edgeedge

EDGE
Perfecting Practice & Revenue Cycle Management
PTs Conquer
the 2013
G code
Challenge
March 2013
Lynn S. Berry, PT, CPC
Plus: May MAYnia • Foot and Toe Amputations • Hospital Jobs • Fracture Coding
Medical Accreditation
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Contents
28
[Coding/Billing]
52
54
[Auditing/Compliance]
[Practice Management]
March 2013
[contents]
In Every Issue
7 Letter from the President
9 Letter from Member Leadership
10 Letters to the Editor
10 Kudos
12 AAPCCA: May MAYnia
13 AAPCCA Handbook Corner: Pop Quiz
Therapy Services:
The Uphill Climb to Better Codes and Reimbursement
37
14 Coding News
[Coding/Billing]
Special Features
Features
14 Quick Tip
16 ICD-10-CM Raises the Clinical Bar
Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC
20 Colonoscopy: Screening or Surveillance?
Anna Barnes, CPC, CEMC, CGSCS
24 Get Busy Learning New Cervico-cerebral Imaging, Re-imagined
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
28 Open Mouth, Insert Foot: Partial Foot and Toe Amputations
Maryann C. Palmeter, CPC, CENTC
34 PTs Rise to 2013 G code Challenge
Lynn S. Berry, PT, CPC
40 Fine Details Are Critical in Fracture Coding
Ken Camilleis, CPC, CPC-I, CMRS, CCS-P
44 Know What Your Coding Says to Your Payers
David Peters, CPC, CPC-P
48 Be an Attractive Candidate for a Hospital Coding Position
Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, RCC, RMC
52 Be an Effective Coding Compliance Professional
Ida Landry, MBA, CPC
54 Provider Productivity Is Key to Financial Success
Dixon Davis, MBA, MHSA, CPPM
58 Contracts: Create a Health Plan Contact Database
Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ
66 Minute with a Member
Education
19 A&P Quiz
63 Newly Credentialed Members
OnlineTest Yourself – Earn 1 CEU
Go to: www.aapc.com/resources/
publications/coding-edge/archive.aspx
Coming Up
• 2013–2015 NAB
• Anesthesia
• Emergency Coding
• Auditing Plan
• ICD-10 Chiropractic
On the Cover: Lynn S. Berry, PT, CPC, is well aware of the payment challenges physical therapy services face as she hikes
in Creve Coeur Park in St. Louis, Mo. Cover photo by McCarty
Photography, Inc. (www.mccartyphotography.com).
www.aapc.com
March 2013
3
Serving 119,000 Members – Including You!
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Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC
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Brad Ericson, MPC, CPC, COSC
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John Verhovshek, MA, CPC
g.john.verhovshek@aapc.com
Director of Member Services
Danielle Montgomery
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Director of Publishing
Managing Editor
Editorial and Production Staff
Michelle A. Dick, BS
Renee Dustman, BS
Tina M. Smith, AAS
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from AAPC is prohibited. Contributions are welcome. AAPC Cutting Edge is a publication for members of AAPC. Statements of fact or opinion are the responsibility of the authors alone and do not represent an opinion of AAPC, or sponsoring organizations.
CPT® copyright 2012 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not
part of CPT®, and the AMA is not recommending their use. The AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or
not contained herein.
The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for
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Volume 24 Number 3
ZHealth Publishing, LLC................................67
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4
AAPC Cutting Edge
March 1, 2013
AAPC Cutting Edge (ISSN: 1941-5036) is published monthly by AAPC, 2480 South 3850
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Letter from the President
Our Thanks to Reed Pew
J
anuary is always a transitional month
for AAPC membership. There are the
personal goals we set for the upcoming year and the professional and regulatory
changes that make our industry so dynamic. We felt this transition keenly at AAPC’s
national office when Reed Pew, our CEO
and President of seven years, retired at
month’s end.
Reed brought his vision and leadership to
an organization on the edge of becoming a
powerful, national voice for coders, steered
it to a new level of professionalism, added
many benefits for members, and expanded its scope to include all participants in the
revenue stream of health care. Reed emphasized to all of us that members are first, and
that everything we do for them must be better, faster, and cheaper. AAPC’s members
deserve it.
A Leader for Us All
Director of Member Services Danielle
Montgomery said of him, “Reed is driven by a clear vision. He is strong-willed,
focused, dedicated and, at times, intimidating. He pushed employees until they
thought they were going to break. We
didn’t. He challenged, nurtured, and supported us. He knew that in doing so, not
only would we grow as employees but as
individuals. He understood that the success of AAPC lies both within the members
and employees. Reed was instrumental in
making AAPC what it is today, and cared
about members and employees more than
any leader I’ve seen. I am forever in debt to
him for the lessons he taught me through his
example and leadership.
“Under Reed’s business exterior, he is kind,
accepting, gentle, caring and funny. I’m
happy that Reed now gets to spend his retirement with his family, friends and, of
course, the golf course! To Reed, I say, thank
you and, ‘we will continue to do good until
there is no more good to be done.’”
Praised by Members
National Advisory Board (NAB) member Jaci Johnson, CPC, CPC-H, CPMA,
CPC-I CEMC, said, “Reed brought professionalism to this organization and truly put us on the map. Working with him
for the past two years on the NAB provided me with an incredible insight into the
way he thinks…he is always ‘on’…he is always thinking of what is best for this organization and its members. He impressed me
with his ability to be so a part of the present and yet project and analyze the future
all within the same conversation. He is truly a gifted individual and I consider myself
lucky to have had the opportunity to work
closely with him on the NAB and gain that
incredible knowledge that he is willing to
share.”
“It seems I have known Reed for 20 years,
though it has been far less,” David Dunn,
MD, FACS, CPC-H, CIRCC, CCC, CCS,
RCC, president-elect of the NAB, wrote.
“Some people have that effect on others. As
a mentor and an inspiration, Reed helped
me to achieve many of my personal and professional goals just as he has for many at
AAPC. We have shared many special times
together and though I will miss him, I wish
him the best in the next phase of his life.
God Speed.”
Reed dedicated his tenure at AAPC to its
membership. He was undeterred by the obstacles and winds of change AAPC and its
members face every day. We all benefit from
his clear vision and steady hand.
I wish Reed all the luck in the world, and he
will be missed.
Sincerely,
Korb Matosich
President
www.aapc.com
March 2013
7
NEW
ICD-10 DEADLINE:
OCT 1, 2014
2014 COMPLIANCE
DEADLINE FOR ICD-10
The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change
every part of how you provide care, from software upgrades, to patient registration
and referrals, to clinical documentation, and billing. Work with your software vendor,
clearinghouse, and billing service now to ensure you are ready when the time comes.
ICD-10 is closer than it seems.
CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get
your practice ready.
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
Letter from Member Leadership
2011–2013 NAB, at a Glance
Where did the time go?
It seems like just a short time ago I was introducing myself to all of you in my first
Letter from Member Leadership article;
and, now it’s time to say goodbye to this role
and prepare for AAPC’s next chapter.
2011–2013 NAB Represents Health Care’s Diversity
Thank you 2011-2013 National Advisory
Board (NAB) for your hard work and dedication to membership over the past two
years. This NAB represented our members
across multiple specialties throughout the
business and clinical side of health care,
including providers, consultants, instructors, commercial and governmental payers, auditors and health care fraud investigators, practice managers, administrators
and directors of compliance, billing, coding, and the revenue cycle. The diversity of
this amazing group of people allowed for a
true representation of our career field and
the entire membership.
Each board member kept the needs of
AAPC and its members a top priority.
Board members’ diversity of skills and expertise fueled discussion, forecasting, and
planning that provided members with the
tools, skills, and direction necessary to excel
in this rapidly changing and uncertain environment of health care.
Focus on NAB Accomplishments
As with most advisory boards, the bulk of
the work this board took on went unseen by
membership. Allow me to recap just a few
accomplishments:
• Accountable Care Organizations
(ACOs) were introduced to members.
• The AAPC Chapter Association
(AAPCCA) developed a liaison
member role filled by Angela Jordan,
CPC, to lead a partnership between
both boards and members.
• An American Medical Association
(AMA) liaison, Marie Mindeman,
was added to build understanding
of AAPC commitment to its
membership and accurate coding.
• The value of the Certified
Professional Coder – Apprentice
(CPC-A®) credential was reviewed,
with membership feedback and
opinion considered.
• Methods for increasing health care’s
understanding of the Certified
Professional Coder – Hospital
Outpatient (CPC-H®) credential
were identified and shared with
membership.
• Membership feedback was
incorporated to improve the AAPC
National Conference, so each year
will be an even better experience for
members.
The 2011–2013 board has brought many
changes to benefit AAPC members during
the 2013 National Conference. If you enjoy
the changes and additions, please be sure to
thank one of your remarkable and creative
NAB members.
It Has Been a Privilege
Best wishes,
Cynthia Stewart, CPC, CPC-H, CPMA,
CPC-I, CCS-P
President, National Advisory Board
On a final note, I am giving a big thank
you to former AAPC Chairman and CEO
Reed Pew for believing in me, supporting
me, and having faith in me. I could not have
served in the NAB without his help and
guidance. Reed’s leadership will be missed
at AAPC. He created a strong organization
that members are proud to be part of.
Enjoy retirement, Reed, and I wish you all
the best in your future endeavors.
I also am sending a special thanks to YOU,
our membership, for allowing me to represent and serve you on the NAB for the past
six years. This privilege has truly been the
greatest highlight of my career.
www.aapc.com
March 2013
9
Please send your letters to the editor to: letterstotheeditor@aapc.com
Letters to the Editor
Debridement Codes Have Zero Global Days
LD, Not LC, Describes Descending Coronary Artery
“Build up Better Pressure Ulcer Surgery Coding” (January 2013)
includes a misleading statement on page 39:
Example 2 in the article “Changes Plus more Changes for Cardiology in 2013” (January, page 43) discusses stenosis in the LD, which
is the left anterior descending coronary artery. The answer, however, lists the applicable codes with modifier LC, which describes the
left circumflex coronary artery. Did you mean to report the CPT®
codes with modifier LD?
Gretchen Wilson, CPC
Yes, the appropriate modifier in the case you describe is LD, which
denotes the left anterior descending coronary artery. Therefore,
proper coding for example 2 is: Base code 92928-LD for the left
anterior descending stent, along with 92929-LD, 92978-LD, and
92920-RC.
AAPC Cutting Edge
“If the surgeon performs several debridements over time, and the subsequent debridements occur during the global period of the
previous debridements, append modifier 58
to the appropriate subsequent debridement
code(s).”
Per the 2013 Physician Fee Schedule, there
are 0 global days associated with CPT® debridement codes 11042-11047. Therefore, it would be inappropriate to add modifier 58 Staged or related procedure or service by the
same physician during the postoperative period to these codes, regardless of when debridement occurs.
Branden Chavez, CPC
Please send your KUDOS to: kudos@aapc.com
KUDOS
Burlington, Vt. Chapter Keeps on Giving
The Burlington, Vt. chapter’s generosity keeps on growing. It began in 2011, when former president, Gail Donlin, CPC, started
the theme “Giving back to the community.” The chapter put their
change buckets to use and raised almost $800 for the Vermont Children’s Hospital as part of the Big Change Roundup, sponsored by local radio station WOKO.
The Burlington chapter was hooked on giving and in 2012, their
new goal was to send a child to Camp Ta-Kum-Ta, a camp for children with cancer or who have had cancer. The cost to send a child:
$2,500 for one week. The chapter raised a whopping $3,416!
Raising that much money isn’t easy. They pooled their resources by:
• Holding 50/50 raffles at chapter meetings and at their Annual
Fall Foliage Coding Cruise.
• Having a fundraising event featuring a “Calcutta.” Organized
by Treasurer Shirley L. Sweet, CPC. With help from friends
and co-workers, the fundraising tickets were sold for $30
each, which included dinner. The Calcutta itself raised
$1,500 for Camp Ta-Kum-Ta, plus the 50/50 raffle and
another game all added to the total raised.
The Calcutta was a success because of the organizers of the event,
the supporters who bought tickets, the community who gave gifts
as prizes, and the grand prize winner who donated 50 percent of the
winnings to Camp Ta-Kum-Ta.
Kudos to the Burlington chapter for giving so much, and a special
thanks to Sweet for sending AAPC Cutting Edge her chapter’s story.
10
AAPC Cutting Edge
What on Earth Is a Calcutta?
According to Shirley L. Sweet, CPC, here’s how a Calcutta fundraising
event works:
•
Participants buy a ball with a number that ranges from 1-100 to
win a cash prize.
•
One ball is kept out to be raffled at the event and is guaranteed to
be in the last 10 balls in the bag.
•
The balls are randomly drawn out of a bag and if your ball number
is called, you’re no longer in the running to be the last ball in the
bag.
•
When ball numbers are being drawn, you may win a gift, which are
donated by various businesses and organizations.
•
The last ball out wins the grand prize. The winner gives back 50
percent of the winnings to the appointed charity.
Note: Please check your state’s regulations regarding raffles and giveaways.
Appendicitis Doesn’t Stop Dr. Z
David Zielske’s, MD, CPC-H, CIRCC, CCC, CCS, RCC, dedication to coding excellence is unstoppable. When AAPC Cutting
Edge requested that he send Test Yourself questions to accompany
his “Get Busy Learning New Non-cardiac Endovascular Codes” article (February 2013), we found a surprise in our inbox a few days later. With the questions was an apologetic note saying, “Sorry for the
delay. Had appendicitis Saturday, took it out that night. Home recouperating now. –z.”
Kudos Dr. Z for your loyalty and dedication, despite the removal of
a body part!
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21131
AAPCCA
By Barbara Fontaine, CPC
Get Ready for May MAYnia!
“Spring to Your Local Chapter” to feel the excitement.
Our annual May MAYnia is fast approaching. Is your chapter ready to celebrate with
a program that will attract new members?
Last year, there was widespread growth in
participation. We hope to see even more
chapters catch on to the fun in 2013. When
properly organized and executed, this exciting event can attract new members and energize participants in your chapter.
Need some ideas on how to entice member
participation during May MAYnia? Here
are some great ideas successful chapters did
last year.
Free Seminars and Free Advertising
Wendy Grant, CPC, said the Little Rock,
Ark. chapter offered a half-day seminar for
FREE! They used Facebook to advertise the
event. They also sent emails to members
and provided online registration to make
the process easier. The meeting had interesting topics and was held in a convenient location to attract the greatest number of guests.
Bigger Audience and Goody Bags
Marion Attaway, CPC, CPMA, from
Greensboro, N.C. said that her chapter marketed their May MAYnia luncheon to all of
the medical offices and local members of
Medical Group Management Association
(MGMA) and Guilford Medical and Dental Managers Association (GMDM) in their
area. This meeting burgeoned attendance
from 30 to 100. The program on anatomy
featured goody bag handouts containing an
anatomy coloring book and other items donated by vendors in their offices.
Go All Out, Go Hawaiian
In Topeka, Kan., Brenda Edwards, CPC,
CPMA, CPC-I, CEMC, said her chapter “went all out” in 2012. Members were
encouraged to attend with an almost daily countdown of emails prior to the meeting. They celebrated with a luau. Officers,
dressed in orange (Region 5 color), handed
out colorful leis, while Vice President Da12
AAPC Cutting Edge
and wise local speaker, a game of “Blinko”
for prizes, and recognition of officers from
past years.
Tranquil Park and Cinco de Mayo
Earl D. Bills, CPC, told us that the Palm
Beach, Fla. chapter took their meeting to
a peaceful, lakeside park to host an exciting Cinco de Mayo celebration—complete
with Tex-Mex food. The meeting topic was
ICD-10 and what members should do to
prepare for upcoming changes. Bills said
this was a great way to take the “hum-drum”
out of any CEU presentation.
rin Fieger, CPC, led a pep rally before the
meeting. With Jimmy Buffet music playing in the background, he had the audience competing to be the loudest before the
networking game began. The prizes followed the all-orange theme and included
things like oranges and Reese’s Peanut Butter Cups. The meeting was so much fun,
members have asked for more like it—officers have been delivering lively meetings
since last May.
Another luau was held in York, Pa., where
Roxanne Thames, CPC, CEMC, reported her chapter had two speakers and announced information about the Hardship
Scholarship Fund. The chapter purchased
leis, hair flowers, and sunglasses. One of the
speakers tossed around a beach ball that had
both coding and personal questions written
on it. The member who caught it had to read
and answer the question nearest to his or her
right thumb. Ten great door prizes included tee shirts, coding books, and free attendance to an event worth six continuing education units (CEUs). The key to their successful event was getting attendees to loosen up and have fun.
Gainesville, Ga. also hosted a meeting in
a large venue that offered a catered meal.
Melissa Corral, CPC, said that the chapter decorated with lots of festive balloons
and greenery. Chapter fun included a witty
Flyers and Raffles
In Whittier, Calif., President Susan
Brown, CPC-A, said her chapter’s speaker topics centered around ICD-10. A doctor spoke on how essential a coder can be in
training physicians to document properly.
To get students interested in AAPC membership, flyers were taken to local adult education schools. The result: Attendance nearly doubled! Raffles for gift cards and coding
books were the icing on the cake. Since the
last May MAYnia, the momentum continues and attendance at regular meetings has
increased.
Free Dinner and Door Prizes
In the City of Palms, Fort Myers, Fla., Judy
L. Smith, CPC, CPC-I, said their May
MAYnia event was cosponsored by a local
technical college that provided the meeting
space and covered half of the cost of the dinner. The program, “Employment – How to
Get It, How to Keep It,” included an eventspecific brochure designed by the chapter.
Members and guests attended for free (a
great incentive), and gift cards were donated as door prizes, which captured attendees’
attention. This chapter also more than doubled their normal attendance.
Field Trip Destination and Nurturing Future Officers
The May MAYnia organizer in Springfield,
AAPCCA: Handbook Corner
By Erin Andersen, CHC, CPC
Take the Handbook Pop Quiz
How well do you know the Local Chapter Handbook? If this was “Who Wants to Be a Millionaire,” would you walk away the winner? Take our test to find out:
Mo., Pamela Baumgardner, CPC, reported a great turnout, almost doubling their
average attendance. Members invited coworkers to “see what coding can do for your
future.” Members reached out to local trade
colleges, where a professor earned the grand
prize for inviting the most guests by offering the meeting as an official field trip to her
students. What a great way to teach about
the value of networking! When assembling a
May MAYnia team, Springfield deliberately recruited members who hadn’t been very
involved in chapter activities before. They
gave them small, attainable jobs and supported them in becoming an integral part
of the chapter—making homegrown potential officers.
Less ICD-10 Stress and Massages
In St. Louis West, Mo., my chapter, we celebrated and doubled our attendance with a
program designed to relieve stress associated
with ICD-10’s approach. Favors for the evening were colorful Slinky toys, highlighting the theme “Spring to Your Local Chapter.” A delicious catered dinner was prefaced
by five therapists who gave short chair massages to all attendees. People were relaxed
when listening to the American Heart and
Stroke Association speaker as she presented a program on the causes (such as the onset of ICD-10) and effects of stress in our
lives. Prizes centered around the relaxation
theme, such as gift cards, lotions, candles,
and the grand prize was a trip to a day spa.
Whatever your chapter decides to do to celebrate May MAYnia in 2013, we hope that
you bring fun and laughter to your meeting.
Don’t let the opportunity pass to really enjoy being an AAPC member.
Barbara Fontaine, CPC, serves on the AAPCCA Board of Directors and is business office supervisor at Mid County Orthopaedic Surgery
and Sports Medicine, a part of Signature Health
Services. She served on several committees
before becoming a local chapter officer. In
2008, she earned the St. Louis West, Mo. local chapter and
AAPC’s Coder of the Year awards.
1. Do all officers need to hold an AAPC credential?
a. Yes, of course
b. Only president, vice president, and education officer
c. Only president, secretary, and treasurer
d. No, but they do have to be AAPC members
2. What is the minimum number of officers needed for a chapter?
a. Two – president and treasurer
b. Three – president, vice president, secretary/treasurer
c. Three – president, secretary, treasurer
d. Six – president, vice president, education officer, secretary, treasurer, member development
3. You attend a chapter meeting that lasts one hour and 45 minutes. How many CEUs
may you claim?
a. One CEU – You can’t round up to the next whole number.
b. Two CEUs – You can round up to the next whole number.
c. 1.5 CEUs – There are only half and whole CEUs.
d. 1.75 CEUs – Every 15 minutes equals 0.25 CEUs.
4. How many consecutive years may a member be an officer?
a. Four years – just like the president of the United States
b. Two years – just like a U.S. representative
c. Six years – just like a U.S. senator
d. No limit – just like a dictator
5. Can local chapters charge an attendance fee?
a. Yes – A nominal fee to cover the cost of the room, food, parking, etc., is allowed.
b. Yes – It must be less than $10 per meeting.
c. Yes – Officers may charge whatever they’d like. Because they aren’t paid to be officers, this is how they are reimbursed for their time.
d. No – It is strictly forbidden to charge anything.
6. Members can earn CEUs for coding-related topics. Which topics below are considered to be coding-related by AAPC?
a. HIPAA
b. Pharmacy
c. OSHA, employee issues, and time management
d. All of the above
The answers are on page 60. This is just a sample of the useful information you will find in
the Local Chapter Handbook. To find out more useful information, read the handbook at:
http://static.aapc.com/ppdf/LC_Handbook1.pdf.
www.aapc.com
March 2013
13
Coding News
NCD Deems LSG as
Acceptable Bariatric Surgery
CMS Tests Bundled Payments
for Care Improvement
The Centers for Medicare & Medicaid Services (CMS) will accept laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity on the implementation date of Feb. 28, 2013. Standalone LSG may be billed using
CPT® code 43775 Laparoscopy, surgical, gastric restrictive procedure;
longitudinal gastrectomy (ie, sleeve gastrectomy), effective for service dates
after June 27, 2012.
CMS recently announced a new Bundled Payments for Care Improvement
initiative under the Affordable Care Act. Five hundred organizations will
be selected to participate in this initiative, as CMS tests “how bundling
payments for episodes of care can result in more coordinated care for
beneficiaries and lower costs for Medicare,” the agency said in a press
release issued Jan. 31.
According to MLN Matters ® MM8028, Medicare beneficiaries are covered
for standalone LSG only when all of these conditions are met:
The bundled payment initiative includes four bundling models with varying providers and services:
•
“The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2;
•
Model 1: Retrospective Acute Care Hospital Stay Only
•
The beneficiary has at least one co-morbidity related to obesity; and
•
•
The beneficiary has been previously unsuccessful with medical
treatment for obesity.”
