Shimon, CPC-A Sterling IL
Tamara Ortiz, CPC-A Stickney IL
Mindy Ann Gorman, CPC-A West Peoria IL
Sarah Skirvin, CPC-A Beech Grove IN
Leon Creech, CPC-A Churubusco IN
Lacy M Eguia, CPC-A Decatur IN
Lauren A Haiflich, CPC-A Ft Wayne IN
Tina Marie Schultis, CPC-A Ft Wayne IN
Linda Downey, CPC-A Indianapolis IN
Stephany Elias, CPC-A Indianapolis IN
Angela Margaret Hickman, CPC-A Indianapolis IN
Sherryl Meyers, CPC-A Indianapolis IN
Beverly Kay Schwegman, CPC-A Indianapolis IN
Nyree Sellars, CPC-A Indianapolis IN
Joyce Ann Voirol, CPC-A Monroeville IN
Randy Alan Colby, CPC-A Pittsboro IN
Diane Kranich, CPC-A Wheatfield IN
Paula Nichols, CPC-A Augusta KS
Felicia A'vise Newman, CPC-A Bonner Springs KS
Chelsea Ione Johnson, CPC-A Carbondale KS
Jessica Rae Smith, CPC-A Carbondale KS
Shawn Williams, CPC-A Leavenworth KS
Marcia Glueck, CPC-A Leawood KS
Marla Brems, CPC-A Overland Park KS
Ellen Granstrom Bray, CPC-A Shawnee Mission KS
Sherry Pullen, CPC-A Wichita KS
Tracy Wigley, CPC-A Wichita KS
Crystal Lynn Burton, CPC-A Bowling Green KY
Aaron Dutton, CPC-A Brandnburg KY
Melissa A DeVries, CPC-A Crestwood KY
Timna Williams, CPC-A Dry Ridge KY
Jennifer Parker, CPC-A Florence KY
James Brad Greever, CPC-A Glasgow KY
Angie Marie Hampton, CPC-A Independence KY
Sarah Martinez, CPC-A Independence KY
John Meredith, CPC-A Lexington KY
Shannon Terrell Brown, CPC-A Louisville KY
Kevin Cuthbertson, CPC-A Louisville KY
Deanna G Davis, CPC-A Louisville KY
Theresa Rae Griffiths, CPC-A Louisville KY
Dina Grivicic, CPC-A Louisville KY
Myles Douglas Gullett, CPC-A Louisville KY
Vinodini Kulkarni, CPC-A Louisville KY
Michael Myers, CPC-A Louisville KY
Joshua Edward Neukam, CPC-A Louisville KY
Danelle D Newson, CPC-A Louisville KY
Lisa Michelle Puryear, CPC-A Louisville KY
Erin Kathleen Shea, CPC-A Louisville KY
Yolanda Smith, CPC-A Louisville KY
Stephanie Valdez-Thomas, CPC-A Louisville KY
Veronica Waddles, CPC-A Mount Vernon KY
Tina Vance, CPC-A Richmond KY
Fredia B Gilliam, CPC-A Scottsville KY
Cathy Arleen Barnett, CPC-A, CPC-H-A Taylorsville KY
40 AAPC Coding Edge
Rhonda Olt, CPC-A Taylorsville KY
Donna Brinkman, CPC-A Union KY
Toni Pratt, CPC-A Winchester KY
Julie Ann-Marie Debeauville, CPC-A Benton LA
Ashley Denise McKnight, CPC-A Bossier City LA
Millie Smithson, CPC-A Bossier City LA
Tiffany Young, CPC-A Bossier City LA
Deondra Deanne Irving, CPC-A Harvey LA
Gina Corvers, CPC-A River Ridge LA
Lauren Andrews Edwards, CPC-A Shreveport LA
Margaret Anne Hostetter, CPC-A Shreveport LA
Angela R Koen, CPC-A Shreveport LA
Jennifer Suzanne Rhoads, CPC-A Shreveport LA
Angela Scott, CPC-A Shreveport LA
Laura Norman Steward, CPC-A Shreveport LA
Kaycee Mae Streetman, CPC-A Shreveport LA
Alica Kathleen Kittle, CPC-A Stonewall LA
Sarah Wood, CPC-A Ashland MA
Donna Pope, CPC-A Boston MA
Robert Oliveira, CPC-A Marshfield MA
Sherry A Scully, CPC-A New Bedford MA
Mary Jean Conlon, CPC-A Quincy MA
Alres Dinnall, CPC-A Springfield MA
Shari Johnson, CPC-A Springfield MA
Lorraine Aniello, CPC-A Annapolis MD
Patricia Anne Burris, CPC-A Cecilton MD
Lisa Douthit, CPC-A Centreville MD
Sharyn Crump, CPC-A College Park MD
Debbie Caldwell, CPC-A Columbia MD
Renee Campbell, CPC-A Columbia MD
Barbara T Archer, CPC-A Easton MD
Linda Oliver, CPC-A Easton MD
Patricia Serio, CPC-A Easton MD
Kimberly Shorter, CPC-A Easton MD
Harinder Kaur, CPC-H-A Edgewood MD
Binu Cherian, CPC-A Ellicott City MD
Jayan Jacob, CPC-A Ellicott City MD
Rebecca Jean Smith, CPC-A Frederick MD
Denise Ann Perkins, CPC-A Keedysville MD
Aziza Z Wilson, CPC-A Laurel MD
Erin Danielle Mielke, CPC-A Middletown MD
David Lee Wenner Jr., CPC-A Middletown MD
Keri A Diebold, CPC-A North East MD
Deborah Lennon, CPC-A Owings Mills MD
Ghazala Chohan, CPC-A Reisterstown MD
Monica L Scharp, CPC-A Thurmont MD
Linda Flynn, CPC-A Berwick ME
Karen Begin, CPC-A Sanford ME
Melissa Fromm, CPC-A Athens MI
Linda Hogan, CPC-A Auburn Hills MI
Donna Leyman, CPC-A Belleville MI
Suzanne Garrett, CPC-A Dearborn Hts MI
Bridgette Ampey, CPC-A Kalamazoo MI
Elizabeth Wilson, CPC-A Leonard MI
Marlene Khzouz, CPC-A Livonia MI
Shawn Sobaszko, CPC-A Livonia MI
Kellie Boudrie, CPC-A Luna Pier MI
Shawn Adams, CPC-A Newaygo MI
Julie Marie Cook, CPC-A Niles MI
Lyna Mok, CPC-A Owosso MI
Penny Costello, CPC-A Paw Paw MI
Jacqulyn L Hagan, CPC-A Plymouth MI
Michelle Souligney, CPC-A Roseville MI
Rachael Schlaufman, CPC-A Warren MI
Barbara Marie Shipman, CPC-H-A Ypsilanti MI
Julie Meyer, CPC-A Buckman MN
Debra J Kurt, CPC-A Cohasset MN
Charissa Marie Hauff, CPC-A Eden Prairie MN
Kathryn Bonnie, CPC-A Hampton MN
Lila Halverson, CPC-A Pillager MN
Julie Solem, CPC-A St Anthony MN
Kimberly Severs, CPC-A Underwood MN
Alanna Epping, CPC-P-A Waconia MN
Yamila Ismail Jaber, CPC-A Cederbill MO
Frances Ann Balke, CPC-A Eugene MO
Roger L Smith, CPC-A Florissant MO
Jennifer Dawn Colborn, CPC-A Jonesburg MO
Deloris Lea Coffer, CPC-A Kansas City MO
Sandra Garcia-Kane, CPC-A Kansas City MO
Sabrina Hunt, CPC-A Kansas City MO
Gretchen Marie Jay, CPC-A Kansas City MO
Stephanie J Pope, CPC-A Kansas City MO
Marilyn Sunta, CPC-A Kansas City MO
Scott Crosby, CPC-A St Ann MO
Denise Ilene Crawford, CPC-A St Louis MO
Karon D Harpole, CPC-A St Louis MO
Shavon Renee Works, CPC-A St Louis MO
Terri A Harrell, CPC-A Warrenton MO
Kristina Michelle Stufflebean, CPC-A Warrenton MO
Stacy Elizabeth Lastinger, CPC-A Wentzville MO
Marschand K Martin, CPC-A Clinton MS
Megan Wissing, CPC-A Diamondhead MS
Robert Michael Windham, CPC-A Ripley MS
