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HEALTHCARE
BUSINESS MONTHLY
Coding | Billing | Auditing | Compliance | Practice Management
From Coder to Colleague: 20
Join forces with providers without using Jedi mind tricks
Patient Rights to Medical Records: 44
HHS clarifies PHI requests, denials, and appeals
Let the MIPS Countdown Begin: 54
Hop on the MIPS train, scheduled to arrive in 23 months
May 2016
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Healthcare Business Monthly | May 2016
COVER | Member Feature | 16
Member of the
Year Stitches Her
Way to the Top
By Michelle A. Dick
[contents]
■ Coding/Billing
■ Auditing/Compliance
■ Practice Management
20 From Coder to
Colleague through Querying
44 PHI Requests,
Denials, and Appeals
54 MIPS Is Coming in 23 Months
Linda R. Farrington, CPC, CPMA,
CPC-I, CRC
Robert Pelaia Esq., CPC, CPCO, and
Drew Krieger, Esq., MBA
Douglas J. Jorgensen, DO, CPC,
FAAO, FACOFP, CAQ Pain Medicine
[continued on next page]
www.aapc.com
May 2016
3
Healthcare Business Monthly | May 2016 | contents
■ Coding/Billing
28
24 Category III Codes: Use to Prompt Category I Codes
John Verhovshek, MA, CPC
26 Added Edge: Maximize Your Resources
LeAndrea Abercrombie, CPC, NR-CM
27 ICD-10 (S00-T88): Key Terms Lead to Proper 7th Character
Jill M. Young, CPC, CEDC, CIMC
28 CPT® 2016: Neuro-interventional Coding
48
David Zielske, MD, CIRCC, CCVTC, COC, CCC, CCS, RCC
32 Workers’ Compensation: Limited Liability for Healthcare Services
Michael Strong, MSHCA, MBA, CPC, CEMC
35 The Latest on Dialysis Access Maintenance Reporting
Stacie L. Buck, RHIA, CIRCC, CCS-P, RCC
40 10 Tips to Improve Your Influence on Providers
Marea Aspillaga, BS, CPC, COC, CPMA, CHC
■ Auditing/Compliance
48 Are Auditors, Billers, and Coders Liable for False Claims?
56
Joe Rivet, CPC, CEMC, CPMA, CCS-P, CICA, CHC, CHRC, CHPC, CCEP
51 CMS Sets Standards for Medicare Overpayments
Julie Roth, MHSA, JD, RHIA
■ Practice Management
56 Learn from CDI Programs
Ida Landry, MBA, CPC
COMING UP:
•• Chapter of the Year
•• Wound Care
•• HEDIS
•• IT Support
•• Taxonomy Codes
On the Cover: 2015 Member of the Year Jeanne Gershman, CPC,
COC, CEMC, CPB, is an AAPC role model who makes quilts to help
members. Cover photo by Robin Howard of C&C Design Studio
(www.ccdesignstudio.com).
4
Healthcare Business Monthly
DEPARTMENTS
60 Ethics Committee
7
Letter from Membership Leader
65 Alphabet Soup
8
Letters to the Editor
66 Minute with a Member
8
Chat Room
9
I Am AAPC
EDUCATION
10 AAPC Chapter Association
60 Newly Credentialed Members
Online Test Yourself – Earn 1 CEU
12 2016-2017 Chapter Association
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HEALTHCARE
BUSINESS MONTHLY
May 2016
Publisher
Brad Ericson, MPC, CPC, COSC
[email protected]
Managing Editor
John Verhovshek, MA, CPC
[email protected]
Editorial
Michelle A. Dick, BS
Renee Dustman, BS
Graphic Design
Mahfooz Alam
Kamal Sarkar
Advertising
Jon Valderama
[email protected]
Address all inquires, contributions, and change of address notices to:
PO Box 704004
Salt Lake City, UT 84170
(800) 626-2633
©2016 Healthcare Business Monthly. All rights reserved. Reproduction in whole or in part, in
any form, without written permission from AAPC® is prohibited. Contributions are welcome.
Healthcare Business Monthly 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.
Ask the Legal Advisory Board
From HIPAA’s Privacy Rule and anti-kickback statute, to compliant coding,
to fraud and abuse, there are a lot of legal ramifications to working in
healthcare. You almost need a lawyer on call 24/7 just to help you make
sense of all the new guidelines. As luck would have it, you do! AAPC’s Legal
Advisory Board (LAB) is ready, willing, and able to answer your legal questions. Simply send your health law questions to [email protected] and let
the legal professionals hash out the answers. Select Q&As will be published
in Healthcare Business Monthly.
Medical Coding Legal Advisory Committee:
Timothy P. Blanchard, JD, MHA, FHFMA
Julie E. Chicoine, JD, RN, CPC
Michael D. Miscoe, JD, CPC, CPCO, CPMA, CASCC, CCPC, CUC
Christopher A. Parrella, JD, CPC, CHC
Robert A. Pelaia, Esq., CPC
Stacy Harper, JD, MHSA, CPC
6
CPT® copyright 2015 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 Medicare and Medicaid Services and no endorsement by the
AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.
CPT® is a registered trademark of the American Medical Association.
CPC®, COCTM, CPC-P®, CPCOTM, CPMA®, and CIRCC® are registered trademarks of AAPC.
Volume 3
Number 5 May 1, 2016
Healthcare Business Monthly (ISSN: 23327499) is published monthly by AAPC, 2233 South Presidents
Drive, Suites F-C, Salt Lake City UT 84120-7240, for its paid members. Periodicals Postage Paid
at Salt Lake City UT and at additional mailing office. POSTMASTER: Send address changes to:
Healthcare Business Monthly c/o AAPC, 2233 South Presidents Drive, Suites F-C, Salt Lake
City UT 84120-7240.
Letter from Member Leadership
Seek Positive Influence and
Inspire Others with Your Time
T
his year at HEALTHCON Jeanne Gershman, CPC, COC, CEMC, CPB, was announced as the 2015 Member of the Year. I
had the pleasure of working with Jeanne on
the National Advisory Board (NAB) for two
years. During that time, I witnessed her ability to dive into projects and really make herself available to others. She is a great role model for members, both new and old.
I hear so many stories of members who volunteer their time and it inspires me to want to do
more. There are many ways to help our members, many of which do not require a huge
time commitment. For example, if you are
well versed on a topic, share your knowledge
with others by writing an article for Healthcare Business Monthly. It’s a great way to educate and help members nationwide.
Don’t Use Time As an Excuse
If you think you don’t have time to volunteer,
remember the old adage: Many hands make
light work. I’ve always found that recruiting
the help of others resolved the time issue. For
example, when you get your local chapter or
a group at work involved, organizing a fundraiser isn’t nearly as daunting of a task.
Another great use of your time is to meet
with co-workers or chapter members to talk
about what’s happening in your community.
Is there an issue being discussed in the news
that could impact the healthcare industry? If
so, reach out to your NAB representative to
find out if it’s an issue AAPC has on their radar. This is a team effort. The NAB is here to
assist you and to help AAPC serve members,
and our industry’s needs.
Surround Yourself
with Positive Inspiration
I have been so fortunate in my career to be in
the company of vital, active individuals, who
constantly inspire me to do more. The management at AAPC (i.e., Jason VandenAkker;
Bevan Erickson; Rhonda Buckholtz, CPC,
CPCI, CPMA, CRC, CHPSE, CENTC,
CGSC, CPEDC, COBGYN; and Raemarie Jimenez, CPC, CPB, CPMA, CPPM,
CPC-I, CANPC, CRHC, CCS, to name just
a few) are always seeking ways to make information more accessible to the membership.
They want to provide the tools needed to inspire and encourage you to accomplish all of
your goals. By providing so much information in one place, the hope is to save you time.
I think we all have it in us to inspire our family, friends, and co-workers. Each of us should
find our own way to give something of ourselves — whether we give back to the community, to those who need a little encouragement, or to those who have been our inspiration or mentors.
Take care,
This is a team
effort, and the
NAB is here to
assist you and
help AAPC serve
members and our
industry’s needs.
Jaci Johnson Kipreos, CPC, COC, CPMA,
CPC-I, CEMC
President, National Advisory Board
www.aapc.com
May 2016
7
Letters to the Editor
Additional 30 Minutes, Beyond
First Hour of Prolonged Clinical Staff
Service Calls for 99416
“2016 Brings Opportunity to Increase Revenue” (March 2016) included an error on page
41. Under the subhead “Reporting Criteria,”
condition 5 states, “+99415 is for each additional 30 minutes.”
In fact, as correctly stated elsewhere in the
article, +99145 Prolonged clinical staff service
(the service beyond the typical service time) during an evaluation and management service in
the office or outpatient setting, direct patient
contact with physician supervision; first hour
(List separately
in addition to
HEALTHCARE
BUSINESS MONTHLY
code for outpatient Evaluation and Management service) describes
the first hour
of prolonged
services, while
+99416 Prolonged clinical
March 2016
www.aapc.com
Fight for Insurance Carrier Payment: 27
Have a game plan that gets you paid
staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting,
direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service) describes each additional 30 minutes, beyond
the first hour of prolonged services.
Healthcare Business Magazine
Artificial vs. Natural Openings
In “Make the Most of HCC” (March 2016),
the final sentence on HCC 188 (page 39)
states, “Port-A-Cath®, PICC (peripherally inserted central catheter) line, indwelling urinary catheter (Foley), and chest tubes are not
artificial openings because these are placed
in natural openings.” On the contrary, all of
these are artificial openings, made by man
— with the exception of Foley, which goes
through a “natural opening,” the meatus.
Phuc Huynh, DO, CMD, CPC
Improve Your Odds of
Unlisted Procedure Code Payment
The NPP Scope of Practice Scoop: 48
Meet state practitioner authorization requirements
Time Is Ticking on Old Accounts: 55
Manage unpaid claims now to increase revenue
March2016_HBM.indd 1
I enjoyed reading “Fight for Insurance Car-
11/02/16 9:33 pm
Chat Room
Spreading AAPC Love through Social Media
If you post on AAPC’s Facebook page, many AAPC members and employees read
your threads. Our staff enjoys reading your posts and receiving feedback, and
especially loves when you spread positive messages to fellow members. In March
the common thread in many posts was credentials. And one thing is for sure about
AAPC members: They get
really excited when they pass a
certification exam and gain a new
credential. Two members were
beaming with credential pride
in March and posted about it on
Facebook: Candice M. Fenildo,
CPC, CPB, CPMA, CPC-I,
CENTC, and Marilyn Glidden,
CPC, CPCO, CPMA, CGIC,
CGSC. Congratulations on your
new credentials, ladies!
8
Please send your letters to the editor to:
[email protected]
rier Payment” (March 2016), and would like
to supplement the information concerning
unlisted codes (page 28, under the subhead
“Claim Needs More Information”).
In addition to supplying the operative note
when submitting unlisted procedure codes, I
recommend citing comparable codes and the
total relative value units, to guide the insurer’s payment decision. Also, you should submit the supporting documents with the original claims for non-Medicare payers.
Marie Anne B. Maignan, CPC, CPMA, CPB
75984 Descriptor Correction
In “CPT® 2016: Urinary Interventional
Coding” (March 2016, page 21), the transcatheter diagnostic radiology code 75984 is
described as Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter. This description is for procedure 50684. The correct description for 75984 is Change of percutaneous tube or drainage catheter with contrast
monitoring (e.g., genitourinary system, abscess),
radiological supervision and interpretation.
Allison A., CPC
MARCELLA CICIRELLO, BS, CPC
T
he first article I read each month in
Healthcare Business Monthly is I Am
AAPC. I enjoy reading about the steps
my fellow AAPC members took on the
road to becoming healthcare business
professionals.
Here is my journey.
From Medical
Books to Medical Coding
I had dreamed of a career in healthcare
since I was 12 years old. I used to flip
through the pages of my mother’s anatomy, physiology, and medical terminology textbooks (she was studying to
be a medical assistant). It wasn’t until
I turned 25 that I officially began my
journey to becoming a Certified Professional Coder (CPC®). My first job
in healthcare was as a file clerk in 1995
at Hahnemann University Hospital in
Philadelphia. Now, 20 years and several promotions later, I am a CPC® and a
billing/accounts receivable manager at
Penn Medicine.
Gaining Knowledge through
Experience and Education
I was working at Penn Medicine as a
billing coordinator in 2002 when I was
first exposed to coding. One of my duties was to code evaluation and management (E/M) visits and surgeries. I
had no experience or education in cod-
ing, but through an Internet search
I found AAPC and learned how to
become certified in coding. I studied
for the exam while working as a coder. I took the CPC® exam in 2006 and
passed it on my first try. After earning
my CPC® credential, I began working
as a coding specialist. I also became
more active with AAPC by becoming
secretary for the Greater Philadelphia
local chapter. In the time I’ve been an
officer, I’ve maintained the chapter’s
member database, emailed event notifications, planned events, and proctored exams. I’ve also been a speaker at
a local chapter meeting. All the while,
I’ve been going to college. This year, I
will graduate with a master’s degree in
Health Administration from Saint Joseph University.
#IamAAPC
I Am AAPC
Sharing with Others
My career goal is to teach billing, coding, and healthcare administration at
the university level. I also would like to
be a speaker at local, regional, and national AAPC events. My advice to fellow AAPC members is to take advantage of every education and networking opportunity available while attending AAPC conferences and meetings,
and to get involved with your local
chapter.
#IamAAPC
Healthcare Business Monthly wants to
know why you chose to be a healthcare
business professional. Explain in less than
400 words why you chose your healthcare
career, how you got to where you are, and
your future career plans. Send your stories
and a digital photo of yourself to:
Michelle Dick ([email protected]) or
Brad Ericson ([email protected]).
#IamAAPC
www.aapc.com
May 2016
9
AAPC Chapter Association
By Barbara Fontaine, CPC
Time Well Spent
istock.com/Dirima
AAPC Chapter Association
chair reflects on the past five
years of accomplishments.
I
t seems like yesterday I was attending my
first AAPC National Conference in Long
Beach, California, as a member of the AAPC
Chapter Association (AAPCCA) board of
directors. I had attended national conferences before, but this was different. It was 2011,
and I looked forward to what the next three
years of my term would bring. That stretched
into four years when I was elected to serve
as chair for the 2014-15 term, and then five
years when I filled that spot again for the
2015-2016 term.
It’s time for me to step down and give someone else a chance!
Five Years Flies By
AAPCCA has accomplished so much these
past five years. We have reached out to our
members through:
• The articles we publish in Healthcare
Business Monthly;
• The kudos we pass on to share your
triumphs;
• The Local Chapter Handbook that we
update every year to help you manage
your chapter; and
• Assisting you when things aren’t going
the way you envisioned.
We’ve developed many new chapters and
have grown into an international organization along the way. It’s been a lot of work, but
it’s been totally rewarding.
10
I subscribe to the
theory “When you rest,
you rust,” so I choose
not to rest.
Reaching Out and Educating
I’m very proud of the chance we’ve had over
the last two years to bring officer training to
chapters. Some chapters I personally trained,
and others I met through email while connecting them to other AAPCCA or National
Advisory Board members for training. I enjoyed getting to know all of you, and I have
loved staying in touch with so many of you.
This year we reached out to more chapters and
officers than ever before. I thank AAPC’s Jason VandenAkker and Bevan Erickson for
making this possible. And where would we be
without Marti Johnson and Linda Litster
of AAPC’s Local Chapter Department? They
are the hard-working soul of local chapters.
Positive, Lasting Relationships
Many of the wonderful members I’ve met over
the past five years I will remain friends with for
the rest of my life. We shared common goals
and interests amidst our work with AAPC,
and then discovered we shared hobbies and
interests in our outside lives. Parenting and
marriage advice has been exchanged between
us, along with caring for each other in our daily lives, supporting each other in our illnesses, extending sympathy when needed, and being kind, always. It’s a wonderful thing when
a business association can affect others so positively and permanently.
Time Is Your Most Cherished Gift
I subscribe to the theory “When you rest, you
rust,” so I choose not to rest. I make the most
of my time. Lao Tzu said, “Time is a created
thing. To say ‘I don’t have time,’ is like saying,
‘I don’t want to.’” For our chapters to thrive,
we need members to step up and accept the
challenges of becoming an officer — a person who makes the time to be there for their
chapter.
I am truly glad that I made the time to meet
and get to know you, and I hope that more of
you will do the same.
Barbara Fontaine, CPC, is business office supervisor
at Mid County Orthopaedic Surgery and Sports Medicine (part of Signature Health Services). Her more than
30 years in the medical field have taken her from a parttime admissions clerk in a rural Arkansas hospital to coding and billing for
a single family practice physician, and then to a multi-physician clinic,
which became a multi-practice group in northwest Arkansas. Fontaine
focuses on keeping up to date with correct coding and billing for her providers, and continuing education for physicians and staff. She became a
member of the St. Louis West, Missouri, local chapter, serving on several
committees before becoming an officer. In 2008, she was her local chapter’s Coder of the Year and AAPC’s national Coder of the Year. She served on
the AAPCCA from 2011-2016 and was chair from 2014-2016.
AAPC CHAPTER ASSOCIATION ■
Retiring Is Bittersweet for the AAPC Chapter Association
As we welcome new faces to the AAPC Chapter Association (AAPCCA) board of directors, we must also say
goodbye to four hardworking, dedicated ladies who are retiring from the board. Here are their sentiments on
serving on the board for the past three years.
Sharon J. Oliver, CPC, CPMA, CPC-I
One of the best professional decisions I ever made was to apply for the AAPCCA BOD [board of directors]. The
experience has given me insight into the hard work that is accomplished by the AAPC Local Chapter Department
with the assistance of the AAPCCA BOD. If I hadn’t been on the board, I might not have had the privilege to befriend such a wonderful group of professionals. These lasting relationships are dear to me. We refer to each other as
“BOD sisters.”
I will miss the “hands on” workings of the AAPCCA BOD, but deep down: Once on the board, always on the board.
My experience in one word: priceless.
Pam Brooks, MHA, CPC, COC, PCS
Being on the AAPC Chapter Association board of directors has provided me with both professional and personal rewards. The opportunities that come with being on the board — writing articles, presenting workshops, participating in conferences, and having that level of visibility within the coding field — have allowed me to elevate my career in the healthcare business industry. More importantly, I’ve met many knowledgeable and exceptional people —
many of whom I consider dear friends who I can reach out to for assistance and advice.
Faith McNicholas, RHIT, CPC, CPCD, CDC, PCS
2016 is the marking of another milestone in my AAPC life, as it signifies the end of my term on the AAPCCA board
of directors. The past three years have been exciting and went too quickly.
I’ve had a wonderful time serving our members during my tenure. I have met great, smart, and very professional
women, who I now call my family. I cannot explain the pleasure and sense of gratitude I get from helping AAPC
members.
I’ve grown both personally and professionally. I will carry the lessons I’ve learned and the friends I’ve made throughout my life. I will always be ready and willing to share the wisdom, should I be called on again to serve.
Cynthia (Cindi) Colangelo, CPC, COC, CPB
I started on the BOD after serving in a variety of offices at my local chapter. It seemed like a natural progression to
jump in and expand my horizons. I have learned how much work goes into pulling together a successful event like
the annual HEALTHCON or regional conferences. I have gained great respect for those who are able to do this and
who continue to make the next event even better than the last.
These past three years have gone by quickly. While it has been fun and rewarding to share and serve with the “BOD
sisters,” there have been hours of learning and assisting our local chapter officers. I hope we have left them feeling
better informed and prepared to help chapter members receive the best AAPC has to offer them.
Thanks to the wonderful team of patient and diligent women at the AAPC local chapter office. Marti Johnson and
Linda Lister are awesome mentors and gracious, hard-working women who strive to do the best for local chapter
officers and members. I am thankful for this experience and will carry the friendship and comradery of the “BOD
sisters” with me for the rest of my life.
www.aapc.com
May 2016
11
■ AAPC CHAPTER ASSOCIATION
Chapter
SAY HELLO
2016-2017
TO YOUR
Leaders
AAPC is excited to announce the 2016-2017 AAPC Chapter Association (APPCCA) Board of Directors — a voting board of 16 coders and one AAPC representative. This elected board is dedicated
to providing local chapters with the resources and support necessary to be successful. Here are
your new regional representatives and executive committee officers for 2016-2017.
1 - Northeast
Maine, New Hampshire, Vermont,
Massachusetts, Connecticut, Rhode Island, New York
Yolanda T. Haskins, CPC, CRC, CMCO
Lead Coder, Howard University Faculty Practice Plan
Yolanda Haskins brings more than 30 years of experience to the medical billing and coding field. She has
worked in many specialty offices, hospital systems, and as owner of
a billing company. Haskins received her CPC® in 2006 and CRC™
in 2015. She helped establish the Alexandria, Virginia, local chapter,
which now has more than 350 members. She loves mentoring and encouraging new coders.