Model 2: Retrospective Acute Care Hospital Stay plus
Post-Acute Care
•
Model 3: Retrospective Post-Acute Care Only
•
Model 4: Acute Care Hospital Stay Only
For discharges on or after June 27, 2012, inpatient hospital claims submitted with standalone LSG are covered, under the Medicare contractor’s
discretion, using ICD-9-CM code 43.82 Laparoscopic vertical (sleeve) gastrectomy.
Other bariatric procedures previously determined as acceptable by Medicare in 2006 are:
•
Open and laparoscopic Roux-en-Y gastric bypass;
•
Laparoscopic adjustable gastric banding; and
•
Open and laparoscopic biliopancreatic diversion with duodenal
switch.
Depending on the model type, CMS says it “will bundle payments for services beneficiaries receive during an episode of care, encouraging hospitals, physicians, post-acute facilities, and other providers as applicable to
work together to improve health outcomes and lower costs.”
Thirty-two awardees have been selected for Model 1, with testing of bundled payments for acute care hospital stays starting April 2013. The start
of Phase 1 of Models 2, 3, and 4 is also underway.
For more information go to: http://innovation.cms.gov/initiatives/
bundled-payments.
See CMS transmittal R150NCD for complete details: www.cms.gov/
Regulations-and-Guidance/Guidance/Transmittals/Downloads/R150NCD.pdf.
Quick Tip: Coding/Billing
By G.J. Verhovshek, MA, CPC
Bundling Rules Apply to Gastric Band Adjustments
Some types of bariatric (weight loss) surgery rely on a band (often
called a lap band) placed around the upper part of the stomach to create a small pouch to hold food. The reduced stomach size limits the
amount a person can eat, promoting weight loss. Following surgery,
a physician can adjust the band via a port to allow food to pass more
or less quickly through the digestive system.
Adjustments to the band during the global period of the surgical
procedure are bundled into the surgical payment, and are not separately reimbursed when performed by the same physician who performed the surgery.
There is a HCPCS Level II code, S2083 Adjustment of gastric band
diameter via subcutaneous port by injection or aspiration of saline, to
describe adjustments to the band outside of the global period of the
original procedure. Note, however, that not all payers accept this
code. Medicare payers, in particular, do not recognize S codes.
When reporting lap band adjustments outside the global period for
Medicare payers, turn to CPT® Category I unlisted procedure code
14
AAPC Cutting Edge
43999 Unlisted procedure, stomach and write “adjustment of lap
band” (or other carrier-designated language) in the narrative field of
the claim form. Imaging to locate the port is included in 43999. For
Medicare payers, the service is reimbursed only in the office setting.
Avoid reporting an evaluation and management (E/M) service in addition to the lap band adjustment unless there is a medically necessary reason (beyond the simple lap band adjustment) to perform the
service. E/M services must be separately identifiable from the gastric
restrictive device adjustment to be payable.
If a separate and distinct E/M service is provided, append modifier 25 Significant, separately identifiable evaluation and management
service by the same physician or other qualified health care professional
on the same day of the procedure or other service to the appropriate E/M
code. As always, documentation must support the separate and distinct E/M service.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
Be Our Guest . . .
Last Chance to Register!
•
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•
•
•
•
•
•
ICD-10 Code Set Training Begins in Orlando
26 Specialty Coding Sessions
Six Auditing Sessions
Four Billing Sessions
Three Compliance Sessions
Four Facility Sessions
Six Practice Management Sessions
CPPM Boot Camp available concurrent with this Event
2013
AAPC
NATIONAL CONFERENCE
Walt Disney World Resort - Florida
www.aapc.com/orlando2013
■ Roadmap to ICD-10
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC
ICD-10-CM Raises the Clinical Bar
Walk through real cases to help you strengthen A&P.
P
reparing for ICD-10-CM implementation requires a strategy to minimize
productivity losses. Remember how
painfully slow it was to search the ICD9-CM codebook when you first started to
learn coding? Although ICD-10-CM may
be familiar to you (if you are well versed in
ICD-9-CM), the educational bar has been
raised. To remain productive, coders need a
good understanding of anatomy and pathophysiology (A&P), as they relate to clinical
specificity in ICD-10-CM.
Physicians do not write in coding terms;
they document for the patient’s clinical condition. The clinical terms do not match
up entirely with the coding descriptors—
meaning that you
Do Your Skills Measure Up?
Will you be able to interpret the clinical
documentation? Or will you be constantly searching and querying your provider?
Worse yet, will you just assign unspecified
codes? Answering yes to either of the latter
two questions will cost you. Either your provider will question your ability to code, the
practice will lose revenue by using unspecified codes, or both.
To assess your readiness, review these clinical documentation examples and then
choose the correct ICD-10-CM code.
Case No. 1: Debilitating Migraine
Subjective: Patient complains of
intermittent headaches. He has had
similar headaches for eight years. He
comes in now because the headaches
used to occur 3-4 times a year, and now
they are occurring 3-4 times a month.
The headaches are so severe that he is unable to work. He describes them as a throbbing pain behind his right eye. The headaches are often accompanied with nausea,
and in the last few months he has occasionally vomited during an episode. Light aggravates his symptoms, but he has no associated
visual symptoms.
Objective: His neurologic exam is unremarkable.
Assessment: Chronic migraine
ICD-10-CM choices for chronic migraine:
P
A
need to be able to uncover the pertinent information and assign codes appropriately.
Illustration by iStockphoto © MireKP
G43.701 Chronic migraine without aura, not
16
AAPC Cutting Edge
intractable, with status migrainosus
G43.709Chronic migraine without aura,
not intractable, without status migrainosus
Roadmap to ICD-10: A&P
Physicians do not write in coding terms; they
document for the patient’s clinical condition.
To figure out which code is correct, you
must know the answer to these questions:
• What is an aura?
• What is the definition of intractable,
or status migrainosus?
Here’s some help:
An aura is a physiological warning sign that
a migraine is about to begin. Migraines with
auras occur in about 20-30 percent of migraine sufferers. An aura can occur one hour
before the attack of pain and last for 1560 minutes. The symptoms always last less
than an hour. Visual auras include:
• Bright flashing dots or lights
• Blind spots
• Distorted vision
• Temporary vision loss
• Wavy or jagged lines
Auras also can affect the other senses. These
auras may be described simply as having a
“funny feeling,” or the person may not be
able to describe the aura. Other auras may
include ringing in the ears or changes in
smell, taste, or touch.
Status migrainosus refers to a rare and severe
type of migraine that can last 72 hours or
longer. The pain and nausea are so intense
that people who have this type of headache
often need to be hospitalized. Certain medications, or medication withdrawal, can
cause this type of migraine syndrome.
Intractable headaches are those that don’t respond to medications or therapy, and require intervention outside of the standards.
In this case, the patient has had the condition for eight years, and it has gotten progressively worse. Light bothers the patient,
but he has no visual impairments. There is
no note that medications are not working,
or that the headaches last longer than 72
hours. Based on this information, we can assign code G43.709.
Case No. 2: Coronary Heart Disease, Myocardial Infarction
A second, more complex example requires
multiple diagnosis codes:
Chief complaint: CAD, MI.
History of present illness: An 85-year-old
male, new patient who has a history of coronary artery disease with previous myocardial infarction and inducible monomorphic ventricular tachycardia. He has a dual
chamber cardio defibrillator model and a
dual chamber cardioverter with an atrial
lead. He presents for evaluation of a recent
myocardial infarction and inducible monomorphic ventricular tachycardia. He was
walking in his house when suddenly, without warning, his device fired. He had no
symptoms of palpitations or heart racing
prior to the event. He felt the same before
and after the event, aside from anxiety related to shock. His device was interrogated and
demonstrated the shock occurred for atrial fibrillation with a rapid ventricular response. This resulted in slowing of his ventricular response, but did not convert him
from his chronic atrial fibrillation. As a result of this shock, his Inderal® has been increased from 80 mg once daily to 120 mg
daily. He does not notice any difference in
the increased dose of Inderal®. He has no
symptoms of chest pain or angina. He has
mild symptoms of exertional dyspnea and
NYHD Class II symptoms, but no symptoms of rest dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema.
Medications: Medicines were reviewed and
include Inderal® LA - 120 mg daily, Cozaar® 25 mg daily, aspirin - 325 mg daily, a multivitamin - one daily, and valium - as needed.
Examination: Vital signs: Pulse 78 bpm
and irregular; blood pressure 118/74; respirations 16; height 5' 6"; weight 165 lbs.
Cardiovascular: The cardiac apex is
not displaced. The first and second heart
sounds are normal. There is a grade systolic murmur of mitral insufficiency. The JVP
is normal at 3 cm. The carotids have normal
upstrokes without bruits.
Respiratory: The chest expands normally.
There is good air entry to both bases. No adventitious sounds are heard.
Laboratory data: His device was evaluated and his battery voltage is currently
2.64 volts with a replacement indicator at
2.62 volts. His atrial fibrillation is noted
with a ventricular response about 80 bpm.
An echocardiogram from Aug. 21, 2009,
showed a dilated left atrium at 4.9 cm. His
left ventricular function was normal with an
ejection fraction of 60 percent.
Impression: 1) ICD shock secondary to
paroxysmal atrial fibrillation with rapid
ventricular response. 2) Normal functioning cardioverter defibrillator - nearing end
of life. 3) Ventricular tachycardia. 4) Coronary artery disease. 5) lschemic cardiomyopathy - EF 60 percent, NYHD class II. 6)
Hypertension. 7) Allergy to ACE inhibitors.
Recommendations: This gentleman received an implantable cardiac defibrillator
shock because of a rapid response from his
underlying atrial fibrillation. He recently
had his beta blocker dose increased, but his
ventricular response is still somewhat rapid.
I have recommended he increase his Inderal® to Inderal LA® 80 mg twice daily. If hypotension ensues, lowering his dose of Cozaar® would be appropriate. His CHADS2
score is only one; therefore, I would continue with aspirin for his anticoagulation. It
is interesting to note that the defibrillator
www.aapc.com
March 2013
17
ICD-10 Roadmap: A&P
shock did not convert his atrial fibrillation
to sinus again, supporting the idea that this
is chronic atrial fibrillation. He should have
his defibrillator changed when he reaches an elective replacement indicator of 2.6
volts. I will be pleased to change out his device at the appropriate time. I hope this letter is useful to you in the management of
this patient.
ICD-10-CM coding:
A.
B.
C.
Atherosclerosis:A. Healthy artery
B. Plaque formation
C. Rupturing, clotting, and blood flow occlusion
I48.0
Paroxysmal atrial fibrillation
I47.2
Tachycardia, ventricular
I25.10
Atherosclerotic heart disease of native
coronary artery without angina pectoris
I25.5
Cardiomyopathy, ischemic
I10
Hypertension
I25.2
Old myocardial infarction
Z88.8
History, personal, allergy, other drugs,
medicaments, and biologic substances
Here are some pathophysiology elements
you need to understand to tie in the proper coding:
Coronary heart disease (CHD), also called
coronary artery disease (CAD), is a condition in which plaque builds up inside the
coronary arteries. It is the most common
type of heart disease. The coronary arteries supply oxygen-rich blood to the heart
muscle. Plaque is made up of fat, cholesterol, calcium, and other substances found in
the blood. When plaque builds up in the
arteries, the condition is called atherosclerosis. The buildup of plaque occurs over
many years.
A common symptom of CHD is angina.
Angina is chest pain or discomfort that occurs if an area of your heart muscle doesn’t
get enough oxygen-rich blood. Angina may
feel like pressure or squeezing in your chest.
You also may feel it in your shoulders, arms,
neck, jaw, or back, and it may even feel like
indigestion. The pain tends to get worse
with activity and goes away with rest. Emotional stress also can trigger the pain.
Another common symptom of CHD is
shortness of breath. This symptom happens
if CHD causes heart failure. In the event of
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ICD-10-CM separates
codes for ischemic
heart disease by
the type of vessel
affected, and
whether the patient
is also experiencing
angina.
ICD-10 Roadmap: A&P
heart failure, the heart can’t pump enough
blood to meet the body’s needs.
ICD-10-CM separates codes for ischemic
heart disease by the type of vessel affected,
and whether the patient is also experiencing angina.
Heart failure is coded by the type, such as
systolic, diastolic, or a combination of both,
as well as whether the condition is acute or
chronic.
Systolic heart failure is a form of heart failure
in which the heart’s lower chambers (ventricles) have become too weak to contract and
pump out enough blood to meet the body’s
needs, resulting in shortness of breath and
other heart failure symptoms.
Diastolic heart failure is defined as symptoms of heart failure in a patient with preserved left ventricular function. A stiff left
ventricle often is characterized with decreased compliance and impaired relaxation, which leads to increased end diastolic pressure.
The patient in this example has multiple diagnoses. He is diagnosed with paroxysmal
atrial fibrillation, ventricular tachycardia,
and CAD with no mention of previous coronary artery bypass graft (CABG); therefore, it’s coded as a native artery. There is no
mention of angina, ischemic cardiomyopathy, hypertension (which is not described as
due to heart disease), or history of myocardial infarction (MI). He also has an allergy
to angiotensin-converting-enzyme (ACE)
inhibitors.
Without a working knowledge of A&P,
these two examples may have taken you
quite awhile to look up everything necessary
to make the appropriate code selections. By
preparing now with a solid A&P course, you
will be more effective in your coding, and
worry less about productivity losses with the
new coding system.
Rhonda Buckholtz, CPC, CPMA, CPCI, is
vice president of ICD-10 Training and Education
at AAPC.
A&P QUIZ
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC
Think You Know A&P? Let’s See …
Hypertension is the term used to describe high blood pressure.
High blood pressure increases the risk of heart disease, stroke,
kidney failure, and eye problems—so it’s important to know
how to lower high blood pressure. Hypertension risk factors can
include obesity, excessive alcohol consumption, smoking, and
family history.
Blood pressure is a measurement of the force against artery walls as
the heart pumps blood through the body.
Blood pressure readings are usually given as two numbers; for
example, 120 over 80 (written as 120/80 mm Hg). Normal blood
pressure is when your blood pressure is lower than 120/80 mm Hg
most of the time. High blood pressure (hypertension) is when your
blood pressure is 140/90 mm Hg or above most of the time. If your
blood pressure numbers are 120/80 or higher, but below 140/90,
it is called pre-hypertension. If you have pre-hypertension, you are
more likely to develop high blood pressure.
Test yourself to find out where your A&P skills rank:
When blood pressures are documented, what does the top number
reference?
a. Diastolic blood pressure
b. Diastolic rate and rhythm
c. Systolic blood pressure
d. Systolic rate and rhythm
The correct answer is on page 60.
Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is vice president
of ICD-10 Training and Education at AAPC.
www.aapc.com
March 2013
19
■ Coding/Billing
By Anna Barnes, CPC, CEMC, CGSCS
Colonoscopy:
Screening or Surveillance?
Consider patient history and reason for the visit for
accurate diagnosis coding.
he advent of the Affordable Care Act (ACA) has increased patient access to a greater number of preventative services. Physicians and patients have both benefited from this new law. Patient disease processes are being diagnosed at an earlier stage, ensuring less invasive treatments and better outcomes, while physicians
are seeing an increase in revenue for preventative services.
Practices performing colonoscopies for colon and rectal cancer
screenings have seen a corresponding rise in requests for “screening” colonoscopy. As a result, there is an increase in incorrectly coded colonoscopies. Practices may not understand that a majority of
patients are actually not screening colonoscopies, but are following
surveillance regimens. There are several steps you must take to determine the difference and correctly code colonoscopy.
Step 1: Define Screening vs. Surveillance
Colonoscopy, Determine Patient Need
Physicians and coders must be able to distinguish between a screening and surveillance colonoscopy. As defined by The U.S. Preventive
Services Task Force (USPSTF):
• A screening colonoscopy is performed once every 10 years
for asymptomatic patients aged 50-75 with no history of
colon cancer, polyps, and/or gastrointestinal disease.
• A surveillance colonoscopy can be performed at varying
ages and intervals based on the patient’s personal history of
colon cancer, polyps, and/or gastrointestinal disease. Patients
with a history of colon polyp(s) are not recommended for a
screening colonoscopy, but for a surveillance colonoscopy.
Per the USPSTF, “When the screening test results in the
diagnosis of clinically significant colorectal adenomas or
cancer, the patient will be followed by a surveillance regimen
and recommendations for screening are no longer applicable.”
(www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colosum.htm)
The USPSTF does not recommend a particular surveillance regime for patients who have a personal history of polyps and/or cancer; however, surveillance colonoscopies generally are performed in
shortened intervals of two to five years. Medical societies, such as
the American Society of Colon and Rectal Surgeons and the American Society of Gastrointestinal Endoscopy, regularly publish recommendations for colonoscopy surveillance (see: www.fascrs.org/patients/
treatments_and_screenings/assess_your_risk_for_colorectal_cancer/screening/).
The type of colonoscopy will fall into one of three categories, depending on why the patient is undergoing the procedure.
1. Diagnostic/Therapeutic colonoscopy (CPT® 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure))
• Patient has a gastrointestinal sign, symptom(s), and/or
diagnosis.
20
AAPC Cutting Edge
Coding/Billing: Colonoscopy
Splenic
flexure
Transverse
colon
The scope
travels beyond
the splenic
flexure
Sigmoid
flexure
Rectum
2. Preventive colonoscopy screening (CPT® 45378, G0121
Colorectal cancer screening; colonoscopy on individual not meeting
criteria for high risk)
• Patient is 50 years of age or older
• Patient does not have any gastrointestinal sign, symptom(s),
and/or relevant diagnosis
• Patient does not have any personal history of colon cancer,
polyps, and/or gastrointestinal disease
• Patient may have a family history of gastrointestinal sign,
symptom(s), and/or relevant diagnosis
Exception: Medicare patients with a family history (first degree relative with colorectal and/or adenomatous cancer) may qualify as
“high risk.” Colonoscopy for these patients would not be a “surveillance,” but a screening, reported with HCPCS Level II code G0105
Colorectal cancer screening; colonoscopy on individual at high risk.
3. Surveillance colonoscopy (CPT® 45378, G0105)
• Patient does not have any gastrointestinal sign, symptom(s),
and/or relevant diagnosis.
• Patient has a personal history of colon cancer, polyps, and/or
gastrointestinal disease.
Step 2: Properly Report Personal/
Family History with Screening/Follow-up
According to ICD-9-CM Official Guidelines for Coding and Reporting, section 18.d.4:
There are two types of history V codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists
and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the
need for a test or procedure.
Common personal history codes used with colonoscopy are V12.72
and V10.0x Personal history of malignant neoplasm of the gastrointestinal tract. The family history codes include V16.0 Family history of
malignant neoplasm of the gastrointestinal tract; V18.51 Family history of colonic polyps; and V18.59 Family history of other digestive disorders. Lastly, V76.51 describes screening of the colon.
Scope
Descending
colon
Sigmoid
colon
A flexible colonoscope is inserted into the
anus and fed beyond the splenic flexure for
diagnostic purposes, with or without
collection of specimen(s) by brushing or
washing, and with or without colon
decompression (45378)
Examination
using flexible
scope
Anatomical Illustrations © 2012, Optuminsight, Inc.
Per the ICD-9-CM official guidelines, you would be able to report
V76.51 (screening) primary to V16.0 (family history of colon polyps). In contrast, you would not use V76.51 (screening) with V12.72
(personal history of colon polyps) because family history codes, not
personal history codes, should be paired with screening codes. Personal history would be paired with a follow-up code.
Just because you get paid doesn’t mean the coding is correct: Most
carriers will pay V76.51 with V12.72 because their edits are flawed
and allow it. The patient’s claim will process under a patient’s preventative benefits with no out-of-pocket; however, an audit of the record with the carrier guidance will reveal that the claim incorrectly
paid under preventative services when, in fact, the procedure should
have paid as surveillance. The best strategy is to contact your payer
to be sure you are coding correctly based on that payer’s “screening
vs. surveillance” guidelines.
Step 3: Understand Government
and Carrier Screening Definitions
Following USPSTF recommendations, the ACA preventative guidelines state patients with a personal history of adenomatous polyps
and/or colon cancer are not covered under a screening guidance, but
rather under a surveillance regimen. Many third-party payers also
have incorporated the personal history, shortened interval surveillance colonoscopy concept into their policies.
www.aapc.com
March 2013
21
Coding/Billing: Colonoscopy
Form A
Surveillance colonoscopies are most often covered under diagnostic benefits, even if the patient is asymptomatic. Guidelines are inconsistent across payers; check with your individual payers for their
guidelines.
Step 4: Educate the Patient
Under the ACA, payers must offer first-dollar coverage for screening colonoscopy but are not obliged to do so for a surveillance or diagnostic colonoscopy. The patient’s history and findings determine
the reason for and type of colonoscopy, driving the benefit determination. This can be very frustrating for patients who may not understand why they are being charged for what they thought was a covered, physician-recommended “screening.” In fact, that screening
might be a follow-up (surveillance) colonoscopy, or may become a
diagnostic colonoscopy if there are findings.
To avoid angry, confused patients, educate them about the types of
colonoscopy (preventative, surveillance, or diagnostic) and insurance benefits associated with each procedure. Accomplish this by
providing the patient with the correct tools. Atlanta Colon and Rectal Surgery ask patients to review the “Colonoscopy: What You Need
to Know” form (see Form A) prior to coming into the office to schedule their procedure. This form includes defining the patient procedure type, giving the patient the CPT® and ICD-9-CM codes to call
22
AAPC Cutting Edge
insurance, and informing them of the practice policy of not illegally
changing documentation to produce better benefit determination.
During the scheduling process, the scheduler will present the “Colonoscopy Notification Form” (see Form B), and discuss the patient’s
responsibility for obtaining his or her insurance benefit.
Step 5: Correctly Apply the Principles
Scenario 1: An asymptomatic patient is scheduled for a colonoscopy.
The patient had an adenomatous polyp removed from the descending colon two years ago. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
CPT®: 45378
ICD-9-CM: V12.72
Rationale: The patient’s last colonoscopy was two years ago. He is
being followed by a surveillance regime due to his history of polyps.
ICD-9-CM guidelines do not allow the use of the V76.51 screening
code with the V12.72 personal history code.