Becky Coleman, CPC-A Wesson MS
Susan M Wall, CPC-A Alberton MT
Jessie Leanne Howlett, CPC-A East Helena MT
Richard E Martin, CPC-A East Helena MT
Michelle Lynn Shannon, CPC-A East Helena MT
Carrie Ann Cameron, CPC-A Great Falls MT
Dawn Renee Atwood, CPC-A Helena MT
Debra Lynne Gray, CPC-A Helena MT
Renea M Howard, CPC-A Helena MT
Bessye Rae Pretty Weasel, CPC-A Helena MT
Jennifer Marie Wilson, CPC-A Helena MT
Brandee Lee Zitnik, CPC-A Helena MT
Scott R Cannon, CPC-A St Regis MT
Libby Ragan, CPC-A Boone NC
Lisa Ann Dodson, CPC-A Burlington NC
Dana Theiss, CPC-A Burlington NC
Mary Louise Barringer, CPC-A Charlotte NC
Lynette Canady, CPC-A Charlotte NC
Lavonne M Daniel, CPC-A Charlotte NC
Shannon Mouzon, CPC-A Charlotte NC
Geryl Deloris Rice, CPC-A Concord NC
Sarah Eldridge, CPC-A Durham NC
Delphina Josephine Peluso, CPC-A Fayetteville NC
Tanya Brooks, CPC-A Kannapolis NC
Dawn Henry, CPC-A Matthews NC
Patricia Jones, CPC-A Matthews NC
Gregory Homjak, CPC-A Monroe NC
Tina Harris Mills, CPC-A Oriental NC
Channing Paschal, CPC-A Raeford NC
Traci Richter, CPC-A Sanford NC
Lisa Wade Basden, CPC-A Seven Springs NC
Karen Van Dexter, CPC-A Spring Lake NC
Brittany Nicholson, CPC-A Statesville NC
Jandyl Doyle, CPC-A Wake Forest NC
Brook Masters, CPC-A Wake Forest NC
Amanda Medlin, CPC-A Wake Forest NC
Becky Gardina, CPC-A Waxhaw NC
Karen Mayer, CPC-A Fargo ND
Wendy Mathison, CPC-A Reiles Acres ND
Denise M Herman, CPC-A Bellevue NE
Kyu C McCarron, CPC-A, CPC-H-A Bellevue NE
Chris Alan Michener, CPC-A Bellevue NE
Anna L Miller, CPC-A Bellevue NE
Stephanie L Manganaro, CPC-A Bennington NE
Marilyn T Faulconer, CPC-A Elkhorn NE
Stephanie A Schmidt-Fuhrman, CPC-A Elkhorn NE
Kandi G Stafford, CPC-A Herman NE
Lindsey Walsh, CPC-A Lincoln NE
Jazmin F Bellido, CPC-A Omaha NE
Shelda L Cole, CPC-A Omaha NE
Allison A Cuva, CPC-A Omaha NE
Felicia R Hadnot, CPC-A Omaha NE
Pallavi Mohanty, CPC-A Omaha NE
Bonnie L Niemeier, CPC-A Omaha NE
Audrya G Pappas, CPC-A Omaha NE
Daniel M Shepard, CPC-A Omaha NE
Cynthia M Wingert, CPC-A Omaha NE
Shereen Rahimi, CPC-A Derry NH
Dawn Paine, CPC-A Greenville NH
Michelle Kelley, CPC-A Londonderry NH
Jennifer Lucido, CPC-A Londonderry NH
Jennifer Williams, CPC-A Manchester NH
Janice Bosteels, CPC-A Nashua NH
Linda C Smith, CPC-A Nashua NH
Dawn Frampton, CPC-A New Castle NH
Deanine Donohoe, CPC-A Newton NH
Pamela Stypinski, CPC-A Webster NH
Renee M Odenheimer, CPC-A Bayville NJ
Melissa Gaudreau, CPC-A Browns Mills NJ
Neal Goldman, CPC-A Cherry Hill NJ
Jessica Lynn Chmiel, CPC-A Clifton NJ
Visalakshi Dindigal, CPC-A East Windsor NJ
Elaine Zager, CPC-A Ewing NJ
Alan Beckman, CPC-A Flemington NJ
Jonathan Estaris Garcia, CPC-A Jersey NJ
Robyn Malejko, CPC-A Lake Hopatcong NJ
Whitney Holman, CPC-A Marlton NJ
Michelle Lee Preziosa, CPC-A Mt Holly NJ
David O'Hearn, CPC-A Normandy Beach NJ
Mary Louise Matthews, CPC-H-A Pitman NJ
Joan M Santanello, CPC-A Point Pleasant Beach NJ
Lisa-Marie Clark, CPC-A Red Bank NJ
Miroslava Brach, CPC-A Toms River NJ
Donna Lee Cisco, CPC-A Toms River NJ
Paul J Lynn, CPC-A Toms River NJ
Jinky Cabanero, CPC-A Union NJ
Linda Carol Carter, CPC-A Albuqerque NM
Michelle Baker, CPC-A Las Vegas NV
Kris E Fiddler, CPC-A Adams NY
Wes Wilkert, CPC-H-A Apalachin NY
Diana Crasno, CPC-A Bronx NY
Jules A Hamilton, CPC-A Bronx NY
Tiffany Yvonne Becton, CPC-A Brooklyn NY
Hyacinth Guy, CPC-A Brooklyn NY
Latoya Faye Isidore, CPC-A Brooklyn NY
Francoise Neptune, CPC-A Cambria Heights NY
Carmen Raye Applegarth, CPC-A Candor NY
Lori Ann Marotta, CPC-A Copiaque NY
Francine Beaulieu, CPC-A Coram NY
Panagiota Korisianos, CPC-A Flushing NY
Martha Fernandez, CPC-A New Hyde Park NY
Patricia Maria Silva, CPC-A New York NY
Mary E Mathews, CPC-A North Babylon NY
Michelle T Sebastian, CPC-A Owego NY
Tracey I Egbo, CPC-A Rosedale NY
Christopher CA Ellis, CPC-A Rosedale NY
Sanjay K Arya, CPC-A Scarsdale NY
Tiffany R Herring, CPC-A West Hempstead NY
Marisol Lopez, CPC-A Woodside NY
Cornelius Samuel Doss, CPC-A Yonkers NY
Terry L Gerber, CPC-A Amherst OH
Kelly M Orrenmaa, CPC-A Ashtabula OH
Sean Scanlon, CPC-A Brunswick OH
Jennifer Hattery, CPC-A Canton OH
Virginia Ella Armes, CPC-A Cincinnati OH
Dianne Carol Butler, CPC-A Cleveland OH
Valerie Rogers, CPC-A Cleveland OH
Stacy R Danforth, CPC-A Conneaut OH
Veronica Mae Ballew, CPC-A Dalton OH
Brittany Lacock, CPC-A Elyria OH
Erika A Taylor, CPC-A Elyria OH
Linda Marie Valencic, CPC-A Elyria OH
Shannon Moore, CPC-A Girard OH
Emily Diane Graham, CPC-A Grove City OH
Mary Niceswanger, CPC-A McConnelsville OH
Jennifer Kendro, CPC-A Medina OH
Leah L Skinner, CPC-A Miamisburg OH
Tamarin Danford, CPC-A North Ridgeville OH
Kelly Ferrell, CPC-A North Ridgeville OH
Tara Debevec, CPC-A Roaming Shores OH
Jisha Indiradeviamma, CPC-A Solon OH
Krystle Hernandez, CPC-A Strongsville OH
Chandra Nedro, CPC-A Vermilion OH
Debbie Ball, CPC-A Wellington OH
Bryanna Brown, CPC-A Wellington OH
Kandise J Whitney, CPC-A Wellington OH
Jo Anne Fannin, CPC-A Willoughby OH
Mary Rees Rees, CPC-A Wooster OH
Dale Constantino, CPC-A Bristow OK
Cindy J Branson, CPC-A Shawnee OK
Melonie Monique Taylor, CPC-A Tecumseh OK
Anne Catherine Alsabrook, CPC-A Tulsa OK
Reid Sanders, CPC-A Bend OR
Marie Clinton, CPC-A Deer Island OR
Marie Littleton, CPC-A Hillsboro OR
Mallory Espejo, CPC-A McMinnville OR
Mary Ellen Griffin, CPC-A Portland OR
Heather Smith, CPC-A Portland OR
Zachary Posch, CPC-A Rainier OR
Kathy DeMello, CPC-A Sherwood OR