Contact: [email protected]
Chapter affiliation: Alexandria, Virginia
Offices held: President, vice president, member development officer
Kristie Stokes, CPC
Facility Coding Quality Analyst & Educator,
Change Healthcare
Kristie Stokes began working in the medical billing
and coding field in 1997 as a follow-up clerk for an ambulance service. From there, she went on to work as a medical biller, administrative assistant, assistant manager, manager, and coder. Stokes now
works for Change Healthcare (formerly Altegra Healthcare) as a facility coding quality analyst, performing internal reviews, and as an
educator, teaching coders employed by Change Healthcare. She loves
to mentor new coders and those interested in making a career change
to become a coder.
Chapter affiliation: Pensacola, Florida
Offices held: President, vice president
12
2 - Atlantic
New Jersey, Pennsylvania, Delaware, Maryland, Washington DC
Meeting Coordinator Maria Rita (Rita) Genovese, CPC, PCS
Administrator, Jefferson Infusion Centers
Rita Genovese has over 20 years of experience in billing
and practice management, most recently in the areas of family medicine and medical oncology. As administrator of revenue cycle for the
Department of Medical Oncology and Jefferson Infusion Centers at
Thomas Jefferson University she is active in educating the physicians
and staff in medical coding and compliance regulations. Genovese is
a former member of AAPC’s National Advisory Board and a frequent
speaker at AAPC national and regional conferences.
Chapter affiliation: Greater Philadelphia, Pennsylvania
Stephanie Moore, CPC, CPMA
Auditor/Educator, Wentworth-Douglass Hospital
Stephanie Moore has over 15 years’ experience in
healthcare, and is an auditor/educator for WentworthDouglass Hospital in Dover, New Hampshire. She started out at the
front desk of a multi-physician surgical practice, and quickly learned
and transferred into the coding and billing role. Moore became a patient access supervisor at Wentworth-Douglass Hospital, where she
developed an authorization, pre-certification and scheduling team.
She specializes in E/M auditing, outpatient services, and educating
providers; her specialty experience is in cardiology, vascular, OB/
GYN, behavioral health, and palliative care. Prior to Moore’s career
in healthcare, she served in the U.S. Marine Corps.
Chapter affiliation: Seacoast Dover, New Hampshire
2016-17 AAPCCA Board
3 - Mid-Atlantic
4 - Southeast
Virginia, West Virginia, Kentucky, North Carolina, South Carolina
Georgia, Florida, Alabama, Tennessee, Puerto Rico, Bahamas
Judy Wilson, CPC, COC, CPCO, CPPM,
CPB, CPC-P, CPC-I, CANPC, CMRS
Business Administrator, Anesthesia Specialists
Judy Wilson has been in the medical field as a business
administrator for more than 38 years. For the past 25 years, she has
been the business administrator for Anesthesia Specialists, a group
of 10 cardiac anesthesiologists who practice at Sentara Heart Hospital. She served as treasurer for the AAPCCA board of directors in
2011 and 2013. Wilson has presented at several AAPC regional and
national conferences.
Secretary - Holly Brown, CPC, COC, CEMC,
CPCO, CCS
Coding Quality Analyst, Optum360
Holly Brown has worked in medical billing and coding for over 10 years, starting out at the front desk of a multi-physician cardiology practice. She quickly learned the billing/coding side
and transferred to the billing office, where she scrubbed charges and
helped to code office visits and procedures. Brown specializes in quality/training and auditing E/M and outpatient services for physicians
and hospitals. She helped to start the St. Augustine, Florida, local
chapter in 2009, and she worked with other coders in 2012 to start
the Orange Park, Florida, local chapter.
Chapter affiliation: Chesapeake, Virginia
Offices held: President, vice-president, secretary/treasurer,
education officer
Cindy Stephenson, CPC, CRC
Self-pay Collections, Nat’ l Revenue Service Center,
St. Vincent Health
Cindy Stephenson has worked at St. Vincent Health
for 14 years. She worked in accounts payable for 10 of those years before venturing into patient financial services and then physician business services. Stephenson earned her CPC® in 2011 and her CRC™ in
2015. She enjoys networking with coders, billers, and other healthcare industry professionals to hear about what works for them and the
struggles they encounter.
Chapter affiliation: Indianapolis, Indiana
Offices held: Vice president, treasurer
Chapter affiliations: St. Augustine, Florida and Orange Park, Florida
Offices held: President, president-elect
Randee Herner, CPC, CEMC
Certified Medical Coder, Cleveland Clinic Florida
Randee Herner has been in the medical field for over
23 years. Her present line of work is coding and auditing for multi-specialty physicians. Herner obtained her CPC® in 1997
and her CEMC® in 2011. She is very involved in her local chapter,
which has more than doubled its membership during her presidency. Herner strives to create the ideal place for coders to thrive through
networking, education, and employment. She is a very goal-oriented,
team player who empowers everyone around her.
Chapter affiliation: Weston, Florida
Offices held: President, president-elect, treasurer
www.aapc.com
May 2016
13
5 - Southwest
Texas, Oklahoma, Missouri,
Kansas, Louisiana, Arkansas, Mississippi
Sarah Wechselberger, CPC, CPB, CPMA
Clinic Coding and Reimbursement Manager,
Baxter Regional Medical Center
Sarah Wechselberger started her medical coding career in 2002 with a multi-physician OB/GYN practice. She later went
on to work for a multi-specialty billing group, and now works for a
healthcare system. Wechselberger’s role as clinic coding and reimbursement manager with Baxter Regional Medical Center (BRMC)
began as a professional coder; she manages the first physician coding department for BRMC’s 16+ multi-specialty outpatient clinics.
Chapter affiliation: Mountain Home, Arkansas
Offices held: President, secretary/treasurer, education officer
Najwa N. Liscombe, CPC, CMA, BHSA
Coding and Reimbursement Analyst III, University of
Florida Community Health & Family Medicine
Najwa Liscombe has been working in the medical field
for more than 30 years. She has coded and taught coding for multiple
specialties, including anesthesia, radiology, OB/GYN, family medicine, and orthopedics. Liscombe has worked in the private sector
and as a consultant. She was instrumental in starting the Gainesville,
Florida, local chapter, and was the first president. Liscombe works
in an academic practice, and is a valuable resource for coding and reimbursement issues among many practices in Florida and Georgia.
Chapter affiliation: Gainesville, Florida
Offices held: President, treasurer, member development officer,
education officer
14
6 - Northeast
Wisconsin, Minnesota, Illinois, Indiana, Michigan, Ohio
Chair - Candice M. Fenildo, CPC, CPB, CPMA,
CENTC, CPC-I
Associate Consultant, Acevedo Consulting, Inc.
Candice Fenildo conducts coding and compliance
audit projects; provides consulting services to clients’
management, physicians, and staff; and provides input for developing each client’s annual audit plan. She has more than 17 years’ experience in coding and billing for multi-specialty physicians, with a focused interest in otolaryngology and rheumatology. Fenildo enjoys
mentoring and guiding others to fulfill their career goals.
Chapter affiliation: Stuart, Florida
Offices held: President, secretary
Teresa (Terri) Bartrom, CPC, CPB
Billing Manager, Aspire Plastic Surgery, LLC
Terri Bartrom has more than 25 years’ of billing and
coding experience in the specialties of plastic and reconstructive surgery, OB/GYN, pain management, and podiatry.
She has been instrumental in organizing multiple programs and ICD10-CM boot camps in her local chapter, where she inspires officers
and members to perfect their professions in the medical field. Bartrom has been an AAPC member for 13 years and a certified coder for
12. She is a lifetime member of the American Business Women’s Association and Girl Scouts, and she holds an associate degree in Digital and Computer Electronics from Indiana Vocational Technical
College and business certifications from Indiana Business College.
Chapter affiliation: Fort Wayne, Indiana
Offices held: President, vice president, education officer
7 - Mountains/Plains
Idaho, Utah, Arizona, New Mexico, Montana,
Wyoming, Colorado, North Dakota, South Dakota, Nebraska, Iowa
Treasurer - Ruby Woodward, BSN, CPC, CPMA,
COSC, CSFAC, CPB
Clinical Technical Editor, Educator Decision Health
Ruby Woodward has over 40 years of experience in the
medical arena, serving 30 of those years in both nursing and the business of medicine. She has expertise in coding, education, auditing,
and compliance, and has been heavily involved in orthopedic regulations. Woodward has presented at AAPC conferences, both regional and national, as well as at the local level. She was a member of the
AAPC ICD-10-CM training team. She has been twice selected as the
Member of the Year for the Minneapolis, Minnesota, local chapter.
Woodward is passionate about orthopedics and obsessed with feet.
Chapter affiliation: Minneapolis, Minnesota
Offices held: President, vice president, member development officer
Melody S. Irvine, CPC, CPMA, CEMC, CFPC,
CPB, CPC-I, CCS-P, CMRS
Consultant, Certified Auditor, Education, Curriculum
Development, Career Coders
Melody Irvine has more than 30 years of experience in the medical
profession. She is the founder of Career Coders Online Medical Billing and Coding School; and she specializes in physician auditing, education, curriculum development. Irvine is in the process of publishing a Basic Physician Auditing book and guidelines. Her past responsibilities have included director of coding, auditing, compliance, and
urgent care for a 48 multi-specialty physician practice, and contract
auditor for the State of Colorado Attorney General. Irvine started
the Loveland, Colorado, local chapter, and is a former officer of the
AAPC National Advisory Board.
Chapter affiliation: Loveland, Colorado
Offices held: President, president-elect, education officer
8 - West
California, Oregon, Washington, Nevada, Hawaii, Alaska
Vice Chair - Linda Martien, CPC, COC, CPMA
Reimbursement Business Manager, Osiris Therapeutics, Inc.
Linda Martien began her career more than 30 years
ago — starting out as an emergency medical tech. She then went into
coding, billing, practice management, hospital outpatient revenue
cycle management, and consulting. She served and held office on the
AAPC National Advisory Board from 2005-2009. Martien has also
served in several officer positions with the Jefferson City and Columbia, Missouri, chapters.
Chapter affiliation: Jefferson City, Missouri
Offices held: President, president-elect, education officer
Sherri McDow, CPC, CPMA, CCC, CCS
Director of Coding Operations, Kaiser Permanente
Sherri McDow has worked in the medical field for 27
years, beginning her career as a biller at a home health
agency. She has since worked as a coder, biller, and an auditor for
both small physician groups and large medical centers. McDow is the
Northern California regional process director, coding operations at
Kaiser Permanente. She enjoys teaching, mentoring coders, and being involved in her local chapter.
Chapter affiliation: Sacramento, California
Offices held: President, president-elect, treasurer
Marti G. Johnson
Director of Local Chapter Support, AAPC
Since 1994, when Marti Johnson joined AAPC, the
number of chapters has grown from 30 to more than
500. Her tenure has been dedicated to establishing and supporting
AAPC members and local chapters.
www.aapc.com
May 2016
15
■ MEMBER FEATURE
By Michelle A. Dick
Jeanne Gershman’s quilt donations are just a glimpse into her kindness.
Y
ou may know AAPC’s 2015 Member of the Year award recipient,
Jeanne Gershman, CPC, COC, CEMC, CPB, for the beautiful
quilts she creates and donates to raise money for the AAPC Chapter
Association’s Hardship Scholarship Fund. She has a knack for stitchery, but she is also known as an AAPC role model and leader of the
highest standards.
Gershman is well versed in the nuances of our industry, having
worked in the healthcare industry for 36 years, and she is passionate
about her profession. Her career began in health information, working as a department secretary and computer operator in hospitals and
clinic settings. Gershman received her first coding certification in
2009. She coded for a couple of years for an ambulatory clinic, and is
now a denials analyst for Lifespan, Comprehensive Cancer Center.
Gershman was named 2015 Member of the Year because she is an
AAPC advocate, a local chapter president, and a humanitarian who
continues to put AAPC members’ needs before her own.
Helping Others One Stitch at a Time
AAPC asked Gershman why she thinks she won the 2015 Member
of the Year award, to which she replied, “I am assuming it began with
Photos by Robin Howard of C&C Design Studio (www.ccdesignstudio.com).
my donation of the quilt for the hardship fund. I have made a commitment to continue to donate the quilt yearly, if we are able to raise
funds to benefit the members.”
Making and donating the quilts has allowed her to do two of her passions: quilting and helping members in need. For Gershman, “This
is not a chore; it’s a pleasure.” The quilts have helped to raise awareness for the Hardship Scholarship Fund* and give members a chance
to win the quilt as they donate to this much needed fund. Her passion
for stitchery has been a gift of love and hope to others, as well. Outside
of AAPC, she donates her handiwork to unwed mothers.
Although Gershman’s sewing talents may seem to have landed her
top billing as Member of the Year, she did not receive this recognition just because of her sewing contributions. Her kindness, generosity, and commitment to helping others is worth so much more than
her beautiful quilts.
*For information on the Hardship Scholarship Fund, see the accompanying informational sidebar “Quilts for a Cause.”
Reaching Out to All Members
Time and time again, Gershman has proved to be a humble leader
who enjoys helping others. She takes members under her wing to ensure they are successful, and she makes sure educational resources and
opportunities are available to all, especially those with special needs.
Quilts for a Cause
Jeanne Gershman, CPC, COC, CEMC, CPB, donates her quilts for auction at HEALTHCON to raise money for the
Hardship Scholarship Fund, which was established by the AAPC Chapter Association to help chapter members
who have fallen on difficult times. The fund is used to help members retain their credentials while unemployed,
and can be applied toward the cost of the ICD-10-CM proficiency exam, renewing national memberships, or purchasing coding books. The fund also helps provide AAPC educational services, books, etc., to chapter members
who can’t afford them.
If you or your chapter would like to contribute, donations should be in check form, made payable to the Hardship
Scholarship Fund, and mailed to:
AAPCCA-Hardship Scholarship Fund
2233 S. President Drive
Salt Lake City, UT 84120
To find out more, read the article, “Experiencing Hard Times? There’s Help,” in the April issue of Healthcare Business Monthly or go to www.aapc.com/memberarea/chapters/scholarship-application.aspx.
16
Member of the Year
Making and donating the quilts has allowed her to do two
of her passions: quilting and helping members in need.
To be more specific, Gershman has:
• Been serving as president for the Rhode Island local chapter for the 2014-2016
terms;
•Served as education officer and vice president in prior terms;
• Served on the AAPC National Advisory Board (NAB) from 2013-2015;
• Volunteered to be part of the conference committee;
• Proctored exams;
• Given her time twice to proctor one-on-one exams for a student
with a traumatic brain injury;
• Volunteered to assist AAPC Chapter Association board of
directors with officers training in the New England area;
• After her term ended on the NAB, she went to the regional
conference in Dallas and volunteered as if it was still her
responsibility;
• Ran two ICD-10 boot camps prior to the ICD-10 transition;
• Helped to put together a local seminar and brought in national
speakers for members who were not able to attend a regional or
national conference;
• Donated a handmade quilt last year, which raised $1,500 for the
Hardship Scholarship Fund;
• Donated another handmade quilt this year to auction at
HEALTHCON for the Hardship Scholarship fund;
• Collaborated with AAPC’s Greg Waddoups, PhD, vice
president of learning, and Community College of Rhode
Island to establish a contract to use the AAPC curriculum in the
school’s coding program;
• Coordinated educational sessions for members who needed
additional education because they were having difficulty
passing their certification exam; and
• Helped members find open exams slots, and opened exams to
accommodate more members.
Firsthand Accounts of Dedication and Kindness
NAB Member Relations Officer Angela Clements, CPC, CPC-I, CEMC,
COSC, CCS, who served on the NAB with Gershman from 2013-2015, recalls a
time when Gershman proved to be an extraordinary person and a valuable member of AAPC:
www.aapc.com
May 2016
17
Member of the Year
Jeanne Gershman: Up Close and Personal
What has been your biggest challenge as a coder?
Education. Trying to find resources that are affordable and
available is a challenge. Most of my education has been paid
by myself. I would love to see more specific workshops to
prepare for additional certification.
How have your coding credentials helped your career?
My employer will only hire and advance people who are
certified, so being certified was necessary for my current
position. My coding credentials also have substantiated the
knowledge that I have obtained.
If you could do any other job, what would it be?
I would like to be a cancer patient advocate to help people
with the challenges they face with medical costs, and to
help with their struggles while transitioning through cancer
“I called Jeanne and she was on her way (I don’t remember how far she
commuted, but it wasn’t around the corner.) to proctor a one-on-one
exam for a member who had a traumatic brain injury and struggled with sitting for
an exam in a large group. When
he didn’t pass, she did the same
for his retake. I thought, ‘Wow,
what a way to serve our members!’
Most proctors view proctoring as
a responsibility, but Jeanne went
the extra mile to help someone in need.”
treatment. I’d also like to run a food pantry.
How do you spend your spare time? Tell us about your
hobbies, family, etc.
I am married with two teenage children. I enjoy traveling with
my husband and family. My hobbies are knitting and quilting,
and donating the completed items to help others.
According to Clements, the wheels in Gershman’s head are always
turning, wondering what more she can do for the membership. “She
is always eager to volunteer and help AAPC members any way she
can,” Clements said.
Even after Gershman’s NAB term had ended, and she was no longer required to serve at conference, she contacted AAPC Conference
Director Melanie Mestas and asked how she could help at the Dallas conference. “Gershman showed up and provided any help needed,” Mestas said.
Encouraged to Reach for the Stars
Gershman says her success has been inspired and supported by many
members, particularly by Brenda Edwards, CPC, CPB, CPMA,
CPC-I, CEMC, CRC; Judy A. Wilson, CPC, CPCO, CPPM,
COC, CPC-P, CPB, CANPC, CPC-I; and Chandra Stephenson,
CPC, COC, CPB, CPCO, CPMA, CIC, CCS, CPC-I, CANPC,
CEMC, CFPC, CGSC, CIMC, COSC.
“They are the three most positive people in my professional life. I am
so fortunate to have them,” Gershman said.
Gershman first met Edwards and Wilson at conference, where they
encouraged and supported her decision to run for NAB.
“They made me believe I could achieve any of my goals, and that I
could make a difference in my local chapter,” Gershman said. “They
are truly inspirational individuals” who encouraged her “to step out
of her comfort zone, try new things, and reach for the stars.”
Gershman said about Stephenson, “She has been a positive and
influential role in encouraging me to keep challenging myself
with additional certification. I have been so fortunate to have
her as a coding reference, as well.”
Giving Back to Members
Gershman told AAPC that achieving this award has made her
feel like she has won the lottery. She has become an AAPC superstar, but remains humble, grateful, and eager to continue serving
others and our organization.
“Everything I have done for AAPC is my way of showing my
appreciation for all the support and generosity I have received,”
Gershman said.
Michelle A. Dick is executive editor at AAPC.
18
AAPC VIRTUAL WORKSHOPS
NOW AVAILABLE!
Any Time, Any Where
Membership (Scribe)
FEATURES
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www.aapc.com
May 2016
19
■ CODING/BILLING
By Linda R. Farrington, CPC, CPMA, CPC-I, CRC
With a little
encouragement, you can
rise to challenges and
become the “go-to” person.
I
f you answer yes to any of these questions, you need some professional encouragement:
• Do you sometimes think you will be where you are in your coding
career forever?
• Do you feel unheard or disregarded by your providers?
• Are you too intimidated to query your providers?
Encouragement can make something more appealing or more likely to happen, or it can make someone more determined, hopeful, or
confident. I want to encourage you.
Let’s explore the above questions and brainstorm solutions that will
make your work more appealing; help you to be more determined,
hopeful, and confident; and empower you to take action — all of
which will lead to greater satisfaction in your career.
Move Up the Ranks
Do you sometimes think you will remain where you are in your coding career forever?
It’s important to get up every morning excited about the challenges
ahead in your current role. If you feel stuck in your position, consider
whether you’re taking steps to change where you are.
20
Opportunity often comes knocking disguised as challenge. To see
if you are rising to career challenges presented to you, ask yourself:
• Am I learning new things every day as I search for solutions to
coding conundrums?
• Do I share what I learn with fellow coders and my providers?
• Am I positioning myself to be the coding expert in my office,
specialty, or coding group?
• Have I stepped up to serve as a local chapter officer?
Accomplishing one or more of these things could help move your career forward. Attitude can lead to altitude.
Arm Yourself with Knowledge and Speak Up
Do you feel unheard or disregarded by your providers?
You may lack confidence to speak up and engage your providers because you think you aren’t knowledgeable enough.
Knowledge is power. You can empower yourself as you discover answers to questions that you encounter each day. Research, study, gather information, and create an arsenal of conundrums paired with solutions found in source documents and references.
■ Coding/Billing
■ Auditing/Compliance ■ Practice Management
istock.com/RyanKing999
From Coder to Colleague
through Querying
Coder to Colleague
Query Providers
Are you too intimidated to query your providers?
Don’t be intimidated. When you run into a circumstance where you
cannot correctly code from the written documentation, you must
query. Practice “authoritative” query, which is to justify your query and educate the provider using the guidelines they are held to in
audit. It becomes an educational opportunity for the provider and
raises your standing in the provider’s eyes. Plus, you are giving the
provider something of value: You are helping to increase the likelihood of correct coding (that leads to proper payment) and possibly
preventing future queries regarding that issue.
The ICD-10-CM Official Guidelines for Coding and Reporting
instruct the coder to query the provider in certain circumstances.