Scenario 2: An asymptomatic patient is scheduled for a colonoscopy. The patient is 50-years-old and has a mother who was diagnosed
with colon cancer at age 55. The patient has never undergone a colo-
To discuss this article or topic, go to
www.aapc.com
Coding/Billing: Colonoscopy
Form B
Most carriers will pay V76.51
with V12.72 because their
edits are flawed and allow it.
… an audit of the record with
the carrier guidance will reveal
the claim was incorrectly paid
under preventative services
when, in fact, the procedure
should have been paid as
surveillance.
noscopy and has no other personal or family history. The patient is
scheduled and undergoes a complete bowel preparation followed by
a colonoscopy to the cecum. No abnormalities are found.
CPT®: 45378
ICD-9-CM: V76.51, V16.0
Rationale: The patient is 50-years-old and never undergone a colonoscopy procedure. His only relevant history is a mother with colon
cancer; family history. ICD-9-CM guidelines allow the use of the
V76.51 screening code with the V16.0 family history code.
Scenario 3: An asymptomatic Medicare patient is scheduled for a
colonoscopy. The patient had an adenomatous polyp removed from
the transverse colon five years ago. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No
abnormalities are found.
HCPCS Level II: G0105
ICD-9-CM: V12.72
Rationale: This is a Medicare patient with a history of adenomatous
polyps undergoing a colonoscopy only five years from the last one.
The patient is considered high risk under Medicare guidelines. ICD9-CM guidelines do not allow the use of the V76.51 screening code
with the V12.72 personal history code.
Scenario 4: An asymptomatic Medicare patient is scheduled for a
colonoscopy. The patient was recently diagnosed with breast cancer
and has never undergone a colonoscopy. The patient has no other
personal or family history. The patient is scheduled and undergoes
a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
HCPCS Level II: G0121
ICD-9-CM: V76.51, 174.9 Malignant neoplasm of breast (female),
unspecified
Rationale: This is a Medicare patient with no personal or family history of gastrointestinal disease; breast cancer is not considered an indication under Medicare guidelines. The patient is classified as an
average risk screening.
Screening and surveillance colonoscopy coding is driven by the diagnosis and reason for the visit. Physicians and coders must take the
time to educate themselves on the definition and guidelines, both
coding and carrier, to correctly bill colonoscopies.
Anna Barnes, CPC, CEMC, CGSCS, is the director of operations for Atlanta Colon and Rectal Surgery. She oversees corporate compliance programs, physician
auditing and education, and is director of information technology. She also manages billing department activities, including staff coding compliance and education.
She has a BSEd from the University of Georgia and 17 years of management experience in colon and rectal surgery.
www.aapc.com
March 2013
23
■ Coding/Billing
By David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
Get Busy Learning
New Cervico-cerebral Imaging,
Re-imagined
It’s time to re-evaluate your
cervico-cerebral imaging
coding for new concepts and
codes in 2013.
For 2013, CPT® has developed an entirely new concept and set of
codes for imaging of the cervico-cerebral (head and neck) arteries.
These codes do not apply to selective venous head and neck procedures, but do include the venous follow-through imaging often performed with selective cerebral angiography.
Codes 36221-36228 include catheter placements for the vessels selected and imaged. Catheter placements can be in:
• The aortic arch (36221 Non-selective catheter placement,
thoracic aorta, with angiography of the extracranial carotid,
vertebral, and/or intracranial vessels, unilateral or bilateral, and
all associated radiological supervision and interpretation, includes
angiography of the cervicocerebral arch, when performed)
• The innominate or common carotid (either 36222 Selective
catheter placement, common carotid or innominate artery,
unilateral, any approach, with angiography of the ipsilateral
extracranial carotid circulation and all associated radiological
supervision and interpretation, includes angiography of the
cervicocerebral arch, when performed or 36223 Selective catheter
placement, common carotid or innominate artery, unilateral,
any approach, with angiography of the ipsilateral intracranial
carotid circulation and all associated radiological supervision and
interpretation, includes angiography of the extracranial carotid
and cervicocerebral arch, when performed).
Editors’ note: CPT® brought 74 new interventional radiology, endovascular, cardiac chamber, and coronary arterial interventional codes for 2013, while deleting 32 codes for many
of the same types of procedures. Last month, we focused on the chest drainage procedures and non-cardiac endovascular codes changes, which include retrieval of intravascular foreign body and thrombolysis (see “Get Busy Learning New Non-cardiac Endovascular
Codes,” February 2013, pages 18-20).
24
AAPC Cutting Edge
Coding/Billing: Imaging
The new codes are unilateral. If bilateral carotid imaging with
selective catheterization is performed, report the appropriate
code with modifier 50 Bilateral procedure appended
• The internal carotid (36224 Selective catheter placement,
internal carotid artery, unilateral, with angiography of the
ipsilateral intracranial carotid circulation and all associated
radiological supervision and interpretation, includes
angiography of the extracranial carotid and cervicocerebral arch,
when performed).
Code 36221 for arch imaging is bundled with all selective cervicocerebral imaging codes, and cannot be reported with any codes in the
36222–36228 range; carotid code 36222 describes placement of the
catheter selectively into the innominate or common carotid artery
with unilateral imaging of the cervical carotid artery; code 36223
includes imaging of the intracranial vessels, as well; and code 36224
requires catheter placement in the internal carotid artery for carotid cerebral imaging.
All three selective codes include arch imaging, if performed, while
the cerebral codes 36223 and 36224 include the cervical carotid imaging, if performed. Only one code from this group can be reported
per side imaged, with a hierarchy of 36224 > 36223 > 36222.
Example 1: A 75-year-old patient with carotid stenosis identified
on Doppler ultrasound is here for angiographic evaluation. Via a
right femoral puncture, a catheter is advanced into the arch and cervicocerebral arch imaging is performed (36221). The catheter is advanced into the right innominate artery, and imaging of the cervical and cerebral carotid arterial distribution is performed (delete
36221, add 36223).
Severe stenosis of the right common carotid precludes selective advancement of the catheter into the carotid artery. A catheter is then
placed into the left common carotid artery and left cervical carotid imaging is performed (36222-59). The catheter is then advanced
into the left internal carotid artery for cerebral imaging of possible aneurysm (delete 36222-59, add 36224, append modifier 59 to
36223 for the right carotid, above). The catheter is removed.
New Codes Bundle Imaging
Code 36221 includes catheter placement in the aorta and imaging of
the arch, and the innominate, proximal subclavian, and common carotid arteries (as in the past). This year, imaging from an arch injection also includes complete imaging of the cervical carotid and vertebral arteries, along with the intracranial carotid and vertebral cerebral arteries, when performed. Last year, the imaging codes for these
Takeaways:
• 2013 CPT® includes major changes to interventional radiology
codes for cardiovascular services.
• Cervico-cerebral (head and neck) arteries have new codes.
• New codes bundle imaging.
specific regions could be reported; this year, a single code describes
all regions imaged via an arch injection.
The new codes are unilateral. If bilateral carotid imaging with selective catheterization is performed, report the appropriate code with
modifier 50 Bilateral procedure appended.
If a higher-level diagnostic study is performed on one side, report
both sides with accurate codes and modifier 59 on the lesser unilateral procedure (e.g., 36224 for internal carotid selection and intracranial imaging on the right, and 36223-59 for cervical and cerebral
imaging on the left, with the catheter in the common carotid artery).
Similar guidelines apply to unilateral vertebral artery imaging
(36225 Selective catheter placement, subclavian or innominate artery,
unilateral, with angiography of the ipsilateral vertebral circulation and
all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed) to report unilateral vertebral artery imaging with a catheter placed in the innominate or subclavian artery; as well as to imaging via a catheter selectively placed into the vertebral artery (36226 Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and
interpretation, includes angiography of the cervicocerebral arch, when
performed).
Both 36225 and 36226 include imaging of the neck and head. These
codes are unilateral, and follow similar guidelines as the carotid arteries for bilateral procedures. Selective vertebral codes include imaging of the arch (if done), and have a hierarchy of 36226 > 36225.
Example 2: The patient is 57-years-old with possible vertebro-basilar insufficiency. Via a right common femoral puncture, a catheter
is advanced into the arch and cervico-cerebral arch angiography is
performed (36221). A catheter is advanced into the right subclavian
artery and vertebral artery imaging is performed (delete 36221, add
36225). This injection fails to show retrograde flow down the left
www.aapc.com
March 2013
25
36222-36223
vertebral. The catheter is then placed into the left subclavian and advanced further into the left vertebral artery, and selective left vertebral artery imaging is performed (add 36226, append modifier 59 to
36225, above). The left vertebral ends in the posterior inferior cerebellar artery (PICA).
Add-ons Paint a Complete Picture
Report add-on code +36227 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)
with codes 36222–36224 when the external carotid artery is selectively catheterized, and imaging is performed of the external carotid artery and any additional branches. Report +36227 only once per
side. Do not report +75774 Angiography, selective, each additional
vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure)
for any additional super-selective external carotid branch selection
and imaging.
Use +36228 Selective catheter placement, each intracranial branch of
the internal carotid or vertebral arteries, unilateral, with angiography
of the selected vessel circulation and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure)
when an intracranial artery is super-selectively catheterized, with
imaging performed of any intracranial artery (e.g., anterior cerebral,
posterior cerebral, middle cerebral, callosal marginal, peri-callosal,
basilar superior cerebellar, PICA, AICA, etc.). Code +36228 may be
reported twice per side (right cerebral, left cerebral, and posterior fos26
AAPC Cutting Edge
36224
Anatomical Illustrations © 2012, Optuminsight, Inc.
Coding/Billing: Imaging
sa), but only with 36224 and 36226; however, the medically unlikely edit (MUE) for +36228 is four units. It would be an unusual case
that requires super-selective intracranial arterial catheterization and
imaging from all three territories.
Variant Anatomy & Diagnostic
Cervico-cerebral Angiography Coding
The new cervico-cerebral arterial imaging code set is not influenced
by variant anatomy. This means, the codes for selective bilateral
common carotid and bilateral selective vertebral imaging with catheter placement in the common carotid and vertebral arteries, in a patient with a normal arch, are the same codes as reported for a patient
with variant anatomy consisting of a bovine arch, or with an aberrant right subclavian artery.
These codes only apply to cervico-cerebral imaging performed as a
diagnostic study (with or without neuro-intervention). If a neurointerventional procedure is performed without diagnostic imaging
(e.g., diagnostic study of stable aneurysm done on the prior day, here
for intervention only today), the “selective above diaphragm” catheter placement codes (36215–36218) are appropriate, along with the
interventional codes for the procedure performed. If diagnostic imaging and neuro-intervention are performed at the same session, do
not submit selective catheter placements. Instead, report only 3622136228 because catheter selections are included.
Example 3: The patient is 41-years-old with wide-mouthed, supraclinoid internal carotid aneurysm. The patient had complete diagnostic angiography performed one day earlier and now consents to
embolization with Pipeline™ device for therapy. Via a right femoral
To discuss this article or topic, go to
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Coding/Billing: Imaging
36228
Code +36228 may be reported
twice per side (right cerebral, left
cerebral, and posterior fossa),
but only with 36224 and 36226.
puncture, a guiding sheath is advanced into the right common carotid artery. The device catheter is then advanced to the level of the
aneurysm (36217 Selective catheter placement, arterial system; initial
third order or more selective thoracic or brachiocephalic branch, within a vascular family) and the Pipeline™ device successfully deployed
for flow diversion and aneurysm embolization (61624 Transcatheter permanent occlusion or embolization (eg, for tumor destruction,
to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) and
75894 Transcatheter therapy, embolization, any method, radiological
supervision and interpretation). Completion angiography demonstrates flow diversion and successful procedure with patency of the
native vessel (75898 Angiography through existing catheter for followup study for transcatheter therapy, embolization or infusion, other than
for thrombolysis). The catheter is removed.
Example 4: Same patient as example 3; however, the patient had bilateral internal carotid arterial catheter placements with carotid cerebral imaging (add 36224-50 to prior example) on the same day as
the intervention (delete 36217 from prior example).
Example 5: The patient is 60 years old with transient ischemic attacks (TIAs). Via a transfemoral approach, a catheter is placed to the
aortic arch and imaging of the arch is performed. Proximal carotid and brachiocephalic ulcerated stenoses preclude selective catheter placements, so repeat arch injection is performed with imaging
focused on the cervical and cerebral carotids. Excellent detail is obtained, demonstrating 90 percent right internal carotid artery (ICA)
stenosis, 60 percent left ICA stenosis, and normal intracranial vessels. The entire right vertebral artery is imaged and appears normal.
Code 36221 describes all imaging of the cervico-cerebral vasculature
via this non-selective arch injection.
Example 6: Same case as example 5, but the proximal arch vessels do
not have stenoses, so the right common carotid, right vertebral, and
left common carotid arteries are selected and images of the cervical
and cerebral carotids, as well as the vertebral artery, are obtained.
Code 36223-50 describes bilateral carotid imaging. Code 36226
describes selective right vertebral imaging. Arch imaging (36221) is
bundled in both the selective carotid and vertebral codes, and is not
separately reported.
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiologist and president of ZHealth Consulting and ZHealth Publishing in Brentwood,
Tenn.
www.aapc.com
March 2013
27
■ Coding/Billing
By Maryann C. Palmeter, CPC, CENTC
Open Mouth, Insert Foot: Partial Foot and Toe Amputations
Knowing anatomy and procedure differences will clarify coding
and save you from embarrassing misconception.
I recall reviewing some documentation where a patient had a foot
amputated, and about two months later the same patient underwent
an amputation of the same foot. I thought, “How many times can the
same foot be amputated? There’s something wrong here.”
It’s Not All or Nothing
Review Your Anatomy and Terminology
An understanding of the skeletal anatomy of the ankle, foot, and toes
is key in amputations because CPT® code selection is based primarily on the joint(s) through which the disarticulation occurs. See Figure A for a labeled diagram of its anatomy.
Assigning codes will be easier, too, if you are familiar with various
types of ankle, foot, and toe amputations. Types of amputations are:
Boyd – Similar to Syme amputation (below), but provides a broad
weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus. This provides
more length and better preserves the weight-bearing function of the
heel pad than the Syme. The Boyd amputation preserves the calcaneus, and the calcaneus is fused to the tibia. This relieves the problem of migration of the heel pad because the heel pad remains firmly
attached to the calcaneus. Both malleoli are preserved.
Chopart – Midtarsal amputation of the foot between the calcaneus
and the cuboid bones (Calcaneocuboid joint) and the talus and the
navicular bones (Talocalcaneonavicular joint).
Hey – Amputation of the foot between the metatarsus
and tarsus or tarsometata rsa l
Photo by iStockphoto © woewchikyury
I am glad I didn’t say out loud what I was thinking, or I would have
ended up with a foot in my mouth, so to speak. As it turns out,
my perception of foot amputations was wrong. Not every operation labeled a foot amputation
results in the removal of the
entire foot; therefore, it is indeed possible for a patient to
have multiple amputations
at more proximal levels, if a
disease progresses.
A partial foot amputation
(PFA) may occur in patients with advanced
vascular disease secondary to diabetes
and its complications, but also may
occur due to injury, infection, or
birth defect.
Numerous complications—including skin breakdown, non-healing ulceration, osteomyelitis, and/or gangrene—can lead to a subsequent and more proximal amputation.
The goal of amputation is successful healing, preserving as much
function as possible, and creating a residual limb that will work best
with or without a prosthesis. Other issues that affect decisions about
the type and extent of surgery include the patient’s overall health and
his or her ability to withstand anesthesia, the level at which there is
adequate blood flow, the potential for successful rehabilitation, and
the desired activity level afterward.
28
AAPC Cutting Edge
Coding/Billing: Amputations
An understanding of the skeletal anatomy of the ankle, foot, and
toes is key in amputations because CPT® code selection is based
primarily on the joint(s) through which the disarticulation occurs.
Figure A
joint, which is located between the base of
the first through fifth metatarsal bones and
their connection with the medial, intermediate, and lateral cuneiforms and the cuboid
bone in the foot.
Lisfranc – Same as the Hey amputation.
Pirogoff – Amputation of the foot at the
ankle wherein the anterior two thirds of the
calcaneus is removed, and the posterior process of the calcaneum is retained at the skin
Photo credit: Courtesy of Dr. Foot, (www.drfoot.co.uk); copyright 1994–2012; used with permission.
flap and opposed to the cut end of the tibia.
Both malleoli are preserved.
Ray – Amputation of the toe along with
all or part of the corresponding metatarsal bone.
Syme – Disarticulation of the foot with removal of both malleoli, followed by forward rotation of the heel pad over the end of
the residual tibia. This technique provides
an end-bearing stump that allows ambula-
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Coding/Billing: Amputations
The toe is amputated
tion over short distances. The residual limb ends at the distal base of the tibia. A
complication of the Syme amputation is migration of the heel pad, which is not
firmly fixed to the tibia.
Terminal Syme – Amputation of part of the distal phalanx, which is performed
via an elliptical incision and involves resection of the toenail, nail bed, and approximately half of the distal phalanx. The wound is closed by placing the skin
flap over the stump and suturing the skin. Although the skin flap technique is
similar to the one used in the Syme amputation of the ankle, do not confuse these
two very distinct procedures.
Transmetatarsal – Amputation of all toes at the metatarsals.
The CPT® codes to report ankle, foot, and toe amputations are:
27888 Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of nerves
Finished amputation
of great toe
(Use this code for Boyd amputation, as well.)
27889 Ankle disarticulation
28800 Amputation, foot; midtarsal (eg, Chopart type procedure)
Interphalangeal
amputation (28825)
A single toe is amputated at the level
of the metatarsal bone. Report 28825
when the amputation is performed
at an interphalangeal joint.
Anatomical Illustrations © 2012, Optuminsight, Inc.
Key Definitions
Anterior – Front.
Articulation – Bones joined to one another at different
parts of their surfaces.
Chopart’s joint – The articulation between the hindfoot
and the midfoot (midtarsal joint).
Disarticulation – Separation or amputation through a
joint.
Dorsal – Top surface of the foot.
Intermediate – Middle.
Interphalangeal joints – Any of the joints between the
phalangeal bones.
Lateral – Outer.
(Use this code for Hey and Lisfranc amputations, as well.)
28805 Amputation, foot; transmetatarsal
28810 Amputation, metatarsal, with toe, single
(Use this code for a ray amputation.)
28820 Amputation, toe; metatarsophalangeal joint
(Use this code for amputation between the metatarsal joint and proximal phalanx.)
28825 Amputation, toe; interphalangeal joint
Use this code for amputation between proximal and middle phalanges or middle
and distal phalanges in toes two through five, or amputation between the distal
and proximal phalanges in the big toe.
11752 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; with amputation of tuft of distal
phalanx
Use this code to report amputation of distal tuft of phalanges or terminal Syme
amputation of the toe.
Don’t forget to use modifiers to denote laterality (modifier LT Left side and RT
Right side), and to distinguish one toe from another.
Toe Modifiers
Left Foot Digit
Modifier
Right Foot Digit
Modifier
Great (big) toe – This little piggy
went to market.
TA
Great (big) toe
T5
Second – This little piggy stayed
home.
T1
Second
T6
Third – This little piggy had roast
beef.
T2
Third
T7
Plantar – Bottom surface of the foot.
Posterior – Back.
Fourth – This little piggy had none.
T3
Fourth
T8
Proximal – In relation to amputations, subsequent
amputations closer to the ankle.
Fifth (pinky toe) – This little piggy
went wee, wee, wee all the way
home.
T4
Fifth (pinky toe)
T9
Lisfranc joint – The articulation between the midfoot
and the forefoot.
Malleolus (plural: Malleoli) – The bony projections on
the medial and lateral sides of the ankle at the distal
ends of the tibia and fibula, respectively.
Medial – Inner.
Tuft – In regard to the toes, the head of the distal
phalanges.
30
AAPC Cutting Edge
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Coding/Billing: Amputations
Examples Show the Coding Way
32 1
54
1
Metatarsals
5 4 32
Scenario: A diabetic patient suffers from gangrene in the fourth and fifth toes
of the right foot. The physician performs a ray amputation of these toes and documents that if the ray amputation does not halt the progression of the gangrene,
a more aggressive course of treatment may need to be taken. Three weeks later, the gangrene has progressed at a rapid pace and the same physician performs
a Chopart amputation of the right foot. The physician documents the previous
procedure as unsuccessful at stopping the progression of the tissue death, and a
more extensive procedure was warranted. A temporary closure was made and
the operative note states the plan is to perform a secondary closure the following
week. The patient was returned to the operating room five days later, and an extensive secondary closure was performed. The physician documents that the secondary closure was planned prospectively at the time of the Chopart amputation.
Initial Surgery
28810-T8 (ray amputation with application of modifier for forth digit on the
right foot)
28810-51-T9 (ray amputation with application of Multiple procedures modifier,
and modifier for fifth digit on the right foot)
Second Surgery
28800-58-RT (Chopart amputation with application of modifier for Staged or
related procedure or service by same physician during the postoperative period of the
initial surgery followed by RT modifier to designate right side of the body)
Because the Chopart amputation was performed during the post-operative period of the ray amputations and it was a more extensive procedure, append modifier 58 to the Chopart amputation procedure code. Also, the documentation mentioned that a more extensive course of treatment may need to be followed if the
ray amputations were not successful in mitigating the necrosis.
Third Surgery
13160-58-RT (Secondary closure of surgical wound or dehiscence, extensive or complicated)
Because the secondary wound closure was planned prospectively at the time of
the Chopart amputation, and it was performed within the post-operative period
of the Chopart amputation (remember a new post-operative period began with
the Chopart procedure), append modifier 58 to this procedure code. Modifier
RT was appended to reflect that the procedure was performed on the right side
of the body.
When appending multiple modifiers, append the modifier that impacts payment first. In this case, modifier 58 affects payment because it triggers the start
of a new global period.
Tarsals
Metatarsals
Midtarsal
(28800)
Transmetatarsal
(28805)
A portion of a foot is amputated.
Report 28800 for a midtarsal
amputation and 28805 for a
transmetatarsal amputation.
Anatomical Illustrations © 2012, Optuminsight, Inc.
Let My Experience Be a Lesson
The next time you come across something in an operative or procedure note that
appears a bit unusual, do a little more research before you end up with a foot in
your mouth.
Maryann C. Palmeter, CPC, CENTC, has over 29 years of experience in the health care industry,
with emphasis on federal and state government payer billing and compliance regulations. She has
gained extensive experience through her work on both the billing and government contractor ends
of the health care industry spectrum. Ms. Palmeter is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance for the University of Florida
College of Medicine – Jacksonville. She is a member of the AAPC National Advisory Board (NAB) and
was named 2010 Member of the Year.