Christopher Carstensen, CPC-A Tigard OR
Teresa Marie Anderson, CPC-A Troutdale OR
Barbara Shubin, CPC-A Turner OR
Gwenn Amos, CPC-A Ambler PA
Judy Conner, CPC-A Berwick PA
Regina M King, CPC-A Blue Bell PA
Deborah Gaspari, CPC-A Camp Hill PA
Dana Lee Shade, CPC-A Camp Hill PA
Debra Scudder, CPC-A Carlisle PA
Belinda A Croak, CPC-A Chadds Ford PA
Deena Smith, CPC-A Conshohocken PA
Lindsey M Ream, CPC-A Dauphin PA
Jaclyn Suzanne Rogers, CPC-A Duncannon PA
Stephanie Larcinese, CPC-A Eagleville PA
Nicole Yeager, CPC-A Easton PA
Shari Kay Waldman, CPC-A Enola PA
Miranda Grom, CPC-A Erie PA
Leslie A Stewart, CPC-A Erie PA
Robbin Dale Green, CPC-A Friendsville PA
Catherine Plank, CPC-A Green Lane PA
Janine Woodhouse, CPC-A Green Lane PA
VaDenea K Barges, CPC-A Greencastle PA
Claudia W Briggs, CPC-A Harrisburg PA
Mark L Goldman, CPC-A Harrisburg PA
Jodi Iannarone, CPC-A Hatboro PA
Daniel McLaughlin, CPC-A Kennett Square PA
Shawn Scavone, CPC-A King of Prussia PA
Heather Chavez, CPC-A Lancaster PA
Ewa Krzeminska, CPC-A Lancaster PA
Elizabeth Mathew, CPC-A Langhorne PA
Jeffrey L Grinnage, CPC-A Lebanon PA
Jaimie Baxter, CPC-A Mount Joy PA
Robert Paul Hernandez, CPC-A Mt Bethel PA
Barbara Eisenhart, CPC-A New Berlinville PA
Debra M Lackey, CPC-A New Cumberland PA
Lillian O'Donnell, CPC-A Norristown PA
Theresa Hudson, CPC-A Philadelphia PA
Rashidah Robinson, CPC-A Philadelphia PA
Lisa Jane Carness, CPC-H-A Pittsburgh PA
Paula Garrison, CPC-A Pocono Summit PA
Brenda Conbeer, CPC-A Pottstown PA
Penelope A Mylin, CPC-A Quarryville PA
Christine Brinson, CPC-A Royersford PA
Gene Kati, CPC-A Sharon PA
Sherry Waltemire, CPC-A Shermansdale PA
Marian Valevas, CPC-A Skippacl PA
Danielle N Werntz, CPC-A Strasburg PA
Jennifer Weiss, CPC-A Whitehall PA
Shelley Anne Wilcox, CPC-A York PA
Joanne Legro, CPC-A Barrington RI
Susan Sirois, CPC-A Chepachet RI
Emily Miga, CPC-A Cranston RI
Katherine A Smith, CPC-A Exeter RI
Linda Ann Mallozzi, CPC-A Glocester RI
Samantha Caparelli, CPC-A Johnston RI
Elizabeth Ashley, CPC-A Narragansett RI
Lisa Davies, CPC-A North Kingstown RI
Jane Crossley, CPC-H-A Providence RI
Elizabeth Driscoll, CPC-A Providence RI
Deborah Ann Lee, CPC-A Rumford RI
Cassidy Silvia, CPC-A Tiverton RI
Nicole Cann, CPC-A Warwick RI
Sharon Rand, CPC-A West Kingston RI
Leila Brittany Walters, CPC-A Abbeville SC
Kristen Leanne Loffler, CPC-A Anderson SC
Christina Ann Brown, CPC-A Belton SC
Christine Lee Shaffer, CPC-A Blythewood SC
Audrey Diana Edwards, CPC-A Easley SC
Jorge Rojo Lopez, CPC-A Greenville SC
Emily Elizabeth Dorn, CPC-A Greenwood SC
Heather Leigh Corley, CPC-A Johnston SC
Diane Bishop, CPC-A Piedmont SC
Margie Nesbitt Morse, CPC-A Prosperity SC
Revada P Moon, CPC-A Redmont SC
Kelli H Cross, CPC-A Society Hill SC
Eva K Davis, CPC-A Travelers Rest SC
Tami Renae Napoli, CPC-A Rapid City SD
Janzen Scinta, CPC-A Antioch TN
Jo Wolff, CPC-A Blountville TN
Charlotte Ann Phinnessee, CPC-A Brownsville TN
Deborah S Blansit, CPC-A Chattanooga TN
Mary Feickert, CPC-A Franklin TN
Vicki D Seeley, CPC-A Hixson TN
Ava Keller, CPC-A Jackson TN
Lydia Nichole Garst, CPC-A Jonesborough TN
Michelle Czynszak, CPC-A La Vergne TN
Lisa Luter, CPC-A McEwen TN
Nikki Linnea Golden, CPC-A Memphis TN
Denise M Plunkett, CPC-A Memphis TN
Stacey Marie McCord, CPC-A Murfreesboro TN
Jharna Charudatta Barapatrey, CPC-A Nashville TN
Patricia Gearheart, CPC-A Nashville TN
Bonita Laneise House, CPC-A Nashville TN
Deqa Hassan Mohamed, CPC-A Nashville TN
Kisha B Stewart, CPC-A Nashville TN
Kacie Lee Sorace, CPC-A Pegram TN
Amanda J Mills, CPC-A Soddy Daisy TN
Sheila C Troutt, CPC-A Westmoreland TN
Kari Lynn Carver, CPC-A Amarillo TX
Noemi Grimes, CPC-A Brady TX
Candice Golden, CPC-A Cleburne TX
Toni Gonzalez, CPC-A Clint TX
Yvonne Renee Wright, CPC-A El Paso TX
Linda Michele Isaacs, CPC-A Fort Worth TX
Amber Scott, CPC-A Fort Worth TX
Lisa Rena Simmons, CPC-A Gladewater TX
Margaret Brewer, CPC-A Houston TX
Natalie Catherine Dias, CPC-A Houston TX
Melanie Martin, CPC-A Houston TX
Dana Buenger, CPC-A Hurst TX
Keren Takesue, CPC-A Irving TX
Jennifer Gonzales, CPC-A Keller TX
Sally W Edwards, CPC-A Pasadena TX
Vanessa Danielle Darden, CPC-A River Oaks TX
Jeremy Lyman, CPC-A Cedar Hills UT
Vicki Griego, CPC-A Kearns UT
Susan Bristow, CPC-A Lehi UT
Bethany Everett, CPC-A Murray UT
Vicky Benzon, CPC-A Riverton UT
Lorraine Cunningham, CPC-A Riverton UT
Shannon A Salcedo, CPC-A Riverton UT
Diana L Chase, CPC-A Salt Lake City UT
Lori Muhlestein, CPC-A Salt Lake City UT
Angela Cox, CPC-A Sandy UT
Sue Kiisel, CPC-A Sandy UT
Alyssa Mann, CPC-A Sandy UT
Malissa Giles, CPC-A South Jordan UT
Regie O'Neil, CPC-A South Jordan UT
Lissa Winget, CPC-A South Salt Lake UT
Lacey Sandoval, CPC-A West Jordan UT
Liz L Wheeler, CPC-A West Jordan UT
Zehra Rauf, CPC-A Bedford VA
Robin Houston Bolden, CPC-A Chesapeake VA
Donna Lee Demski, CPC-A Cross Junction VA
Theresa Highsmith, CPC-A Dumfries VA
Kimberly Krusie Dickerson, CPC-A Edinburg VA
Julia Marie Boswell, CPC-A Front Royal VA
Megan Louise Perrero, CPC-A Front Royal VA
Linda Sue Sheldon, CPC-A Front Royal VA
Amber Leigh Gonzalez, CPC-A Ft Eustis VA
Zulfikar Ali, CPC-A Glen Allen VA
Ben Beach, CPC-A Glen Allen VA
Lee A Dibble, CPC-A Hampton VA
Brooke Jasmine Waugh, CPC-A Harrisonburg VA
Marissa Davis, CPC-A Herndon VA
Hillary Mariah Callis, CPC-A Hudgins VA
Katie Walker, CPC-A Kilmarnock VA
Brenda Ann Smith, CPC-A Lebanon Church VA
Ashley D Moffett, CPC-A Middletown VA