These guidelines are not just recommendations; they are requirements acknowledged under federal law. Per the introduction of the
Official Guidelines, “Adherence to these guidelines when assigning
ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”
CODING/BILLING
Learn the CPT® rules and documentation guidelines well enough
to explain what quantifies a particular level of service to a provider.
Know the ICD-10-CM guidelines so well that you can identify an
error or omission, and know when and what to query.
When a provider uses the term “borderline” (section I.B.17):
• “Whenever the documentation is unclear regarding a
borderline condition, coders are encouraged to query for
clarification.”
When coding acute organ failure and sepsis and severe sepsis (sections I.C.1.d.1.a.iv and I.C.d.1.b):
• “If the documentation is not clear as to whether an acute
organ dysfunction is related to the sepsis or another medical
condition, query the provider.”
• “Due to the complex nature of severe sepsis, some cases may
require querying the provider prior to assignment of the
codes.”
When coding acute respiratory failure (section I.C.10.b.3):
• “If the documentation is not clear as to whether acute
respiratory failure and another condition are equally
responsible for occasioning the admission, query the provider
for clarification.”
When coding ventilator-associated pneumonia (section I.C.10.d.1):
• “If the documentation is unclear as to whether the patient
has a pneumonia that is a complication attributable to the
mechanical ventilator, query the provider.”
Note: This article focuses on ICD-10-CM coding queries. We’ll consider CPT® coding queries in
a future issue of Healthcare Business Monthly.
istock.com/monkeybusinessimages
Know When to Query
Choose what to query carefully and thoughtfully. If an official
guideline pertains, query. If it makes a difference to the portrayal of
medical necessity on the claim form, query. It could mean the difference between payment and denial.
Here are some examples of when the ICD-10-CM Official Guidelines for Coding and Reporting instruct coders to query:
When coding complications of care (section I.B.16):
• “Query the provider for clarification, if the complication is
not clearly documented.”
www.aapc.com
May 2016
21
To discuss this
article or topic, go to
www.aapc.com
Coder to Colleague
CODING/BILLING
Having a thorough understanding of the guidelines
and instructional notes will help you easily identify
errors and omissions, and know when to query.
When coding pressure ulcers (section I.C.12.a.5):
• “If the documentation is unclear as to whether the patient has
a current (new) pressure ulcer or if the patient is being treated
for a healing pressure ulcer, query the provider.”
When coding acute traumatic versus chronic or recurrent musculoskeletal conditions (section I.C.13.b):
• “If it is difficult to determine from the documentation in the
record which code is best to describe a condition, query the
provider.”
When coding complication of kidney transplant (sections
I.C.14.a.2 and I.C.19.g.3.b):
• “If the documentation is unclear as to whether the patient
has a complication of the transplant, query the provider.”
When coding conditions present on admission (Appendix I):
• “If at the time of code assignment the documentation
is unclear as to whether a condition was present on
admission or not, it is appropriate to query the provider for
clarification.”
• “Coders are encouraged to query the providers when the
documentation is unclear.”
You should also query when you see an error or omission in the provider’s assignment of ICD-10-CM codes into the assessment in the
electronic health record (EHR).
Error Example: The provider codes both the definitive diagnosis
and the associated signs and symptoms (section IV.D).
Error Example: An outpatient provider populates the code for a definitive diagnosis, yet in the freeform field, she types language such
as, “probable,” “suspected,” “rule out,” or lists differential diagnoses (e.g., this vs. this vs. this). A coder who understands the guideline (section IV.H.) is able to recognize the provider has coded incorrectly.
Omission Example: You see a code populated into the assessment
whose descriptor ends “in diseases classified elsewhere” without another code first. You know the provider missed the instruction to
“code first underlying disease,” or “code first underlying condition,”
or “code first underlying disorder” because the instruction is in the
Tabular List and many EHR systems are void of the guidelines and
instructional notes.
22
A thorough understanding of the guidelines and instructional notes
will help you identify errors and omissions and know when to query. Provide value with every query; the best way to do that is to copy
and paste the pertinent guideline(s) or instructional note(s) into
your query. This will educate your provider, which will reduce the
number of future errors and omissions.
Remember: Correct coding — coding that is both accurate and
complete (right code, right number of codes, and right order of
codes) — is intended, according to the ICD-10-CM Official
Guidelines for Coding and Reporting, to be a “joint effort between
the healthcare provider and the coder … to achieve complete and
accurate documentation, code assignment, and reporting of diagnoses …”
Consider Yourself a Colleague
Be excited about the coding challenges you encounter. See them as
opportunities to grow, learn, and shine. Have greater confidence in
your provider interactions knowing you are officially instructed to
query them and have the authority to do so. I hope I’ve encouraged
you to be more determined than ever to grow personally and professionally, and to have the confidence to take positive action to move
from coder to colleague.
Linda R. Farrington, CPC, CPMA, CPC-I, CRC, is an ICD-10-CM Trainer, senior provider
training and development consultant at Optum, and owner and instructor of Medisense
“Making Sense of Medical Coding” (www.medisensemedicalcoding.com). She has over 30
years’ experience in healthcare, specializing in cardiovascular thoracic surgery and risk adjustment. Farrington has written articles; presented audio conferences, workshops, and
trainings; and served on the AAPC National Advisory Board from 2007-2011. She has served in various leadership roles for the Phoenix, Ariz., and Colorado Springs, Colo., local chapters.
Resources
http://www.merriam-webster.com/dictionary/encouragement
www.cms.gov/outreach-and-education/medicare-learning-networkMLN/MLNedwebguide/emdoc.html
www.cdc.gov/nchs/icd/icd10cm.htm
www.cdc.gov/nchs/data/icd/10cmguidelines_2016_final.pdf
Zhealth
www.aapc.com
May 2016
23
■ CODING/BILLING
By John Verhovshek, MA, CPC
CATEGORY III CODES:
Use to Prompt Category I Codes
0381T External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in
heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure
events; includes report, scanning analysis with report, review and interpretation by a physician or
other qualified health care professional
0382T 0383T External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in
0384T 0385T C
review and interpretation only
External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in
0386T PT® Category III codes don’t capture a lot of attention, but they are
vital to proper coding. These codes generally do not have an established payment amount; per CPT® guidelines, however, if a Category III code is available, you must report it instead of a Category I unlisted procedure code.
Here’s a summary of significant Category III code changes for 2016.
istock.com/kasto80
Discover what new emerging technologies may
or may not be coded in 2016.
Leadless Pacemakers
There are five new codes to describe services related to permanent
leadless pacemakers:
0387T Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular
0388T Transcatheter removal of permanent leadless pacemaker, ventricular
0389T New Codes for Emerging Technologies
Programming device evaluation (in person) with iterative adjustment of the implantable device to
test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system
0390T Seizure Data Recording
Peri-procedural device evaluation (in person) and programming of device system parameters before
or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system
0391T Interrogation device evaluation (in person) with analysis, review and report, includes connection,
recording and disconnection per patient encounter, leadless pacemaker system
The Category III codes now include six codes to describe external
heart rate and 3-axis accelerometer data recording. Seizure frequency
is an important factor when treating epileptic seizures. Per the American Medical Association’s (AMA’s) CPT® Changes 2016: An Insider’s
Guide, “The epilepsy seizure monitor-system (0381T-0386T) is similar to the Holter monitor (93224) because of its continuous event recording and interpretation and reporting to a physician or other qualified health care professional. … [but] differ from the Holter monitoring code (92334) in that they capture the target data for epilepsy seizure detection, rather than electrocardiographic (ECG) data.”
The codes are broken down according to the number of days the recording takes place, as well as whether the service includes the report,
review, and interpretation; or review and interpretation only.
24
CPT® Changes 2016 advises, “Existing CPT codes only addressed
procedures for traditional pacemaker systems and did not adequately describe the procedure of implanting a leadless pacemaker. Therefore, these codes have been established to report leadless and pocketless system procedures.”
Esophageal Sphincter Augmentation
Esophageal sphincter augmentation is performed for treatment of
gastoesophageal reflux disease (GERD). The device employs magnets, placed around the gastroesophageal junction. The attraction of
opposing magnets narrows the opening, but allows food to pass when
the patient swallows.
■ Coding/Billing
To discuss this
www.aapc.com
Category III
Category III codes describe emerging technologies, and are
often an intermediate step in establishing a Category I code.
Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter
augmentation device (ie, magnetic band)
Deleted
Category III Code
Replacement Category I Code
0393T Removal of esophageal sphincter augmentation device
0099T
65785 Implantation of intrastromal corneal ring segments
0262T
33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed
0311T
93050 Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine
central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive
Myocardial Strain Imaging
CPT® Changes 2016 explains, “Myocardial strain imaging can be
used in the diagnosis and management of ischemic heart disease.
… For example, in patients undergoing chemotherapy and radiation treatments.”
+0399T Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based
analysis of local myocardial dynamics) (List separately in addition to code for primary procedure)
As an add-on code, 0399T may be applied with 93303, 93304,
93306, 93307, 93308, 93312, 93314, 93315, 93317, 93350, 93351,
and 93355.
Multi-spectral Digital Skin Lesion Analysis (MSDSLA)
MSDSLA is an imaging and analysis procedure for lesions that
may be high-risk for melanoma, and typically are performed on the
same day as an evaluation and management (E/M) service. If biopsy is required following MSDLA, you may report the biopsy codes
on the same day.
0400T Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for
detection of melanomas and high risk melanocytic atypia; one to five lesions
0401T six or more lesions
Placement of Ethmoid Sinus Drug Eluting Implant
Two Category III codes were introduced in CPT® 2016 to describe
endoscopic ethmoid sinus surgery to implant a stent that delivers a
drug (typically, a steroid) to keep the ethmoid sinus patent (open)
after surgery, either with or without biopsy, polypectomy, or debridement.
CPT® tells us not to report 0406T Nasal endoscopy, surgical, ethmoid
sinus, placement of drug eluting implant; or 0407T Nasal endoscopy,
surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement with 31200, 31201, 31205, 31231,
31237, 31240, 31254, 31255, 31288, or 31290 when performed on
the same side.
Moving Up to Category I
CODING/BILLING
0392T Category III code 0182T is deleted and replaced by two new Category III codes:
0394T High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed
0395T High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed
For 0395T, report one unit per fraction, regardless of whether basic
dosimetry is performed.
Codes that Didn’t Make the Cut
If a Category III code is not replaced by a Category I code (or otherwise revised) within five years, the Category III code “sunsets” (i.e.,
is archived), “unless it is demonstrated that a temporary code is still
needed.” For 2016, a number of Category III codes have been sunset
without establishing a Category I code equivalent. To report these
procedures, turn to a Category I unlisted procedure code.
Deleted
Category III Code
Category I Unlisted Equivalent
0103T
0123T
0223T , 0224T, 0225T
0233T
0240T , 0241T
0243T , 0244T
84999 Unlisted chemistry procedure
66999 Unlisted procedure, anterior segment of eye
93799 Unlisted cardiovascular service or procedure
88749 Unlisted in vivo (eg, transcutaneous) laboratory service
91299 Unlisted diagnostic gastroenterology procedure
94799 Unlisted pulmonary service or procedure
John Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Hendersonville-Asheville,
N.C., local chapter.
Category III codes describe emerging technologies, and are often an
intermediate step in establishing a Category I code. A few Category
III codes deleted for 2016 were replaced by new, Category I codes.
www.aapc.com
May 2016
25
■ ADDED EDGE
By LeAndrea Abercrombie, CPC, NR-CMA
Maximize Your
RESOURCES
A
istock.com/eenevski
Line up and use coding
resources for the most
efficient and successful
outcomes in the workplace.
fter landing a position with a prestigious (and busy) orthopedic
and sports medicine office, my skills were put to the test. In those
first few weeks, no two days or two patients were alike, the course of
treatment varied widely, and the physicians tailored treatment plans
for each of their patients. I learned quickly to use my resources to understand examinations, medications, and procedures.
3. Reputable websites
Planning
Commit to attending one webinar each quarter. This practice will
serve to sharpen your coding skills, help you develop a deeper understanding of various topics, and keep you abreast in the ever-changing
world of healthcare.
Bonus: Choose a webinar that allows you to get ahead on your continuing education units.
Learning how to use resources to answer tough coding questions
should be planned out well before you need an answer. Every successful coder has several resources lined up to address new, unfamiliar,
and difficult coding conundrums.
What Are Your Lifelines?
When you have coding questions, what materials do you reach for?
You should have a system in place to get your questions answered
quickly. Here are a few ideas:
1. Newsletters and publications
Consult with your office or hospital administrator to select coding
newsletters and publications that relate to your specialty. Most administrators are open to providing publications that address the facilities’ needs and specialties. Set aside at least one hour per week to
read and stay up to date on current topics in coding, billing, auditing,
compliance, and practice management.
2. Build a relationship with other coders
Having a few coders in your contact list never hurts. Trading information and experiences can be key in solving specific coding issues.
Local AAPC chapters offer mentors who can be essential, in a pinch.
Building relationships with other coders in your facility or practice is
important, too; it encourages comradery, as well as insight.
26
Keeping a list of reliable sites will help you sift through and bypass unreliable search engines that pull up incorrect, non-credible, and outdated coding information.
4. Webinars
5. Well-marked books
Get familiar with your ICD-10, CPT®, reference books, and other
materials. If there’s a section you visit frequently, tab, fold, highlight,
or mark it so it’s easy to find the next time. This will reduce the time
you spend thumbing through these tomes for answers.
Empower Yourself
Resources are abundant, but when you need that coding question answered quickly, spending precious minutes seeking answers can be
frustrating. Having a well-mapped strategy for finding answers will
empower you to be swift, accurate, and self-sufficient at successfully
resolving most coding questions.
LeAndrea Abercrombie, CPC, NR-CMA, is a coder at Carondelet Orthopaedic Surgeons and
Sports Medicine in Overland Park, Kan. She was a certified medical assistant for more than 13
years before gaining her CPC®. She is a new member of the Kansas City, Mo., local chapter.
Quick Tip
By Jill M. Young, CPC, CEDC, CIMC
th
ICD-10 (S00-T88):
Key Terms Lead to Proper
Character
istock.com/BakiBG
Know if you’re
coding initial
(active) vs.
subsequent
(routine) care.
T
he question of whether to use an A (initial encounter) or a D (subsequent encounter) as a seventh character for ICD-10-CM codes in
Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes remains a thorny one.
To put things into perspective, consider this: When 20 physicians
were asked, “When does acute pain become chronic pain?” the answers ranged from two months to 12 months.
The correct answer is: When the physician writes the words “chronic
pain” in the patient record.
As coders, our job is to code from the documentation, and it’s the physician’s job to document the patient’s diagnosis and status. You can assist providers by showing them the nuances of coding — for instance,
if the patient has a concussion, the provider must document if there
was a loss of consciousness and for how long.
This is an example of the “joint effort between a health care provider
and the coder” of which the ICD-10-CM guidelines speak.
Just as there were differing answers for when pain becomes chronic,
answers may vary among physicians about when active treatment be-
comes routine. When does active treatment become routine? When
the provider documents it as such.
Note that in 2015 the ICD-10-CM guidelines changed significantly
relative to the A character. Previously, any new physician visit was indicated to be an A. Now, the guidelines indicate that if the patient is
in the “routine” healing status, even if the patient is “new” to the provider, the appropriate seventh digit is D.
I was told many years ago: “If the physician documents what was
done, and you code what was documented and bill what was coded,
you can’t go wrong.”
Jill Young, CPC, CEDC, CIMC, has more than 30 years of medical experience working in all areas of the medical practice, including clinical, billing, and rounding with physicians. Her expertise is used in several publications and heard on a variety of audio conferences. She speaks at educational lectures for the Michigan State Medical Society and other national organizations, including The Coding Institute and Eli Research. Young has been a workshop presenter for AAPC
and a topic speaker at AAPC National Conference. She has held office for the Lansing, Mich., local chapter and has
served on the AAPC Chapter Association board of directors.
www.aapc.com
May 2016
27
■ CODING/BILLING
By David Zielske, MD, CIRCC, CCVTC, COC, CCC, CCS, RCC
CPT® 2016:
Neuro-interventional Coding
head and neck region, and the spine. Highly trained subspecialty
physicians — who focus on transcatheter techniques to diagnose
and treat pathology in these complex locations — perform the
procedures. Abnormalities treated include aneurysms, arterial-venous
malformations (AVMs), vasospasm, stroke, stenoses, and tumors.
Aneurysm
An aneurysm is an outpouching or widening of an otherwise normal
vessel due to either weakness of, or trauma to, the vessel wall. This
may result in vessel rupture with subsequent stroke or death related
to the affected region of the brain.
Intracranial aneurysm treatment has transitioned from open surgery via craniotomy to percutaneous embolization via transcatheter
technique. Intracranial aneurysms may occur at the bifurcation of a
vessel (berry aneurysm), or may be diffusely enlarged (dolichoectasia), wide-mouthed, or “giant” in nature. Percutaneous treatment for
these aneurysms consists of occluding the aneurysm with specialized
coils, sometimes requiring stent-like scaffolding, balloon assistance,
or vessel sacrifice. AVMs are treated with liquid embolic agents (e.g.,
Oynx®) and/or particle embolization, and often require multiple sessions to shrink the AVM to a size that can be treated with definitive
gamma knife therapy. Dural fistulas and cavernous carotid (CC) fistulas may be embolized with coils or flow-diverters for curative intervention while embolization of a tumor is performed to decrease
the arterial blood flow to the tumor, making surgical resection safer.
Cerebral Embolization
F
or 2016, the biggest CPT® coding changes affecting interventional radiology occur within the subspecialties of urinary, biliary, and
neurologic intervention. In March, we covered urinary intervention
and in April we covered percutaneous biliary interventional coding.
This month, we’ll finish our series by focusing on transcatheter neuro-interventions and describing three new codes for 2016.
Neuro-interventional procedures are focused on the percutaneous
treatment of the central nervous system (brain and spinal cord), the
28
Embolizations of the central nervous system (CNS), which includes
the brain and spinal cord, is reported with 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 supervision
and interpretation (S&I) code 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation. These
codes describe coil embolization of a well-defined berry aneurysm or
a wide-mouthed aneurysm requiring balloon assistance, and placement of a scaffolding stent (e.g., Neuroform™, Enterprise™, LVIS®, or
LVIS® Jr.) or a flow diverter (e.g., Pipeline™ Flex, FRED™). After deployment of a coil, embolic material, a flow diverter, or glue, it is often
necessary to determine the results of the embolization using followup angiography (75898 Angiography through existing catheter for fol■ Coding/Billing
istock.com/SKapl
Part 3: Understand the changes affecting neuro-interventional procedures.
Neuro-interventional Radiology
low-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis).
Report 75898 for each fully documented follow-up imaging performed during and at the conclusion of a CNS embolization procedure. This code may be submitted more than once per patient encounter for CNS embolizations, with the exception of head and neck
(non-CNS) embolizations, which are limited to once per session.
Catheter placements or diagnostic imaging (which bundles catheter
placements) are separately reported with embolization procedures.
Example: A patient with known left middle cerebral artery (MCA)
bifurcation aneurysm presents for embolization. Via a right femoral
access, a sheath is placed and a guiding catheter is advanced into the
left common carotid artery, followed by placement of a microcatheter into the MCA (36217 Selective catheter placement, arterial system;
initial third order or more selective thoracic or brachiocephalic branch,
within a vascular family). Guiding angiography delineates the dimensions of the aneurysm. The aneurysm is selected, and a framing coil is
placed with follow-up imaging, showing good positioning of the coil
without vasospasm or distal vessel embolization (75898). Two more
coils are placed to complete embolization (61624, 75894). Completion angiography (75898-59 Distinct procedural service) confirms
complete occlusion of the aneurysm without complication.
Spinal Embolization
Percutaneous transcatheter spinal cord interventions (also CNS) are
used primarily to diagnose and treat spinal AVMs. Spinal angiography may be initially performed, followed by embolization. Both are
reported at the same session when the imaging is diagnostic in nature. The embolization codes remain 61624 and 75894. The spinal
cord is considered to be one surgical site, and is coded as one embolization procedure, even if multiple vessels are embolized.
Other Embolization
Treatment of an AVM, arteriovenous fistula, carotid-cavernous (CC)
fistula, or tumor in the CNS is reported with the same embolization
codes as an aneurysm treatment (61624, 75894). Code 61624 is an
inpatient-only procedure (C-status indicator) for Medicare patients.
When similar procedures for similar pathologies are performed
in the head and neck region (non-CNS), report 61626 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to
CODING/BILLING
By CPT® definition, there are three cerebral
territories: the right cerebral hemisphere, the left
cerebral hemisphere, and the posterior fossa territory.
achieve hemostasis, to occlude a vascular malformation), percutaneous,
Renal
any method; non-central arteries
nervous system, head or
neck (extracranial, brachiocephalic branch) and
75894. These proceAbdominal
aortic aneurysm
Stent
dures are not necessarily inpatient procedures
(not C-status indicaCommon
tor), and are routinely
iliac arteries
performed in outpatient
settings. Another comIllustration copyright 2015 of Optum 360
monly performed head
and neck embolization
is treatment for epistaxis (nose bleed).