Credits: The author would like to acknowledge Stephen Meritt,
DPM, and Joseph Sindone, DPM, with the University of Florida
College of Medicine – Jacksonville Department of Orthopaedics
and Rehabilitation, for sharing their clinical insight. Thanks also
to Smart Feet Savannah: www.smartfeetsavannah.com/smartreference-library/where-does-it-hurt/foot-types/amputations.
www.aapc.com
March 2013
31
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By Lynn S. Berry, PT, CPC
PTs Rise to 2013 G code Challenge
Follow physical therapy
service requirements
for new G code and
modifier reporting.
A new, claims-based collections system implemented through the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule (www.gpo.gov/fdsys/pkg/FR-2012-1116/pdf/2012-26900.pdf) calls for adding non-payable G
codes with additional severity modifiers on each therapy claim—along with the normal charges and therapy modifiers and applicable Physician Quality Reporting System (PQRS) codes and modifiers.
Rule of Thumb for G Code Use
In the final rule, the Centers for Medicare & Medicaid Services (CMS) instructs us to use G codes and severity modifiers during:
• The initial treatment
• Defined progress periods
• Any subsequent evaluation or re-evaluation
• The end of care (or discharge)
• When reporting of the primary functional
limitation has ended with further therapy
required
• When reporting begins on a different or
subsequent functional limitation
G codes signify the patient’s primary impairment as
determined by the therapist. The therapist determines
the severity by using a standard set of functional outcome measures denoted by a severity modifier added
to the G codes. A G code with a severity modifier is
also required for the projected outcome of the patient
(the patient’s goal).
The measures for both the goal and the initial level of
impairment should be noted in the patient’s plan of
care; the goal and current level of impairment should
be noted in progress reports no later than every 10
treatment days (a new definition of progress report
34
AAPC Cutting Edge
Coding/Billing: Cover
Table A: G codes for 2013
Takeaways
Mobility: Walking and Moving Around
• CMS requires a G code and severity modifier be
reported with PT, OT, and SLP services.
G8978
Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals
• The G codes signify impairment as defined by the
therapist.
G8979
Mobility: walking & moving around functional limitation, projected goal status, at
therapy episode outset, at reporting intervals, and at discharge or to end reporting
• The severity modifiers identify the extent of
impairment.
G8980
Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting
Changing and Maintaining Body Position
time frames); and the goal and final level of impairment should be noted in the discharge note or when
the goal is reached. For most claims, two G codes are
required, with two exceptions:
• When therapy services are under multiple plans
of care (physical therapy (PT), occupational
therapy (OT), and/or speech-language
pathology (SLP)) from the same therapy
provider; or
• When it is a one-time visit and all three G
codes (current status, goal status, and discharge
status) must be reported.
Know Therapy G Codes and
Severity Modifier Requirements
To provide an audit trail, the G codes and severity
modifiers, their rationale for use, and the pertinent
tests provided need to be documented in the medical
record. After the primary impairment goal is reached,
secondary impairments may be noted and treatment
continued until the goal for that impairment is met or
final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or
secondary payer. The G codes and severity modifiers
for PT, OT, and SLP are noted in the final rule (and
shown in Table A).
Select only one impairment as primary. If a specific
category does not apply, or if using a composite functional measurement tool, select the “other” category.
Each impairment category has three applicable codes.
Note: The SLP G codes are aligned with their functional reporting system, the National Outcomes Measurement System (NOMS). For SLP, the “other” category is used for any of the eight remaining NOMS categories not specified in the rule.
G8981
Changing & maintaining body position functional limitation, current status, at
therapy episode outset and at reporting intervals
G8982
Changing & maintaining body position functional limitation, projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to
end reporting
G8983
Changing & maintaining body position functional limitation, discharge status, at
discharge from therapy or to end reporting
Carrying, Moving, and Handling Objects
G8984
Carrying, moving & handling objects functional limitation, current status, at
therapy episode outset and at reporting intervals
G8985
Carrying, moving & handling objects functional limitation, projected goal status,
at therapy episode outset, at reporting intervals, and at discharge or to end
reporting
G8986
Carrying, moving & handling objects functional limitation, discharge status, at
discharge from therapy or to end reporting
Self Care
G8987
Self care functional limitation, current status, at therapy outset and at reporting
intervals
G8988
Self care functional limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting
G8989
Self care functional limitation, discharge status, at discharge from therapy or to
end reporting
Other PT/OT Primary Functional Limitation
G8990
Other physical or occupational primary functional limitation, current status, at
therapy episode outset and at reporting intervals
G8991
Other physical or occupational primary functional limitation, projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to
end reporting
G8992
Other physical or occupational primary functional limitation, discharge status, at
discharge from therapy or to end reporting
Other PT/OT Subsequent Functional Limitation
G8993
Other physical or occupational subsequent functional limitation, current status,
at therapy episode outset and at reporting intervals
G8994
Other physical or occupational subsequent functional limitation, projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to
end reporting
G8995
Other physical or occupational subsequent functional limitation, discharge
status, at discharge from therapy or to end reporting
www.aapc.com
March 2013
35
Coding/Billing: 2013 G Codes
Swallowing
Attention
G8996
Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9165
Attention functional limitation, current status at time of initial
therapy treatment/episode outset and reporting intervals
G8997
Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy
G9166
Attention functional limitation, projected goal status at initial
therapy treatment/outset and at discharge from therapy
G8998
Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation
G9167
Attention functional limitation, discharge status at discharge
from therapy/end of reporting on limitation
Motor Speech
Memory
G8999
Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9168
Memory functional limitation, current status at time of initial
therapy treatment/episode outset and reporting intervals
G9157
Motor speech functional limitation, projected goal status at
initial therapy treatment/outset and at discharge from therapy
G9169
Memory functional limitation, projected goal status at initial
therapy treatment/outset and at discharge
G9158
Motor speech functional limitation, discharge status at discharge from therapy/end of reporting on limitation
G9170
Memory functional limitation, discharge status at discharge
from therapy/end of reporting on limitation
Spoken Language Comprehension
G9159
G9160
G9161
Voice
Spoken language comprehension functional limitation, current
status at time of initial therapy treatment/episode outset and
reporting intervals
Spoken language comprehension functional limitation, projected goal status at initial therapy treatment/outset and at
discharge
Spoken language comprehension functional limitation, discharge status at discharge from therapy/end of reporting on
limitation
G9171
Voice functional limitation, current status at time of initial
therapy treatment/episode outset and reporting intervals
G9172
Voice functional limitation, projected goal status at initial
therapy treatment/outset and at discharge from therapy
G9173
Voice functional limitation, discharge status at discharge from
therapy/end of reporting on limitation
Other SLP Functional Limitation
Spoken Language Expression
G9162
G9163
G9164
Spoken language expression functional limitation, current
status at time of initial therapy treatment/episode outset and
reporting intervals
Spoken language expression functional limitation, projected
goal status at initial therapy treatment/outset and at discharge from therapy
G9174
G9175
Spoken language expression functional limitation, discharge
status at discharge from therapy/end of reporting on limitation
The severity/complexity modifiers for reporting each
functional G code on the claim are shown in Table B.
Here is an example of how to use G codes on a claim:
A 66-year-old patient presents at the clinic and receives
a full initial evaluation, including specific impairment
and functional measures testing and administration of
three PQRS outcome measures: falls, body mass index,
and pain level. A plan of care is developed (with specific
goals based on the patient’s impairments, co-complexities, and severity) to submit to the physician for certification. Treatment is initiated as specified in the plan. Documentation is completed, and includes all of the tests
G9176
Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset
and reporting intervals
Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at
discharge from therapy
Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on
limitation
Table B: Severity modifiers for reporting therapy G codes
Modifier
Impairment Limitation Restriction
CH
CI
0 percent impaired, limited or restricted
At least 1 percent but less than 20 percent impaired, limited or
restricted
At least 20 percent but less than 40 percent impaired, limited or
restricted
At least 40 percent but less than 60 percent impaired, limited or
restricted
At least 60 percent but less than 80 percent impaired, limited or
restricted
CJ
CK
CL
CM
CN
At least 80 percent but less than 100 percent impaired, limited or
restricted
100 percent impaired, limited or restricted
To provide an audit trail, the G codes and severity modifiers,
their rationale for use, and the pertinent tests provided, need
to be documented in the medical record.
36
AAPC Cutting Edge
Coding/Billing: Therapy Services
By Lynn S. Berry, PT, CPC
Therapy Services:
The Uphill Climb to Better
Codes and Reimbursement
History shows documentation improvement
as therapists strive to overcome obstacles.
photo by iStockphoto©iskra
and measures used and the rationale for the treatment and severity modifier chosen. G codes and
modifiers are added to the documentation. The
claim is filed for the patient for the date of service
with the following entries:
97001 GP X1
$XX.00
97112 GP X1
XX.00
97116 GP X1
XX.00
G8978 GPCL
0.00
G8979 GPCI
0.00
1101F
0.00
G8731
0.00
G8417
0.00
Note: Modifier GP Services delivered under an
outpatient physical therapy plan of care (or “other therapy” modifier) must be added to the data
codes because they are always therapy codes. The
order does not matter when assigning the therapy or severity modifier. Therapy modifiers are
not required to be added to PQRS codes. Neither modifier KX Requirements specified in the
medical policy have been met nor modifier 59 Distinct procedural service can be used with these G
codes. These codes are not only added for 2013,
but CMS notes they will continue to require data
code submission until a new payment system is
developed.
Over the last three decades, there has been remarkable change in therapy services
billing rules due to legislative efforts to bring the cost of health care down and to pay
for the quality (rather than quantity) of care. Therapists must juggle clinical concerns
with documentation burdens to meet the challenge.
Rules Changed Due to Costs
From 1998-2008 therapy expenditures increased 10.1 percent
per year, while the number of beneficiaries receiving that
therapy increased only 2.9 percent. In 2010, 7.6 million
beneficiaries received outpatient services, with Medicare
payments exceeding $5.6 billion. Since then, expenditures have continued to rise.
The reason for this is largely because of how
physical and occupational therapists (PTs and
OTs) are reimbursed. Their therapy codes
include both timed codes (with multiple
units) and untimed codes. Therapists
use a combination of treatment
codes at each visit, which could
become problematic if payment is based on the
number of codes billed.
First, it allows
for misuse of
codes. Some
procedures and
modalities are
assigned higher
relative value
units (RVUs)
than others, so
they are paid at
a higher rate. If
there is insufficient documentation of the
rationalization of
each procedure,
an incorrect,
higher-value code
may be used.
Lynn Berry, PT, CPC, had over 35 years of clinical and
management experience before beginning a new career
as a coder and auditor and later becoming a provider
representative for a Medicare carrier. She now has her
own consulting firm, LSB HealthCare Consultants, LLC,
furnishing consulting and education to diverse providers, and is a senior coder and auditor for the Coding Network. Berry has
held a variety of offices for her local AAPC chapter and continues as
one of the directors of the St. Louis West Chapter.
www.aapc.com
March 2013
37
Coding/Billing: Therapy Services
Therapists, like other providers, must add the
non-payable G codes and modifiers to their
claims in addition to the therapy modifiers.
Second, there could be incorrect calculation of timed code units due
to insufficient documentation of minutes, or inclusion of independent treatment time (which is non-billable). For some, it could also
include maximizing the number of treatments billed, as they are not
bundled. These factors increase use of care and drive up costs.
Therapy Caps Limit Expenditures
In 1972, Medicare law first allowed payment of PTs in independent
practice. In 1979, section 279 (b) of the Social Security Act (SSA)
amendments put a limit on payment for services furnished by a PT
in independent practice of no more than $100 of incurred expenses
in a year. Continued legislative acts have increased the cap.
In 1987, OT in independent practice was recognized with a $500
cap for services per year (equal to the PT cap). The caps continued
to rise until 1997, when the Balanced Budget Act expanded the cap
to outpatient therapy services furnished in skilled nursing facilities
(SNFs), physician’s offices, and home health agencies (Part B), in
addition to PT private practice offices. Section 4541 (c) and (d) of
the SSA increased the financial limitation to no more than $1,500 of
the incurred expenses in a year, and included one cap imposed on
PT and speech-language pathology (SLP) combined, and another cap
on OT. Outpatient hospitals were exempt from the cap. There were
moratoria on the caps (except for January – November 1999) until
2001, when they were finally applied.
Since then, the cap amount has increased each year, rising to
$1,880 in 2012 and to $1,900 in 2013 for each cap, with any amount
over the cap being denied. The services were tracked on claims
through the use of modifier GP Services delivered under an outpatient
physical therapy plan of care for PT, modifier GO Services delivered an
outpatient occupational therapy plan of care for OT, and modifier GN
Services delivered under an outpatient speech-language pathology plan of
care for SLP.
Most years, Congress has enacted an automatic exception to the
cap when there is documented medical necessity for exceeding it.
The therapist is required to attest to medical necessity of the care
by adding modifier KX Requirements specified in the medical policy
have been met on the claim. The American Taxpayer Relief Act
(ATRA) of 2012 reflects new legislation reinstating this automatic
exception from Jan. 1, 2013 through Dec. 31, 2013; and it applies
the $1,900 cap to the outpatient hospital setting.
Multiple Procedure Reductions and More
In 2011, the Medicare Physician Fee Schedule (MPFS) Final Rule
brought therapists a multiple procedure payment reduction (MPPR),
with a 25 percent reduction on the practice expense component
of facility payments and a 20 percent reduction on the practice
expense of outpatient services, if any one of the three therapies
or any more than one unit is billed. This had an effect on payment
38
AAPC Cutting Edge
of services, but not enough to reduce the skyrocketing costs. The
Medicare Payment Advisory Commission (MedPac) advised Congress
late in 2012 to increase the MPPR to 50 percent for all outpatient
therapy settings. ATRA puts this into effect as of April 1, 2013.
Therapists also participate in the Physician Quality Reporting System
(PQRS), which will start imposing penalties in 2015 if successful
reporting standards are not attained. Therapists, like other providers, must add the non-payable G codes and modifiers to their claims
in addition to the therapy modifiers.
The Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA)
added another caveat. From Oct. 1, 2012 to Dec. 31, 2012, hospital
outpatient departments were added as subject to the cap process
for claims from Jan. 1, 2012 to Dec. 31, 2012. For the three-month
period, a manual review was required for any services over $3,700.
This was a three-phased process, in which a therapist could apply
for pre-approval of services up to 20 days at a time with a 10-day
turnaround, or the claims were suspended and subject to prepayment manual review with a 60-day turnaround. This has caused
many problems for therapists, including delays in getting claims
paid and some denials if documentation was judged inadequate to
justify medical necessity. There were also glitches in the system and
problems with each contractor having their own process for manual
review. Many beneficiaries dropped their care because of fear they
would have an increased financial burden.
MedPac also advised Congress to have the manual therapy review
process continue for all outpatient settings. ATRA adopts this as
part of the legislation from Jan. 1, 2012 to Dec. 31, 2012. Whether
this will include a pre-approval process or just suspension with prepayment manual review is not yet clear.
One more regulation from section 2005 (g) of MCTRJCA was implemented through the 2013 MPFS Final Rule: The establishment of a
claims-based data collection system is designed to collect data on
functional outcomes of patients through an entire episode of care (to
determine whether therapy is effective), and to aid in the design of a
new payment therapy system. The goal is to reduce the cost of care
while increasing its quality.
New G Code Reporting
Adds to Administrative Burden
The new, claims-based collections system (see companion article,
“PTs Rise to 2013 G Code Challenge”) is effective Jan. 1, 2013, with
implementation no later than July 1, 2013. Its goal is to establish an
improved payment system based on quality care, which produces
efficient (less costly) and effective (measurable) results for patients
with similar conditions and functional limitations who have good
potential to benefit from the treatment provided. It’s effective for
all outpatient settings, including hospitals, critical access hospitals,
SNFs, comprehensive outpatient rehabilitation facilities, rehabilita-
To discuss this article or topic, go to
www.aapc.com
Coding/Billing: Therapy Services
The imposition of these codes on initial
claims … will cause great burden to all
therapists in the outpatient setting.
tion agencies, and home health agencies (when the beneficiary is not
under a home health plan of care). It applies to both therapists and
therapy services furnished either personally by or incident-to physicians and certain non physician practitioners, including applicable
nurse practitioners, certified nurse specialists, and physician assistants.
The imposition of these codes on initial claims, every 10 days, at
discharge, with assessments that must be completed to determine
which impairments and modifiers to apply, plus added documentation requirements, will cause great burden to all therapists in the
outpatient setting.
On the Horizon
For PT, the American Physical Therapy Association (APTA) is already
working on a new payment system. Their draft of an Alternative
Payment System (APS), or the Physical Therapy Classification and
Payment System (PTCPS), was released to members for comment
March 15, 2012. The CPT® Editorial Panel in Memphis, Tenn., Oct.
2-3, 2012, fully supported their efforts. A workgroup will be started
that is open to all advisors to rewrite the Physical Medicine and
Rehabilitation Section of CPT®. This is a two-part, per session payment system: One set of codes for evaluations, and another set of
per-session codes for treatments. Each combines consideration
of the complexity of the visit and the severity or complexity of the
patient’s condition. APTA expects this system to begin Jan. 1, 2015.
What It All Means for Therapy
At some point, we’ll have a new coding system for therapy acknowledging the complexity of evaluation and treatment options used,
as well as the severity of the variety of patients encountered by the
therapist, which reimburses accordingly. Therapists can then move
forward to provide efficient, effective care for their patients and meet
the challenge of high quality care at reasonable cost.
www.aapc.com
March 2013
39
■ Coding/Billing
By Ken Camilleis, CPC, CPC-I, CMRS, CCS-P
Fine Details Are Critical in Fracture Coding
Analyze documentation to understand the intricacies
of diagnostic and procedural fracture coding.
Takeaways:
• Understanding the different types of
fractures will help you code precisely.
• Code by location and if the break has
broken the skin.
• Coding fractures accurately now will help
you transition to ICD-10-CM coding.
B
ecause there are so many types of
fractures and fracture treatments,
appropriate diagnostic and procedural coding is very complex. Obtaining
appropriate reimbursement in compliance
with payer regulations and coding guidelines requires a thorough analysis of the documentation. Before you can do that, however, you have to understand what you’re looking at, and know which details you’re looking for.
Code by Location/Open or Closed
The formal definition of fracture in ICD-9CM is, “a complete or incomplete break in
a bone resulting from application of excessive force.” The ICD-9-CM Alphabetic Index (Volume 2) arranges fracture diagnosis
codes alphabetically by location, and often
by relative position of a given site (e.g., distal
end or proximal end). For example, the entry “fracture; clavicle” contains codes specific to the interligamentous region, the acromial end, the shaft (middle third), and the
sternal end of the bone.
The first three digits of a fracture diagnosis code identify the general location of the
fracture (e.g., 800.xx-804.xx for skull fractures, 805.xx-809.xx for neck and trunk
fractures, etc.). The fourth digit generally identifies the fracture as either open or
closed. Open means there is a skin wound
caused by the fracture. Closed means there
is a breakage of bone but not of surrounding
skin. If a fracture is not specified as either
open or closed, you must assume it is closed,
as indicated by an instructional note at the
beginning of ICD-9-CM chapter 17, in the
Fractures section (categories 800-829).
40
AAPC Cutting Edge
Most ICD-9-CM fracture diagnoses require a fifth digit. Typically, the fifth digit
of a fracture repair diagnosis code indicates
more specific bones within the general site,
but may also indicate other specified information. For example, when coding for skull
fracture (800.xx-804.xx), the fifth digit indicates if there was a loss of consciousness,
how long it lasted, and whether there was
a return to the previous level of consciousness. Clinicians should be careful to document these and other associated conditions
(e.g., spinal cord injury).
Stress Fractures May
Warrant Causation Codes
Clinicians and coders must often distinguish between traumatic fractures (caused
by an acute injury), pathologic fractures
(caused by an evolving disease process that
weakens bone, such as osteoporosis), and
stress fractures (due to repeated strain from
overuse).
Traumatic fractures are reported from
ICD-9-CM categories 800-829 while the
patient is receiving active treatment, such as
surgical or emergency department care. Aftercare treatment requires different codes
(see “Fracture Aftercare Calls for Unique
Coding” on page 42 for more detail).
To identify a pathologic fracture receiving
active treatment, report 733.1x.
For example, a 58-year-old man is diagnosed with a pathologic fracture of his C6
spinous process. Because this is a pathologic fracture, the correct code is 733.13 Pathologic fracture of vertebrae.
If the same patient had suffered from a traumatic fracture, you would code from cate-
Coding/Billing: Fractures
If a fracture is not specified as either open or
closed, you must assume it is closed.
gory 800-829. For the C6 spinous process,
you would report 805.06 Fracture of vertebral column without mention of spinal cord
injury; cervical, closed; sixth cervical vertebra.
A stress fracture, aka an insufficiency fracture, is caused by repeated strain from overexertion or due to a weakened bone (i.e., osteoporosis). Look to category 733.93-733.99
to report stress fractures. Also assign the appropriate diagnosis code to describe any underlying external cause.
For example: A 13-year-old boy was lifting
heavy weights at his school’s gym when he
began to clutch his left knee in pain. He was
diagnosed with a stress fracture of his tibia
shaft. Because this is a stress fracture rather
than an impact fracture, and is specified as
of the tibia, the proper code is 733.93 Stress
fracture of the tibia or fibula. You must also
specify the external cause of the stress fracture, including E927.0 Overexertion from
sudden strenuous movement and E010.2 Activity involving other muscle strengthening
exercises; free weights. You can also specify
place of occurrence, E849.6 Place of occurrence; public building.
History of pathologic fracture or stress fracture, when documented, should be reported
secondarily to the active fracture. The history codes are V13.51 Personal history of pathologic fracture and V13.52 Personal history of
stress fracture.
illustration by iStockphoto©tharrison
Tips for Diagnosis Sequencing
Official ICD-9-CM Guidelines for Coding and Reporting (section I.C.17.b) stipulates three primary rules for assigning and
sequencing fracture diagnoses:
1. Code all fractures separately. This inwww.aapc.com
March 2013
41
Coding/Billing: Fractures
cludes multiple unilateral or bilateral
fractures classified to different fourthdigit subdivisions (bone part) within the
same three-digit category (bone).
2. Combination codes are used only for triage on patients with multiple injuries
when the extent of the individual injuries
is unknown prior to transfer of care.
3. Report multiple fractures by severity
(most severe first), as determined by the
treating physician.