Anita Gale Chenault, CPC-A Newport News VA
Annette Leone Gravely, CPC-A Newport News VA
Travis Dyer Gravely, CPC-A Newport News VA
Luz E Mendez, CPC-A Newport News VA
Janet Grant, CPC-A Norfolk VA
Charlene P Goodson, CPC-A Poquoson VA
Elizabeth Dozier, CPC-A Richmond VA
Shelley Duganne Ergens, CPC-A Richmond VA
David Leon Muroski, CPC-A Richmond VA
Kimberly Fisher Coleman, CPC-A Roanoke VA
Jennifer Dooley, CPC-A Roanoke VA
Tracy Goodwin, CPC-A Roanoke VA
Terri Lynch, CPC-A Roanoke VA
Linda Nader, CPC-A Roanoke VA
Susan Ormsbee, CPC-A Roanoke VA
Sarah Sotherden, CPC-A Roanoke VA
Sally Stanley, CPC-A Roanoke VA
Evelyn Wright, CPC-A Roanoke VA
Kathryn Kiser, CPC-A Stanton VA
Susan Paige Heller, CPC-A Stephens City VA
Paula Jean Knight, CPC-A Stephens City VA
Chelsea Jennings, CPC-A Stuarts Draft VA
Michael Nedelman, CPC-A Vienna VA
Mark Santos Sabater, CPC-A Virginia Beach VA
Christine Hewitt, CPC-A Waynesboro VA
Judy Moyers, CPC-A Waynesboro VA
Paula Poole, CPC-A Waynesboro VA
Donna Marie Moore, CPC-A Williamsburg VA
Mariela Alejandra Delgadillo, CPC-A Winchester VA
Janelle D McClain, CPC-A Winchester VA
Gwynn Dolores Middleton, CPC-A Woodstock VA
Wendy Carol Yarnold, CPC-A Woodstock VA
Deborah K Murray, CPC-A Yorktown VA
Thomas G Leary, CPC-A Burlington VT
Teresa Ann Dorr, CPC-A Pittsford VT
Bekah Kutt, CPC-A Williston VT
Gerald Westmore, CPC-A Auburn WA
Steven Carter, CPC-A Burien WA
Deanna Endsley, CPC-A Des Moines WA
Kim Porter, CPC-A Marysville WA
Carol L Fike, CPC-A Olympia WA
Tannis Alley, CPC-A Port Townsend WA
Takemi Alyse Marston, CPC-A Puyallup WA
Jennifer Joan Thomas, CPC-A Puyallup WA
Marie Joy Estacio, CPC-A Seattle WA
Marlene Smith, CPC-A Bay City WI
Victoria Casperson, CPC-A Oshkosh WI
Gayle L Hanneman, CPC-A Plover WI
Bonnie DeRosier, CPC-A South Range WI
Lisa Kerber, CPC-A Wauwatosa WI
Wendy Lynn Fait, CPC-A Wisconsin WI
Sherry Ann Russell, CPC-A Charleston WV
Lynn Noelle Williams, CPC-A Inwood WV
Cindy Freeman, CPC-A Parkersburg WV
Chirstine Roush, CPC-A Parkersburg WV
Traci Michelle Houchins, CPC-A Shady Spring WV
Christopher Paul Knapp, CPC-A West Columbia WV
Specialties
Layla Eberlein,
COSC Mobile AL
Kelly Jo Cieszinski,
CPEDC Desert Hills AZ
Mary Whitmore,
CPC, CASCC Grass Valley CA
Gina Marie Dolce,
CPC-H, CASCC Solana Beach CA
Sarah J Kneefel,
CFPC Aurora CO
Andrew Matheson,
CPC, CANPC Bradenton FL
Denise Casella,
CEDC Deland FL
Donna Christian,
CEDC Deltona FL
Jennifer Sue Barry,
CPC, CPMA Newberry FL
Maxine B Rosenfeld,
CHONC Ormond Beach FL
Heather R Coulter,
CPC, CHONC St Petersburg FL
Gian Armestar,
CEDC Sunrise FL
Jeffrey Eckmann,
CPC, CPC-H, CPC-P, CEMC Tampa FL
Andrew Heisler,
CPC, CPMA Boise ID
Tesja Erickson,
CPC, COBGC Idaho Falls ID
Mariana Abarca,
CPC, CPCD Cicero IL
Lovena Jean Chesak,
CPC, CASCC Rockford IL
Chandra Lynn Stephenson,
CPC, CPC-H, CPMA, CPC-I, CANPC, CEMC, CFPC,
CIMC, COSC Lebanon IN
Sara J Ketterer,
CPC, CPMA, CPEDC Covington KY
Tracy Lee Rada,
CPC, COSC Effie LA
Teresa Rose Neskow-Logan,
RN, CPC, CEDC Forest Hill MD
Amy Miller,
CASCC Hagerstown MD
Kelly Elizabeth Kamps,
CPC, CIRCC, CEMC Rising Sun MD
Santa Allaire,
CPC, CEMC No Berwick ME
Brandy Sasse,
CEMC Alma MI
Heather Joyal,
CEDC Hancock MI
Deena B Karson,
CPC, CHONC Kalamazoo MI
Kathy L Serocki,
CPC, CHONC Sterling Heights MI
Sue Jordan,
CPC, CGSC Blaine MN
Becky Mccluskey,
CPC, CEMC Rice MN
Katherine A Nulph,
CPC, CPMA, CANPC Columbia MO
Tiffany Morgan,
CPC, CPMA Raytown MO
Tracy Wagner,
CPC, CPMA Raytown MO
Jessica Hobson,
CPCD St Charles MO
Lloie L Schultz,
CPC, CPMA Clinton MT
Lioubov Petrova,
CPC, CHONC Asheville NC
Claudia E Villalobos,
CPC, CGSC Charlotte NC
Dorothy J Murphy,
CPC, CPMA Hickory NC
Charlene N Miller,
CPC, CCC, CGIC Statesville NC
Jeri L Wettstein,
CHONC Fargo ND
Lisa Shannon Cole,
CPC, CEMC Scottsbluff NE
Jessica Marie Hessler,
Peggy Lynn Sheets,
Diana Mercurio,
CUC Henderson NV
Lara Marie Tobias,
CPC, CHONC Henderson NV
Carmel Marie Schmidt,
CPC, CHONC King Ferry NY
Sue E Morgan,
CPC, CPMA, CPEDC Cincinnati OH
Lindsey Jo Harr,
CPC, CCC Circleville OH
Melanie Zinser,
CPMA Columbus OH
Robin A Reynolds,
CPC, CPMA, CPEDC Harrison OH
Melissa Monak,
CHONC Huron OH
Misti Gardner,
CPC, CCVTC Madison OH
Judith Tekulve,
CPC, CPEDC Milford OH
Nancy S Swope,
CPC, CCVTC Zanesville OH
Kris Duncan,
CPC, CEDC Oklahoma City OK
Jaimi Sullivan,
CGSC Bend OR
Glenda Martinez,
CPC, COBGC East Stroudsburg PA
Rebecca Almquist,
CPC, COSC Tobyhanna PA
Charlisa Dillard,
CPC, CGSC Greenville SC
Rhonda L Fletcher,
CPC, CPMA, CENTC Church Hill TN
Colleen Bradford,
CPEDC Tullahoma TN
Lytonya Johnson,
CPC, CIMC Arlington TX
Robin M Black,
CPC, CEMC, CFPC Cisco TX
Monica Pajestka McDougall,
CPC, CPCD Temple TX
Susannah Nelson,
COBGC Eagle Mountain UT
Tanya D Perkins,
CPC, CANPC Bothell WA
Jennifer Willis,
CPC, CCC Mount Vernon WA
Kaye Ann Simonet,
CPC, CHONC Green Bay WI
Jessica Larson,
CPC, CEDC Osceola WI
Susan Marie Stewart,
CPC, CCC Alum Creek WV
Shana Hensley,
CPC, CCC Hurricane WV
Amanda Raveaux,
CPC, CFPC Weirton WV
Recognition
and CEUs, too!
We seek coding-related articles for Coding
Edge written by our members. If you have
knowledge or experience you want to share with
your colleagues, contact
John Verhovshek at g.john.verhovshek@aapc.com,
director of Editorial Development, for more information.
It’s a great way to share your knowledge and experience and earn some
CEUs at the same time.
www.aapc.com
September 2010
41
hot topic
Get the Most Out of
EHR Meaningful Use