Example: The patient is a 14-year-old male with uncontrolled epistaxis. Via femoral access, a catheter is placed into the arch with
imaging. Both common carotid arteries are selected and cervical
carotid imaging is performed (36222-50 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 ‒
Bilateral procedure). No fibromuscular dysplasia is seen. The right
external carotid artery, internal maxillary artery, and sphenopalatine arteries are progressively selected and imaged (+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)), showing hypervascularity off the sphenopalatine, with no evidence of extracranial/intracranial communication. Embolization is performed with embospheres until stasis of flow (61626, 75894). The catheter is pulled
back to the common carotid for completion angiography (75898),
showing successful distal embolization without complication.
The left side is selected, imaged, and embolized in a similar fashion. Final imaging on the left similarly shows no complication (no
additional embolization code is used because the “nose” is one surgical site, and 75898 may be reported only once with non-CNS
embolization procedures).
www.aapc.com
May 2016
29
CODING/BILLING
If two cerebral territories are
treated, 61645 is reported twice.
Cerebral Infusion Therapy
After aneurysm repair (for rupture), blood may spill into the subarachnoid space, settling on the cerebral vessels, causing irritation
and spasm of the vessels around the repaired vessel. This is called
vasospasm, and can be quite severe and may result in complete occlusion of the vessel (and resultant stroke) if not quickly treated. Because the onset of vasospasm symptoms may be rapid, emergent angiography and trans catheter treatment is usually necessary. This
vasospasm therapy includes catheter placements, imaging, infusions of medications, and follow-up imaging.
It may be necessary to repeat the infusion treatment multiple times
during the week following original repair of the aneurysm. Some
commonly infused drugs to treat vasospasm include verapamil, papaverine, milrinone, and nimodipine. The injection of a drug is not
separately reported.
NEW! Two codes were implemented in CPT® 2016 to describe initial and additional cerebral vessel infusion therapy, which includes
infusions for cerebral vasospasm treatment and infusion of chemotherapy for brain tumors):
61650 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for
thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory
+61651
each additional vascular territory (List separately in addition to code for primary procedure)
Code 61650 describes the initial cerebral territory treated, and
+61651 describes each additional cerebral territory treated. By
CPT® definition, there are three cerebral territories: the right cerebral hemisphere, the left cerebral hemisphere, and the posterior
fossa territory. These are supplied by the internal carotid and vertebral arteries.
To justify use of codes 61650 and +61651, the infusion therapy must
total at least 10 minutes (continuous or intermittent). Codes 61650
and +61651 cannot be submitted for treatment of “iatrogenic” vasospasm, which sometimes occurs after carotid stent or embolization procedures. Vasospasm treatment may require use of a specialized balloon to dilate a vasospastic vessel. Codes 61640-61642 describe this type of balloon dilation; however, when associated with
and performed at the same session as the infusion therapy, the balloon dilation codes are bundled into the same territory.
Example: The patient is 31 years old; two days superiorly project30
ing, anterior communicating artery aneurysm embolization for subarachnoid hemorrhage, now with decreased mental status. Patient
is brought emergently to the angiography suite. Via femoral access,
right and left internal carotid selection with cerebral angiography
is performed along with selective left vertebral angiography. This
shows diffuse vasospasm of the vertebrobasilar system and both cerebral territories. A 15-minute verapamil infusion was performed
in the right internal carotid artery, followed by the same procedure
in the left internal carotid and right vertebral. Follow-up imaging
shows improved perfusion diffusely (61650, +61651, +61651).
Note: All catheter placements, imaging, and infusion therapy are bundled in these new codes
for 2016.
Cerebral Stroke Therapy
Non-hemorrhagic stroke may require immediate intervention by a
neuro-interventionalist to prevent permanent disability. Treatment
includes catheterization and imaging of the affected regions of the
brain, any method, to remove identified thrombus (including infusion thrombolysis and thrombectomy techniques), and treatment
of any associated intracranial stenosis/occlusion with angioplasty
(61630 Balloon angioplasty, intracranial (eg, atherosclerotic stenosis),
percutaneous) or stent placement (61635 Transcatheter placement of
intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed).
NEW! CPT® 2016 includes:
61645 Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter
placement, and intraprocedural pharmacological thrombolytic injection(s)
Code 61645 includes all the above procedures (when done) performed on one cerebral territory for diagnosis and treatment of a
stroke. If two cerebral territories are treated, report 61645 twice.
Stroke and vasospasm may occur at the same session; however, coding guidelines allow you to report only one of the two procedure
codes at a single session, with 61645 preferentially-billed over 61650.
NEW! CPT® codes 61645, 61650, and +61651 are inpatient-only
procedural codes for Medicare patients, and are all-inclusive of imaging, catheter placements, angioplasty, and/or stent placement.
Example: A 45-year-old male with patent foramen ovale presents
with left hemispheric stroke. He is emergently taken for comput-
To discuss this
www.aapc.com
ed tomography scan of the brain (no hemorrhage identified), and
then to the angiography suite. Via a femoral access, selective left carotid angiography is performed of the neck and head, demonstrating occlusion and thrombus in the left MCA distribution. This involves M1, superior and inferior M2 segments. Initial infusion of
tissue plasminogen activator (TPA) is performed, followed by placement of a stent retriever device for thrombus extraction. Follow-up
angiography shows residual thrombus in the superior M2 segment.
Further infusion of TPA over 10 minutes is performed after balloon
maceration of thrombus. Angiography shows clearing of thrombus
with some iatrogenic vasospasm in the high internal carotid artery.
This is treated with 5 mg infusion of verapamil over 10 minutes. Vasospasm resolved, and excellent perfusion to the MCA distribution
is demonstrated (61645).
Note: All catheter selections, imaging, infusion therapy, balloon maceration, clot extraction,
and follow-up imaging are bundled with 61645. Vasospasm infusion therapy for iatrogenic
vasospasm is not reported with a CPT® code.
Cerebral Venous Therapy
Venous intervention of the cerebral system may involve patients with
venous thrombosis, which may be treated with venous thrombectomy (37187 Percutaneous transluminal mechanical thrombectomy,
vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, 37188 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy), venous
infusion thrombolytic therapy (37212-37214), and venous approach
to treatment of dural or CC fistulas. The above-listed thrombolysis
and thrombectomy codes may be performed in the outpatient setting
for Medicare recipients; while venous cerebral embolization requires
inpatient status. Venous embolization procedures of the CNS are
described by the same CPT® codes as arterial embolization (61624,
75894); however, the treatment of venous thrombus is described by
the peripheral codes because 61645 reports only treatment of arterial cerebral thrombus/embolus.
Example: Patient is a 2-year-old with dehydration and superior sagittal sinus thrombosis. Via femoral venous access, a catheter is advanced into the right jugular vein with imaging (36012 Selective catheter placement, venous system; second order, or more selective, branch (eg,
CODING/BILLING
istock.com/Svisio
Angiography shows clearing of thrombus with some
iatrogenic vasospasm in the high internal carotid artery.
left adrenal vein, petrosal sinus), 75860 Venography, venous sinus (eg, petrosal and inferior sagittal) or jugular, catheter, radiological supervision
and interpretation), then advanced into the superior sagittal sinus with
imaging (75870 Venography, superior sagittal sinus, radiological supervision and interpretation). A thrombectomy catheter is used to remove
some thrombus (37187), followed by placement of an infusion catheter. Infusion of TPA is initiated (37212 Transcatheter therapy, venous
infusion for thrombolysis, any method, including radiological supervision
and interpretation, initial treatment day) at 1 mg/hr. Patient is sent to
intensive care unit for monitoring.
Note: This is a venous intervention. Do not use 61645 for cerebral “venous” therapy. Thrombolysis and thrombectomy of a venous structure is a “day of service” procedure and cover work
related to these procedures from midnight to 11:59 pm.
Simplifying Complex Procedures
Neuro-interventional coding requires an understanding of the following:
• Arterial and venous anatomy of these complex regions;
• Catheter selectivity codes; and
• Diagnostic imaging codes (along with the bundling issues
associated with these imaging procedure codes).
With knowledge of these prerequisites, the 2016 addition of comprehensive codes for treatment vasospasm and stroke related to
thrombosis/embolism will simplify coding for some of the most
complex procedures performed in the CNS.
David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC, or Dr. Z, is the founder and CEO of
ZHealth, LLC, and ZHealth Publishing, LLC. He practiced as an interventional radiologist for 15
years and has 16 years of experience as a coding reviewer and educator. Dr. Z is Board Certified
in Radiology with the Certification of Added Qualification (CAQ) in Interventional Radiology
(ABR) (1995, 2005). He was on the AAPC National Advisory Board from 2005-2009, and is a
member of the Nashville, Tenn., local chapter.
www.aapc.com
May 2016
31
■ CODING/BILLING
By Michael Strong, MSHCA, MBA, CPC, CEMC
Workers’ Compensation:
Limited Liability for Healthcare Services
compensation creates a new claim number. Consequently, the
insurance identification number for an injured worker changes with each new injury claim. This means the medical services need to be related to that injury for coverage.
Obtain from the patient a clear and comprehensive description
of the injury and associated complaints. The lack of a comprehensive and well-documented history and injury description
is a catalyst for conflict. If the injury and associated signs and
symptoms are not documented or clearly related, the insurers
may deny the charges due to a lack of clear evidence the treatment or services are work-related.
Ask the patient if the injury is work-related, or if it occurred
while on the job. The CMS-1500 form allows the biller to report this in box 10a. The UB-04 allows the biller to report this
as an occurrence code. Additionally, billers may use external
cause of injury diagnosis codes.
W
hen we think of health insurance, we typically think of government programs (e.g., Medicare, Medicaid, TRICARE®), major
medical, and private pay. But there are patients with non-traditional insurance, such as auto and — the subject of this article — workers’ compensation.
Limited Liability
Workers’ compensation insurance carriers have limited liability. In
other words, they are responsible only for the work-related injury and
treatment directly related to that injury.
For example, an employee with arthritis, heart disease, diabetes, and
epilepsy gets injured at work. While carrying some boxes, the employee has a seizure and falls backward, also dropping boxes on his right
foot. The employee comes out of the seizure, complaining of lower
back pain and severe pain in his right foot. The workers’ compensation carrier is notified, and a first report of injury (FROI) is filed with
the state. In this case, the workers’ compensation carrier is liable for
the injury to the foot and the low back, only. Treatment or testing related to the seizure, heart, diabetes, etc. would be denied as unrelated.
Documentation Must Establish Liability
Unlike traditional insurance, where an individual has a unique identification number assigned by the health plan, each injury in workers’
32
Verify Patient Information
When working with the insurance on determining reimbursement
and obtaining the address to send medical bills, verify the following information with the carrier early in the treatment of the patient:
• Date of injury
• Covered/Compensable injury and body parts
• Any coverage limitations
Provide also the insurance and patient with a clear and comprehensive treatment plan, which may include:
• Report of workability
• Healthcare provider report
• Work restrictions
• Impairment rating (if applicable)
• Maximum medical improvement
• Medical necessity and coverage limitations
Open Communication and Transparency Is Key
When dealing with workers’ compensation patients, providers often
must submit medical records with all bills for verification. Payment
may be delayed or denied as bills may be scrutinized for compensa■ Coding/Billing
istock.com/Izabela Habur
Providers, payers, coders, employers, and carriers must
communicate effectively to get the claim paid.
To discuss this
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Treatment Guidelines and Payment Vary by State
Workers’ compensation laws vary by state. There is a federal workers’ compensation division for federal employees through the U.S.
Department of Labor Office of Workers’ Compensation Programs.
In many states, appropriate care is determined through treatment
guidelines set forth by the state.
The Workers Compensation Research Institute (WCRI) has compiled a list of states with treatment guidelines in January 2015. Although the list may change, it provides a starting point for providers to determine if treatment guidelines exist for the injury or recommended care. Treatment guidelines often exist for the cervical
spine, thoracic spine, lumbar spine, upper extremities, lower extremities, carpal tunnel, pain management, and/or controlled substances. Where guidelines exist, they are implemented by the state
in which the patient resides.
Treatment guidelines are just one form of cost containment. Other
forms of cost containment include fee schedules, bill reviews, limited provider changes, utilization review, and managed care.
Understand Payment
Most states have some form of fee schedule for professional healthcare charges. Facility payments are more likely to vary. Some states
have a facility fee schedule for hospital inpatient, hospital outpatient, and/or ambulatory surgery centers. When fee schedules do
not exist, reimbursement may be determined through negotiations,
provider contracts, a percentage of the provider’s usual and customary method, or another method.
To complicate matters further, some states may have more than 200
workers’ compensation insurance carriers, as well as many thirdparty administrators for self-insured employers. As a result, each
carrier and administrator may review medical bills and claims differently. For example, some carriers may not review the bills for
coding or billing practices. Some may not apply all of the payment
limitations that exist. This often increases the administrative costs
throughout the system. Providers need to keep track of more payers
for prompt payment.
Providers may also see different reimbursement for the same services by different payers because of the payer review process. Reach out
to the payer to understand their payment. Payers may simply need
documentation or clarification, or it’s possible that the payer denied
the service(s) for relatedness, insufficient documentation, incorrect
coding, or other factors.
ICD-10 and Workers’ Compensation
Not all states are requiring the adoption of ICD-10 for workers’
compensation. Some states have created their own unique codes for
workers’ compensation, such as Colorado. HIPAA, in part or its entirety, may not apply to workers’ compensation. Understanding the
state rules for reimbursement and treatment guidelines will reduce
questions on payment reductions and increase understanding of the
explanation of benefits (EOBs) or explanation of reviews (EORs).
CODING/BILLING
bility and relatedness. The review also may include coding and/or
medical necessity. With this scrutiny, adversarial relationships may
develop. Transparency and open communication are crucial to reduce these challenges. Providers and billers should establish a relationship with the claims adjustor for the insurance carrier.
Workers’ Comp
Unrelated Services May Be Billed to Other Insurers
Services not related to a workers’ compensation claim may be the
liability of another payer. Consequently, providers may be able to
bill the patient’s primary medical insurance carrier or another appropriate carrier if the services are deemed not related to the workers’ compensation claim.
Takeaways
When treating individuals for a workers’ compensation injury; providers, payers, coders, employers, and employees should remember
the following:
• Be sure communication is open and transparent.
• Read the EOB/EOR.
• Always request explanations for denials or reduction of payment.
• Services unrelated to the workers’ compensation claim are
not the liability of the workers’ compensation payer and may
be the liability of another carrier.
• Treatment guidelines may exist.
• Proper documentation and coding will increase payment
accuracy.
• Balancing costs, including administrative costs, improves
the system.
It’s in everybody’s best interest to contain claim costs for medical
and indemnity charges and return an employee to work quickly.
Communication should be open to determine what coverage and
care is needed to return the employee back to baseline function.
Michael Strong, MSHCA, MBA, CPC, CEMC, is the bill review technical specialist at SFM
Mutual Insurance Company. He is a former senior fraud investigator with years of experience
performing investigations into fraud and abuse. Strong also is a former EMT-B and college
professor of health law and communications. He is a member of the St. Paul, Minn., local
chapter, and can be contacted at [email protected].
Resources
WCRI: www.wcrinet.org/studies/public/books/wcri305.pdf
www.aapc.com
May 2016
33
Membership (CDI)
CING
N
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ANN
AAPC’s First
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CDEO
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Advancing the Business of Healthcare
800-626-2633
CODING/BILLING ■
By Stacie L. Buck, RHIA, CIRCC, CCS-P, RCC
The Latest on Dialysis
Access Maintenance Reporting
Understanding the procedures and patient scenarios will
help you code this evolving specialty.
D
ialysis access maintenance is one area of interventional
radiology coding that always seems to be evolving. This
can make it difficult to code these encounters. To be sure
you are current with the latest changes, here is a refresher
on how to report angioplasty, stent placement, thrombectomy, and embolization of hemodialysis arteriovenous grafts
(AVG) and arteriovenous fistulae (AVF).
Hemodialysis Access
AVGs and AVFs are types of hemodialysis access. An AVF
is a direct connection between an artery and a vein; and an
AVG is an indirect connection between the artery and vein.
An AVG may consist of a plastic tube, or it may be made of
cadaver arteries or veins. Often, grafts and fistulas develop
occlusions (blockages) that require therapeutic intervention
such as angioplasty, thrombectomy, stent placement, or embolization to restore proper flow within the graft.
When coding such services, AV dialysis shunts are considered one vessel. The AV shunt begins with the arterial anastomosis and extends to the right atrium. This definition includes both upper and lower extremity AVF/AVG (CPT®
Professional Edition, 2016).
Fistulagrams
A physician most often gains access into the AVF/AVG
by direct puncture; however, occassionally the physician
chooses to access the AVF/AVG via the brachial artery or
other point of access. After gaining access, the physician
places the catheter at the desired position and injects contrast material to visualize the occlusion. This is called a fistulagram.
Dialysis Access Catheterization and Fistulagram Codes
istock.com/Dario Lo Presti
36147 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis
(graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of
shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)
■ Coding/Billing
www.aapc.com
May 2016
35
Dialysis Access Maintenance
CODING/BILLING
Note that angioplasty is bundled with stent placement
codes 37236-37239 when performed in the same vessel, so
the stent codes take precedence over the angioplasty codes.
+36148 additional access for therapeutic intervention
75791
Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injection of all
contrast and all necessary imaging from the arterial anastomosis and adjacent artery through
the entire venous outflow including the inferior and superior vena cava), radiological supervision and interpretation
CPT® 36147 describes a direct puncture into the AVG/AVF followed by injection of contrast for evaluation of the hemodialysis access. This code not only includes imaging of the AVG/AVF, but also
the venous outflow all the way to the superior and inferior vena cava.
Do not assign 75825 Venography, caval, inferior, with serialography,
radiological supervision and interpretation and 75827 Venography,
caval, superior, with serialography, radiological supervision and interpretation when only the hemodialysis access is evaluated.
Following imaging, the physician may elect to perform a therapeutic intervention through the existing access, used to perform the fistulagram, or a new access. Assign 36147 one time per encounter, regardless of the number of fistulagrams performed with or without
performance of a therapeutic intervention.
If the therapeutic intervention is performed through a second direct
puncture into the hemodialysis access, assign +36148 in addition to
36147. Report +36148 only when a therapeutic intervention is performed via the second access. If the second access is used only for
additional imaging do not report +36148. You may report +36148
more than once if an additional access is required for a therapeutic
intervention, but these cases are rare.
Report 75791 when the physician performs a fistulagram through
a different means of access (other than direct puncture of the hemodialysis access), such as via an existing access or by an initial access
in a lower extremity or upper extremity artery. Like 36147, 75791
includes imaging of the AVG/AVF and also the venous outflow all
the way to the superior and inferior vena cava. In addition to 75791,
report any applicable catheterization code(s).
1. AVG/AVF: includes the area from the peri-arterial anastomosis
all the way through the axillary vein or the entire cephalic vein in
the case of a cephalic venous outflow.
2. Central segment: consists of the subclavian, innominate, and
the vena cava. These three vessels make up their own vessel or
“zone” when coding.
When procedures are performed outside of the graft in the separate,
central segment, you may assign additional codes for the intervention performed in the central segment. Regardless of the number of
lesions treated in each zone, you may report each therapeutic intervention only one time, per zone.
Angioplasty
Percutaneous transluminal angioplasty (PTA) eliminates areas of
narrowing or occlusion in AV dialysis shunts. During a PTA, a balloon catheter is inserted through the skin into a vessel to the site of
narrowing, and the balloon is inflated to restore flow to the vessel.
Dialysis Access Angioplasty Codes 35475
Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel
75962
Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery,
iliac or lower extremity, radiological supervision and interpretation
35476
Transluminal balloon angioplasty, percutaneous; venous
75978
Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision
and interpretation
Angioplasty is reported only one time, regardless of the number of
lesions treated in a vessel. The Society of Interventional Radiology
(SIR) has stated that all angioplasty performed within the hemodialy-
General Rules for Therapeutic Interventions
Although AV dialysis shunts are considered one vessel for coding
purposes, with the AV shunt beginning with the arterial anastomosis and extending to the right atrium for fistulagrams, when coding
therapeutic interventions in AV shunts, this area is divided into two
vessel segments. The two designated treatment zones are:
Illustration
copyright 2015
Optum 360
36
Cephalic vein
Radial artery
To discuss this
www.aapc.com
sis access vessel is coded as a single angioplasty, regardless of the number of stenoses treated within the segment (from the level of the inflow
artery, through the length of the graft to the venous outflow to the
level of the axillary vein). This same logic applies to stent placement.
The AV dialysis shunt is considered to be a venous vessel and, therefore, most of these interventions are coded with the venous intervention codes. Report 35476 and 75978 once to describe all angioplasty within the AV dialysis shunt, regardless of the number of lesions treated within the segment or the number of balloon inflations. There are some exceptions to this rule:
• Angioplasty is performed of the arterial anastomosis only:
Report 35475 and 75962 instead of 35476 and 75978
because this is considered an arterial angioplasty.
CODING/BILLING
Angioplasty should only be reported
additionally when an underlying stenosis is
treated in addition to a thrombotic occlusion.