For example, following a motor vehicle accident, the patient arrives in the emergency department with multiple open depressed
skull and facial bone fractures, facial lacerations, and contusions. She has experienced
a 90-minute loss of consciousness. The appropriate ICD-9-CM code is 804.63 Multiple fractures involving skull or face with other
bones; open with cerebral laceration and contusion; with moderate [1-24 hours] loss of consciousness. In this case, a combination code
may be used. The code also describes other,
associated conditions (e.g., loss of consciousness).
CPT® Coding for Fracture Treatment
“Fracture” appears in the CPT® Index as a
main term (just as it does in ICD-9-CM).
This is where you’ll begin your search for fracture treatment codes. The terms “fracture”
and/or “dislocation” appear at the category
level in the main section of the CPT® codebook. For example, codes 27750-27848 represent treatments of fractures of the tibia, fibula, and ankle joints.
There are three major approaches to treat fractures: closed, open, and percutaneous.
• Closed treatment means the fractured
bone is not exposed to the view of the
surgeon.
• Open treatment means the bone is
exposed by incision.
• Percutaneous treatment (aka
percutaneous skeletal fixation) involves
the placement of a fixative device—
such as a rod, wire, or pin—across the
fractured bone usually under imaging
guidance.
The treatment type will not necessarily match
the fracture type. For instance, an orthopedic
surgeon may perform an open treatment of a
closed fracture, or a percutaneous treatment
of either a closed or open fracture.
When coding for physician services for surgeries to correct fractures, pay particular attention to terms such as closed/open/percutaneous treatment and details describing the
specific site (such as nasal bone, nasal septum,
nasoethmoid, nasoethmoid complex, or nasomaxillary). You’ll also need to understand
which combinations of terms are mutually exclusive with each of the three treatment methods. Read all CPT® descriptors carefully, noting terms such as “open reduction with internal fixation.” Observe when certain services
(such as the application of the fixative device)
are included in the descriptor, and not reported separately.
For both procedural and diagnostic coding,
experts generally agree that if one bone is
both fractured and dislocated, code only the
service and diagnosis for the fracture and
not the dislocation (see Coding Clinic, third
quarter 1990, page 13). Some CPT® codes
specifically describe surgeries on a bone that
is both fractured and dislocated.
For example, an 87-year-old man with history of falling presents for repair of fractured
proximal ulna and dislocated radial head. He
Fracture Aftercare Calls for Unique Coding
Codes 800-829 for traumatic fractures, 733.1x
for pathologic fractures, and 733.93-733.99 for
stress fractures should be reserved for when
the patient is receiving active treatment for
the fracture. ICD-9-CM Official Guidelines for
Coding and Reporting defines active treatment
as “surgical treatment, emergency department
encounter, and evaluation and treatment by a
new physician.”
42
AAPC Cutting Edge
When reporting services provided during the
healing or recovery phase of the fracture,
turn instead to fracture aftercare codes from
category V54. Examples of aftercare include
cast change or removal, removal of external
or internal fixation devices, medication adjustment, and follow-up fracture treatment visits.
To discuss this article or topic, go to
www.aapc.com
Coding/Billing: Fractures
Read all CPT® descriptors carefully, noting terms
such as “open reduction with internal fixation.”
slipped on ice, landing on his right elbow,
and sustained a Monteggia fracture. The
orthopedic surgeon performed an open reduction and internal fixation (ORIF) over
the site.
The correct CPT® and ICD-9-CM codes to
describe this scenario are:
• 24635-RT Open treatment of
Monteggia type of fracture dislocation
at elbow (fracture proximal end of
ulna with dislocation of radial head),
includes internal fixation, when
performed-Right side to describe the
ORIF for Monteggia fracture.
• 813.03 Fracture of radius and ulna;
upper end, closed; Monteggia’s fracture
for the traumatic fracture. Because
the fracture is not indicated as open,
you would code it as closed.
• V15.88 History of fall indicates the
patient has a history of falling.
• E885.9 Fall from other slipping,
tripping, or stumbling describes a fall
on same level, such as slipping.
ICD-10-CM Ups the Documentation Ante
As ICD-9-CM gives way to ICD-10-CM on Oct. 1, 2014, the importance of complete documentation for fracture coding will take a big leap forward. To cite two examples: In ICD-9-CM,
there is no provision for specifying laterality (left or right) and healing processes are very
broadly classified. For example, there is only one code for a malunion of a fracture (733.81)
and only one code for a nonunion (733.82).
In ICD-10-CM, not only do we indicate laterality but we also have the capability to code a disease process known as “stage of healing.” The four distinct fracture healing processes are:
•
Routine healing
•
Delayed healing
•
Nonunion
•
Malunion
These features, as well as routine and delayed healing, are built into the seventh-character
“extension” of the ICD-10-CM code. Aftercare following fracture treatment is indicated by the
extension “D,” and late effects of fractures are indicated by the extension “S.” In ICD-10-CM,
closed and open fractures are further broken down into many subdivisions, which are only
tabulated in a list in ICD-9-CM.
When mapping fracture codes from ICD-9-CM to ICD-10, it becomes clear that much more
information must be documented in medical records and operative reports. For example,
a patient suffers a traumatic open fracture to the lower end of the femoral condyle. In ICD9-CM, this is simply coded as 821.31 Fracture of other and unspecified parts of femur; lower
end, open; condyle, femoral. In ICD-10-CM, however, we add the dimensions of:
•
Which condyle (unspecified, lateral or medial; fifth character)
•
Laterality (right or left thigh or unspecified; sixth character)
•
Whether displaced or nondisplaced (also in the sixth character)
•
Type of open fracture (using the Gustilo Open Fracture Classification System; seventh
character extension)
•
Stage of healing (as listed above; also in the seventh character)
A single ICD-9-CM code (821.31) potentially crosswalks to 36 possible ICD-10-CM code
choices in the category S72.4- (including three designations of condyle, three designations of
laterality, two binary designations of displacement, and two designations of Gustilo groups
[Type I/II and Type IIIA/IIIB/IIIC]). The S72.42- and S72.43- subseries follow a similar progression, with the fifth character representing the lateral condyle in S72.42- and the medial
condyle in S72.43-. All of these codes map backward from the general equivalence mapping
(GEM) files to 821.31.
• E849.0 Place of occurrence, home notes
where the fracture occurred.
You would not code the dislocation because
the same bone is also fractured.
In a second example, a 26-year-old woman
is injured in a downhill skiing accident. She
fractures and dislocates her left shoulder.
The impact was to her left distal humerus,
medial condyle. Using anesthesia, the orthopedic surgeon repairs her shoulder by reducing the fracture without directly visualizing the injured site.
The correct CPT® and ICD-9-CM codes
are:
• 23665-LT Closed treatment of
shoulder dislocation with fracture
of greater humeral tuberosity, with
manipulation; requiring anesthesiaLeft side. Because the orthopedist
performed the surgery without
visualizing the fracture site, this is a
closed treatment.
• 812.43 Fracture of humerus; lower
end, closed; medial condyle. Do not
code the dislocation as well because
the fracture of the same bone is the
more serious injury.
• E885.3 Fall from skis
• E003.2 Activities involving ice and
snow; snow (alpine) (downhill) skiing,
snow boarding, sledding, tobogganing
and snow tubing
This is a lot of information to take in. In
a nutshell, just remember: Diagnosis coding should report the location of the fracture, the severity of the fracture, and whether there were complications due to the fracture. Procedure coding should report the
approach for treatment, the location being
treated, and any extenuating circumstances
due to treatment.
www.aapc.com
Kenneth Camilleis, CPC, CPC-I, CMRS,
CCS-P, is a medical coding and billing specialist. He is a full-time PMCC instructor and parttime educational consultant for Superbill Consulting Services, LLC.
March 2013
43
■ Coding/Billing
By David Peters, CPC, CPC-P
Know What Your Coding
Says to Your Payers
Arm yourself with coding tips to
withstand payer scrutiny AND get paid.
Make Modifiers Matter
One of the most common errors reported by payers is the incorrect application of
modifiers. Modifiers help tell the story of
your coding. Make sure the story is fact,
not fiction. The most frequently misused
modifiers are 22, 24, 25, 59, and 79. Let’s
go into a little detail for each.
Modifier 22 Unusual procedural service:
Use this modifier judiciously, or you’ll
throw up red flags with payers. To give you
an idea of just how (un)common modifier 22 claims are, according to recent comments made by a Centers for Medicare &
Medicaid Services (CMS) medical director for the Wisconsin Physician Services Corporation, only 2.5 percent of cases
warranted use of this modifier to accurately denote increased work incurred.
Many coders have developed a habit of using modifier 22 whenever mention of “lysis of adhesions” is included in the operative report, for instance. But this is only appropriate when “extensive” or “significant”
time was documented as spent freeing the
organ due to adhesions.
Modifier 24 Unrelated evaluation and
management service by the same physician or
44
AAPC Cutting Edge
Takeaways:
• Misuse of modifiers is one of payers’
biggest complaints.
• The most frequently misused modifiers
are 22, 24, 25, 59, and 79.
• Code at the correct level. Watch out for
payer guidelines.
other qualified health care professional during a postoperative period: CPT® and CMS
guidelines differ in the use of this modifier, so consider which payer will be processing the claim before you use it. CPT®
guidelines state, “Follow-up care for therapeutic surgical procedures includes only
that care which is usually a part of the
surgical service. Complications, exacerbations, recurrence or the presence of other diseases or injuries requiring additional services should be separately reported.”
CMS guidelines, by contrast, state that
Medicare’s global period includes any
complications, unless they are significant
enough to send a patient back to the operating room (in which case, you’d need to
use modifier 78 Unplanned return to the
operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related
procedure during the postoperative period).
Both CPT® and CMS guidelines agree
that you should apply modifier 24 only on
evaluation and management (E/M) codes
when the examination is furnished by the
same physician who performed the procedure. Note that “same physician” also refers to members of the same practice who
are of the same specialty as the physician
who performed the procedure.
photo by iStockphoto©YvanDube
Whether you work in a hospital, physician
office, or other health care setting, gone
are the days when claims are processed,
paid, and filed away. Instead, claims are
dissected, scrubbed, and analyzed for numerous data systems. How does your coding measure up? Is it outstanding, or does
it “stand out” in a bad way? Here are a few
tips to ensure your claims can withstand
the scrutiny they’re bound to receive.
Coding/Billing: Hospital
Whoever the payer, you’re not getting paid
unless the E/M visit is documented as unrelated to the surgery. When possible, assign a diagnosis code that is different from
that used to report the procedure.
Modifier 25 Significant separately identifiable evaluation and management service by
the same physician or other qualified health
care professional on the same day of the procedure or other service: Some offices that perform minor procedures in-house add an
E/M code with modifier 25 to every claim.
Any provider using modifier 25 statistically more than the national average will be
under scrutiny for possible fraudulent billing practices.
Here are some guidelines to keep in mind:
• Modifier 25 is not the equivalent
of modifier 57 Decision for surgery
for minor procedures. For example,
if a patient presents to your office
specifically for the removal of skin
tags (11200 Removal of skin tags,
multiple fibrocutaneous tags, any
area; up to and including 15 lesions),
it isn’t appropriate to include
a separate E/M code because a
minimal evaluation is inherent to
the removal procedure.
• It is unnecessary to apply modifier
25 to your E/M code when billed
with diagnostic testing codes (i.e.,
lab or X-ray codes). For example,
a patient presents with a finger
injury and the provider performs
an X-ray to check for bone injury
(73140 Radiologic examination,
finger(s), minimum of 2 views) and
a hematocrit (85014 Blood count;
hematocrit (Hct)) due to extensive
bruising. In this case, it would not
be necessary to append modifier 25
to the E/M code to describe the E/M
of the patient.
• Ask your provider to separate his or
her E/M notes from any procedure
performed so it’s clear to the payer
that it’s a significant, separately
identifiable service.
Modifier 59 Distinct procedural service:
This is the most frequently misused modifier—so much so that the misuse of modifier 59 has been a part of the Office of Inspector General’s (OIG’s) annual Work
Plan for identifying fraudulent claims
since 2007.
Although appending modifier 59 will allow claims for multiple procedures to bypass National Correct Coding Initiative
(NCCI) bundling edits, using it for the
sake of getting a higher payment will get
you into big trouble. Here are some tips to
keep in mind when billing multiple procedures:
• When billing procedures with a
potential bundling relationship
in the NCCI edit tables, always
append modifier 59 to the lesser
code (column 2 in the NCCI edit
tables). For example, consider 38221
Bone marrow; biopsy, needle or trocar
and 38220 Bone marrow; aspiration
only. Code 38221 is a column one
code, and 38220 is a column two
code. If both were performed at the
same site, it would be inappropriate
to report both codes. If they were
done as distinct procedures at two
Modifiers are used to
tell the story of your
coding. Make sure
the story is fact, not
fiction.
www.aapc.com
March 2013
45
Coding/Billing: Hospital
When
using EHRs,
payers will become suspicious if
multiple chart entries
for office visits carry
identical verbiage in
the records.
different
anatomic sites,
however, it would be appropriate
to report both with modifier 59
appended to the column two code
(e.g., 38220-59).
• Use modifier 59 only when a more
descriptive modifier (e.g., a modifier
that describes location) is not
available. For instance, if a patient has
a malignant lesion measuring 0.4 cm
removed from the right arm (11600
Excision, malignant lesion including
margins, trunk, arms, or legs; excised
diameter 0.5 cm or less), and another
lesion of the same size and type from
the left arm, append modifiers RT
Right side and LT Left side, rather than
report the second code with modifier
59.
• Do not report modifiers 51 and 59 on
the same code.
• In general, modifier 59 is used to
denote: different session or patient
encounter; different procedure
or surgery; different site or organ
system; separate incision, excision
or lesion; or a separate injury not
ordinarily encountered or performed
on the same day by the same provider.
Modifier 79 Unrelated procedure or service
by the same physician or other qualified health
care professional during the postoperative period: Apply this modifier for a second surgery
unrelated to a prior surgery. A common example is bilateral cataract surgery. This is
usually done on each eye individually, several days apart. Report the second procedure
with modifier 79 appended to the proce46
AAPC Cutting Edge
dure code,
as the global period for
the first surgery is still in effect. Do not use
modifier 79 for staged
(modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the
postoperative period) or repeat (modifier 76
Repeat procedure or service by the same physician or other qualified health care professional) procedures.
Getting E/M Right
Now that we’ve addressed modifiers, let’s
look at E/M services to make sure you’re
coding at the correct level.
We’ve all been taught the “bean counter”
method of adding up the key components of
history and examination and scoring your
code based on those numbers. But keep in
mind: Medical decision-making (MDM)
should be the primary component for selecting the correct level of care.
In these days of electronic health records
(EHRs), it’s easy to document a comprehensive history and a comprehensive examination using templates and information
from previous visits—but if the MDM is
straightforward, that will be the determining factor of the visit. Per the Medicare Internet-Only Manual, pub. 100-4, chapter 12:
“Medical necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT® code. It
would not be medically necessary or appropriate to bill a higher level of evaluation and
management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon
which a specific level of service is billed.”
Remember also that time may be used as
a factor in determining the correct level of
service—but this should be the exception,
not the rule. Some offices have taken up
the habit of billing all E/M services based
on time. Once again, with template phrases, it’s just too easy to tag, “Total time spent
face to face with patient was 60 minutes
and more than 50 percent of that time spent
in counseling.” In an actual case, when an
office was audited for consistently billing
Level V services, it was discovered all patients were booked in 30-minute appointment slots, and there were no patient wait
times reported (which would be impossible
if each patient was receiving 60 minutes or
more of service).
Other E/M practices that will raise red flags
with payers are:
• Billing every patient visit at the same
level of care
• Frequently submitting corrected or
amended claims
• Splitting claims for the same day of
service into multiple claims
When using EHRs, payers will become suspicious if multiple chart entries for office
visits carry identical verbiage in the records.
The “Where” Matters
Another area under scrutiny by the OIG
and others is reporting the incorrect place
of service (POS) on claims. Because the
POS can effect payment, accurate reporting is critical.
Services performed in an ambulatory surgery center (ASC) or hospital outpatient facility are paid at a lower rate than services performed in the office setting. Be accurate with all POS designations. Outpatient hospital (POS 22) and ASCs (POS 24)
are not the same thing, just as skilled nursing (POS 31) and custodial care (POS 33)
are different.
To discuss this article or topic, go to
www.aapc.com
Coding/Billing: Hospital
Outpatient hospital (POS 22) and ASCs
(POS 24) are not the same thing…
Speaking of hospital services: Always make
certain the time element for both hospital
discharge and critical care services is properly documented in the patient record. Time
is the only descriptor of 99238 Hospital discharge day management; 30 minutes or less
and 99239 Hospital discharge day management; more than 30 minutes, and includes
face-to-face time as well as “floor time.”
Watch Out for
Individual Payer Guidelines
Lastly, payers may have their own specific
rules—be aware of them. Billing bilateral
procedures is a prime example. Some payers
expect the code to be submitted once with
modifier 50 Bilateral procedure, which they
pay at 150 percent of the allowable. Others
may want the code submitted twice, once
without a modifier and again with modifier 50, which will pay at 100 percent for the
first line and 50 percent for the second line.
Not knowing these rules could result in underpayment.
Here’s another example: Most payers say it
isn’t necessary to use modifier 51 Multiple
procedures for multiple surgery procedures
because their systems will automatically re-
duce those services. Not all payers will resequence your coding order, however. It’s important to list the code with the highest relative value unit (RVU) as the first code, or
run the risk of having a lesser code used as
the primary procedure and a higher RVU
code reduced by 50 percent under the multiple procedure guidelines.
David Peters, CPC, CPC-P, is contracts manager for Sutter Pacific Medical Foundation, Santa Rosa, Calif.
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March 2013
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■ Coding/Billing: Hospital
By Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC,
CPUM, CPUR, CPHM, CCS-P, RCC, RMC
Be an Attractive Candidate
for a Hospital Coding Position
Be ready if a hospital employment opportunity arises in a
facility near you.
In our changing health care environment, there may come a time
when you need to look beyond your physician practice and branch
out in another direction. For example, based on the latest trend, your
practice could be bought out by a hospital. If that happens, you’ll
need to be able to prove you’re a viable candidate to hospital coding
managers. However, many physician trained coders find hospital requirements very different and the transition difficult. You’ll have a
much easier time if you are prepared, and a good place to start is by
reviewing the hospital revenue cycle, which has significant differences from that of the physician office.
Review the Hospital Revenue Cycle
There will be differences between facilities in regards to the revenue
cycle, depending on the size of the facility and whether they are for
profit or not for profit. Typically, however, the chief financial officer looks at the hospital’s revenue producing departments and establishes certain monetary monthly goals for that department using service utilization, patient flow, and other data. The chief revenue officer typically determines a positive or negative outcome for each revenue-producing department using various reporting programs. If a
department has an income deficit, this prompts a close look at why
the deficit has occurred. There can be many reasons, but if the de-
48
AAPC Cutting Edge
Takeaways:
• As hospitals buy out more physician groups and practices, it’s
important to learn about how hospital coders code.
• Learn about CDMs for outpatient billing.
• Learn about MS-DRG coding in case you are called on to pitch in.
partment does not produce expected revenue, particularly if the deficit occurs frequently, the department’s management must give an
accounting of why and how he or she plans to improve the deficit.
The revenue cycle starts in Patient Access and moves to Benefits Verification. These are critical steps in obtaining correct demographic
information, determining whether services will be covered, and calculating patient responsibility amounts. Errors in these steps usually have a ripple effect. If the patient is admitted as an inpatient or into
observation, typically, case management is responsible for monitoring the stay and determining if the stay meets inpatient criteria and
(if a Medicare patient) whether there is adequate inpatient days to
cover the stay. If an observation patient is converted to inpatient status by the physician, this group will advise Benefits Verification that
new authorization for inpatient services is necessary.
Coding/Billing: Hospital
Become very knowledgeable about coding conventions and
guidelines in the front of your ICD-9-CM coding book. This is
how hospital coders are expected to code the records.
Understand Your Role
in the Hospital Revenue Cycle
The next step in making yourself marketable in the hospital environment is to determine your role in the revenue cycle. The health information management (HIM) manager ensures that attending physicians complete the patient records in a timely manner and records are
ready for the coders. Here is where a physician trained coder must be
ready to shift gears. Regardless of what you are initially hired to do,
you must realize that at some point, you will need to code inpatient
records. This is where the money is for hospitals, so inpatient records
take priority over outpatient encounters, even if outpatient coding is
your normal assignment. To prepare for this new assignment and to
stand out as a candidate for inpatient coding:
• Be proactive in showing an interest in learning inpatient
coding.
• Take time to look at inpatient records coded by inpatient
coders.
• Realize that inpatient and outpatient coding guidelines are
somewhat different.
• Become very knowledgeable about coding conventions and
guidelines in the front of your ICD-9-CM coding book.
This is how hospital coders are expected to code the records.
Encoders that are structured for hospital use will also
assign codes based on these conventions. National Correct
Coding Initiative (NCCI) edits are included in the encoder
and generally flag the coder to look closely at two reported
codes. Coding Clinic and CPT® Assistant are normally sources
available within the encoder.
• Understand that CPT® is not reported on inpatient records.
Procedures are coded using ICD-9-CM Volume 3, and there
is not a direct crosswalk between CPT® and Volume 3. To
assign codes from Volume 3, ask yourself: Is the procedure
surgical in nature? Does it carry a surgical or anesthetic risk?
Does it require specialized training to perform the service? If
your answer is yes to any of these questions, a code is assigned.
Using this information, take a look at some familiar CPT®
codes and determine how the service might be reported
using Volume 3. A reasonable rule of thumb is that if CPT®
describes multiple steps, often more than one code from
Volume 3 must be used to report the same service.
• Know that hospital coders report all conditions that the
physician manages or affect the management of the patient.
Inpatient records may require 10, 15, or even 20 diagnosis
codes.
• Realize that sometimes there are different reporting protocols
in CPT®, depending on whether you report for physician
or facility services—infusions are a good example. Review
the reporting hierarchy for facility infusions in your CPT®
codebook to see how they differ from physician reporting.
• Be aware that facility evaluation and management (E/M)
reporting is captured only in the emergency department
and in facility clinics. History, exam, and medical decision
making (MDM) are not factors in facility E/M; levels are
determined based on use of resources and assigned based on
a point system. Each facility typically determines their own
point system; however, the service must be documented in the
medical record, meet medical necessity, and be reasonable in
the point assignments. Look at outpatient modifiers 73, 74,
and 27, used by facilities, and know when these modifiers are
applicable.