Greater flexibility facilitates physicians’
ability to earn incentive payments.
APPRENTICE
By Renée Dustman
“The current, paper-based medical records system that relies
on patients’ memory and reporting of their medical history
is prone to error, time-consuming, costly, and wasteful. With
rigorous privacy standards in place to protect sensitive medical record, we will embark on an effort to computerize all
Americans’ health records in five years. This effort will help
prevent medical errors, and improve health care quality,
and is a necessary step in starting to modernize the American health care system and reduce health care costs.”
— President Barack Obama
The American Reinvestment and Recovery Act of 2009
(ARRA) served to facilitate the president’s vision by establishing programs under Medicare and Medicaid that provide
incentive payments to eligible professionals (and hospitals)
who readily adopt, upgrade or demonstrate meaningful use of
certified electronic health record (EHR) technology by 2015.
Unfortunately, Congress left out of the bill one crucial piece
of information: the definition of “meaningful use.” That was
left up to the discretion of the Centers for Medicare & Medicaid Services (CMS) to define at a later time.
Nearly a year later, CMS released Jan. 13 a notice of proposed
rule making (NPRM) defining meaningful use of EHR
technology. The proposed rule, however, did not appease
the health care industry’s concerns. CMS received more than
2,000 comments mainly stating that the proposed reporting
requirements for earning incentive payments were impossible
to achieve as written.
“We heard those comments and we have provided a degree of
flexibility in the final rule,” CMS said.
In fact, CMS made some significant changes to the EHR
Incentive Program Final Rule—put on public display July 13
and published in the Federal Register July 28.
Note: This article focuses on eligible professionals reporting
under the Medicare Fee-For-Service (FFS) program and Stage
1 criteria.
What Hasn’t Changed
The EHR incentive program provides incentive payments to
eligible providers (EPs) who demonstrate meaningful use of
certified EHRs.
42 AAPC Coding Edge
As in the NPRM, the final rule defines an EP as a licensed
doctor of medicine or osteopathy, a doctor of dental surgery
or dental medicine, a doctor of podiatric medicine, a doctor of
optometry.
Likewise, the maximum amount EPs can earn remains
$44,000 ($48,400 for EPs who predominantly furnish services
in geographic Health Professional Shortage Areas (HPSAs))
under Medicare. Specifically, qualifying EPs can earn an
annual incentive payment as high as $18,000 if their first
payment year is 2011 or 2012. The annual incentive payment
limits in the first, second, third, fourth, and fifth years are
$15,000, $12,000, $8,000, $4000, and $2,000 respectively.
And as in the proposed rule, the final rule deploys the EHR
incentive program in three stages. Stage 1 pertains to reporting years 2011 and 2012.
What Has Changed
Compared to the proposed rule, the final rule adds a degree of
flexibility, designed to make it easier for EPs to demonstrate
meaningful use and qualify for incentive payments.
Meaningful Use Objectives
Whereas the proposed rule expected EPs to meet all reporting objectives to demonstrate meaningful use, the final rule
divides the proposed objectives into a core set and a menu set
of procedures from which providers can alternately choose. For Stage 1, there are 25 objectives/measures for EPs—20 on
which EPs must report. Of the 20 required objectives/measures, 15 must be from the core set and five can be from the
menu set.
Core Set of 15 Objectives for EPs
1. Computerized physician order entry (CPOE)
2. E-prescribing (eRx)
3. Report ambulatory clinical quality measures to CMS/states
4. Implement one clinical decision support rule
5. Provide patients with an electronic copy of their health
information, upon request
6. Provide clinical summaries for patients for each office visit
7. Drug-drug and drug-allergy interaction checks
hot topic
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article or topic, go to
www.aapc.com
8. Record demographics
9. Maintain an up-to-date problem list of current and active
diagnoses
10.Maintain active medication list
11. Maintain active medication allergy list
12.Record and chart changes in vital signs
13. Record smoking status for patients 13 years or older
14.Capability to exchange key clinical information among providers of care and patient-authorized entities electronically
15. Protect electronic health information
Menu Set Objectives for EPs
• Drug-formulary checks
• Incorporate clinical lab test results as structured data
• Generate lists of patients by specific conditions
•Send reminders to patients per patient preference for preventive/follow-up care
•Provide patients with timely electronic access to their
health information
•Use certified EHR technology to identify patient-specific
education resources and provide those resources to the
patient, if appropriate
• Medication reconciliation
• Summary of care record for each transition of care/referrals
•Capability to submit electronic data to immunization
registries/systems
•Capability to provide electronic syndromic surveillance
data to public health agencies
To meet these objectives/measures, 80 percent of patients
must have records in the certified EHR technology; and at
least one public health objective must be selected.