• Angioplasty is performed in both the arterial anastomosis
and the venous anastomosis or within the graft: Assign
35475 and 75962 over the venous angioplasty codes, in
accordance with National Correct Coding Initiative (NCCI)
edits.
• When the AVG/AVF is present in the lower extremities,
assign 37224 or 37220 for angioplasty at the arterial
anastomosis, depending on the exact location, instead of
35475 and 75962, which are assigned for upper extremity
angioplasty.
You may assign codes when angioplasty is performed in the central
veins (subclavian/innominate/vena cava) or within a native artery.
In addition to the codes used to describe the angioplasty of the graft,
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CODING/BILLING
Note that angioplasty is bundled with stent placement
codes 37236-37239 when performed in the same vessel, so
the stent codes take precedence over the angioplasty codes.
report either 35476/75978 or 35475/75962, depending on the location of the angioplasty. If one or more central venous stenoses are
treated with angioplasty, report a single venous angioplasty, regardless of the number of lesions treated within the segment because the
central veins are considered their own treatment “zone.”
Stent Placement
Dialysis Access Stent Codes 37236
Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or
coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery
+37237 each additional artery
37238
Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when
performed; initial vein
CPT® instructs to use 37239 with 37238 (not 37236). If you assign
37238 for the graft stent placement, assign +37239 for the central
segment stenting.
Note that angioplasty is bundled with stent placement codes 3723637239 when performed in the same vessel; therefore, the stent codes
take precedence over the angioplasty codes. For example, when an
angioplasty is performed at the arterial anastomosis and a stent is
placed with the hemodialysis access vessel, assign 37238, with the
arterial angioplasty bundled.
Thrombectomy
Dialysis Access Thrombectomy Codes 36870
Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis)
+37239 each additional vein
Report stent placement only one time, regardless of the number of
stents placed within the hemodialysis access vessel; the AV shunt is
considered to be a venous vessel when selecting the stent placement
code. Code 37238 describes a venous stent placement, and is reported once to describe all stents placed in the hemodialysis access segment, regardless of number of lesions treated within the segment.
There are some exceptions to this rule:
• A stent is placed at the arterial anastomosis only: Report
37236 instead of 37238 because this is considered an arterial
stent placement.
• A stent is placed at both the arterial anastomosis and the
venous anastomosis or within the graft: Report 37236 over
the venous stent code.
• When the AVG/AVF is present in the lower extremities:
Report 37226 or 37221 for stent placement at the arterial
anastomosis depending upon the exact location, instead of
37236.
You may report stent placement in the central veins (subclavian/
innominate/vena cava) in addition to stent placement in the graft.
The correct code for stent placement in the central zone will depend
on the code reported for the stent placed in the hemodialysis access
vessel. If you assign 37236 for the graft stent placement, you should
assign 37238 for the central segment stent (not 37239) because
38
Radial
artery
Arteriovenous
fistula graft
(for dialysis)
Vein
The thrombus is
removed from
the graft
Illustration
copyright 2015
Optum 360
A thrombus (clot) is removed percutaneously
from an autogenous or nonautogenous
arteriovenous fistula
To discuss this
www.aapc.com
CODING/BILLING
Angioplasty should only be reported
additionally when an underlying stenosis is
treated in addition to a thrombotic occlusion.
Coding Examples
Access is gained via direct puncture into the AVG. A
fistulagram is performed. A second puncture is made at
the opposite end of the AVG for therapeutic intervention.
Angioplasty is performed at the venous anastomosis and
the arterial anastomosis.
Codes: 36147, +36148, 35475, 75962
Access is gained via direct puncture into the AVG. A fistulagram is performed. An angioplasty is performed of the AVG,
followed by angioplasty of the subclavian vein.
Codes: 36147, 35476, 75978, 35476-59, 75978-59
Access is gained via direct puncture into the AVG. A fistulagram is performed. A second puncture is made at the
opposite end of the AVG for therapeutic intervention. An
angioplasty is performed at the venous anastomosis, followed by stent placement in the AVG.
Codes: 36147, +36148, 37238
Access is gained via direct puncture into the AVG. A fistulagram is performed. A second puncture is made at the opposite end of the AVG for therapeutic intervention. Angioplasty
is performed within the AVG followed by stent placement at
the arterial anastomosis.
Codes: 36147, +36148, 37236
Access is gained via direct puncture into the AVG. A fistulagram is performed. Angioplasty is performed at the arterial
anastomosis followed by stent placement within the AVG.
Codes: 36147, 37238
Thrombectomy is performed to remove a thrombus from an occluded AV dialysis shunt using a device such as an AngioJet®, Trerotola®,
Amplatz®, or Fogarty® catheter, and is described by 36870.
Code 36870 includes all of the work necessary to remove the thrombus, both mechanical and pharmacological; therefore, thrombolysis of the shunt is also included in this code. The codes for thrombolysis (37211-37214) may only be assigned when thrombolysis is performed through a catheter in a separate and distinct vessel from the
shunt. If a balloon is used to facilitate a thrombectomy, it is considered part of the thrombectomy and should not be coded separately.
Angioplasty should only be reported additionally when an underlying stenosis is treated in addition to a thrombotic occlusion. A balloon catheter used for removal of an arterial plug should not be assigned a separate code.
Embolization
Access is gained via direct puncture into the AVG. A fistulagram is performed. Angioplasty and stent placement are
performed in the AVG. A collateral vein is catheterized and
embolized.
Codes: 36147, 36011, 37241, 37238
Access is gained via direct puncture into the AVG. A fistulagram is performed. A second puncture is made at the
opposite end of the AVG for therapeutic intervention. A
thrombectomy is performed and a balloon catheter is used
to clear the arterial plug.
Codes: 36147, +36148, 36870
Although less common, a physician may need to perform embolization of a hemodialysis access. Assign 37241 to report venous embolization of hemodialysis access. Because the hemodialysis access and
its branches are considered one operative field, assign 37241 only
one time, regardless of the number of embolized branches.
When the embolization procedure requires catheterization of collateral veins (additional venous side branches), assign the selective
venous catheterization codes 36011 and 36012, as appropriate. You
may report codes in addition to 36147 and +36148 (SIR Interventional Radiology Coding Update 2015).
Stacie L. Buck, RHIA, CIRCC, CCS-P, RCC, is president and senior consultant at RadRx in
Stuart, Fla. (www.radrx.com). She is a national speaker who provides consulting services to
providers of diagnostic and interventional radiology services and is the author of the book
Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding
and creator of Mastering Interventional Radiology & Cardiology Virtual Boot Camps. Buck may be contacted at
[email protected]. She is a member of the Stuart, Fla., local chapter.
Dialysis Access Embolization Codes 37241
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation,
intraprocedural roadmapping, and imaging guidance necessary to complete the intervention;
venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and
capillary hemangiomas, varices, varicoceles)
36011
Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein)
36012 second order, or more selective, branch (eg, left adrenal vein, petrosal sinus)
www.aapc.com
May 2016
39
■ CODING/BILLING
By Marea Aspillaga, BS, CPC, COC, CPMA, CHC
10 TIPS
to Improve Your
Influence on Providers
Here’s some food for
thought to help you
carry more weight with
your doctors.
In the coding and auditing world, the provider is in the driver’s seat.
Coding and auditing professionals must have the soft skills to share
their expertise, collaborate with providers, and in some cases influence
providers to change behaviors to improve documentation and coding
accuracy.
Here are 10 tips to consider when communicating with healthcare
providers.
1. Use Facts and Data
Providers are highly educated, data-driven individuals. They have
been trained to make decisions based on data, not opinions or feelings. Would a healthcare provider change a patient’s cholesterol medication without reviewing their lab values? Probably not. Why would
they change their documentation practices based on a coder’s or an
auditor’s feelings or opinions?
Before you approach your provider regarding a needed change, do
your research. To support your position, refer to and site relevant resources, such as:
• National or local coverage determinations
• The Centers for Medicare & Medicaid Services (CMS) or your
local Medicare administrative contractor
• Codebooks
• National Correct Coding Initiative (NCCI) policy manual
• Commercial payer policies
A recommendation backed by credible, nationally recognized sources will carry much more weight.
2. Be Respectful
Providers, by virtue of their role in clinical practice, are accustomed
to being the leader in the room. They are often the person someone
calls when they need an answer or advice; so it can often be disarming and uncomfortable for them to not know the answer to a question.
When approaching your provider about an issue or question, be sure
your communication is respectful. Avoid sounding condescending,
critical, or “teachy.” Approaching providers in a respectful manner
shows you’re trying to help and support them. This will make it safe
40
for them to accept your recommendations, and help to diffuse potential defensiveness.
3. Time Your Conversations
At the end of a rough day or right before lunch might not be the best
time to launch into a long dissertation about your provider’s documentation and coding shortcomings. If possible, schedule these dis■ Coding/Billing
Influence
CODING/BILLING
When meeting with your provider, be prepared
and get to the point. They really do have a
million other things to do — and so do you.
you’re fighting the flu, distracted by a personal situation, or upset
about an issue with a co-worker, it might be more of a challenge to
remain supportive, objective, and collaborative with your provider.
Everyone has a job to do, even when circumstances aren’t perfect,
but by being selective about when you discuss issues with your provider, you can improve the likelihood of a positive outcome.
4. Be Concise
If there’s one thing providers wish they had more of, it’s time. Unfortunately, we all get the same number of hours in the day, so be intentional about how you spend yours and theirs.
When meeting with your provider, be prepared and get to the point.
They really do have a million other things to do — and so do you.
If you’re scheduled to meet for one hour and you can finish in 30
minutes, do so. The providers will appreciate this, and they’ll begin to trust that you won’t ask for their time unless it’s truly needed.
When meeting during patient care or on-call time, prioritize the issues you wish to discuss and address the most important ones first.
Even with careful scheduling, you never know when the provider
might run long with a patient and arrive to your meeting late or get
called out for an emergency, leaving less time than planned for your
discussion. Always begin with the issues that will make the most
impact; that way, if you run out of time and can’t address all of your
agenda items, at least you covered the most important ones.
istock.com/Steve Debenport
5. Connect Recommendations with Goals
cussions for a time when your provider is mentally fresh, has had
breakfast or lunch, and can engage without distractions.
Even with careful planning, you may find your provider is running
an hour behind, or perhaps just heard about the passing of a patient.
If you discover the timing isn’t ideal for a productive conversation
with your provider, offer to reschedule.
Make sure the timing is conducive to your own success, as well. If
Is your provider patient-centered? Show you understand by explaining how your recommendations will help keep her coding on
track, so she can focus on her patients. If your provider is looking
for a work/life balance, show how implementing your recommendations will reduce the number of coding queries she receives and
help her get home earlier. If your provider is motivated by money,
show that by coding correctly she can improve collections, reduce
costly denials, and avoid paying interest, fines, and penalties. Showing how your recommendations align with your provider’s goals
will make her more likely to buy in and implement the recommendations long term.
www.aapc.com
May 2016
41
To discuss this
www.aapc.com
Influence
CODING/BILLING
Presenting a problem without a recommendation
is not productive, it’s just complaining. Offer
practical solutions whenever possible.
6. Focus on the Problem, Not the Person
We’ve all heard the old saying, “It’s not what you say, but how you
say it.” When raising a concern with your provider, be sure your
statements focus on the problem, not the person. Use “I” statements
rather than “you” statements. For example, “I wasn’t able to find
the order for this service,” rather than “You didn’t document the order.” Although both statements identify the issue of the missing order, the first states the problem factually, while the second assigns
blame and could be perceived as an accusation instead of an attempt
to solve a problem.
Another great technique is to focus on the documentation, rather
than the person. For example, “The documentation was missing a
signature” may be better received than “You didn’t sign your notes.”
7. Offer a Solution, Not Just a Problem
Presenting a problem without a recommendation is not productive,
it is just complaining. Offer practical solutions whenever possible.
Better yet: Provide options. For example, if you’re proposing an update to the provider’s documentation template, you might come up
with two different solutions and propose, “We could do either A or
B. Do you have a preference?”
By offering specific recommendations, you’re not only showing
the provider you’re interested in helping to solve the problem, but
you’re also increasing the likelihood of arriving at a solution you
can live with.
8. Understand First, Be Understood Second
It’s difficult to address a problem without understanding its root.
When attempting to collaborate with your provider on an issue, ask
questions to gather more information about why a particular problem, workflow, or behavior exists. For example, when discussing
an error identified in an evaluation and management (E/M) audit
regarding the level of service selected, you could say, “Dr. Smith,
help me understand why you felt the decision making was higher
for this encounter.” By understanding the provider’s thought process, you can often identify where the misunderstanding occurred
and address it. You might even find the misunderstanding was on
42
your part. Either way, the provider will likely appreciate you seeking to understand her point of view before jumping to conclusions.
9. Recognize the Positive
Believe it or not, healthcare providers often get little thanks for the
work they do, and receive quite a lot of scrutiny. Occasionally, take
the time to let your providers know what they are doing well. Be sure
that your feedback is genuine and sincere. They’ll appreciate the kudos, and will begin to see you as being “in their corner,” which can
build rapport and make them more open to your recommendations
in the future.
10. Evaluate Your Own Image
Politicians are really good at making appearances. They constantly
evaluate how their actions and words will affect how voters perceive
them. You may find it helpful to do the same.
Think about the way you dress, speak, and interact with others in
your workplace. Do not gossip or joke inappropriately in the break
room and then expect to be taken seriously in meetings. If you overreact when errors are discovered, change your behavior by responding with composure and reason to ensure they are corrected.
REMEMBER: Your influence isn’t limited to the conference room
or meeting area. In a sense, you are marketing yourself in every
email, every meeting, and every discussion to which you contribute. You are ultimately in control of elevating or diminishing your
ability to influence others in the workplace. Be sure the image you
build is consistent with the level of influence you wish to have.
Marea Aspillaga, BS, CHC, CPC, COC, CPMA, has more than 13 years of management and
compliance experience in both private and employed professional practices. She serves as the
system director of compliance and privacy of professional practices for the Baptist Health System in Kentucky. Aspillaga is a member of the Lexington and Louisville, Ky., local chapters.
Smart Design.
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www.aapc.com
May 2016
43
■ AUDITING/COMPLIANCE
By Robert Pelaia Esq., CPC, CPCO, and Drew Krieger, Esq., MBA
PHI Requests,
Denials, and Appeals
istock.com/Maksimchuk Vitaly
Know HIPAA rights when patients request protected health information.
E
arlier this year, the U.S. Department of Health & Human Services
(HHS) clarified certain patient rights under HIPAA regarding access to protected health information (PHI) in their January 2016 release of Individuals’ Right under HIPAA to Access their Health Information 45 CFR § 164.524. Generally, an individual (patient) has
a right to access his or her own medical records under HIPAA; however, this right is not absolute. The new HHS guidance provides important distinctions regarding the timeliness of responses to requests
for PHI, the narrow grounds for denying such requests, and other various aspects of HIPAA.
44
Rules and Timeliness for Requests
Although there is no request requirement for access to medical records to be in writing, HHS clarified that a covered entity (i.e.,
healthcare plans and providers) may require patients to submit a request in writing as long as the patient has notice of this requirement.
The covered entity must provide access to the requested PHI (unless
access was denied) “no later than 30 calendar days from receiving the
individual’s request,” according to 45 CFR § 164.524(b)(2) (2014),
which begins upon receipt of the request. HHS encourages a covered
entity to respond as soon as possible, and stated the 30-day window
is simply an outer limit.
■ Coding/Billing
Patients’ Rights
The timeline depends on the information being requested. If the
PHI is readily used in the daily operations of the covered entity, the
patient should expect this information quickly; if the PHI is older
or stored off-site, it may take more time. The patient has a right to
PHI regardless of how long ago the provider created it.
The covered entity has the right under HIPAA to extend this timeline by an additional 30 days, but only if the covered entity provides
the patient, in writing, with the rationale behind the delay. HHS
points out in the January guidance, however, that a covered entity
“may not require an individual to provide a reason for requesting
access, and the individual’s rationale for requesting access, if voluntarily offered or known by the covered entity, is not a permitted reason to deny access.”
What Medical Record Information Can Be Disclosed?
Now that the covered entity has received the request, the question
becomes: “Should this information be disclosed to the patient?”
A patient has a right to access PHI in his or her medical record that
is contained in a Designated Records Set (DRS). DRS is a group of
records maintained by or for a covered entity, comprised of:
• Medical records and billing records about individuals
maintained by or for a covered healthcare provider;
• Enrollment, payment, claims adjudication, and case or
medical management record systems maintained by or for a
health plan; or
• Other records that are used, in whole or in part, by or for the
covered entity to make decisions about patients.
Although the DRS should be disclosed to the patient by right under
HIPAA, this does not mean all information kept by the covered entity must be disclosed.
Patients have a right to access a vast range of information, including:
billing and payment records; insurance information; clinical laboratory test results; and medical images (X-rays, wellness and disease
management program files, and clinical case notes), among other
information used to make decisions about them. The covered entity is not, however, required to create new information that does not
already exist in the DRS.
Information excluded from the DRS is that which is not used by
the covered entity to make decisions about the patient. For exam-
AUDITING/COMPLIANCE
There are narrow circumstances in which a covered entity may
deny the request for access to a portion of a patient’s PHI.
ple, quality assessments and improvement records are generally used
to make business decisions rather than patient decisions. Other information that is not disclosed to patients may include peer review
data, physician performance calculations, and quality control records used to improve customer service.
When Can Medical Record Requests Be Denied?
Under HIPAA, there are situations when a covered entity has the
right to deny a patient access to PHI following a request for access.
Universally, the entity may deny access if the information is not kept
in the DRS for that patient. Special circumstances for PHI access
denial, for example, are if the release of the information (as determined by a healthcare professional) could endanger the life or physical safety of the patient or another person.
Denied PHI Access that Can Be Reviewed or Appealed
There are narrow circumstances in which a covered entity may deny
the request for access to a portion of a patient’s PHI. Among these
circumstances, a patient has “a right to have the denial reviewed by
a licensed healthcare professional designated by the covered entity who did not participate in the original decision to deny.” These
special circumstances are defined under HIPAA as “reviewable”
grounds for denial.
HHS clarified that general concerns about psychological or emotional harm are “not sufficient to deny an individual access” (i.e., the
patient would be upset by the information). The mere possibility of
harm is not sufficient; instead, the licensed professional needs to determine whether the possibility is “reasonably likely.” HHS expects
this ground for denial will be used in a very small number of cases.
According to 45 CFR § 164.524(a)(3), the other reviewable grounds
occur when a licensed healthcare professional uses professional judgment to determine “access requested is reasonably likely to
cause substantial harm to a person (other than a health care provider) referenced in the PHI; or the provision of access to a personal representative of the individual that requests such access is reasonably likely to cause substantial harm to the individual or another person.”
Example: If the entity believes the release of the information would
lead a patient to commit suicide or harm another person, the entity
has grounds to deny the request and the patient has the right to have
www.aapc.com
May 2016
45
AUDITING/COMPLIANCE
Patients’ Rights
Denied PHI Access that
Cannot Be Reviewed or Appealed
There also are circumstances where the individual has no right to
have the PHI access denial reviewed. The “unreviewable” grounds
for denial under HIPAA include a request for “psychotherapy notes,
or information compiled in reasonable anticipation of, or for use in,
a legal proceeding,” according to the 2014 45 CFR § 164.524(a)(2).
Another example of unreviewable grounds are when an inmate requests PHI kept by a covered entity that is a correctional institution (or healthcare provider acting under the direction of the institution), and providing that information would “jeopardize the
health, safety, security, custody, or rehabilitation of the inmate or
other inmates, or the safety of correctional officers, employees, or
other person at the institution or responsible for the transporting
of the inmate.”
HIPAA also allows a covered entity to deny, without review, any request for PHI that:
• Is contained in a research study that includes treatment;
• Is PHI protected (i.e., under the control of a federal agency);
or
• Is PHI under the control of someone other than the covered
entity, and providing it is “reasonably likely to reveal the
source of the information.”
In other words, a patient does not have the right to access psychotherapy notes of a provider that are kept separate from the patient’s
medical and billing records. More specifically for psychotherapy
46
istock.com/zimmytws
this denial reviewed. HHS says this exception is “narrowly construed” to protect the
patient’s independence and their right under HIPAA “to obtain information about
themselves, which is fundamental in facilitating individuals’ active participation
in their own health care.” The reviewable
grounds contain a reasonableness standard, and the patient is allowed to appeal
the denial in these special circumstances.
notes, “individuals do not have a right to access the psychotherapy
notes that a mental health professional maintains separately from
the individual’s medical record and that document or analyze the
contents of a session with the individual,” according to the January
2016 HHS guidance.
Denial Process Under Reviewable Grounds
If a denial occurs, it must be provided to the patient in writing. If
the patient requests a review, the covered entity “must promptly refer the request to the [independent] designated reviewing official,”
according to HHS’s January 2016 guidance. This “reviewing official” is allowed a reasonable period of time in which to either reaffirm or reverse the denial. From there, the covered entity must notify the individual of the decision.