Understand How Charge
Description Masters Are Used
In assessing your qualifications, hospitals may also look at your
knowledge of charge description masters (CDM). Facilities establish
services in the CDM that are charged to the patient’s financial record
and are entered usually by the department performing the service.
Hospital coders typically code for all diagnosis coding, surgical procedures, and infusions. They may code for other services, depending on if the service is already embedded in the CDM. Your coding
manager will advise of these services, but typically drugs, supplies,
laboratory, radiology, and anesthesia are not coded by the hospital
coder. Some clinics, such as pain management, may charge through
the CDM or be coded by a coder, depending on how the hospital
handles these functions.
Another important thing to remember: The physician is not available to clarify documentation; and you will not be able to use charge
tickets, encounter forms, or super bills for coding assistance.
www.aapc.com
March 2013
49
To discuss this article or topic, go to
www.aapc.com
Coding/Billing: Hospital
Time spent collaborating with other coders must be kept to a
minimum if you intend to meet your productivity requirements.
Meet Productivity and Accuracy Standards
Accuracy and meeting quota also may factor into whether you are a
good candidate for hospital coding. When the coding department
experiences a backlog of records for coding, the manager must take
action to bring the records current. This is a good example of when
an outpatient coder may be asked to code inpatient records, and why
hospital coders are held to productivity and accuracy standards. You
will be held to these same productivity standards.
Although there may be slight differences, depending on expectations of the coding manager, typical coding time is approximately:
• Inpatient records: 18-20 minutes. This includes all diagnosis
codes, Volume 3 codes, assigning the present on admission
(POA) indicator, and abstraction of the record.
• Ambulatory surgery records: 7-10 per hour
• Emergency department records: 20 per hour
• Referral encounters (example: patients coming for lab,
X-ray): 30 per hour
These numbers translate to three minutes for emergency department
records and two minutes for referral encounters.
If you are given a pre-employment coding test, the coding manager will not only look at accuracy, but whether there is reasonable expectation you can reach these production standards by the end of
the normal 90-day probationary period. When records are not coded quickly, the entire revenue cycle is affected, in billing, insurance
follow up, and other collection efforts. Accounts receivable days are
closely monitored by hospitals, and are a primary measure used to
determine their financial health. Slowdowns and backlogs of the revenue cycle directly affect the revenue stream. Time spent collaborating with other coders must be kept to a minimum if you intend to
meet your productivity requirements.
Seek Training
When I speak with physician coders about transitioning to hospitals I am asked, “Where can I obtain this type of training?” Here are
some ideas that may be helpful:
• Invite someone from your hospital to present at a chapter
meeting. If a coding professional is not available, use someone
from the billing or revenue cycle department.
• If there is a community college in your area that has a HIM
program, invite someone from that program to speak at a
chapter meeting.
50
AAPC Cutting Edge
• Use Quality Improvement Organizations (QIO) as a
resource. They review disputes between Medicare and
hospitals about correct Medicare Severity Diagnosis Related
Groups (MS-DRG) assignments and necessity of inpatient
admissions. They may send coding disputes to a contracted
coder for supporting opinions, but they have already done an
in-house review prior to that step.
• If you have a hospital-based member in your chapter, ask that
person to help you get training underway.
Interested in implementing physician-to-hospital coder training in
your chapter? Based on the three-day workshops I present, training
might begin with an overview of hospital coding and billing on day
one. On days two and three, activities might include hands-on coding of sample hospital records—reviewing accuracy and looking at
how quickly coders can determine codes and POA indicators. Consider holding sessions on three consecutive days or on three separate
Saturdays. Something else to consider: This is a good opportunity to
collaborate with another chapter to arrange a group session.
Sell Yourself Using
Knowledge and Adaptability
Through my experience when speaking with hospital managers
about an ideal candidate, they often mention the need for coders to
be able to code multiple types of records, meet productivity standards, and be familiar with hospital encoders. You may not have an
opportunity to use encoders unless you are actually in a hospital, but
you can focus on building efficiency in multiple encounters, being
open minded, and knowing that you will need to meet productivity standards.
Take advantage of opportunities to learn the facility side of coding.
Realize hospitals provide many more services than physician offices. If general surgery is your specialty, it’s likely you’ll need to code
for many other types of services. Hospitals in smaller towns may be
more lenient when using a physician coder, but you should still sell
yourself in an interview by showing you are ready for the challenge. If
you welcome the opportunity and are proactive in learning about the
facility world, doors that are not easily opened will open for you.
Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM,
CPUR, CPHM, CCS-P, RCC, RMC , is a technical college instructor in Atlanta and
an independent consultant, performing physician audits and education for the
Quality Improvement Organization in Georgia. Her 34 years of experience in health
care includes working as a Medicare specialist for a large hospital system, as well
as contributing to various medical publications, presenting at health care conferences, and developing training classes on facility billing, coding, and reimbursement.
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■ Auditing/Compliance
By Ida Landry, MBA, CPC
Be an Effective Coding Compliance Professional
Do You Have What It Takes?
Know How Compliance Fits into Today’s Coding and Billing
Payment is generated or denied by the guidelines, rules, and federal
laws payers use to direct their part of the revenue cycle. In the past, payers acted as compliance overseers, but in recent years legislation like the
Tax Relief and Health Care Act of 2006 and the Affordable Care Act
of 2010 have mandated more oversight regarding documentation and
coding compliance. An example of the reimbursement climate resulting from these regulations is increased scrutiny by recovery audit contractors (RACs). “From 2005 through 2008, the Medicare RACs identified and corrected over $1 billion in improper payments. The majority, or 96 percent, of the improper payments were overpayments, while
the remaining 4 percent were underpayments,” according to the Federal Register, 2011, p. 57808 (www.gpo.gov/fdsys/pkg/FR-2011-09-16/pdf/201123695.pdf).
A byproduct of increased oversight is the establishment of more compliance departments and restructuring in health care organizations to
meet the growing need for proper coding and documentation.
Key Compliance Principles
To understand fully coding compliance and be an effective medical
coding compliance professional, you must have a commitment to the
core principles, rules, guidelines, and laws that embody medical compliance. This is the first objective to successfully mastering compliance elements. Another important element is adhering to a code of ethics and integrity.
Compliance is an important part of medical coding. Novice coders are
instructed early on that “correct coding is the No. 1 objective,” and “if
it isn’t documented, it wasn’t done.” These rules of thumb are the backbone of compliant coding for all coders. To be an effective coding compliance professional, however, you must also stay current with coding
and billing regulations and have a solid code of ethics.
52
AAPC Cutting Edge
Compliance Means Trust, Not Opinion
As a coding compliance professional, you should provide tangible information whenever you instruct another health care professional on
appropriateness of coding or documentation. If established guidelines,
specifications, and/or legislation cannot provide validation, than any
guidance given is considered opinion.
Protect trust at all cost. When an opinion is given as fact and later proven to be incorrect, this is unprofessional and risky. Once trust is broken, your opinion as a coding compliance professional is no longer credible. This guidance is simple; however, there are instances in the coding
community where trust is destroyed.
photo by iStockphoto©s-dmit
Knowing coding and billing
rules, and following them with
integrity, is key to success.
These core elements can be realized through successful instruction,
education, and guidance of compliant coding and documentation requirements.
To discuss this article or topic, go to
www.aapc.com
Auditing/Compliance: Coding Compliance
Using information consistently also shows ethics
and integrity. To maintain consistency throughout
an organization, consider following a code of ethics.
Trust also is abused when a compliance professional tells a coder one
thing and the health care provider something different. This behavior
can stem from provider pressure or a provider’s inability to comply with
rules and guidelines. To prevent inconsistent information from being
disseminated, present the same guidelines, rules, and regulations to all
parties involved. Using information consistently also shows ethics and
integrity. To maintain consistency throughout an organization, consider following a code of ethics.
Code of Ethics
AAPC has a code of ethics which addresses coding professionalism and
compliance integrity. The eight components of AAPC’s Code of Ethics are:
• Maintain and enhance the dignity, status, integrity, competence,
and standards of our profession.
• Respect the privacy of others and honor confidentiality.
• Strive to achieve the highest quality, effectiveness, and dignity in
both the process and products of professional work.
• Advance the profession through continued professional
development and education by acquiring and maintaining
professional competence.
• Know and respect existing federal, state, and local laws,
regulations, certifications, and licensing requirements applicable
to professional work.
• Use only legal and ethical principles that reflect the profession’s
core values, and report activity that is perceived to violate this
Code of Ethics to the AAPC Ethics Committee.
• Accurately represent the credential(s) earned and the status of
AAPC membership.
• Avoid actions and circumstances that may appear to compromise
good business judgment or create a conflict between personal
and professional interests.
Other places to look for a code of ethics are your compliance or coding
departments. Human Resource departments also may assist you if your
company has a written code of ethics.
Use Compliance Tools at Your Fingertips
You can easily find useful tools to help you attain your goals. Here is a
list of some typical resources you use:
• Office of Inspector General (OIG) website - On the
“Compliance Guidelines” page (https://oig.hhs.gov/compliance/
compliance-guidance/index.asp), there are links to “Compliance 101
and Provider Education” and “Compliance Resource Material,”
as well as other useful tools.
• Coding books - CPT® codebook, CPT® Assistant, ICD-9-CM,
HCPCS Level II, AHA Coding Clinic for ICD-9, AHA Coding
Clinic for HCPCS, OptumInsight’s™ Uniform Billing Editor,
DRG Expert, and the AAPC website
• Government coding/billing resources - Centers for Medicare
& Medicaid Services (CMS) manuals; National Coverage
Determinations; Medlearn Matters; the Federal Register;
1995 and 1997 Documentation Guidelines for Evaluation and
Management Services; Medicare administrative contractors,
Local Coverage Determinations, etc.
• Freedom of Information Act – Used to request federal agency
records not publicly available (www.nist.gov/admin/foia/).
• Federal acts - Health Insurance Portability and Accountability
Act (HIPAA); Health Information Technology for Economic
and Clinical Health (HITECH) Act; the Affordable Care Act;
Tax Relief and Health Care Act of 2006; False Claims Act;
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003; Stark law; anti-kickback statute, etc.
• Commercial payer resources – Look to company manuals,
websites, webinars, and newsletters for guidance.
• Company compliance manuals – Your employer should be
anxious to share its compliance manuals and plans with coding
and billing staff.
Being a coding compliance professional is a noble profession with ethics and integrity, knowledge of documentation and coding guidelines,
and trust and validation at the core of its foundation. If you think you
have what it takes to be a coding compliance professional or are thinking about becoming certified, AAPC now offers the Certified Professional Compliance Officer (CPCO™) credential. Go to aapc.com for details on how to begin this exciting journey.
Ida Landry, MBA, CPC, works for CareOregon and has worked in the health care
industry since 1995. She acquired CPC ® certification in 2004. Ms. Landry holds a
Bachelor of Science in Health Administration and a Master of Business Administration in Health Care Management. She enjoys teaching and sharing her knowledge
of coding.
www.aapc.com
March 2013
53
■ Practice Management
By Dixon Davis, MBA, MHSA, CPPM
Provider Productivity is Key to Financial Success
Keep close tabs on productivity measurements, identify revenue opportunities,
and share them with your provider.
Takeaways:
• Managing provider productivity can help
you increase revenue.
• Consistently track providers’ performance
and share the results with them.
• Take full advantage of benchmark data
and production reports.
The most important factor in achieving financial success in a clinic is productive providers. Higher productivity results in higher
revenue, while lower productivity results in
less revenue. This is a simple concept, but we
often don’t give it the proper attention. Effectively monitoring provider productivity
helps manage his or her expectation of compensation and the business’ bottom line.
Look for Ways to Enhance Revenue
Go beyond simply understanding the correlation between productivity and financial
outcomes. A manager should look for ways
to create more efficient
processes and additional services that add to
the revenue stream.
Too often, people look
at where to cut costs
rather than where to increase revenue. This is a
misconception: Maximizing revenue is number one for financial
strength.
For example, a provider
says she should be making more money. She
explains that the practice (schedule) is full,
yet she is not making
as much as a colleague
down the street. Upon
54
AAPC Cutting Edge
review, you discover that this provider sees
25 patients per day, whereas the provider
down the street sees 35 patients per day. The
national benchmark for the same specialty is
over 28 patients per day.
The next calculation is very important to
understand. For this practice, the average
revenue per patient visit is about $100. For
a provider who takes off three weeks per
year, seeing one additional patient per day
equates to about $25,000 more per year. Ten
more patients per day equates to $250,000
more per year. As we apply financial calculations to this revenue, there will be associated overhead costs (all of the revenue will not
hit the bottom line); however, also remember that once the fixed costs and certain level of variable costs are incurred, the incremental overhead allocation to additional
revenue will usually be a lower percentage.
This means a greater percentage of revenue
brought in from increased productivity will
find its way to the bottom line.
Show Providers the Numbers
When it comes to productivity in a medical
practice, the majority of billable production
is performed by the provider (physician,
mid-level provider, etc.). For this reason, it’s
very important that providers are given the
information, know how to interpret it, and
understand how it will affect them personally and as a practice.
To effectively use productivity numbers,
first identify what productivity measurements will be tracked. Possibilities include
total number of patient visits, total evaluation and management (E/M) visits versus
procedure visits, the number of units for
each CPT® code billed, total work relative
value units (wRVUs) earned, amount of collections received, and hours worked. Measurements may vary depending on the spe-
Practice Management: Productivity
cialty or culture of the practice. It’s important to identify a consistent metric and one
that is understood by the provider(s).
Once a productivity metric is identified,
the report (or dashboard) needs to provide
a clear picture of how productivity numbers influence financials. To help identify
target goals, use historical productivity and
financial data as a starting place. Benchmark data can be an effective tool to identify target numbers. Charts A and B on the
next page illustrate a simple example of how
both net revenue (collections) and wRVUs
are tracked on a monthly basis and are compared to an internal goal and to a national
benchmark.
To get providers invested in productivity,
some provider compensation models are
built on a straight productivity formula. Examples include paying providers a dollar value for every wRVU earned or paying based
on an identified percentage of collections. If
the provider knows he or she will make $51
per wRVU, there is a clear understanding of
how the level of work (productivity) will directly tie to total compensation. Likewise,
if a provider is paid 48 percent of total collections, it’s clear that providing more billable services will directly affect compensation. This compensation model confirms
that when a provider sees more patients, or
provides more billable services, compensation increases.
Chart A
Chart B
Take Advantage of Benchmark Data
Using and comparing benchmarks, either internal or external, can provide additional information for setting goals or expectations. For example, a provider may
know they will be compensated $51 for every wRVU they generate, but providing her
with a benchmark that the average provider in the specialty is earning 4,200 wRVUs
per year (350 per month) and is making
$214,000 a year helps to create an expectation of where productivity should be.
You start to accomplish objectives when the
provider understands:
• How much he or she is paid for each
wRVU;
• Where the total number of wRVUs
should be;
• How much compensation is expected
at that level of production; and
• That the level of compensation for
the associated level of productivity is
equitable.
www.aapc.com
March 2013
55
Practice Management: Producivity
By reviewing
productivity reports
and benchmarking
them against better
performers, you
become aware of
opportunities for
greater productivity
and increased
revenue.
You can set up similar models using the varied metrics. If revenue numbers are identified as the metric, will it be gross revenue
(charges) or net revenue (collections) that
is measured? If a practice uses a fixed fee
schedule, charges may represent pure production better, but will not represent actual
money received.
Effective productivity reports that tie to
provider compensation will:
• Identify the metric(s) that will be
measured.
• Associate a conversion factor that
relates to compensation or practice
profits.
• Compare productivity numbers
to either internal or external
benchmarks.
• Create clear goals and expectations of
productivity and financials.
Take Full Advantage of Production Reports
You can report production measures to create competition among a group or to motivate providers on an individual level. That
should not, however, be the end of the productivity monitoring.
Productivity reports also can be a valuable
tool for practice managers to increase revenue streams. By reviewing productivity reports and benchmarking them against better performers, you become aware of opportunities for greater productivity and increased revenue.
For example, the manager of a neurology practice becomes aware that providers
in the practice are not making as much as
other community physicians or as much as
national salary benchmarks. It’s up to the
manager to help discover why this may be
the case. The providers are working from
8 a.m. to 6 p.m., the same as other providers in the area. The office workflow appears to be efficient within the office with
full schedules and patients moving through
56
AAPC Cutting Edge
their visits in a timely fashion. Further review of a good productivity report, however,
identifies that the providers in this office see
a higher percentage of E/M visits compared
with industry benchmarks where providers
do more office-based procedures, such as
electroencephalograms (EEGs), nerve conduction tests, and spinal taps.
The manager can track these trends, educate the providers on the missed opportunities to provide more office-based procedures, illustrate how revenue would be affected by making the change, and then let
the physicians determine if this is something they are comfortable doing. Using
productivity reports provides the manager
with good data on how changes in productivity patterns can affect revenue streams.
The effective use of productivity reports by
managers can help them to:
• Identify opportunities for workflow
efficiency to increase number of
patients seen per day
• Identify information technology
tools that improve productivity
• Modify scheduling models to
increase patient volumes
• Identify opportunities for offering
new services in the office
• Benchmark to better performing
offices and new opportunities
• Identify ways to use staff differently
to increase billable services
By keeping close tabs on productivity measurements in the practice, you can identify opportunities for better revenue to share
with physicians. These numbers will help
them to understand how the work done in
the office relates to financial outcomes and
to make good business decisions on how
work is performed to maximize revenue opportunities.
Dixon Davis, MBA, MHSA, CPPM, is vice president of practice management at AAPC.
Join NAMAS at the AAPC Conference
April 2013 in Orlando, FL
NAMAS’ CPMA® Training will be offered as a
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877-418-5564
■ Practice Management
By Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ
Contracts: Create a Health Plan Contact Database
Part 3: Identify your practice’s
health plans’ counterparts and
create an “Alpha Payer Contact
List” for your practice.
Takeaways:
• Renegotiate your contracts with the right people at your payers.
• Don’t settle for high turnover provider relations departments when
you need to speak to decision-makers.
• Be creative in trying to contact the payers’ staff members who can
make decisions.
Imagine trying to renegotiate your payer agreements by calling
health plans’ toll-free phone numbers. In my experience, calling a
provider relations department is not helpful with regard to contractrelated issues because of high turnover and limited authority. Unfortunately it’s not always easy to know who the best person is at each
health plan to handle your contract inquiries. Certainly you don’t
want correspondence with a health plan to be generic, such as “To
Whom It May Concern.” The solution is to create a database of payer contacts.
Look for Contacts with Authority
Ideally, you want your payer contact to be the representative for your
geographic area and someone with enough authority to make decisions—the more authority, the better. Generally, don’t approach a
medical director unless it’s for a very specific reason. In my consulting firm, we create
an overview for our clients, listing their payers alphabetically and with the data shown
in Table 1. We call this an “Alpha Payer
Contact List.”
There are several methods to help you identify the best payer contacts:
• Look at who signed your existing
agreement for the health plan. Even if that
person is no longer there, you might get
transferred to his or her replacement.
• Look at recent correspondence from
the health plan, such as a cover letter
announcing a change in Utilization
Management Policies.
• Look at the “Notice” section of
your existing agreement and contact the
building address using the white pages.
• If you have a number for anyone in
58
AAPC Cutting Edge
photo by iStockphoto©CAP53
Who You Gonna Call?
Practice Management: Contract Negotiations
the building, hit “0” for operator or use the name directory
to dial one digit off the last number until you get someone to
answer the phone and direct you to the appropriate contract
representative. As a general rule, network management or
contract representatives are better equipped to discuss your
payer contract than personnel in provider services or provider
relations.
• For-profit health plans have Investor Relations departments
with contact information readily accessible on their website.
They may be kind enough to redirect your call to the correct
department.
• State Divisions of Insurance have public health maintenance
organization (HMO) quarterly filings, which contain upperlevel management contact information for the health plan. If
you need just one issue addressed (e.g., a supply you provide
is not being reimbursed at invoice cost), this technique will
narrow the focus to something attainable to get the right
name of the contracting person.
• If you have a contact you work with for credentialing, he or
she may be able to direct you to the best network management
or contract representative in your area.
In addition to these tips, you can also try contacting hospitals where
the physicians have privileges (the bigger the hospital or hospital system, the better) and ask to speak with the hospital’s managed care
contractor. Hospitals generally have a full-time person responsible
for payer contracts and have a robust database.
Be aware that most health plans have entirely different contracting
departments for hospital/facilities than for physicians. If you ask the
managed care contractor at a hospital for their list of payer contacts,
however, they will probably be more than happy to give it to you.
Your physician referrals to the hospital are invaluable and the hospital wants to see private practice physicians stay in business.
Make Contact and Complete the List
When you get the list, call the payer contacts using the name of the
hospital’s managed care contractor (with whom the health plan has
a relationship) as your source. This might go something like this:
• “I’m ______ and I got your name and number from _______
at _______ Hospital.”
This will get the attention of the health plan’s managed care person,
who will be happy to help you because he or she will want to maintain a great relationship with the hospital.
• “I’m calling on behalf of a physicians’ office. I know you
do facility contracting. Can you please tell me who within
[PAYER NAME] handles the physician contracts for our
area?”
Then obtain the information to complete your “Alpha Payer Contact List” for that payer.
If, during your investigation, you speak to or email the payer contact
directly, just state that you are new to the practice or position, and
are reviewing your agreements on file (remember the importance of
data gathering, which we discussed in the article, “The Big Picture
of Contract Negotiations,” pages 29-32, October 2012, Coding Edge.
Table 1: Sample Alpha Payer Contact List
Health Plan
Company Name
Contact
Name
Title
Phone
and Fax
Email
Address
Alpha HMO
Beta PPO
Delta Workers Comp
Gamma Plan
www.aapc.com
Notes
March 2013
59
To discuss this article or topic, go to
www.aapc.com
Practice Management: Contract Negotiations
Ideally, you want your payer contact to be the representative
for your geographic area and someone with enough authority
to make decisions—the more authority, the better.
Helpful Tidbits for Success
Here are additional tips to help you create an Alpha Payer Contact
List:
• Never start the conversation stating that you are interested in
negotiations. It turns off the payer contact every time.
• Remember: You are only confirming your current contracts.
The payer contact should be eager to provide this information
because, at this stage, you aren’t making them do any other
work (e.g., a renegotiation).