An EP who works at multiple locations, but does not have
certified EHR technology
at all of them, must have 50 percent of his or her total patient
encounters at locations where certified EHR technology
is available and base all meaningful use measures only on
encounters at those sites.
Clinical Quality Measures
For 2011, EPs also must submit aggregate clinical quality
measures (CQM) numerator, denominator, and exclusion data
to CMS by attestation. For 2012, EPs will be required to electronically submit this data. In general, EPs must report on six
clinical measures: three required core measures (substituting
alternate core measures where necessary) and three additional
measures from a set of 38 CQMs.
The CQM core set includes:
• Hypertension: Blood Pressure Measurement;
•Preventive Care and Screening Measure Pair: a) Tobacco
Use Assessment, b) Tobacco Cessation Intervention; and
• Adult Weight Screening and Follow-up.
The CQM alternate set includes:
•Weight Assessment and Counseling for Children and
Adolescents;
•Preventive Care and Screening: Influenza Immunization
for Patients 50 Years Old or Older; and
• Childhood Immunization Status.
Note: In the final rule, CMS changed the denominator
requirement. For Stage 1, no measure requires manual chart
review to calculate the threshold.
Registration Overview
EPs who meet the eligibility requirements for both the Medicare and Medicaid EHR Incentive Programs may participate
in only one program, and must designate the program in
which they would like to participate. After a payment is
made, EPs will be allowed to change their program selection
once before 2015.
To participate in the EHR Incentive Program, providers must:
•Register via the EHR Incentive Program website at
www.cms.gov/EHRIncentivePrograms
•Be enrolled in Medicare FFS, Medicare Advantage, or
Medicaid (FFS or managed care)
• Have a National Provider Identifier (NPI)
•Use certified EHR technology to demonstrate
meaningful use
•Be enrolled in the Provider Enrollment, Chain and
Ownership System (PECOS)
EHR Incentive Program Timeline
Registration for the EHR Incentive Programs begins January
2011 and attestation begins April 2011. Payments will begin
May 2011. Feb. 29, 2012 is the last day for EPs to register and
attest to receive an incentive payment for 2011. Although participation in the EHR Incentive Program is voluntary, Medicare payment adjustments begin in 2015 for EPs who are not
meaningful users of EHR technology.
More information about Meaningful Use will be provided in
the October Coding Edge. A copy of the EHR Incentive Program Final Rule and related documents are available at
www.cms.gov/EHRIncentivePrograms.
[
Renée Dustman is senior editor at AAPC.
]
www.aapc.com
September 2010
43
coding compass
ZPICs:
Medicare Audits Expands
Learning the ABCs of the ZPIC program
can help you avoid being targeted.
PROFESSIONAL
By Anna M. Grizzle, Esq., and
Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC
when you thought you understood the alphabet soup
Justof Medicare
audits, the Centers for Medicare & Medicaid
Services (CMS) adds a new contractor to the health care audit
vocabulary. This new audit contractor, called the zone program integrity contractor (ZPIC), represents a new approach
by CMS to enforce its benefit integrity activities.
Under the ZPIC program, CMS is replacing two other audit
contractors and consolidating the benefit integrity activities for all Medicare providers in an assigned area to a single
ZPIC. This streamlined approach is expected to lead to
increased enforcement activities in the very near future. For
this reason, health care providers should have a thorough
understanding of the ZPIC program to prepare for upcoming
ZPIC audits.
What Are ZPICs?
Prior to the implementation of ZPICs, program safeguard
contractors (PSCs) and Medicare drug integrity contractors
44 AAPC Coding Edge
(MEDICs) conducted benefit integrity activities for Medicare
providers. PSCs and MEDICs had no uniformity of jurisdiction, which allowed the possibility for one PSC overseeing
Part A claims while an entirely different PSC was overseeing
Part B claims in the same state.
To correct this piecemeal approach CMS is giving ZPICs the
task of ensuring the integrity of all Medicare claims for their
assigned zones.
According to an Oct. 6, 2008 CMS press release (“CMS
Enhances Program Integrity Efforts to Fight Fraud, Waste
and Abuse in Medicare”), ultimately ZPICs “will be responsible for ensuring the integrity of all Medicare-related claims
under Parts A and B (hospital, skilled nursing, home health,
provider and durable medical equipment claims), Part C
(Medicare Advantage health plans), Part D (prescription drug
plans) and coordination of Medicare-Medicaid (Medi-Medi).”
To accomplish the goal of promoting integrity in the Medicare and Medicaid programs, ZPICs have several objectives.
coding compass
Zone
First, ZPICs are charged with identifying, stopping, and preventing Medicare and Medicaid fraud, waste, and abuse and
referring instances of such activity to appropriate law enforcement agencies.
Other objectives include:

decreasing the submission of abusive and fraudulent
Medicare and Medicaid claims;

recommending appropriate administrative action, to
ensure proper and accurate payments for services are
made; and

coordinating identified potential fraud, waste, and abuse
with the appropriate Medicare and Medicaid entities.
To carry out these objectives, ZPICs are authorized to conduct audits, interview beneficiaries and providers; initiate
administrative sanctions (including suspending payments,
determining overpayments and referring providers for exclusion from Medicare); and refer providers and beneficiaries to
law enforcement.
Cases meeting any of the following criteria may be referred to
a ZPIC:

Potential criminal, civil, or administrative law
violations

Allegations extending beyond one provider, involv
ing multiple providers, multiple states, or widespread
schemes

Allegations involving known patterns of fraud

Patterns of fraud or abuse threatening the life or well
being of beneficiaries

Schemes with large financial risk to the Medicare pro
gram or beneficiaries
ZPICs also are expected to use “innovative data analysis
methodologies for the early detection and prevention of abusive use of services, as well as possible fraud, waste and abuse
schemes,” according to Zone Program Integrity Contractors
(ZPIC) Task Order, Statement of Work, Zone 1 – Parts A, B,
DME and HH + H, at 3; See also Zone 1 Medi-Medi Task
Order, Statement of Work, at 2.
How Will ZPICs Be Organized?
The ZPIC transition is taking place at the same time as
CMS consolidates the work of fiscal intermediaries (FIs) and
carriers into Medicare administrative contractors (MACs).
The alignment of ZPIC and MAC jurisdictions serves to
streamline the claims review and benefit integrity processes.
The seven ZPIC zones will coincide with one or more complete jurisdictions of MACs:
Geographic Area
1
American Samoa, California, Guam, Hawaii, Mariana Islands, Nevada
2
Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska,
North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming
3
Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin
4
Colorado, New Mexico, Oklahoma, Texas
5
Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina,
South Carolina, Tennessee, Virginia, West Virginia
6
Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania,
Rhode Island, Vermont
7
Florida, Puerto Rico, U.S. Virgin Islands
How are Providers Chosen for ZPIC Audits?
ZPIC audits are never random. A provider who is selected for
a ZPIC audit should understand that it is under investigation for potential fraud or the ZPIC is trying to determine
if a fraud investigation should be opened. The ZPIC’s initial
request for records often gives insight into the nature of the
investigation.