Other HHS Guidance and Factors
There are other factors and guidance that are mentioned in the Individuals’ Right under HIPAA to Access their Health Information
45 CFR § 164.524 affecting providers, healthcare entities, and payers who receive requests for patient PHI.
Business Associates: A patient has the right under HIPAA to access
their own PHI, and the right extends to PHI held by a business associate of a covered entity. HHS also stressed the business associate
agreement will govern the issue of how the information is disclosed
and how quickly a response to a request is made, provided the agreement complies with HIPAA.
To discuss this
www.aapc.com
Patients’ Rights
istock.com/dolgachov
Payment for Healthcare Services: Although a covered entity or
business associate may charge the individual a “reasonable, costbased fee” for a copy of medical records, the provider may not withhold or deny a patient access to their PHI simply because the patient
has not paid the bill for healthcare services provided to the patient.
Clinical Laboratory Tests: Under HIPAA, a clinical lab test report
becomes part of the lab’s DRS for that patient. HHS explains that
this only applies to “completed” clinical lab test reports; however,
other test information may become part of the DRS, even though
the report is not completed. Examples for this type of information
are test orders, ordering provider information, billing information,
and insurance information.
HHS made clear that the clinical lab is under no obligation to interpret any test result for a patient. The patient’s right under HIPAA is
to “merely inspect or receive a copy of the completed test reports.”
But a clinical lab may provide materials along with the requested
PHI that helps to educate or explain the test results, as well as provide a disclaimer about the limitations of the laboratory data or diagnosis.
EHR Incentive Program Guidelines: There are situations where
a covered entity has incentives to provide a patient with timely access to PHI. For example, there are requirements under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs where a covered entity may receive incentive-based payments
from Medicare or Medicaid for successfully demonstrating meaningful use of certified EHR technology, “which includes providing
patients the ability to view online, download, and transmit their
health information.” HHS notes that these requirements are more
precise than the HIPAA requirements.
AUDITING/COMPLIANCE
There are situations where a covered entity has
incentives to provide a patient with timely access to PHI.
resentative. If the information is not contained in the DRS, the provider can deny the request for PHI under HIPAA; and depending
on the information requested, that denial may (or may not) be eligible for review.
Robert A. Pelaia, Esq., CPC, CPCO, is deputy general counsel at the University of
South Florida in Tampa, Fla. He is certified as a Health Care Law Specialist by the Florida Bar
Board of Legal Specialization and Education, serves on AAPC’s Legal Advisory Board, and
was a 2011-2013 AAPC National Advisory Board member. Pelaia is a member of the Tampa,
Fla., local chapter.
Drew Krieger, Esq., MBA, is a recent law school graduate with experience in healthcare
law. He previously worked for a small, transactional healthcare law firm. Krieger resides in
Jacksonville, Fla.
Be Cautious When Disclosing PHI to Patients
Resources
Covered entities and business associates should be cautious when
complying with a request for medical records by a patient. First,
the provider must determine what information needs to be included in the DRS. Second, the provider must determine if the information requested by the patient is contained within the DRS. If so,
the provider should disclose this information to the patient or rep-
HHS, Individuals’ Right under HIPAA to Access their Health Information 45 CFR § 164.524, January
7, 2016: www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html
HHS, Federal Register, 2014: 45 CFR § 164.524(a)(2); 45 CFR § 164.524(a)(3); 45 CFR § 164.524(b)(2):
www.gpo.gov/fdsys/pkg/CFR-2011-title45-vol1/pdf/CFR-2011-title45-vol1-sec164-524.pdf
HHS, Federal Register, 2013, 45 CFR § 164.501
www.aapc.com
May 2016
47
■ AUDITING/COMPLIANCE
By Joe Rivet, CPC, CEMC, CPMA, CCS-P, CICA, CHC, CHRC, CHPC, CCEP
Are Auditors,
Billers, and
Coders Liable for
False Claims?
T
he False Claims Act (FCA) imposes liability on anyone who knowingly presents, or causes to be presented, a false or fraudulent claim
for payment, or who conspires to submit a false claim for payment.
Because auditors, coders, and billers work on the “front lines” of
claims processing, they are likely to see errors or patterns of improper billing. If claims are not corrected, is the auditor, coder, or billing
“knowingly” causing a false claim to be submitted?
Convictions, Jail, and Penalties
The FCA is an enforcement tool created during the Civil War (not for
use in healthcare), but is now the leading arsenal the government uses
to combat healthcare fraud. Although the FCA is not used to police
minor billing mistakes or errors, here are a few cases that may cause
a lump in your throat.
• A clinic administrator was sentenced to 70 months in prison
for admitting to causing the submission of approximately
$11 million in false claims to Medicare, including paying
healthcare kickbacks and committing healthcare fraud.
• Medicare paid Mobile Doctors more than $30 million for
physician home visits. A grand jury returned an indictment
charging the CEO of healthcare fraud. The charges in this
case stemmed from billing patient visits at an inflated rate
(over-coding). The CEO believed he would avoid audits. In
this case, services were not billed based on what the physician
actually provided.
• A billing assistant, pled guilty to charges involving a scheme
to bill Medicare for orthotics that were never provided to
48
istock.com/oguzdkn
Healthcare business professionals
have a duty to respect the claims
process and our profession.
patients. The billing assistant, along with the doctor submitted
false claims under several companies owned by the doctor.
The scheme generated a loss of over $2.2 million to Medicare,
Medicaid, and private insurance companies.
• A medical biller of a Chicago-area visit physician practice
was sentenced to 45 months in prison for her role in a $4
million healthcare fraud scheme. She was also ordered to pay
approximately $1 million in restitution. The medical biller
was the primary biller for Medicall Physicians Group Ltd.
Evidence showed she and her co-conspirators routinely billed
Medicare for overseeing patient care plans (care plan oversight)
when the doctors at Medicall rarely provided the service.
What If I Knew? Am I at Risk?
Statute 31 U.S.C. § 3729 (b) defines “knowing” and “knowingly” as
meaning the person:
1. Has actual knowledge of the information;
2. Acts in deliberate ignorance of the truth or falsity of the information; or
3. Acts in reckless disregard of the truth or falsity of the information.
The statute expressly states that “no proof of specific intent to defraud” is required.
Under the FCA, whistleblowers may file suit even if they participated in the fraud. In such a case, judges may reduce the whistleblower’s reward.
■ Coding/Billing
To discuss this
www.aapc.com
False Claims
I Have a Concern, What Should I Do?
Respect Our Profession
Having knowledge and being aware of a person or entity generating
fraudulent claims is a crime. As professionals in the auditing, billing, and coding industry, we have a duty to respect our profession
and to have integrity.
If you saw a bank being robbed, would you report it? Sure you
would. People who knowingly cause or contribute to generating a
AUDITING/COMPLIANCE
It’s normal to have fears, or to think, “Wow, if only someone reported this!” You have to have passion and concern. Chances are, patient
lives could be at risk in the most extreme cases, as seen in the case of
Farid Fata, MD, who made more than $17 million in treating patients who did not have cancer with cancer drugs. The whistleblower, George Karadsheh, a former employee, received $1.7 million for
helping to put an end to this bad actor.
It’s important to speak with an attorney who has expertise in the
FCA arena. There are many attorneys who claim to know the FCA,
but very few focus their practice entirely on false claims. Getting the
right lawyer and not making a mistake when filing are key steps in
winning a case and helping end a criminal’s bad acts.
false claim are helping to commit robbery of our nation’s Medicare
dollars. Anyone who uses patient information to create false claims
is not a healthcare professional.
Joe Rivet, CPC, CEMC, CPMA, CCS-P, CICA, CHC, CHRC, CHPC, CCEP, is a law clerk with
MahanyLaw focusing exclusively on the FCA. He brings coding, billing, and documentation
expertise to the firm, which has a unique and highly successful approach to false claim actions. Rivet is a member of the Ann Arbor, Mich., local chapter. You can contact him at jrivet@
mahanylaw.com.
Resources
Department of Justice (DOJ), “Miami Physician Sentenced to 84 Months in Prison for $26.2
Million Medicare Fraud:” www.justice.gov/archive/opa/pr/2008/November/08-crm-979.html
Healthcare Finance, “Mobile Doctors CEO arrested for Fraud:”
www.healthcarefinancenews.com/news/mobile-doctors-ceo-arrested-fraud
DOJ, Medical Biller Sentenced to 45 Months in Prison for Role in $4 Million Health Care Fraud
Scheme: www.justice.gov/opa/pr/medical-biller-sentenced-45-months-prison-role-4million-health-care-fraud-scheme
FBI, Local Chiropractor and Billing Assistant Plead Guilty to Health Care Fraud Charges:
www.fbi.gov/stlouis/press-releases/2015/local-chiropractor-and-billing-assistant-pleadguilty-to-health-care-fraud-charges
USA Today, “Cancer Doctor Sentenced to 45 Years for ‘Horrific’ Fraud:” www.usatoday.com/
story/news/nation/2015/07/10/cancer-doctor-sentenced-years-horrific-fraud/29996107/
TCI
www.aapc.com
May 2016
49
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50
AUDITING/COMPLIANCE ■
By Julie Roth, MHSA, JD, RHIA
CMS Sets Standards for
Medicare Overpayments
Final rule explains how
providers should carry
out timely reporting and
returning of Medicare
overpayments.
I
n February, the Centers for Medicare &
Medicaid Services (CMS) published the
long-awaited final rule Medicare Reporting and Returning of Self-identified Overpayments, establishing official policy for
timely reporting and returning of Medicare overpayments received by healthcare
providers.
Since the enactment of the Affordable Care
Act on March 23, 2010, providers* have
been subject to a statutory 60-day timeline for reporting and returning Medicare
overpayments, and faced liability under the
False Claims Act, Civil Monetary Penalties
Law, and the Medicare exclusion authorities for failure to meet the statutory deadline. The final rule was preceded by CMS’
proposed rule published on February 16,
2012, and brings some clarity to issues such
as when an overpayment is considered to
be “identified” for purpose of the 60-day
deadline, as well as how far providers must
look back when identifying overpayments
subject to the reporting and returning requirement.
* In this article, “provider” or “person” refers
to both a “provider,” as defined in 42 CFR
400.202 (e.g., a hospital), and a “supplier,”
as defined in 42 CFR 400.202 (e.g., a physician).
Basic Standard
istock.com/matt_benoit
Under the final rule, a person who has received an “overpayment” must report and
return the overpayment by the later of either:
(i) The date which is 60 days after the date
on which the overpayment was “identified;” or
(ii) The date any corresponding cost report
is due, if applicable.
In the final rule, “overpayment” means any
funds that a person has received or retained
■ Coding/Billing
www.aapc.com
May 2016
51
Overpayments
AUDITING/COMPLIANCE
According to CMS, a total of eight months (six months for timely
investigation and two months for reporting and returning) is a
reasonable amount of time, absent extraordinary circumstances.
under Medicare Part A or B to which the person, after applicable
reconciliation, is not entitled. CMS published rules for reporting
and returning of overpayments in Medicare Parts C and D in separate rulemaking (79 FR, 29843, May 23, 2014).
overly burdensome for providers in terms of retaining records and
retrieving information from electronic legacy systems.
Six-month Investigation Benchmark
Under the final rule, a provider must use the reporting process established by the applicable Medicare administrative contractor
(MAC) to report the overpayment. This may include applicable
claims adjustment, credit balance, self-reported refund, or other
process set forth by the MAC. If the amount of the overpayment
was calculated using a statistical sampling methodology, then the
provider must describe the statistically valid sampling and extrapolation methodology in the report.
Note: In finalizing this section of the rule, CMS removed a requirement under the proposed rule that would have required providers to
include 13 specific data elements when reporting overpayments to
a MAC. CMS acknowledged that allowing providers to follow the
processes established by each MAC would avoid the administrative
burden of reporting information the MAC considers unnecessary.
CMS also allows the deadline for returning an overpayment to be
suspended when a provider submits a request for an extended repayment schedule to the MAC. The deadline will remain suspended
until CMS or the MAC rejects the suspended repayment schedule
request or the provider fails to comply with the terms of the extended repayment schedule.
An overpayment is identified when a person has, or should have
through reasonable diligence, determined that the provider has received an overpayment and quantified the amount of the overpayment. With this definition, CMS acknowledges that “identification” of an overpayment involves quantifying the amount, which
requires time for a reasonably diligent investigation.
According to CMS, “reasonable diligence” includes:
• Proactive compliance activities conducted in good faith by
qualified individuals to monitor the receipt of overpayments;
and
• Investigations conducted in good faith and in a timely
manner by qualified individuals in response to obtaining
credible information of a potential overpayment.
CMS established a six-month period as the benchmark for what it
considers to be a timely investigation, absent extraordinary circumstances. According to CMS, a total of eight months (six months for
timely investigation and two months for reporting and returning) is
a reasonable time, absent extraordinary circumstances. CMS stated
that “extraordinary circumstances” may include unusually complex
investigations that the provider reasonably anticipates will require
more than six months to investigate, such as Stark Law (the physician self-referral law) violations that are referred to the CMS Voluntary Self-Referral Disclosure Protocol (SRDP). Specific examples of
other types of extraordinary circumstances cited by CMS include
natural disasters or a state of emergency.
Six-year Look-back Period
Overpayments are subject to a six-year “look-back” period. Meaning, overpayments must be reported and returned if they have been
identified within six years of the date the overpayment was received.
Although CMS had originally proposed a 10-year look-back period to be consistent with the outer limit of the False Claims Act statute of limitations, CMS recognized that a 10-year period would be
52
Reporting and Return Process
Relationship to Self-disclosure Protocols
The final rule affords special treatment for overpayments that implicate the fraud and abuse laws enforced by the Office of Inspector
General (OIG) or the Stark Law enforced by CMS.
Specifically, a person satisfies the reporting obligations of the final
rule by making a disclosure under the OIG Provider Self-Disclosure
Protocol or the CMS Voluntary SRDP, resulting in a settlement
agreement using the process described in the respective protocol:
• OIG Provider Self-Disclosure Protocol: The deadline
for returning an overpayment is suspended when the OIG
acknowledges receiving the submission to the OIG Provider
Self-Disclosure Protocol. The repayment deadline remains
suspended until a settlement agreement is entered, the person
withdraws from the OIG Provider Self-Disclosure Protocol,
To discuss this
www.aapc.com
Overpayments
or the person is removed from the OIG Provider SelfDisclosure Protocol.
• CMS Voluntary SRDP: The deadline for returning an
overpayment is suspended when CMS acknowledges receipt
of the self-disclosure. The repayment deadline remains
suspended until a settlement agreement is entered, the person
withdraws from the SRDP, or the person is removed from the
SRDP.
Effective Date
Although the final rule just went into effect March 14, 2016, providers have been subject to the Affordable Care Act’s provisions for
timely reporting and returning of Medicare overpayments since
March 23, 2010.
CMS states that provisions of the final rule are not retroactive. Providers who reported and/or returned overpayments prior to March
14, 2016, and who made a good faith effort to comply with the Affordable Care Act’s “report and return” requirements, are not expected by CMS to have complied with each provision of the final
rule. All providers reporting and returning overpayments on or after March 14, 2016 — even overpayments received prior to this date
— must comply with the requirements of the final rule.
AUDITING/COMPLIANCE
According to CMS, a total of eight months (six months for timely
investigation and two months for reporting and returning) is a
reasonable amount of time, absent extraordinary circumstances.
• Step 3: Providers should maintain records that accurately
document their reasonably diligent efforts to demonstrate
their compliance with the final rule.
• Step 4: Providers should be prepared to look back six years
when identifying potential overpayments.
Disclaimer: This information is provided as an educational resource and is not to be construed as providing legal opinion or creating an attorney-client relationship. Any questions regarding obligations under the final rule should be directed to your healthcare
attorney.
Julie Roth, MHSA, JD, RHIA, is a partner in Lathrop & Gage, LLP, and is co-chair of the
Healthcare Practice Team. She represents healthcare providers on regulatory compliance,
Medicare and Medicaid reimbursement issues, self-disclosure matters, government investigations, HIPAA privacy and security standards, the Stark Law, the Anti-kickback Statute, the
False Claims Act, and other federal and state laws.
Implementation for Providers
Although healthcare providers have long been obligated to report
and return overpayments, providers should take a number of steps
in response to the final rule.
• Step 1: Providers should implement or review processes
to assure they respond appropriately to receiving credible
information regarding a potential overpayment. Credible
information may include, for example, the discovery of
a single, overpaid claim (which may trigger the need to
make further inquiries), or one or more hotline complaints
regarding the same or similar payment-related issue.
• Step 2: Although CMS allows for identifying and
quantifying a potential overpayment to occur after a
reasonably diligent investigation, providers should be
prepared to take no more than six months to complete the
investigative process, absent extraordinary circumstances.
Resources
CMS Fact Sheet, Medicare Reporting and Returning of Self-Identified Overpayments, CMS 6037-F
Final Rule: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheetsitems/2016-02-11.html
79 Federal Register 29843, May 23, 2014:
www.gpo.gov/fdsys/granule/FR-2014-05-23/2014-11734/content-detail.html
Stark Law: http://starklaw.org/stark_law.htm
CMS Voluntary Self-Referral Disclosure Protocol: www.cms.gov/Medicare/Fraud-and-Abuse/
PhysicianSelfReferral/downloads/6409_srdp_protocol.pdf
Fraud & Abuse Laws: http://oig.hhs.gov/compliance/physician-education/01laws.asp
OIG, Provider Self-Disclosure Protocol: www.oig.hhs.gov/compliance/self-disclosure-info/protocol.asp
www.aapc.com
May 2016
53
■ PRACTICE MANAGEMENT
By Douglas J. Jorgensen, DO, CPC, FAAO, FACOFP, CAQ Pain Medicine
MIPS Is
in 23 Months
Move over SGR. Quality performance and reporting payment
methodology is replacing you.
T
he sustainable growth rate (SGR) payment formula is gone, replaced by the Merit-based Incentive Payment System (MIPS),
signed into law April 16, 2015.
Ironically, the SGR became unsustainable within a few years of its introduction. Nearly every year for the past decade and a half, the SGR
formula threatened healthcare providers (doctors of medicine, osteopathic doctors, nurse practitioners, physician assistants, and others
paid under the fee-for-service [FFS] reimbursement system) with payment reductions. And in nearly all of those years, Congress stepped in
to prevent the cuts. These temporary fixes only compounded potential reductions in the years ahead. Providers were faced with a 21 percent reduction last year, just before Congress put an end to the SGR,
once and for all.
Congress has mandated that for the first five years, 50 percent of
Medicare money must be “at risk.” By 2023, that number rises to
75 percent. The “at risk” portion of Medicare payments is that
which may be reduced if providers do not meet defined performance standards. Providers who score well on
performance standards may receive higher payment for
services than they did
under FFS. The more
Medicare patients
a provider sees,
the greater the
Budget Neutrality Slowly Kills Reimbursement
By adopting a program of “budget neutrality” in response to the SGR
cuts, Congress effectively froze provider payments at the 2001 level.
Not only have providers not received a raise in the intervening years,
in real terms their income has fallen because Medicare reimbursements have not kept pace with rising expenses (for example, information technology infrastructure and staffing costs). If we assume a (very
conservative) 3 percent cost-of-living increase, per year, Medicare reimbursements have lost nearly 50 percent of their value in the last 15
years. Providers who feel as though they must now work more to make
less are not necessarily mistaken.
Enter 2018 MIPS
Unless you are (partially or fully) participating in an alternative payment model — or you are in a program not subject to MIPS (i.e., federally qualified health centers [FQHCs]) — MIPS goes into effect,
by law, January 2018.
54
potential penalties or rewards. This has many providers questioning whether they want to continue participating in Medicare.
MIPS measures four basic elements, each focused on
quality performance and reporting.
1. Clinical Quality Indicators (CQIs) - CQIs have
not yet been defined.
2. The Value-based Modifier (VBM) - VBM is a complex algorithm
that measures quality reporting performance.
3. The Physician Quality Reporting System (PQRS) - You should
all be familiar with PQRS by now, which has hundreds of mea■ Coding/Billing
MIPS
PRACTICE MANAGEMENT
FFS medicine may not be dead, but the manner in
which it will run — and how we will be paid — is rapidly
changing. Be educated, be prepared, and be successful.
sures to choose from. Note, however, that electronic health records (EHRs) have only 64 measures on which you can report.
Depending on your specialty, the system you choose may not be
able to support your practice. Buyer beware!
4. Meaningful Use - These dashboards still will be available via
EHR, but other options may be available to
improve efficiency.
Medicare Pushes Providers
to Higher Standards
Under MIPS, providers will
be compared to peers
in their geographic
locale. The determinat ion
of success or failure will be clearly demarcated. Provider performance will be measured via linear analysis: If 69.9 means failure
and 70 is passing, there will be no rounding up. The intent is to
push providers toward a higher standard. Ideally, there will be continuous reporting allowing immediate and ongoing feedback to
the practice and providers, so adjustments can be made.
Beginning in 2019, MIPS and alternate payment models will drive
all Medicare-related payments. Billing and coding will remain important because practices, hospitals, and durable medical equipment vendors still will be paid based on services rendered under
the FFS, volume-based system. The major difference is there will
be a negative, zero, or positive payment adjustment that depends
on successful participation with MIPS or other approved payment
model. We also can be sure the private payers are watching, as these
quality analytics will likely be available for all to see and compare.