• Reference your agreement exactly how the health plan refers
to it (for example, “Specialist Provider Agreement”) so it’s
easier to reference down the road in the context unique to that
payer.
• Make sure to confirm/document the contact’s gender so in
future correspondence you’ll know how to properly address
the person.
A&P Quiz (from page 19)
Blood pressure readings are usually given as two numbers; for
example, 120 over 80 (written as 120/80 mm Hg). Normal
blood pressure is when your blood pressure is lower than 120/80
mm Hg most of the time. High blood pressure (hypertension)
is when your blood pressure is 140/90 mm Hg or above most of
the time. If your blood pressure numbers are 120/80 or higher,
but below 140/90, it is called pre-hypertension. If you have
pre-hypertension, you are more likely to develop high blood
pressure.
When blood pressures are documented, what does the top
number reference?
a. Diastolic blood pressure
b. Diastolic rate and rhythm
c. Systolic blood pressure
d. Systolic rate and rhythm
Answer
The correct answer is C. The top number is called the systolic
blood pressure, and the bottom number is called the diastolic
blood pressure.
60
AAPC Cutting Edge
When you complete your “Alpha Payer Contact List,” the negotiation process can begin. The next time you’ll probably approach the
payer contact is with a Health Plan Proposal Letter. (We will go more
into the content of a Health Plan Proposal Letter in Part 4 of this series on contracts.) All of this up-front work will ensure that this important letter is not stuck under a pile of paperwork; and that, from
the get-go, you are working with the best payer contacts at your contracted health plans.
Marcia Brauchler, MPH, CPC, CPC-H, CPC-I, CPHQ, is the founder and president of Physicians’ Ally, Inc., a health care consulting firm and concierge billing
company for specialty physician practices. She works with physicians on managed
care contracts, reimbursement, and practice administration. Ms. Brauchler’s experience includes hospital, health plan, and independent practice association administration. Her firm sells updated HIPAA policies and procedures and online staff
training. Ms. Brauchler is a published researcher and a frequent public speaker.
Handbook Pop Quiz
(from page 13)
Answers:
1.) B - Only president, vice president, and education officer
2.) B - Three – president, vice president, secretary/treasurer
3.) D - 1.75 CEUs – Every 15 minutes equals 0.25 CEUs
4.) A - Four years – just like the president of the United States
5.) A - Yes – A nominal fee to cover the cost of the room, food,
parking, etc., is allowed.
6.) D - All of the above (HIPAA, Pharmacy, OSHA, employee issues, and time management)
Start earning
free CEUs
today.
Stay up-to-date on important Medicare Program topics.
Billing and coding professionals: Continuing Education Units (CEUs) online by taking a free
web-based training courses offered by the Medicare Learning Network® (MLN). Explore the
fundamentals of the Medicare Program, get in-depth understanding about Secondary Payer
Provisions, Part C and D Fraud and Abuse, the Electronic Prescribing Incentive Program and
so much more.
Our online courses work around your schedule. You can take courses on your terms,
at your pace.
Visit http://go.cms.gov/MLNFreeCEUs
then scroll down to the “Related Links” section and click on
“Web-Based Training Courses” to get started.
R
Official CMS Information for
Medicare Fee-For-Service Providers
ICD-10 IMPLEMENTATION BOOT CAMPS
FINAL TRAINING SCHEDULE
Coder’s Roadmap to ICD-10
AAPC’s implementation bootcamps are ending June 27. If you haven’t
started preparing for ICD-10 implementation our two-day boot camp
can get you on track. These are the LAST implementation training
sessions before we transition to code set training and space will be
severely limited.
2-Day Boot Camp Curriculum:
• Where to Begin – Organizing the Implementation Effort
• Understanding the Information Technology Impact
• What Needs to Change – Assessing Other Key Areas of Impact
• Identifying Documentation Challenges
• Building Your ICD-10 Action Plan
• Budgeting for ICD-10
• Planning Training Approaches and Resources
• Successfully Measuring Outcomes
• Introduction to ICD-10 Coding – Crosswalks and Mapping
• Hands-on Coding Exercises and Documentation Case Studies
• Templates, Tools, and Resources + Course Manual and
ICD-10-CM Book
Step 3
Step 4
Step 2
Step 1
Anatomy &
Pathophysiology
General
Code Set
Training
Specialty
Code Set
Training
Implementation
$695
2-Days | 16 CEUs
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800-626-CODE (2633)
REMAINING IMPLEMENTATION BOOT CAMPS*
DATE
LOCATION
DATE
LOCATION
DATE
LOCATION
Mar 7
Boston, Massachusetts
Apr 25
San Antonio, Texas
Jun 6
Manhattan, New York
Mar 14
Miami, Florida
May 2
St. Louis, Missouri
Jun 20
Atlanta, Georgia
Mar 21
Cleveland, Ohio
May 9
Long Beach, California
Jun 20
Chicago, Illinois
Mar 28
Nashville, Tennessee
May 16
Minneapolis, Minnesota
Jun 27
Dallas/Ft. Worth, Texas
Apr 4
Denver, Colorado
May 16
Phoenix, Arizona
Jun 27
Philadelphia, Pennsylvania
Apr 11
San Francisco, California
May 30
Baltimore, Maryland
Jun 27
Seattle, Washington
*Dates and locations subject to change
For a complete list of all remaining boot camps, visit:
aapc.com/icd10implementation
1-800-626-CODE (2633)
S
newly credentialed members
Adelina Perez, CPC
Alice L Carter, CPC
Allison Ippolito, CPC-H
Allison S Bureau, CPC
Alyssa Savage, CPC
Amanda G Dubose, CPC
Amanda Myers, CPC
Amber L Fee, CPC
Amy Byrd, CPC
Andrew M Liu, CPC, CPC-H
Angela Buckley, CPC
Angelica Pimentel, CPC
Ania Guillen, CPC
Anitrice Johnson, CPC
Anna Chenoweth, CPC
Anne Meadows, CPC
Anne Amature, CPC
Annette Auer, CPC
Annette Marie Smith, CPC
Barbara Jabaay, CPC
Beotta Murray, CPC
Bethany Ann Tapp, CPC
Bethany Kovalaske, CPC
Beverly McClure, CPC
Bren Polivka, CPC
Brenda Lee Parker, CPC
Brenda Sue McKamey-Scott, CPC
Bridget Dancy, CPC
Brittany Nicole McKinney, CPC
C Joanne Trimble, CPC
Candice Smith-Byrd, CPC
Cari L Smart, CPC, CPC-H
Carla Gordon, CPC
Carol Anita Ellison, CPC
Carol Lacroix, CPC
Carrie Bowers, CPC-P
Carrie Farley, CPC
Carrie Johnson, CPC
Cassandra S Ahn, CPC
Catherine A Leach, CPC
Catherine Bene Doyle, CPC
Cathy Eskridge, CPC-H
Cathy Manalaysay, CPC
Charlene Monihan, CPC
Cheyenne Nicole Gomma, CPC
Chitra Muthuvelu, CPC
Chizimbi Sichalwe, CPC
Christel Nuttle, CPC
Christina Congdon, CPC
Christy Wood, CPC
Christy Inouye, CPC, CPC-P, CPMA
Christy Szolis, CPC, CPC-H
Cindy Dunlop, CPC
Connie J Savoie, CPC
Courtney Pullin Strickland, CPC
Cozette Denise Elliott-Harris, CPC
Cristine Kay Walters, CPC
Crystal Howland, CPC
Crystal Marie Norton, CPC
Daja Brown, CPC
Dana Brock, CPC
Danelle M Hauer, CPC
Darleen Sheldon, CPC
Darlene Caldwell, CPC
Darlene Nippert, CPC-H
David Jason Pursell, CPC
Deanna Niles, CPC, CPC-H
Deb Kinkor, CPC
Deborah Kaye Gosser, CPC
Deborah Udall, CPC
Debra Christianson, CPC
Debra L McGary, CPC
Denise Benson, CPC
Denisse Brady, CPC
Diane Marie Sullivan, CPC
Edna Denton, CPC
Emma Quinn, CPC
Eric Eugene Boyer, CPC
Eric Hall, CPC
Erica Inesta Jones, CPC
Erika Lyons, CPC
Eva Stewart, CPC
Francie Meng, CPC
Gayle Guenther, CPC
Georgia Geoghan, CPC
Gina M Richie, CPC
Giovanna Ramos, CPC
Gloria Scott, CPC
Harriette Elizabeth Powell, CPC
Heather Mae Gilham, CPC
Hermine Andikyan, CPC, CPC-H
Hien Thuy Pham, CPC
Holly M. Quinn, CPC
Iryna Trusova, CPC
Jackie L Edge, CPC
Jamie Suzanne Casassa, CPC
Jane A Schnedler, CPC
Janet Porterfield, CPC-H
Janet Gill, CPC
Jean Cunningham, CPC
Jeanette Gosselin, CPC
Jenna LeAnn Duff, CPC
Jennifer Francis, CPC
Jennifer L E DeWitte, CPC, CPC-P
Jennifer Reader, CPC, CPC-H
Jennifer Turner, CPC
Jessica Lewis, CPC
Jessica McGhee, CPC
Jillian E Collamore, CPC
Jordan Heehler, CPC
Judith A Blevins, CPC
Karen J Jarboe, CPC
Karen Nemelka, CPC
Kari Belevender, CPC, CPC-H
Karyn Sutton, CPC
Kathy A Johnson, CPC
Kathy E Taylor, CPC
Katie Fritz, CPC
Katrina Fowler, CPC
Kelly Roos, CPC
Kelly Swann, CPC
Kelly Vitiello, CPC
Kelly Wadle, CPC
Kimberly Darwin-Scott, CPC-H
Kimberly Honesto, CPC
Krista Kelly, CPC
Kristi Waugh, CPC
Kristine Lyn Sulik, CPC-H
Lance Smith, CPC-H, CEMC
LaTisha Bosarge, CPC
Laura Gayle Canaday, CPC
Laura Hutchins, CPC, CUC
Laura Wetherell, CPC
Laurie McMillan, CPC-P
Laurleta Wiliams, CPC
Laverne Keith, CPC
Lee Ann Bailey, CPC, CGSC
Leigh Lawson, CPC
Leslie Cifelli, CPC
Leticia Cardona, CPC
Linda Anderson, CPC
Linda Canada, CPC
Linda M Bickford, CPC
Lisa Irwin, CPC, CPC-P
Lisa Lampkin, CPC, CPC-H
Lisa M Barlet, CPC, CPC-H
Lisa Page, CPC
Lisa Renee Denney, CPC
Lora Floyd, CPC
Louise Sprull, CPC
Lucia Cote, CPC
Lusine Abovyan, CPC
Luz Elenia Wozdusiewicz, CPC
Lyndsey Moore Cosner, CPC
Lyudmila Safranovich, CPC-H
Maria D Toyco, CPC, CPC-H
Maria Minnick, CPC
Marilyn D Blasingame, CPC
Marilyn Michelle Lisenby, CPC
Marissa Anderson, CPC
Marlene Elizabeth Znamirowski, CPC
Mary Ann Tasca, CPC
Mary Galus, CPC
Mary K Chmela, CPC
Melissa Beth Vealey, CPC
Melissa Hutto, CPC
Melisse M.S. Camelo, CPC
Michael Carrigan Walsh, CPC
Michelle Morgan, CPC
Mileidy Ortega, CPC
Mindy Ashbaugh, CPC
Mindy Nicole Flowers, CPC
Mohamed K Salem, CPC
Nancy A Machado, CPC
Nicole Dayhoff, CPC
Nicole Clarice Tarbox, CPC
Nicole Leigh Crager, CPC
Nicolle Ackel, CPC
Nkisha Farrington, CPC
Odette Cabrera, CPC
Olaomo O Ojuri, CPC
Pamela L Golden-Collum, CPC
Pamela Wolfram, CPC, CPC-H
Patricia Crosby, CPC
Patricia Fillion, CPC
Patrick J Murray, CPC
Peggy Feeley, CPC-H
Rachael Cochran, CPC
Rikki Jo Peery, CPC
Rosa Stolz, CPC-H
Sally Kutalek, CPC
Samantha Shaw, CPC
Sandra K Crocker, CPC
Sandra Mitchell, CPC
Selena Nicole Waring, CPC
Shantel Jenkins, CPC
Sharon Hill, CPC
Shelley McWilliams, CPC
Shirley J Spetz, CPC, CPC-H
Stacey Lynn Otero, CPC
Stephanie Coleman Andrews, CPC
Stephanie Douglas, CPC
Stephanie Moore, CPC
Stephanie Taggart, CPC-H
Susan Temerowski, CPC
Susan Warren, CPC
Suzanne Gunter, CPC
Tammi Lynn Edgar, CPC
Tammy Rae Lockhart, CPC
Teresa Anne Leach, CPC
Teresa Herring, CPC
Theresa Grimaldo, CPC, CPC-H
Tina E Greenan, CPC, CPC-H
Tina Shearer, CPC
Tinika Shama Thames, CPC
Toni Castiglione, CPC
Torri Rubertus, CPC
Tracy C Currier, CPC
Tracy D Banks, CPC
Wendy Hummel, CPC
Whitney Warr, CPC
Apprentices
Abel Contreras, CPC-A
Adrianna Corine Hollis, CPC-A, CPC-H-A
Adrienne Nicole English, CPC-A
Adrienne Winbush, CPC-A
Aja Belcher, CPC-A
Alexanderia Octavia Burwell, CPC-A
Ali Bishop, CPC-A
Alice Baker, CPC-A
Alice Escalante, CPC-A
Alice Zuls, CPC-A
Alicia Elizabeth Flower, CPC-A
Allan Rubinstein, CPC-H-A
Alyce Albert, CPC-A
Alyson D Devlin, CPC-A
Amanda Berglund, CPC-A
Amanda Giordano, CPC-A
Amanda Nicole Riley, CPC-A
Amanda Tew Ford, CPC-A
Amanda Walker, CPC-A
Amber Larsen, CPC-A
Amber Michelene Herbert, CPC-A
Amber Straatmann, CPC-H-A
Amber Wheelock, CPC-A
Amy Aarrestad, CPC-A
Amy Arnold, CPC-A
Amy Crites, CPC-A
Amy Nicole Waits, CPC-A
Amy Yang, CPC-A
Andre Woods, CPC-A
Andrea Carmen Garcia, CPC-A
Andrew Rice, CPC-A
Angela Collins, CPC-A
Angela Garcia, CPC-P-A
Angela Potter, CPC-A
Angelina Bianchino, CPC-A
Ann Marie Breeden, CPC-A
Annie Shirbroun, CPC-H-A
Anuradha Rao, CPC-A
April Gasperino, CPC-A
April Wilson Josey, CPC-A
Araceli Ruiz, CPC-A
Araya Thao, CPC-A
Arely Elizabeth Mejia, CPC-A
Argenia Dawn Keeling, CPC-A
Arlene S Weaver, CPC-A
Austin Page, CPC-A
Barbara Aaron, CPC-A
Barbara Jean Rocha, CPC-A
Barbara Lawrence, CPC-A
Barbara Norris, CPC-A
Barbara Scaboo, CPC-A, CPC-H-A
BeLinda Brown, CPC-A
Belinda Yurick, CPC-A
Belkis Abraham, CPC-A
Bellamy Harthun, CPC-A
Ben Kreider, CPC-A
Beth Connaughton, CPC-A
Bethany Seidman, CPC-A
Bobbie Shepherd, CPC-A
Bradley Kristopher Boroughf, CPC-A
Brandy Alexander, CPC-A
Brenda J Sudler, CPC-A
Brian Guthrie, CPC-A
Brian Koch, CPC-A
Brian Lynn Carman, CPC-A
Bridget Loague, CPC-A
Brittani Mundy, CPC-A
Brittany Hufton, CPC-A
Brittney Reve Jones, CPC-A
Brittney Webb, CPC-A
Bryan Hunt, CPC-A
Burdean Wirtz, CPC-A
Caralyn Maerz, CPC-A
Carleisha Moore, CPC-A
Carlissa Ford, CPC-A
Carmen Mundy, CPC-A
Caroline Tavares, CPC-A
www.aapc.com
Carrie Princell, CPC-A
Casie Lynn Johnson, CPC-A
Cassandra Motard, CPC-A
Catherine (Kat) Olson, CPC-A
Cattleya Wimmer, CPC-A
Cecilia Martinez, CPC-A
Cecilia Spencer, CPC-A
Charisse Gibney, CPC-A
Charlene Johnson, CPC-A
Charlene Knaggs, CPC-A
Charles Nathan Johnson, CPC-A
Chelsea R Bright, CPC-A
Chelsey Hansen, CPC-A
Cheryl Ann Van Dyke, CPC-A
Cheryl Blais, CPC-A
Cheryl Wilson, CPC-A
Christina Fuller, CPC-A
Christina J Davis, CPC-A
Christina L. Dempsey, CPC-A
Christina Marie Borst, CPC-A
Christina Marie Thomas, CPC-A
Christina Mastrolia, CPC-A
Christina Medina, CPC-A
Christina Rasa, CPC-A
Christina Vicente, CPC-A
Christine Barrett, CPC-A
Christopher John Jensen, CPC-A
Christopher Wright, CPC-A
Christy Austin, CPC-A
Cindy Clayton, CPC-A
Cindy L Gorton, CPC-A
Claire F Kiehle, CPC-A
Clara Makaipo, CPC-A
Colleen Bauer, CPC-A
Colleen Dannah, CPC-A
Connie Cherry, CPC-A
Consuelo Medina, CPC-A
Corteny Hemmesch, CPC-A
Cristal Dee Ewald, CPC-A
Cristy Fraker, CPC-A
Cullin Schooley, CPC-A
Cynthia Kalen, CPC-A
Cynthia Talcott, CPC-A
Dabborah Limric, CPC-A
Dana Davis, CPC-A
Danielle Thoresen, CPC-A
Darlene Bakaj-Wood, CPC-A
Darlene Pastorius, CPC-A
David Menchaca, CPC-A
David Vrba, CPC-A
Dawn Kantz, CPC-A
Dawn Becerra, CPC-A
Dawn Healey, CPC-A
Dawn Herrington, CPC-A
Deandrea Shevel Gay, CPC-A, CPC-H-A
Debbie Hemstad, CPC-A
Debbie Huffman, CPC-A
Debbie Lyn Haskett, CPC-A
Deborah Aurelio, CPC-A
Deborah Hayes, CPC-A
Deborah Session, CPC-A
Debra Ley, CPC-A
Debra Wangelin, CPC-A
December L. Luttrell, CPC-A
Delores Cooke, CPC-A
Deniece La’Shawn Mobley, CPC-A
Denise Oliff, CPC-A
Derek Tasler, CPC-A
Desiree Dashael Thatch, CPC-A
Diana Helzer, CPC-A
Diana Burrell, CPC-P-A
Diana M Vento, CPC-A
Diane King, CPC-A
Diane Pierce, CPC-A
Dianne Sanford, CPC-A
March 2013
63
Newly Credentialed Members
Dixie Millsaps, CPC-A
Donna Flower, CPC-A
Donna Jensen, CPC-A
Donna Lee Harvey, CPC-A
Donna Marie Valentino, CPC-A
Donna Miller, CPC-A
Donna Putnam, CPC-A
Dorina Green, CPC-A
Ebony Hayes, CPC-A
Edith Faye Reiter, CPC-A
Eileen Mcdonough, CPC-A
Elba Berenice Magana, CPC-A
Elena Nikodym, CPC-A
Elisa Collins-Haines, CPC-A
Elizabeth Reinsvold, CPC-A
Elizabeth Anne Snyder, CPC-A
Elizabeth Doyal, CPC-A
Elizabeth Preskitt, CPC-A
Elizabeth Teresa Rousseau, CPC-A
Elizabeth Thanjan, CPC-A
Ellen Busche, CPC-A
Emily Hunt, CPC-A
Ena Roussel R Buenafe, CPC-A
Erin Sumner, CPC-A
Estrella Forste, CPC-A
Evelyn Rigby, CPC-A
Felecia Williams, MD, MBA, CPC-A
Felicia Cardoz Noronha, CPC-A
Felicia Latson, CPC-A
Felicia Luciana Glover, CPC-A
Fernando L Herdoiza, CPC-A
Florence Theresa Thompson, CPC-A
Frank Lind, CPC-A
Geri Steele, CPC-A
Gina Barrit, CPC-A
Ginger Flemons, CPC-H-A
Giovanna Pringle, CPC-A
Gloria Caballero, CPC-A
Gregg Quander-Smith, CPC-A
Gregory Robinson, CPC-A
Greta Haltiwanger, CPC-A
Gretchen Knake, CPC-A
Hannah Ellerbee, CPC-A
Heather Makoutz, CPC-A
Heather Collins, CPC-A
Heather Lyn Diesing, CPC-A
Heather M Irwin, CPC-A
Heidi Freed, CPC-A
Hilton Higgins Jr, CPC-A
Ilene Braxton, CPC-A
Indira Mantri, CPC-A
Inna Bibikov, CPC-A
Iris D Hernandez, CPC-A
Iris Willensky, CPC-A
Ivana Bevanda, CPC-A
Ivette Pibernus-Ortiz, CPC-A
Jaimie L Snow, CPC-A
James Ianantuoni, CPC-A
James Williamson, CPC-A
Jamie Fiorani, CPC-A
Jamie Lynn Gartee, CPC-A
Jamie Van Cleave, CPC-A
Jan Leslie Reyes, CPC-A
Jana VanHoose, CPC-A
Janet Epp, CPC-A
Janet Haynes, CPC-A
Janet Kalajainen, CPC-A
Janette Staten, CPC-A
Janice Greenlee, CPC-A
January Thomson, CPC-A