ZPIC audits can be generated in a number of ways. First, a
ZPIC audit may be initiated from the ZPIC’s proactive data
analysis. For example, a ZPIC could use data analysis to detect
high frequency of certain services as compared to local and
national patterns, trends of billing, or other information suggesting the provider is an outlier compared to his peers.
In addition to proactive identification of audit targets,
ZPICs conduct audits in response to complaints, such as
a report to the Office of Inspector General (OIG) hotline,
Fraud Alerts, or even directly to the ZPIC. ZPICs also
receive referrals from MACs or other contractors and law
enforcement. Other examples of red flags that may prompt
an audit include improper or inaccurate billing that may be
identified through high claim rejection or recoupment rates,
a mismatch of the claim with physician record, or lengths of
stay outside the industry norm.
What Happens During a ZPIC Audit?
ZPIC audits typically are unannounced or occur with very
little notice, and may consist of pre-payment or post-payment
review. Providers typically receive a written request for records
from the ZPIC, but representatives from the ZPIC sometimes
visit providers to conduct the audit on-site. The ZPIC may
www.aapc.com
September 2010
45
coding compass
ZPIC audits are never random. A provider who is selected
for a ZPIC audit should understand that it is under investigation for potential fraud or the ZPIC is trying to determine
if a fraud investigation should be opened.
request a small number of records to review to determine if
there is a fraud concern. Alternatively, the ZPIC might work
with a statistician prior to contacting the provider to select a
sample of claims for review, and ultimately may use statistical sampling to extrapolate the amount of any overpayment(s)
made on claims based on the error rate within the sample
claims.
In addition to requesting records, the ZPIC may conduct
interviews with beneficiaries and the provider’s employees.
For example, if the ZPIC is investigating whether a provider
appropriately billed a level IV evaluation and management
(E/M) claim, it may ask beneficiaries such things as the
amount of time the provider spent with the beneficiaries
during the visit in question.
What Happens After a ZPIC Audit?
Following a ZPIC audit, providers face one of three potential
outcomes.
1.The most serious potential outcome involves the ZPIC
referring the case to law enforcement for criminal, civil
monetary penalty (CMP) or other sanction. If a referral
occurs, the provider may hear from the OIG of the U.S.
Department of Health and Human Services (HHS) or a
U.S. attorney preparing to bring a False Claims Act case
against the provider. Notably, if an investigation was
triggered initially by a complaint made by the provider’s
current or former employee, the ZPIC is required to
immediately advise the OIG, which could then request
the ZPIC to perform only a limited internal investigation
and immediately refer the case to the OIG.
2.The ZPIC may refer the audit results, including the statistical calculation of an extrapolated overpayment, to
the MAC for collection. In this circumstance, a provider
has the right to appeal the overpayment determination
through the five-step Medicare appeals process. Most
providers typically choose to appeal the audit results due
to the large overpayment amount demanded. If a provider successfully reverses the denial of even a few claims,
the provider can undermine the basis for the ZPIC’s
ability to extrapolate an overpayment amount based on a
sample of claims, and significantly reduce the provider’s
damages.
3.The ZPIC may determine provider education is the
appropriate resolution for the audit. This result is the
best outcome for a provider because it means the provider
46 AAPC Coding Edge
will not be assessed an overpayment demand or other
potential sanction. In this instance, the ZPIC will inform
the provider by letter of questionable or improper practices and the correct procedure to follow. The ZPIC will
also notify the provider that continuation of the improper
practice may result in administrative sanctions.
What Can I Do to Prepare for a ZPIC Audit?
With the implementation of the ZPIC and other audit contractors, providers should expect to see a significant increase
in audits. Providers can take steps to potentially avoid being
a target of these audits and to develop a response plan if they
are targeted.
Stay Out of the ZPIC Spotlight Through a Strong Compliance Program.
In preparing for these increased audits, apply the old adage,
“an ounce of prevention is worth a pound of cure,” and implement robust compliance programs to reduce the likelihood of
being a ZPIC target. In particular, confirm that your provider
is following all Medicare policies and procedures, including any applicable coverage decisions, when billing Medicare
claims.
The inquiry should not end with confirming compliance with
the appropriate Medicare policies. Ensure also that providers document fully and completely all necessary elements
before submitting claims to Medicare. Stay up-to-date on any
changes in Medicare policies and procedures, and conduct
regular training on coding and billing practices. Finally,
conduct periodic internal audits. If billing vulnerabilities are
identified, correct the problems and repay any overpayments
resulting from the billing mistakes.
Have A Plan in Place if the ZPIC Shows Up.
Although a robust compliance program should reduce the
likelihood of a ZPIC audit, there is no guarantee that a provider will not be targeted. Prepare your provider for the possibility of an audit by taking the following steps:

Designate a point person, such as the compliance offi
cer or other administrator, for coordinating a response
to a ZPIC audit. The point of contact is the person
who coordinates the audit, answers questions regarding where records are located, and assists the ZPIC in
setting up interviews with requested individuals. After
this point of contact is designated, instruct personnel to
immediately direct all ZPIC audit requests to this designated individual.
coding compass

Establish
specific policies and procedures for responding
to a ZPIC audit. The policies and procedures include the
name and contact information of the point of contact and
the designation of responsibilities for others in the organization who will participate in the investigation. Include
a list of where all of the provider’s medical records are
located in the policies and procedures. Identifying the
location of records in advance of an audit assists a provider in responding fully to an audit request within the
time frame established by the ZPIC.

Create an intake and tracking system. Because there are
multiple types of audits with different time frames for
response, it is important to have a tracking mechanism
to ensure the designated deadlines are met. For small
organizations, this can be as simple as a spreadsheet.
Larger organizations may consider investing in software
designed to manage the intake and tracking of audit
requests.
Because of their potential ramifications, ZPIC audits are one of
the more serious of the Medicare initiatives. Providers should
understand ZPICs are looking for fraud, not simply billing
errors. Accordingly, take steps to reduce the likelihood of a
ZPIC audit by ensuring your provider is billing Medicare
claims appropriately and that there is a plan in place to respond
to a ZPIC audit. These steps can decrease the chance of your
provider being targeted, and hopefully remove the ZPIC alphabet soup from the menu.
Resources: OIG HHS, “Medicare’s Program Safeguard Contractor Activities to
Detect and Deter Fraud and Abuse” (July 2007) is available at www.oig.hhs.gov/oei/
reports/oei-03-06-00010.pdf.
Brian Petry, CMS, Transition from PSCs to ZPICs, 57 Health Care Fraud 46, 47-50,
53 (Jan. 2009).
Zone Program Integrity Contractor (ZPIC) Umbrella Task Order, Statement of Work at 11.
Zone Program Integrity Contractor (ZPIC) Umbrella Task Order
Zone Program Integrity Contractors (ZPIC) Task Order, Statement of Work, Zone 1
– Parts A, B, DME and HH + H, at 3; See also Zone 1 Medi-Medi Task Order, Statement of Work, at 2.
Anna M. Grizzle, Esq., is a partner of Bass, Berry & Sims PLC in Nashville,
Tenn. where she represents health care providers and companies in operational
and compliance matters, investigations, and litigation. She counsels on health
care operations and compliance matters, such as fraud and abuse, quality, and
risk management issues. She also works with clients in all stages of government and commercial payer claims audits, including those performed by RACs,
ZPICs, and MICs. Anna is a member of the Health Care Compliance Association
and the American Health Lawyers Association.
Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC, is president
of LCA Medical Consulting and a member of the AAPCCA
board of directors. She has more than 25 years of experience
in the health care industry. She assists clients with solutions
to enhance efficiency and opportunities in the health care
delivery system and physicians with third-party payer audits,
including RACs at various stages of appeals. She is a PMCC
trainer and provides consulting services to Hickman Community Health Services (part of Saint Thomas Health Services). She has provided
coding workshops for the Tennessee Medical Association and serves as president of the Professional Coders of Columbia, Tenn. and the Cahaba Physician
Outreach and Education Committee for Tennessee.
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September 2010
47
AAPCCA
2010 G2KYLC
Showcase your chapter at conference.
By Freda Brinson, CPC, CPC-H, CEMC
Secretary, AAPCCA Board of Directors
E
ach year, AAPC’s National Conference
generates many special moments for our
members. One event in particular that holds
fond memories and has been a staple at conference is “Meet Your Local Chapter.” Through
the years, this event has metamorphosed into
the popular and very well attended “Get to
Know Your Local Chapter” (G2KYLC). This
year’s conference in Jacksonville, Fla. was no
exception and proved to bear great anticipation and expectations for participating local
chapters and attending members who shared
in G2KYLC.
With 24 participating tables composed of 20
local chapter tables, three “joint tables,” (which
are multiple chapters presenting one table), and
one table for all users of AAPC’s Forum; this
event displayed unique collaborations.
Participants were challenged to showcase their
chapters using several elements. The criteria
our judges looked for to score each table were:
Best use of region color;
Best display of education info;
Best use of chapter information; and
Most original display.
Jacksonville Community Participates
First Place—Several Florida Chapters
Chapter Participation Calls for
Teamwork
Second Place—Columbia, S.C.
Surprises Around the Corner
Each judge also picked a favorite table, and
scores were tallied to formulate an overall
score for each table. The top five scorers were
awarded with ribbons. No one knew who the
winners were until the doors opened and the
event started. It was exciting to watch participants return to their tables and find a ribbon
acknowledging their efforts!
The top five tables were:
Best in Show: Kansas City, Mo.
First Place: Joint table of several Florida chapters
Second Place: Columbia, S.C. (Capital City Coders)
Third Place: Jacksonville, Fla.
Honorable Mention: Savannah, Ga.
48 AAPC Coding Edge
New this year was the use of outside judges. It
was very important to the G2KYLC planning
committee to involve members of the Jacksonville community. Community participants
were Derek Igou, deputy chief of Administrative Office from the City of Jacksonville,
Lt. Diego Esguerro, department head for
Patient Administration of the Naval Hospital
in Jacksonville, and Lt. Nicole Duffy, RN,
clinic manager in general surgery at the Naval
Hospital in Jacksonville. I would like to personally thank these individuals for the time
they invested judging our tables.
Third Place—Jacksonville, Fla.
Participating in this event involved getting
fellow chapter members on board to help with:
 Making planning decisions
Logistics on getting your display to the
conference
Coming up with creative ways to finance
your giveaways and decorations
Finding time in an already full schedule
of events to set up your display
Enjoying the hundreds of members who
want to learn about your chapter
We are so thankful to the chapters who participated in this year’s G2KYLC event. Our
hope is to see at least 30 local chapters in
Long Beach, Calif. Start planning now for
another unbelievable G2KYLC in 2011.
Freda Brinson, CPC, CPC-H, CEMC, is compliance auditor
for St. Joseph’s/Candler Health System in Savannah.
She has 30 years of health care experience, ranging
from receptionist to office management for physician
practices and charge description master and charge
auditing in the hospital setting. She was the 2008 AAPC
Networker of the Year and chapter president when Savannah was named 2008 AAPC Chapter of the Year.
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minute with a member
Janelle Simpson, CPC
Billing Department Manager at Virginia Neurology & Sleep Disorders Center
coding and management.
In 2007, my husband relocated to Casper
Wyoming and I found a position with
another imaging center and a billing company through the hospital. We recently
returned to Virginia, thawed out from the
winter blast of Wyoming, and I am now
billing department manager for Virginia
Neurology & Sleep Disorders Center. I have
just completed my bachelor of science degree
in health care law. I look forward to owning
my own billing company very soon and
lobbying on Capitol Hill to be a voice for
health care reform.
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.
Janelle: I received in 1992 an associate
degree for Medical Administrative Assisting. I began working for Tidewater Children’s Associates (TCA), a large pediatric
practice, floating between medical assisting
and billing. Eventually, I worked full time
in the billing department where I first was
exposed to coding. This was my first lesson
on CPT®, ICD-9, and insurance do’s and
don’ts. The hospital that owned the practice
offered CPC® training and the exam, and
I received my certification in 2003. After
11 years with TCA, I moved up to billing
manager for a billing company, coding several specialties. Here I was introduced to the
world of Medicare, which made me almost
retire. While working as billing manager, I
received a call from my former administer
to interview for a new billing manager position with a large diagnostic imaging practice. I jumped at the chance and started a
new department from the ground up. With
guidance I was exposed to a new world of
50 AAPC Coding Edge
CE: What is your involvement level with
your local AAPC chapter?
Janelle: I helped start the only AAPC chapter in Wyoming and served as new member
development officer. This was a great experience and I was able to work with other
coders in Casper to help introduce AAPC
and coding certification. The chapter is still
growing under the wing of great people and
I hope to see the chapter and coding certification opportunities expand in the state.
I made life-long friends and colleagues at
the Casper Chapter. Now, I am back in
Virginia and hope to get involved with the
chapter in my area.
CE: What has been your biggest
challenge as a coder?
Janelle: My biggest challenge has been
breaking barriers with physicians and
letting them know certified coders are
necessary and are a wealth of information
for revenue and following guidelines, and
are a resource for explaining to patients
why their claim is coded correctly. On the
insurance end, my head spins trying to
keep up with carrier guidelines, fee schedules, modifiers, the ever-changing world
of Medicare and last, but not least, setting up and monitoring Physician Quality
Reporting Initiative (PQRI). A coder’s
work is never done.
CE: How are you and/or your
organization preparing for ICD-10?
Janelle: We are preparing for ICD-10 by
looking at the top 25 ICD-9 codes used and
cross referencing them with ICD-10. Working in neurology, we have a limited number
of ICD-9 codes, which will make the transition easier than for some. We recently purchased an electronic medical record (EMR)
system that will help with the technical
side of the change. As for my billing staff,
we have attended Centers for Medicare &
Medicaid Services (CMS) webinars and are
following the steps on the AAPC website as
a guide.
CE: If you could have any other job,
what would it be?
Janelle: Own my own billing company
and lobbying health care. There is nothing
outside of medicine that I would want as a
carrier. I love medicine law and my goal is
to be a voice for patients and physicians on
Capitol Hill. Changes are coming and we all
need to be a voice in those changes.
CE: How do you spend your spare time?
Tell us about your hobbies, family, etc.
Janelle: My spare time is spent with my
husband, David, and our two dogs. We
are huge National Association for Stock
Car Auto Racing (NASCAR) and football
fans (go Dolphins!), so our Sundays in the
summer are all about NASCAR (and food)
and in the winter, football. Because we live
on the beach, on any given evening, we’re
fishing and watching the sunset. After
living in Wyoming and experiencing what
a real winter is, I am thankful to be back
where it is not snowing in June and I can
put my toes in the sand and ocean.
I have two children, Amanda and Brittney,
and a step-daughter, Jessica. They are all
grown and out of the house trying to make
their way in the world.
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Bone-up on Anatomy for Arthroscopy Procedures

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