As such, it won’t take long for the UnitedHealthcares, Anthems,
Cignas, Aetnas, and Humanas of the world to move forward with
similar (if not the same) methodology.
FFS medicine may not be history, but the manner in which it will
run — and how we will be paid — is rapidly changing. Be educated, be prepared, and be successful.
istock.com/ChristianChan
Douglas J. Jorgensen, DO, CPC, FAAO, FACOFP, CAQ Pain Medicine, is founder and
owner of Patient360 (a Medicare-approved PQRS entity), which was one of the original private registries when the physician quality reporting program began. He lectures nationally on billing and coding issues, as well as authors articles for peer reviewed medical journals and national newsletters. In addition to litigation consultancy and expert witness
work, Jorgensen consults for the FBI, Drug Enforcement Administration, and the Office of Inspector General.
With his twin brother, Ray Jorgensen, CPC, he released a best-selling healthcare reimbursement guide,
“A Physicians Guide to Coding and Billing.” Jorgensen is a member of the Lewiston, Maine, local chapter.
Resources
www.aapsonline.org/index.php/article/opt_out_medicare/
www.aapc.com
May 2016
55
■ PRACTICE MANAGEMENT
LEARN FROM CDI PROGRAMS
istock.com/BernardaSv
By Ida Landry, MBA, CPC
You’ve been focusing on coding compliance;
now turn to documentation compliance.
C
linical documentation improvement (CDI) programs have become essential in the inpatient setting. Hospitals are seeing the
positive benefits of improved documentation and coding, which are
outweighing administrative costs. It’s time physician practices embrace the merits of CDI, as well.
CDI considers the whole documentation to validate all evaluation and management (E/M) services, CPT®, and HCPCS Level II
codes, modifiers, and diagnoses (or in the inpatient world: revenue
codes (REV); diagnosis related groups (DRG); and ICD-10-CM/
PCS). This type of in-depth review is missing on the physician side of
healthcare, but should be a part of the discussion to meet meaningful use requirements and decrease Comprehensive Error Rate Testing (CERT) and medical review error rates.
The Link between CDI and CQMs
In 2014, healthcare professionals and hospitals eligible to participate
in the Medicare and Medicaid Electronic Health Record (EHR) In56
centive Programs were required to report clinical quality measures
(CQMs) to validate compliance with meaningful use of certified
EHR technology. If these measures were not validated, financial penalties followed.
The payment reduction for eligible professionals for the 2015 reporting period is 1 percent. This reduction increases each year an eligible professional does not demonstrate meaningful use, to a maximum of 5 percent.
Meaningful use requirements have changed over the years – specifically, in three stages. To meet EHR Incentive Program requirements
in 2016 (stage 3), all eligible professionals are required to attest to a
single set of 10 objectives and measures, instead of nine out of 64
CQMs from three out of six objectives. Eligible hospitals are required
to attest to a single set of nine objectives and measures, compared to
16 out of 29 measures from three out of six objectives.
CDI helps to ensure correct charting, vital to proving CQMs are appropriate and validated, and is, therefore, linked to maximum reim■ Coding/Billing
CDI
bursement. As an added bonus: “Improving the accuracy of clinical
documentation can reduce compliance risks, minimize a healthcare
facility’s vulnerability during external audits, and provide insight
onto legal quality of care issues,” according to Journal of AHIMA.
Key to CDI Success
istock.com/Esben_H
CDI also provides documentation guideline education to all parties involved in patient care and charting, and removes the documentation query burden from health information management
(HIM) coders.
To ensure success, however, either coders must expand their skill
set to educate providers on these documentation issues, or new positions must be created so coders can focus solely on coding from
the record.
A CDI associate — often a nurse or other educated, experienced
medical personnel — possesses an in-depth knowledge of medicine,
necessary to read and analyze all information in the patient’s health
record. This person can recognize areas in need
of improvement and communicate, through
clinical language with providers and other medical staff, the need for more robust documentation. If documentation is lacking to validate laboratory orders, radiological tests, or anything
else that should be notated and documented, the
CDI associate will query about those, too.
Concurrent reviews of health records reduce the
need for retrospective reviews, which frees HIM
coders to expedite coding the record and getting
the claim to the insurance company, resulting in
faster payment. If payer or other external audits
are initiated, the documentation supports the
coding, reducing refunds and targeted audits.
PRACTICE MANAGEMENT
If payer or other external audits are
initiated, the documentation supports the
coding, reducing refunds and targeted audits.
For example, a patient presents for a diabetic checkup and comments on numbness in his feet. The provider performs an assessment of the feet and documents decreased sensation and foot risk of
2. In the assessment, the doctor also documents:
1. Diabetes unspecified, uncontrolled
2. Neuropathy in both feet: To podiatry for consult
A CDI associate may send a query to the provider asking:
Can the etiology of the neuropathy of the patient’s feet be further specified? If so, please document the type/etiology of the
neuropathy in the patient’s feet in the progress note.
A CDI associate would never send the following inquiry:
Is the neuropathy due to or because of the patient’s diabetes?
The later query is inappropriate because it leads the provider to the
correct code. You might argue that the diagnosis is invalid because
it did not arise from the provider’s own conclusion of the signs and
Strict Query Protocols Are Necessary
CDI must be guided by specific policies and procedures. In particular, queries cannot lead the
provider to document a particular condition.
www.aapc.com
May 2016
57
CDI
PRACTICE MANAGEMENT
If the inpatient world has seen the merit of CDI
programs, why hasn’t the physician practice side?
is gaining recognition on
the professional side, there
is still more to be done.
Connecting the Dots
symptoms. As such, individuals who query providers must take
heed when asking questions that deal with the provider’s clinical
judgment.
Especially in the wake of ICD-10 implementation, coders who report professional services are advised to query providers when documentation is insufficient. The ICD-10-CM Official Guidelines for
Coding and Reporting frequently instructs the coder to query the
provider for clarification when needed. Nowhere do the guidelines
explain how the coder should query the provider.
Education on querying the provider is not usually part of the coding
curriculum. Although the importance of diagnostic information
Want More on Querying?
For more information on querying providers to improve documentation, read the articles
“From Coder to Colleague through Querying,” on pages 20-22, and “10 Tips to Improve Your
Influence on Providers,” on pages 40-42, in this issue of Healthcare Business Monthly.
58
Per analysis of Part B CERT
results (Novitas Solutions,
2015), “Incorrect coding
of evaluation and management (E/M) services is a top
error in Jurisdiction H.”
One of the top claim findings/core issues from Noridian’s medical reviews has
to do with medical necessity/insufficient documentation (Noridian, 2016).
This information is on par
with the 2015 projected improper payments of physician services data that CMS
has released, with insufficient documentation totaling $5.5 billion and incorrect coding coming in second at $2.7 billion.
The question then becomes: If the inpatient world has seen the merit of CDI programs, why hasn’t the physician practice side? The focus of physician coding departments is coding and billing, with educating squeezed in when time allows. Clearly, something has to
change if insufficient documentation is the biggest reason for CMS
improper payments.
Compliant in Our Mistakes
As a coding community, let’s start a dialog of what we need to do to
combat insufficient documentation:
• Is an outpatient version of the CDI program a vision of the
future?
• What qualifications are necessary for a CDI associate?
• Can education be drafted for coders and auditors, so their
queries are appropriate?
To discuss this
www.aapc.com
CDI
Resources
PRACTICE MANAGEMENT
Journal of AHIMA, “Guidance for Clinical Documentation Improvement Programs,” 81, No. 5 (May 2010): http://
library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343
CMS, “Medicare and Medicaid EHR Incentive Program Basics: Additional Information for Eligible Professionals
Participating in the Medicare EHR Incentive Program” (January 2016): www.cms.gov/regulations-and-guidance/
legislation/ehrincentiveprograms/basics.html
As a community, we need to provide guidance on what
to look for in documentation that warrants query. We
already have a foundation to look at for guidance. The
CDI programs in place today are great tools for us to
use as guides — we don’t have to start from scratch.
Our community just has to begin a dialog on how to
combat the errors seen by the organizations that regulate us. We are great at coding compliance; let’s be just
as great with documentation compliance.
Ida Landry, CPC, works for RevWorks, a division of Cerner Corporation.
As compliance manager of professional services, she and her team ensures revenue cycle compliance. Landry holds a Bachelor of Science in
Health Administration and a Master of Business Administration with a
Healthcare Management concentration. She is a past vice president of
the Portland Metro, Ore., local chapter, and a 2013-2015 National Advisory Board member.
CMS, “The Supplementary Appendices for the Medicare Fee-for-Service 2015 Improper Payments Report” (January
2016): www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/CERT/CERT-Reports-Items/Downloads/AppendicesMedicareFee-for-Service2015ImproperPaymentsR
eport.pdf
CMS, “Public Use File,” (January 2016). Download State Table – Beneficiaries under 65: www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html
CMS, “Public Use File,” (January 2016), Download State Table – Beneficiaries 65 and older: www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html
Haney, Pamela (September 2015), Accurate Documentation is Essential – Knowing When to Query your Providers:
www.aapc.com/blog/32241-accurate-documentation-is-essential-knowing-when-to-query-your-providers/
Noridian, Review Notifications and Findings, (February 2016), Current Noridian Service-Specific Reviews: https://
med.noridianmedicare.com/web/jeb/cert-reviews/mr/notifications-findings
Novitas, Analysis of Part B Comprehensive Error Rate Testing (CERT) Data January – March 2014. (August 2015). What
You Need to Know – Top Error Summary
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■ AAPC
Ethics Committee
By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA
Effectively Submit an Ethics Complaint
Understand the process for
when you witness an AAPC
Code of Ethics violation.
f you believe an AAPC member has acted contrary to AAPC’s Code of Ethics, detail the substance of the complaint by including the information requirements below, and
forward the information to the Ethics Committee via e-mail: [email protected].
The complaint should include:
1. The name of the member or members who are alleged to have violated
AAPC’s Code of Ethics.
2. The AAPC member identification
number of the member(s) who committed the alleged violation (if known).
3. A detailed description of the conduct
you believe violates AAPC’s Code of
Ethics. Minimal details should include what happened, when it happened, and where it happened. Provide the identity of others who might
corroborate the allegations.
4. Information/documentary evidence
supporting the allegations of misconduct. In cases where the conduct violates a statutory provision of the law,
a certified copy of the final judgment
from a court of competent jurisdiction
or administrative agency is required
before the Ethics Committee can pro-
It’s the responsibility
of the complainant
to provide sufficient
evidence of the
misconduct for an
ethics case to proceed.
60
ceed. As an example, allegations of
fraud must be supported by either a
civil or criminal
court judgment
that is not subject
to appeal. Allegations
that the member violated
HIPAA must be supported by
a final determination by the Office of
Civil Rights.
5. Whether you wish to remain anonymous.
How Violation
Complaints Are Handled
The Ethics Committee investigates submitted complaints based on the information and
evidence presented. The committee does not
conduct factual investigations and cannot
make determinations regarding whether the
alleged conduct violates a state or federal statute or regulation. It’s the responsibility of the
complainant to provide sufficient evidence of
the misconduct for an ethics case to proceed.
Mere allegations of misconduct will, in most
cases, be dismissed when additional supporting evidence is not provided.
If a complaint demonstrates a credible, prima
facie (evident) violation of AAPC’s Code of
Ethics, the committee chair will appoint one
of the Legal Advisory Board members of the
Ethics Committee as the investigating member of the case. The investigating member is
responsible for providing the accused member with a Notice of Complaint, which af-
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I
fords the member the opportunity to submit a rebuttal statement and evidence to support their response. Once that
information is received, the investigating
member determines whether the information warrants submission of the matter to
the Ethics Committee for a hearing. When a
hearing referral to the committee is not justified by the evidence submitted, the complaint is dismissed, and the complainant and
member are notified. When a hearing referral to the committee is warranted, the chair
is responsible to schedule a hearing at a time
convenient to all committee members. In
most cases, hearings are held within 60 to 90
days. Following the hearing, the complainant and the member are notified of the committee’s determination.
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC,
CPCO, CPMA, is president-elect of AAPC’s National
Advisory Board, serves on AAPC’s Legal Advisory
Board, and is AAPC Ethics Committee chair. Miscoe
has over 20 years of experience in healthcare coding
and over 18 years as a forensic coding and compliance
expert. He has provided expert analysis and testimony on coding and
compliance issues in civil and criminal cases and represents healthcare
providers in post-payment audits and HIPAA OCR matters. He is a member
and past president of the Johnstown, Pa., local chapter.
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Hariom, CPC-A
Heather Heimer, CPC-A
Heather Kenney, CPC-A
Heidi Pelesky, CPC-A
Helen Cameron, CPC-A
Hemanth Kumar. M, CPC-A
Hemasudha Kankalapati, CPC-A
Herbert Mccutchen, CPC-A
Hilary Henningsen, CPC-A
Holly Whalin, CPC-A
Irukulla Jyothsna Devi, CPC-A
Jackie Dianne Bote, CPC-A
Jaclyn Bojanowski, CPC-A
Jacob Darcey, CPC-A
Jacob Nelson, CPC-A
Jacqueline Brown, CPC-A
Jacqueline Brown, CPC-A
Jade Martinez, CPC-A
Jainy Alphonsa Abraham, CPC-A
James Gregory Inmon, CPC-A
James Hansford, CPC-A
James M Green, CPC-A
Jamie Genzler, CPC-A
Jan Karmela Coson, CPC-A
Jan Todd, CPC-A
Jana Martin, CPC-A
Jane Cabale Prollo, CPC-A
Jannathul Asma, CPC-A
Jarupla Naveen Naik, CPC-A
Jasmine Wells, CPC-A
Jason Allen, CPC-A
Jason Johnson, CPC-A
Jeanette Renee Archibeque, CPC-A
Jeanine Sullivan, CPC-A
Jeff Linton, CPC-A
Jeffrey Davisson, CPC-A
Jeffrey Elipe, CPC-A
Jenifer Peter, CPC-A
Jennifer Bergmann, CPC-A
Jennifer Demo, CPC-A
Jennifer Dennis, CPC-A
Jennifer Dickes, CPC-A
Jennifer Fielding, CPC-A
Jennifer Johnson, CPC-A
Jennifer Lynn Gonfiantini, CPC-A
Jennifer Macias Bermudez, CPC-A
Jennifer Magallon, CPC-A
Jennifer Powell, COC-A
Jennifer Powell, CPC-A
Jennifer Redfield, CPC-A
Jennifer Surtida, CPC-A
Jennifer West, CPC-A
Jerome Abinales, CPC-A
Jerry Felisme, CPC-A