Jason Morse, CPC-A
JauChi Su, CPC-A
Jazmine Chuca, CPC-A
Jazmine Rae Racca-Ventura, CPC-A
Jean Marie Salerno, CPC-A
Jeanette Dossett, CPC-A
Jeanette Rappleye, CPC-A
Jeanette W Yates, CPC-A
Jenara Kilman, CPC-A
Jennifer Maryhew, CPC-A
Jennifer A Smith, CPC-A
Jennifer Erin Mooney, CPC-A
64
AAPC Cutting Edge
Jennifer Jarrard, CPC-A
Jennifer Linn Stephens, CPC-A
Jennifer Nicole Wallis, CPC-A
Jennilyn N Fifield, CPC-A
Jenny Anderson, CPC-A
Jesmine Trinh Nguyen, CPC-A
Jessica Damiano, CPC-A
Jessica Downs, CPC-A
Jessica Campbell, CPC-A
Jessica Ferrell Wong, CPC-A
Jessica Joyce, CPC-A
Jessica Lynn Scott, CPC-A
Jessica M Soto, CPC-A
Jessica Phillips, CPC-A
Jessica Thatcher, CPC-A
Jessie Ehlinger, CPC-A
Jill V Barrick, CPC-A
Joan I Lane, CPC-A
Joanna Moody, CPC-A
Joanne L Kaminski, CPC-A
Jodi Lynn McCormick, CPC-A
Joseph Michael Belich, CPC-A
Judi Kulpa, CPC-A
Julia Ilisirov, CPC-A
Julianna Placido, CPC-A
Julianne Birdt, CPC-A
Julie Ann Burke, CPC-A
Julie C Winans, CPC-A
Julie Gardyasz, CPC-A
Julie Ginther, CPC-A
Julie Miller, CPC-A
Julie Thomson, CPC-A
Justina F Rueda, CPC-A
Justine Marie Blackmon, CPC-A
Jyotsna Bharatkumar, CPC-A
Kai-Kit Lai, CPC-A
Kara Mickel, CPC-A
Karen Ann Byrd, CPC-A
Karen Denise Kendrick, CPC-A
Karen Jackson, CPC-A
Karen Matoush, CPC-A
Karen Posey, CPC-A
Karen S. Irvin, CPC-A
Karen Salvucci, CPC-A, CPC-H-A, CPC-P-A
Karen White, CPC-A
Kari Crull, CPC-A
Kari Dell, CPC-A
Katherine Miller, CPC-A
Katherine Perras, CPC-A
Kathleen A Vacca, CPC-A
Kathryn Biber, CPC-A
Kathryn Davis, CPC-A
Kathryn Gohlke, CPC-A
Kathy Greene, CPC-A
Kathy Lynn Cullen, CPC-A
Kathy Ridener, CPC-A
Katie Feldhut, CPC-A
Katie Stovall, CPC-A
Katrina Howard, CPC-A
Katrina King, CPC-A
Kayla Mardas, CPC-A
Kayla Min Neece, CPC-A
Kaylee Wright, CPC-A
Keith Raymond Donegan, CPC-A
Kelley S Stevenson, CPC-A
Kelli D Carter, CPC-A
Kelli R Sanders, CPC-A
Kelly Herzog, CPC-A
Kelly Therssen, CPC-A
Kerri Fullerton, CPC-A
Kerri Jenkins-Harrison, CPC-A
Kerrian Tina Miller, CPC-A
Kimberly Allen, CPC-A
Kimberly Boesken, CPC-A
Kimberly Brown, CPC-A
Kimberly E Connors, CPC-A
Kimberly I Franks, CPC-A
Kimberly Jacobsen, CPC-A
Kimberly Mays, CPC-A
Kimberly Steinbrink, CPC-A
Kimberly Velo, CPC-A
Korrie Heather Manning, CPC-A
Kris Thacker, CPC-A
Krista Hiller, CPC-A
Kristen Spencer, CPC-A
Kristi Marie Henry, CPC-A
Kristine Heinrich, CPC-A
Kryston McDaniel, CPC-A
Kuuipo A.M. Simmons, CPC-A
Kyllie KTK Kalani, CPC-A
Lance Bennett, CPC-A
Latishia Sanders, CPC-A
Laura E. LeJeune, CPC-A
Laura Penwell, CPC-A
Laura Roberts, CPC-A
Lauren Luckey, CPC-A
Lauren Sanders, CPC-A
Lauren Studley, CPC-A
Laurie Little, CPC-A
Lawanda Filyaw, CPC-A
Layce Hoefer, CPC-A
Leah Jane Mispagel, CPC-A
LeAnne Shelton, CPC-A
Leigh A Bayless, CPC-A
Leisa Day Merrick, CPC-A
Leisa Nunnelee, CPC-A
Lenna Beaty, CPC-A
Lequita Ann Rouse, CPC-A
Leslie Thrift, CPC-A
Linda Richardson, CPC-A
Linda E Gerard, CPC-A
Linda Goodwin, CPC-A
Linda Leclerc, CPC-P-A
Linda Millet, CPC-A
Linda Nay, CPC-A
Linda R Massei, CPC-A
Lindsay Brooke Stone, CPC-A
Lindsay Naquin, CPC-A
Lindsey Pae, CPC-A
Lisa Jennings, CPC-A
Lisa Ann Voge, CPC-A
Lisa Buffis, CPC-A
Lisa Gilmore, CPC-A
Lisa Jon Thomas, CPC-A
Lisa Shute Willson, CPC-A
Lisa Solomon-Craig, CPC-A
Lisa-Marie Schiller, CPC-A
Lisbeth Maria Leiva, CPC-A
Lori Fees, CPC-H-A
Lori Jones Townsend, CPC-A
Lori L Deen, CPC-A
Lucas Cordova, CPC-A
Lucinda Booker, CPC-H-A
Lucretia Martin, CPC-A
Lydia Jo Ann Yauger, CPC-A, CPC-H-A
Lynn McIver, CPC-A
Lynne Asiimwe Kay, CPC-A
Lynne Smith, CPC-H-A
Madeline Mcintosh, CPC-A
Magdalena Kurdziel, CPC-A
Malea Marie Guthrie, CPC-A
Margarita Fundora, CPC-A
Margie Molnar, CPC-A
Mari Elizabeth Olson, CPC-A
Mari Georg, CPC-A
Maria A Ruiz, CPC-A
Maria Gonzales, CPC-A
Maria Gracia Constantino, CPC-A
Maria Padilla, CPC-A
Marianne Morales, CPC-A
Marilyn Milestone, CPC-A
Marinalis Garcia, CPC-A
Marine Shahbazyan, CPC-A
Maritza Salgado, CPC-A
Marjorie Dvoskin, CPC-H-A
Marjorie Willis, CPC-A
Marlene Cox, CPC-A
Marlene Shorey, CPC-A
Martha Lambert, CPC-A
Mary Long, CPC-A
Mary Ann Brabner, CPC-A
Mary Fuller Huddleston, CPC-A
Maureen Nicole Nida, CPC-A
Megan Collier, CPC-A
Megan Eileen Procise, CPC-A
Melanie Harlow, CPC-A
Melanie Knowles, CPC-A
Melissa Alcoces, CPC-A
Melissa G. Canter, CPC-A
Melissa Gene Tuthill, CPC-A
Melissa Keeney, CPC-A
Melissa Marie Banfill, CPC-A
Melissa Schulte, CPC-A
Melissa Wheeler, CPC-A
Melissa Winward, CPC-A
Melitta Dixon, CPC-A
Michele Anne Mazzarella, CPC-A
Michele Hall, CPC-A
Michele Torrey, CPC-A
Michelle Neumann, CPC-A
Michelle Pimentel, CPC-A
Michelle Stansbery, CPC-A
Mildred Haggerty, CPC-A
Minsuk Hally, CPC-A
Miranda Choat, CPC-A
Monica Jean Grocki, CPC-A
Monica L Yap, CPC-A
Monica Taylor, CPC-A
Myra Mosley, CPC-A
Myra O’Kelley, CPC-A
N.D. Weintrob, CPC-A
Nancy Fisher, CPC-A
Nancy Frampton, CPC-A
Nancy Hinojos, CPC-A
Nancy R Brennan, CPC-A
Nancy R Lehmicke, CPC-A
Natacha Graham, CPC-A
Natalie Echols, CPC-A
Natalie Guinta, CPC-A
Natasha Breanna Adams, CPC-A
Natasha Necole Perkins, CPC-A
Nichole Hautala, CPC-A
Nicole Buzianis, CPC-A
Nicole Catherine Sharp, CPC-A
Nicole Chabala, CPC-A
Nikesh K Chand, CPC-A
Norma Tovar, CPC-A
Norma Bravo, CPC-A
Olga Redko, CPC-A
Pam Roepke, CPC-A
Pamela Gwen Morgan, CPC-A
Pamela M Wigglesworth, CPC-A
Pamela Ruprecht, CPC-A
Pamela Wirth, CPC-A
Patricia A Jarvis, CPC-A
Patricia High, CPC-A
Patricia L Lenke, CPC-A
Patricia Wenmoth, CPC-A
Patty Twyman, CPC-A
Paula Delores Sanders, CPC-A
Peter Vreeland, CPC-A
Philorica A Gordon, CPC-A
Poonam Sorary, CPC-A
Rachael Hopko, CPC-A
Rachel L. Becker, CPC-A
Rachel Lima, CPC-A
Rachel Rials, CPC-A
Rachel Slaton, CPC-A
Rafael Rivera, CPC-A
Ranjana Gupta, CPC-A
Rebecca Bognar, CPC-A
Rebecca Conrad, CPC-A
Rebecca Folk, CPC-A
Rebecca Swett Langford, CPC-A
Rebekah Palomino, CPC-A
Reeta Braggs, CPC-A
Renee Reynolds, CPC-A
Renee Wcisel, CPC-A
Rexanna S Ruzic, CPC-A
Rhonda Davidson, CPC-A
Richard Spaeth, CPC-A
Rita Sullivan, CPC-H-A
Robert Kendrick, CPC-A
Robin Ann Smullins, CPC-A
Robin Bennett, CPC-A
Ronald James Edge, CPC-A
Samantha Glenn, CPC-A
Samantha Jn Cacal, CPC-A
Sandra Faye Crum, CPC-A
Sandra Santavicca, CPC-A
Sara Elizabeth Osborne, CPC-A
Sara Forberg, CPC-A
Sara Lyn Kelly, CPC-A
Sara M Dunne, CPC-A
Sara Youmans, CPC-H-A
Sarada Kandala, CPC-A
Sarah Chuyka, CPC-A
Sarah Frances Kamakana ‘I’o-Makamae Nelson,
CPC-A
Sarah Garon, CPC-A
Sarah Jo Hopkins, CPC-A
Sarah Lansing, CPC-A
Sarah Lindo, CPC-A
Serena Schodt, CPC-A
Shahida Parveen, CPC-A, CPC-H-A
Shaji Tharakan, CPC-A
Shanitra Scott, CPC-A
Shannon Sears, CPC-A
Shantelle Niesha Nixon, CPC-A
Sharon A Cook, CPC-A
Sharon Cooley, CPC-A
Shawna Cummins, CPC-A
Shawntee Garcia, CPC-A
Sheila Jamrose, CPC-A
Sheri L Bailey, CPC-A
Sheri Lynette Craig, CPC-A
Sherry Flynn, CPC-A
Sherry Goodwin, CPC-H-A
Shonte L Perry, CPC-A
Silvana Barone, CPC-A
Sinavaiana Samuela Masoe, CPC-A
Sonya Hamilton, CPC-A
Sophie N Callihan, CPC-A
Stacey Nicole Davenport, CPC-A
Staci Henry, CPC-A
Stacy Lee Wingard Owens, CPC-A
Stacy Lynn Keuhs, CPC-A
Stanley Wasileski, CPC-A
Stephanie Hyler, CPC-A
Stephanie Smith, CPC-A
Steven Geron, CPC-A
Sue Ramirez, CPC-H-A
Susan Alaine Landeck, CPC-A
Susan R Karaffa, CPC-A
Susana Alaniz, CPC-A
Susie Bishop, CPC-A
Suzanne Michele King, CPC-A
Suzanne R Burgard, CPC-A
Tammy Garris, CPC-A
Tammy Baldwin, CPC-A
Tammy D Williams, CPC-A
Tanya M Watson, CPC-A
Tanya S Scott, CPC-A
Tara Cochrane, CPC-A
Tara Vaughn, CPC-A
Tasha M Cunningham, CPC-A
Tasha Taylor Quirk, CPC-A
Tawanna Pressley, CPC-A
Taylor Synegal Marcus, CPC-A
Teresa L Thomas, CPC-A
Teri Lynn Smith, CPC-A
Terri Adkins, CPC-A
Terri Kirchler, CPC-A
Theresa Child, CPC-H-A
Tia Denise Manshack, CPC-A
Tiana Uhl, CPC-A
Tiffany Lamkin, CPC-A
Tim VanBennekom, CPC-A
Timi-Am Xavier Neri, CPC-A
Tina Anderson, CPC-A
Tina Wideman, CPC-A
Tiombe I Booth, CPC-A
Tonya Cox, CPC-A
Tonya Kay Wendel, CPC-A
Tonya Sisk, CPC-A
Tracy Wingo, CPC-A
Tracy Domago, CPC-A
Trupti Bhatt, CPC-A
Newly Credentialed Members
Cynthia Stephens, CPC, CEDC
Cynthia Vanderpoest, CPC, COSC
Dana Jo Keck, CPC, CCVTC
Darlene Johnson Lovett, CPC, CPC-H, CPCO,
CPMA, CANPC
Dawn H Allen, CPC, CPMA
Deborah Ann Santos, CPC, CPMA
Deborah Damon, CENTC
Deborah Norris, CPC, CPPM
Diana Iris Santana, CCC
Diann L Steele, CPC, CEMC
Dorothy Rettinger, COBGC
Elizabeth Wernet, CPC, CHONC
Elke E Cranfill, CPC, CPMA, CUC
Florence M Porth, CPC, CCC
Gloria Ann Taylor, CPC, CHONC
Heather Kostoff, CPC, CPMA, CEMC
Holly Ann Johnson Sandbothe, CPC, CEMC,
CHONC
Holly Johnson, CPC, CIRCC
Amy Liu, CPC, CASCC
Irene A Quast-Beck, CPC, CPCO, CPMA, CEMC
Angela L Haggard, CPC, CPMA
Jamie Cutter, CPC, CPMA
Angela L Scallions, CPMA
Jenna Busch, CPCO
Angela M Kiselka, CPC, CPMA
Jennifer Paxton, CPC, CPCO
Aubrey Byrne, COBGC
Jennifer Redline, CPC, CPMA, CEMC
Beata Jablonski, CPCD
Jessica Fenolio, CPC-H, CASCC
Benjamin Gerlach, CPCO
Joanna Arias, CIRCC
Beth Ann Janowiecki, CPC, CCVTC
Joanne Marie Ingrasselino, CPC, CEMC, CUC
Bozena Janus, CPC, CHONC
Johanka Fonseca, CPC-A, CPMA
Carla Kristin Peterson, CPC, CEMC
Juanito Natividad, CIRCC
Carmen Pomares, CPC, CPMA
Judith A Ackerman, CPC, CPMA
Carolyn Lighty, CPC, COBGC
Julian A Molina Jr, CPPM
Cathy E Kirk, CPC, CGIC
Julie L Close, CPC, CANPC
Chalantha Catrese Lewis, CPC, CCC, CCVTC
Karen E Spencer, CPC, CEMC
Clarice Adamson, CPC, CIRCC
Kathe J Kindred, CPC, CEMC
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2:01:16 PM
Crystal G Dupas, CPC, CGSC
Kathleen M Sutyak, CPC, CHONC
Cynthia Bunce, CPC, COSC
Twyla Cook, CPC-A
Valerie Jenson, CPC-A
Vanett Brown, CPC-A
Verkneca Crosby, CPC-H-A
Vernetta Anderson, CPC-A
Veronica Arellano, CPC-A
Veronica Zanini, CPC-H-A
Vickie L Roberts, CPC-A
Vickie Saine, CPC-A
Victoria Franklin, CPC-A
Vito Donald Bolognone, CPC-A
Whitney Goudy, CPC-A
William Nathan Mayfield Jr, CPC-A
William Struck, CPC-A
Windy K Copperthwaite, CPC-A
Wynn Churchey, CPC-A
Zsuzsanna Elonka Suto, CPC-A
Specialties
Katrina Gabrielle Ilagan, CPPM
Kay Kennedy, CPC, CPMA
Kayci Lee, CASCC
Keith D Rekow, CPC, CPMA
Kelly A Fury, CPC, CPMA
Kelly Ann Cookmeyer, CPC, CCC
Kelly L Criss, CPC, CANPC, CGIC
Kelly Lynn Kay, CPC, CEMC
Kenda R Hesse, CPC, CGSC
Kimberly Ann Vaughan, CPC, CPPM
Kimberly Anne McNeff, CPC, COSC
Kimberly Dawn Knight, CPC, CIMC
Kristie Ann Fissler, CPC, COSC
Kristin M Rodriguez, CPC, CEMC
Lauren A. Ayr, CPC, CEMC
Linda Vivian, CPMA
Lisa Urrea Huosseiny, CPC, CPC-H, CPMA, CEMC
Lydia Smith, CPC, CHONC
Marilyn Wilkins, CFPC
Martha A Aragon, CRHC
Martha Darling, COSC
Mary Greene Howard, CPC, CPMA
Mary Schwall, CPC, CPPM
Mary Wilds, CPC, CEMC
Matthew Okaty, CPCO
Melanie Bush, CPCO
Melinda Bromberg, CPC, CPC-H, CPC-P, CPMA,
CCC
Michael Colonna, CPC, CPPM
Michael Nomura, CPC, CPC-H, CPC-P, CANPC,
CEDC
Misty Branham, CPC, CUC
Misty Sebert, CPC, CCC
NaKisha Samples, CPCO
Nancy Dawn Bergen, CPC, CPPM
Nancy R Kennedy, CPC, CIRCC
Natalya Wang, CPC, CIRCC
Pam Mertz, CEDC
Patricia Dean Wilson, CPC, CCC
Patricia Marie Boey, CPC, CEMC
Paula E Guthrie, CPC, CPMA, CPC-I
Paula M Wright, CPC, CIRCC, CPMA, CPC-I,
CEMC
Paula Servis, CIRCC
Rachael J Streight, CPC, CRHC
Rebecca Lynne Roberts, CPC, CPPM
Regina Rene Alvarez, CPC, CGSC
Rhonda L Fletcher, CPC, CPMA, CEMC, CENTC,
CFPC, CPEDC
Robin J Devine, CPC, CPMA
Rochelle A Cushnie, CPC, CPMA
Roger Cunha, CPPM
Ruthmarie Ferguson, CEDC
Sadie Freerksen, CPC, CEDC
Sandra F Rieckman, CPC, CEMC
Sandra Maria Johnson, CPC, CPPM
Sarah Nunez, CPC, CEMC
Scott Jeffrey, CIRCC
Sharon A Peterson, CPC, CEMC
Sheree V Benner, CPC, CPPM
Sherri Baker, CPC, CIRCC
Sonda Kunzi, CPC, CPMA, CPPM, CPC-I
Sonya Bowery, CPC, CPPM
Susan M Wojtasik, CPC, CGIC, COSC
Susann Berlin, CPC, COSC
Suzanne Carol Winters, CPC, CPRC
Svitlana Hanson, CPC-H, CEDC
Tammy M Frazier, CPC, CPMA, CEMC
Teresa Mallory, CPC, CEMC
Toni Renae Jeffries, CPC, CPC-H, CEMC
Valarie Norman, CPC, CPPM
Valerie Myers, CPC, CRHC
Vickie A Pentecost, CPC, CHONC
Vickie C Capley, CPC, CPMA
Vickie Hicks, CPC, COBGC
Yissel Cruz, CPC, CPMA
Magna Cum Laude
Alanna Esler, CPC
Ana Marcela Romero, CPC
Ashley Baumgartner, CPC
Betty Jean Loosmore, CPC
Casee Flood, CPC
Charlotte Hewitt, CPC
Christine Burke, CPC, CPC-H
Christine Dediego, CPC-A
Emily Elizabeth Ray, CPC, CPMA
Eva P Alexander, CPC-A
Huong Tuong, CPC
Jennifer Tinsley, CPC-A
Jennifer Ilardi, CPC-H
Jessica L Tennis, CPC-H, CASCC
Jolyn Gnader, CPC, CASCC
Karla Grimwood, CPC
Laura Ferris, CPC
Laura Johnson, CPC-A
Laurie Boutte, CPC-A
Malissa Ann Bonk, CPC-A
Michelle Cook, CPC, CGSC
Pam Dye, CPC
Rebecca Bostwick-Otero, CPC-A
Sandra Paola Duque, CPC
Sara Scholes, CPC-A
Sheila Ann Hewitt, CPC-A
Telisa Mullins, CPC-A
Teresa Marlowe, CPC-A
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Minute with a Member
Rhonda Zollars, CPC, CPC-H
Scottsdale, Ariz.
“I believe in being proactive in coding
and my career. I am working on my
Certified Professional Medical Coding-Instructor (CPC-I®) and Certified
Professional Medical Auditor (CPMA®)
credentials.”
webmaster on an ongoing basis. I am currently education officer. If a chapter member has a question, he or she knows to email
me. I will find a response or, at least, guide the member to where
he or she can find the answer.
3. What AAPC benefits do you like the most?
I like all of the deals and specials AAPC offers and the great support I receive if I have any issues or need anything for the chapter or myself.
1. 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.
I started as a medical assistant at a physician’s office, and worked
my way up to office manager. During the time I was office manager, I would hear the physician ask the billing company questions they could not answer. I began researching his questions,
which led me to get very involved in coding, more so than I was
before. I decided to take Certified Professional Coder (CPC®)
courses and, after I became certified, I took on coding and billing for the office. Seven years later, I now work for the state of
Arizona. I earned my Certified Professional Coder-Hospital
Outpatient (CPC-H®) credential in 2010.
I believe in being proactive in coding and my career. I am working on my Certified Professional Medical Coding-Instructor
(CPC-I®) and Certified Professional Medical Auditor (CPMA®)
credentials. I can’t wait to take the ICD-10 prep test and get certified for ICD-10-CM!
2. What is your involvement with your local AAPC chapter?
I have been very active in my chapter, serving as president and
as education officer multiple times, as president-elect, and as a
66
AAPC Cutting Edge
4. What has been your biggest challenge as a coder?
My biggest challenge is getting physicians to understand the
importance of correct documentation versus extensive non-supportive documentation.
5. How is your organization preparing for ICD-10-CM?
Although ICD-10-CM was pushed back to 2014, our state
agency still wants to roll it out October 2013 to allow for any
fixes that may arise. This will give our agency a whole year before implementation to help others.
6. If you could do any other job, what would it be?
I honestly can’t imagine doing anything else other than coding
or instructing, unless retirement on an exotic island is a career.
7. How do you spend your spare time? Tell us about your
hobbies, family, etc.
I love to cook and bake, crochet, cross stitch, and attack any other new craft. I love puzzles of all kinds. I especially enjoy spending time with friends and family. I travel to Los Angeles about
once a month for relaxation—it’s my escape from everything.
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