Jess Belant, CPC-A
Jesseca Kiddoo, CPC-A
Jessica Butler, CPC-A
Jessica Chua, CPC-A
Jessica Davis, CPC-A
Jessica Fackrell, CPC-A
Jessica Gardner, CPC-A
Jessica Miller, CPC-A, CPC-P-A, CGIC
Jessica Nicole Beltz, CPC-A
Jessica Patterson, CPC-A
Jessica Rich, CPC-A
Jessica Thomas, CPC-A
Jessica Wendel, CPC-A
Jessica Woessner, CPC-A
Jill Priggemeier, CPC-A
Jillian Chamberlain, CPC-A
JoAnn Toughill, CPC-A
Joanne Sparacino, CPC-A
John Patrick Natan Marca, CPC-A
Jolina Mae Torrago, CPC-A
Jonathan Scott Lukas, CPC-A, COSC
Joni Moss, CPC-A
Joseph Fraszka-Suarez, CPC-A
Joy Morvant, CPC-A
Julia Gillispie, CPC-A
Julian Goss, CPC-A
Julie Jost, CPC-A
Julie Nesbit, CPC-A
Julissa Rodriguez, COC-A
Jungsook Kim, CPC-A
Junilyka Indico, CPC-A
Justine Nguyen-Alwert, CPC-A
Justine Christopher Caysido, CPC-A
K. Nikhita, CPC-A
Kaci Smith, CPC-A
Kailas Ramkrishna Patil, CPC-A
Kairumkonda Phani Chandra, CPC-A
Kalaivani (VANI) Ashokprabhu, CPC-A
Kalepalli Manojna, CPC-A
Kallakunta Susmitha, CPC-A
Kameisha Naomi Oliver, CPC-A
Kamille Virrey, CPC-A
Kanagalakshmi Pasumpon, COC-A
Karen Rida, CPC-A
Karen Williams, CPC-A
Kari Pestka, CPC-A
Kari Taulbee, CPC-A
Karyn vanSanden, CPC-A
Kasa Swetha, CPC-A
Kasey Lindsey, CPC-A
Kassie Bryant, CPC-A
Katherine Abuan Dalope, CPC-A
Katherine Richardson, CPC-A
Kathleena Shepherd, CPC-A
Kathryn Blessing, CPC-A
Kathryn Lamance, CPC-A
Kathryn Mierop, CPC-A
Kathryn Rundman, CPC-A
Kathy Culcasi, CPC-A
Kathy Maruyama, CPC-A
Katia Nelson, CPC-A
Katie Lemoncelli, CPC-A
Katie Selvage, CPC-A
Katie Silverthorn, CPC-A
Katie Talus, CPC-A
Katrina A Miller, CPC-A
Katrina Furman, CPC-A
Katrina Jane Victorio, CPC-A
Kavitha E, CPC-A
Kayla Murphy, CPC-P-A
Kayla Tuchek, CPC-A
Keisha Wilson, CPC-A
Kelli Schall, CPC-A
Kelly Olsen, CPC-A
Kelly Elyse Akard, CPC-A
Kelsey Ross, CPC-A
Kerri Gibbar, CPC-A
Kerry Burrows, CPC-A
Kim Carol Velasco, CPC-A, CPB
Kim Lawrence, CPC-A
Kim Morris, CPC-A
Kim Stoddard, CPC-A
Kim Wheeler, CPC-A
Kimberly Renwrick, CPC-A
Kimberly Fleming Epperson, CPC-A
Kimberly Graham, CPC-A
Kimberly Shields, COC-A
Kirnav Obhrai, CPC-A
Kochurani Padannamakkal Thomas,
CPC-A
Kolli Swarna Latha, CPC-A
Kondampalli Priyanka, CPC-A
Kondoji Pravalika, CPC-A
Kris Kennedy, CPC-A
Krista Gugnacki, CPC-A
Kristel Powers, CPC-A
Kristen M Vicatos, CPC-A
Kristi Starry, CPC-A
Kristie Kammel, CPC-A
Kristie Walls, CPC-A
Kristin Kempinger, CPC-A
Kristin Milsap, CPC-A
Kristina Garis, CPC-A
Kristine Garcia, COC-A
Kristy Johnson, CPC-A
Kumar Anand, CPC-A
Kyshon Wright, CPC-A
Lakshmi Selvaraj, CPC-A
Lana Rutledge, CPC-A
Lara Beegle, CPC-A
Larisa Koinash, CPC-A
LaToya Tarpeh, CPC-A
Latrina Harris, CPC-A
Laura Fugate, CPC-A
Lauralee Holstege, CPC-A
Lauren Brady, CPC-A
Lauren Cupp, CPC-A
Lauren Lumley, CPC-A
Lauren Sightler, CPC-A
Laurie G Reich, CPC-A
Laurie Grigg, CPC-A
Lavanya Sriramoju, CPC-A
Lawrence Galero, CPC-A
Lea Ann Gervacio Arrogancia, CPC-A
Leah Aguiling, CPC-A
Leah Gravelle, CPC-A
Leana Leach, CPC-A
LeAnn Holland, CPC-A
Leann Steinert, CPC-A
Leeann Flanagan, CPC-A
Leslie Boles, CPC-A
Lilybeth Rivera, CPC-A
Linda Adcock, CPC-A
Linda LoPrete, CPC-A
Linda Tawfall, CPC-A
Linda Williams, CPC-A
Lisa M. Phillips, COC-A, CPC-A
Lisa Ryan, CPC-A
Lisa Tang, CPC-A
Lisa Wymer, CPC-A
Lisa Young, CPC-A
Liza Leon, CPC-A
Lola Sadiq, CPC-A
Lora Slack, COC-A
Loraine Marquez, CPC-A
Loren Pulaski, CPC-A
Loretta Baskys, CPC-A
Lori Adams, COC-A
Lori Mower, CPC-A
Lori Sarubbi, CPC-A
Lorna Glase, CPC-A
Louie Reyes, CPC-A
Lydia Colon, CPC-A
Lyn Rose Libre, CPC-A
M. Rithish Kumar, CPC-A
M. Venkata Krishna Babu, CPC-A
Ma Annaliza Mariano, CPC-A
Mackenzie Hertzler, CPC-A
Madhavi V, COC-A
Madhuri M, CPC-A
Mahesh Devaragottu, CPC-A
Mahesh Gunda, CPC-A
Maithreyee Padmanabhan, CPC-A
Maja Mercado, CPC-A
Manas Ranjan Mishra, CPC-A
Manju Bhargavi Amrutala, CPC-A
Manju Mariam John, CPC-A
Margaret Baker, CPC-A
Margaret Richards, CPC-A
Maria Hasmin Pacites Yap, CPC-A
Maria Lozano, CPC-A
Maria Nieves, CPC-A
Maria Wigfall, CPC-A
Marianne Swartzwelder, CPC-A
Marilyn Moffat, CPC-A
Marina Mishchenko, CPC-A
Marisa Kiefer, CPC-A
Marisela Cooper, CPC-A
Marjorie Aragoza, CPC-A
Mark Allan Lintag Saplala, CPC-A
Mark Rosen, CPC-A
Markeisha Suzelle Brailsford, CPC-A
Marly Molinary, CPC-A
Marlys Boyer, CPC-A
Marsha Caloro, CPC-A
Martha Lowrey-Monk, CPC-A
Mary Ann Ambert, CPC-A
Mary Ann Cayago, CPC-A
Mary Boom, CPC-A
Mary Haynie, CPC-A
Mary Huff, CPC-A
Mary Jhean Banez, CPC-A
Mary Joy Aala, CPC-A
Mary Koehler, CPC-A
Mary L Uber Shumway, CPC-A
Mary Louise Ciubal, CPC-A
Mary Stockman, CPC-A
Maryann Aucompaugh, CPC-A
Mathew Spilka, CPC-A
Maureen Ong, CPC-A
Mechelle Baker, CPC-A
Meenakshi Murari, CPC-A
Megan Brown, CPC-A
Megan Webber, CPC-A
Meghan Hoover, CPC-A
Meghan M Sabia, CPC-A
Meka Gayathri, CPC-A
Melanie Briggs, CPC-A
Melanie Fielder, CPC-A
Melanie Huffman, CPC-A
Melanie K Crowe, CPC-A
Melanie K Reed, CPC-A
Melika Singh, CPC-A
Melinda Masa, CPC-A
Melissa Orozco, CPC-A
Micah Swihart, CPC-A
Michael Bieber, CPC-A
Michele Whetstone, CPC-A
Michelle Bement, CPC-A
Michelle Cofer, CPC-A
Michelle Huchko Losapio, CPC-A
Michelle Ritter, CPC-A
Michelle Sabine, CPC-A
Michelle Sanders, CPC-A
Michelle Schueler, CPC-A
Mikerline Agnant, CPC-A
Misty Pingel, CPC-A
Misty Sweet, CPC-A
Mithra Nair, COC-A
Mohammed Abdul Mubeen, CPC-A
Mohanraj Perumal, COC-A
Mohd Sameer, CPC-A
Moire Daniel, CPC-A
Molly Cleary Merrill, CPC-A
Monaliza Evangelista, CPC-A
Monica Hurley, CPC-A
Monika Casey, CPC-A
Myco Jerome Cortes, CPC-A
Naga Vidyullatha Yadavalli, CPC-A
Nagavelli Ushasree, CPC-A
Naiya Dhiman, CPC-A
Najah Prescott, CPC-A
Nalla Karuna, CPC-A
Nalla Sudhakar, CPC-A
Naomi Olin, CPC-A
Nashira Emery, CPC-A
Natasha K Lewis, CPC-A
Nathaniel Carl Japos, CPC-A
Naushin Rajani, CPC-A
Navin Kumar Mishra, CPC-A
Nazia Begum, CPC-A
Neaus Sartorio, CPC-A
Ngwisang Anyangwe, CPC-A
Nichole Erickson, CPC-A
Nicki Brown, CPC-A
Nickie Padgett, CPC-A
Nicole L Cammarano, CPC-A
Nicole Bodden, CPC-A
Nicole Lavender, CPC-A
Nicole Posimato, CPC-A
Nina Kropp, CPC-A
Nina L Lee, CPC-A
Niya Craig, CPC-A
Noah Jan Madet, CPC-A
Norah Wilhelms, CPC-A
Olga Beronda Gomez, CPC-A
Pamela Davis, CPC-A
Pamela Holmes, CPC-A
Pathri Satyadurga, CPC-A
Pati Geurin, CPC-A
Patricia Gonzales, CPC-A
Patti Whitrock, CPC-A
Patty Dargie, CPC-A
Patty Ryal, CPC-A
Paul Benincasa, CPC-A
Paula Hulme, CPC-A
Paula Jones Highsmith, CPC-A
Peggy Warner, CPC-A
Pete Schwartzfisher, CPC-A
Ponny James, CPC-A
Pradeep Kumar Reddy. K, CPC-A
Prathyusha Lanka, CPC-A
Premalatha Thiruvengadam Valarpuram,
CPC-A
Pvn Suyosha, CPC-A
Rachael R Gerard, CPC-A
Rachel Cutshall, CPC-A
Rachel Ramirez, CPC-A
Rachelle Yago, CPC-A
Racquel Miranda Migraso, CPC-A
Rajeshwari Padmanabha, CPC-A
Rakesh Kumar Verma, CPC-A
Rama Bhadri Raju Gadiraju, CPC-A
Ramachandran G, CPC-A
Ramakrishna Govu, CPC-A
Ramel J Hanna, CPC-A
Ranjith Pasuparthi, CPC-A
Rashaunda Whitaker, CPC-A
Ravneet Virk, CPC-A
Ravula Rajesh, CPC-A
Rayna Price, CPC-A
Rebecca Johnson, COC-A
Rebecca Lanning, CPC-A
Reena Mahapatra, CPC-A
Rekha Kumarapillai, CPC-A
Renae Sanders, CPC-A
Rene Reyes, CPC-A
Renee Barbiere, COC-A, CPC-A
Renee Nally, COC-A
Renee Royse, CPC-A
Renessa Wiggins, CPC-A
Repala Prashanthi, CPC-A
Rhonda Bolden, CPC-A
Rhonda Kaye Taulton, CPC-A
Rhonda Sangster, CPC-A
Richard Callaham, CPC-A
Rita Givens, CPC-A
Robert Lenora, CPC-A
Robert Newton, CPC-A
Robin Baker, CPC-A
Robin Johnson, CPC-A
Robin Klemm, CPC-A
Romelia Garcia, CPC-A
Romona Adkins, CPC-A
Ron McDearis, CPC-A
Rosalie Quizon, CPC-A
Rose Ann Schoedel, CPC-A
Rosemary Ramkuri, CPC-A
Roxanne Bullock, CPC-A
Ruby Garza, CPC-A
Rudra Kumar, CPC-A
Ruel Orias, CPC-A
Ryan Jeska, CPC-A
S B. Rajyalakshmi, CPC-A
S. Sravanthi, CPC-A
Sabre R Turner, CPC-A
Sakthivelan Venugopal, CPC-A
Salli Fox, CPC-A
Samantha Garcia, CPC-A
Samantha Smith, CPC-A
Samantha Widener, CPC-A
Sambidi Anitha, CPC-A
Sameera Dhanani, CPC-A
Sandel Johnson-Dockery, CPC-A
Sandy Darylle Aquino, CPC-A
Sangeetha Punyakoti, CPC-A
Sara Hlavaty, CPC-A
Sara Jakicic, CPC-A
Sara Meyers, CPC-A
Sara Schmidt, CPC-A
Sarah Christ, COC-A
Sarah Fraas, CPC-A
Sarah Haywood, CPC-A
Sarah Kobus, CPC-A
Sarah Pena, CPC-A
Sarah Rapaka, CPC-A
Sarah Sell, CPC-A
Sateesh Ganta, CPC-A
Scott Richards, CPC-A
Serena Smelser, CPC-A
Shahira Kayou, CPC-A
Shakira Brown, CPC-A
Teresa Malpass, CPC-A
Teresa Martinez, CPC-A
Teri Brunette, CPC-A
Terri Ashton, CPC-A
Texie-Jane Sanders, CPC-A
Thabitha Lethakula, CPC-A
Theresa MacDonnell, CPC-A
Thomas Hodgkin, COC-A
Tiffany Kolinski, CPC-A
Timothy Blowers, CPC-A
Timothy Duckett, CPC-A
Tina Allred, CPC-A
Tommy Chanthalangsy, CPC-A
Tonya Whitlow, CPC-A, COSC
Tracey Cobaugh-Steele, CPC-A
Traci England, CPC-A
Tracie Jurgens, CPC-A
Tracy Indyk, CPC-A
Tracy Pasquarelli, CPC-A
Tracy Tierney, CPC-A
Trina Doss, CPC-A
V.K. Chaitanya, CPC-A
Valarmathi Venkatesan, CPC-A
Vallie Gaspard RHIA, CPC-A
Vanessa Armendarez, CPC-A
Veena Gowroju, CPC-A
Veerapuram Mamatha, CPC-A
Venkata Parimi, CPC-A
Venkata Suresh Kumar A, CPC-A
Venus Manjares Moyo, CPC-A
Vicki Lavonde DeSena, CPC-A
Vida Laura Opinaldo, CPC-A
Vidhya Karunakaran, CPC-A
Vidya Kv, CPC-A
Vijeesha Vijayan, COC-A
Virginia Lydigsen, COC-A, CPC-A
Virginia Nopia, CPC-A
Vivian Ghisi, CPC-A
Wendy Coffman, CPC-A
Wendy McClellan, CPC-A
Wendy Sherron, CPC-A
Wesley Thomason, CPC-A
Yashowanth Sairam Marripati, CPC-A
Yasmina M Lerma, CPC-A
Yenit Rodriguez, CPC-A
Yesenia Robinson, CPC-A
Ysj. Arun Reddy, CPC-A
Yvette Jimenez, CPC-A
Zaiba Thaseen Mir, CPC-A
Shamyra Johnson, CPC-A
Shannon D Railsback, CPC-A
Shannon Marion Collier, CPC-A
Shanthi Andugula, CPC-A
Shari Kellen, CPC-A
Shari McQuinn, CPC-A
Sharisa Freeman, CPC-A
Sharon Etorma, CPC-A
Sharon Long, CPC-A
Sharon Stoy, CPC-A
Shatrudeen Ramnarine, CPC-A
Shavon Williams, CPC-A
Shawn A Blackburn, CPC-A
Shawn Helie, CPC-A
Shawn Ishihara, CPC-A
Shea McDaniel, CPC-A
Sheila Nelson, CPC-A
Sheniqua Maefau, CPC-A
Shereena K, CPC-A
Sheri Wilson, CPC-A
Sherri Hasner, CPC-A
Shivaranjani Narayana, CPC-A
Siddhanta Mishra, CPC-A
Sigrid Geissler, CPC-A
Smita Nair, CPC-A
Snigdhasmita Tripathi, CPC-A
Sonia Pacheco, CPC-A
Sonia Sirianni, CPC-A
Sonia Soman Thomas, CPC-A
Sonia Stelly, CPC-A
Soumya Alex, CPC-A
Spencer Weissman, CPC-A
Srinija M, CPC-A
Sriperambudur Manjula, CPC-A
Sripriya Arun kumar, CPC-A
Stacey Williams, CPC-A
Stacie Van Der Bosch, CPC-A
Stacy Swanberry, CPC-A
Stephanie Brook, CPC-A
Stephanie Mannes, CPC-A
Stephenie Myers, CPC-A
Sugam Sharma, CPC-A
Sully Lizbeth Avila, CPC-A
Sunchikala Sandeep, CPC-A
Sunil Kumar Yadav, CPC-A
Suresh V, CPC-A
Susan Hayward, CPC-A
Susanna Madrit, CPC-A
Suzanne Ferrenberg, CPC-A
Suzonne Vickers, CPC-A
Swaminath Digambaranath, COC-A
Syed Abdul Razzak, CPC-A
Sylvia Graft, CPC-A
T.V. Uma, CPC-A
Tami Olson, CPC-A
Tammy McKim, CPC-A
Tandy Causey, CPC-A
Tanya Kilgore, CPC-A
Tanya Stipe, COC-A
Tara Schaller, CPC-A
Tasha King, CPC-A
Taundra Roddick, CPC-A
Tejaswy Kasturi, CPC-A
Teresa Peres, CPC-A
Teresa Harper, CPC-A
Aimee Wilcox, CPMA
Aisha Nicole Hargrave, CPCO
Allison Lee Morgan, CPC, CPCO, CPMA
Alma Rackard, COC, CPMA
Alyson Ann Majtan, CPC, CPMA
Amanda Kane, CPC, CPMA, CEMC,
COBGC
Amber Stephens, CPB
Amy Baker, CPC, CCC, CEMC
Amy Rowe, CPC, CPMA, CRC
Ana Teresa Lores, CPB
Andrea Hunemuller, CPMA, CEMC
www.aapc.com
May 2016
Specialties
63
Angela Margaret Hickman, CPC, CPMA,
CEDC
Angela Snyder, CHONC
Ann Silvia, CPC, CPCO, CPB, CPMA,
CPPM, CPC-I, CANPC, CEMC, CFPC
Antoinette Nicole Branch, CPC, CEMC
Antonio Garfield Fraser, CPC, CPMA,
CEDC, CEMC, CRC
Anusree C S, CPMA
April Danish, CHONC
April Parish, CPC, CRC
Aprille Ruiz, CPC, CPB
Arlene Aquino, CIRCC
Aryana Sengezer, CPC-A, CRC
Ashley Kinsey, CPC, CPCO
Asia C Massey, CPC, CPMA
Barbara Peress, CPCO, CPCD
Barbara Scaboo, COC, CPC, CPB
Barbie Isham, CRC
Baskar Sivaprakasam, CPC, CPMA,
CANPC
Bonnie S Peters, COC, CPC, CPC-I, CRC
Brandi Couret, CPC, CPB, CEMC
Brandy Martin, CPC, CPPM
Brandy Schiller, CPC, CPMA
Brenda Anderson, CPC-A, COBGC
Brenda LaChance, CPPM
Brenda Orr, CEMC
Brenda Rongkawit, CPC-A, CPB
Brian Pease, COC-A, CGSC
Bridget Miller, CPC, CCC
Brooke White, CPC, CPB
Bryan Donald Gilpin, CPC, CPCO, CPPM
Bryan Lounsberry, CCC
Cara L Crawford, CPC, CPMA, CRC
Cara Obritz, CPB
Carol Motley, CPC, CPCO
Carol Wigant, COC, CPC, CPMA
Catherine Sovacool, CPC, CPMA
Cathy Kaiser, CPC, CPMA
Charle Titular Lubang, CPC-9-A
Charlene Hutchinson, CPC, CPMA
Chelsea Quay, CPC-A, CEMC
Christine K Cintron, CPC-A, CPB
Christopher Taylor, CPC-A, CUC
Cindy Rae Bondurant, CPC, CPMA, CEMC
Clairissa Gillespie, CPC-A, CPMA, COBGC
Clarice Rilinger, CPC, CPB
Cori Bowmer, CPC, CPMA, CPPM, CFPC,
CRC
Cynthia D Stacy, CPC, CPMA, CPC-I, CRC
Damaris Ramirez, MS, COC, CPC, CPB,
CPMA, CPPM, CPC-I
Damarys Ayala, CPMA, CRC
Dana Drinkard, CPPM
Dana Lee Shade, COC, CPC, CPC-P,
CPMA
Daniel Le, CPB
David Zetterman, CPC-A, CFPC
Dawn Chapman, CPC, CPMA
Dawn Lewis, CPMA, COSC
Dawn Ward, CPC, CPMA
Deana Marie Ryan, CRC
Deborah J Nall, CPC, CRC
Debra Whitehurse, CPC, CPMA
Decarla Sharee Hopson, CPPM
64
Deirdre Thomas, CPC, CPMA
Delores Ann Terry, CPC, CRC
Denise Arrowood, CPB
Denise Bastyr, CPC, CRC
Denise E Taylor, CPC, CPMA, CEMC,
CGSC
Diane Bomba, CPC, CRC
Dianna Cowles, CPC-A, CPB
Dolmaya Thogra, COC-A, CIRCC, CPMA
Dolores O. Tenney, CPC, CRC
Donna Marchesani, CPC, CPCO
Donna Marie Evans, CPC, CPCD
Donna Parker, CPC, COSC
Doret Lyn DeBarros, CPC, CEDC, CEMC
Edward Townley, CPC, CPC-I, CEMC, CUC
Elaine Joy Dimla Capulong, COC, CPC,
CPMA
Elizabeth A Shelton, CPC, CGSC
Elizabeth Garriques, CPC-A, CEMC
Ellen Ryan, CPB
Emily Smith, COC-A, CFPC
Erin Michelle Luke, CPC-A, CPMA
Erwin Duran, CPC, CPMA, CEMC
Evans Hollie, CPB
Fara Castillo, CPC, CPMA, CRC
Florisa Oide Sim, CPC-9-A
Geraldine Weidner, CIRCC
Ginger Flemons, COC-A, CPB
Gladish Stanly, CPC-9-A
Guadalupe Mena, CPC, CRC
Gwen N Price, CPC, CPMA
Harikumar Ramanujan Nair, CPC-9
Haritha Pasupula, CRC
Hayley Summers, CPPM
Heath Seacrist, CPC, CPB, CEMC
Heather B Rice, CPC, CPMA
Heather Dwyer, CCC
Heather Fury, CPC, CPB
Heather Nicole Couch, CPC, CPMA
Heidi Burrows, CPPM
Helen M Shock, CHONC
Helen Yde Brown, CPC, CRC
Hima Bindu, CRC
Holly A Scheaffer, CPC, CPMA, CEMC
Hsiaoyun Tsai, CPB
Irina Verdiyan, CHONC
Jacob Haviland, CPB
Jacque Lynette Weaver, CPC, CPCO,
CPMA
Jamell Richmond, CPC, CPB
Jamsheer C, CPC-9-A
Jane Parrish, CPC, CPMA
Janelle Marie Quick, CPC, CPCO, CPMA,
CGSC
Janet Norton, CPC, CRC
Janine Bickell, CPC, CPMA
Jasmin Johnson, CPC, CPB
Jeanene D Johnson, CPC, CPB, CPPM
Jeannine D Monagle, CPC, CPMA
Jennifer C Williams, CPC, CPMA
Jennifer Councilor, CPC, CEMC
Jennifer Knox, COC, CEDC
Jennifer Pare, CPC, CPB
Jennifer Vasquez, CPC, CEMC
Jessica DeBoever, CPB
Jessica Martensen, CPPM
Jittu Merin John, CPC-9-A
Jodi Smith, CPC, CPCO
Joe Simonich, CPCO
Judy Uzubell, CPPM
Julie Ann Erickson, CPC, CPMA, CEMC
Julie Ann Kemman, CPCO
Julie McDaniel, CPC, CANPC
Julie Otten, CPC, CPMA
Julie Pisacane, CPMA, CPPM, CEMC
Julie Shaunnessey, CPB
Kamalam Sasikumar, CPC-9-A
Karen A Semperger, CPC, CPMA
Karen Browning, CPC, CPMA, CIMC
Karen Cannon, CPC-A, CRC
Karen Chappell, CIRCC, CPMA
Karen F Perry, CPC, CPB, CPC-I
Karen Hale, CPC, CPCO
Karen M Richardson, CPC, CPMA, CPPM
Karen Mills, CPC, CGIC, CGSC
Karen Mitchell, CPC, CEMC
Karen S Sweeney Leighton, CPC, CPMA
Karen Soukup, CHONC
Karina Blanton, CPC, CPMA
Kasenya Jenkins, CPC-A, CPB
Katelyn Felter, CPC, CEMC
Kateri Montano, CIRCC
Katherine Wright, CPC, CPMA, CHONC
Kathleen Archer, COC, CPC, CRC
Kathleen Marshall, CPC, CEMC
Kathleen R Rhodes-Riker, CPC, CPMA,
CPPM, CCC
Kathy Britt, CPC, CPMA
Katie Lynn Johnson, CPC, CRC
Keileigh Neugebauer, CPCO
Kelli Bentley, CPC, CENTC
Kelly Lambert, CPB
Kelly Patrician, CPC, CPPM
Ken Ferguson, CPC, CPCO
Kimberly Nichols, CPC, CPB
Kris Knaus, CPC, CRHC
Kristen Briscoe, CPC, CANPC
Kristen Hurst, CPC, CPMA, CEMC, CGSC,
COSC, CSFAC
Kristine Cooper, CPMA, CPPM
Kurt DeGroot, CPC-A, CHONC
Kyle Wayne Johnson, CPCO
LaDonna Faye White, CPC, CPMA
Laja McGee, CPC, CEMC
LaShaune Nicole Hardin, CPC, CPMA
Latanya Michelle McNair, CPC, CPCO
Laura Jenkins, CPC, CCC
Laura Malytska, CPB
Laura Mitchell, CRC
Lauren Polk, CPCO
LeAnne Elaine Warner, CPC-A, CEMC
Lemay Harkins, CPC, CRC
Le-Nhung Nguyen, CPMA
Lindsay Sobczak, CPC-A, CPB
Lisa Louise Fisher, CPC, COBGC
Lisa Turner, CPB
Lisa V Scott, CPC, CPCO
Loretta Tummino, CPC-A, CPMA
Lori Ann Cajka, CPC, CPMA
Lori Bruggemann, CPB
Lori J Kessel, CPC, CCC
Lori Lynne Stuart, CPPM
Lorie B Pearce, CPC, CRC
Loytia Scott, CRC
Lucretia Bruce, CPB, CPPM
Lynette Laney, CPC, CPMA, CEMC
Magee Xavier, CPC, CRC
Malarvizhi Pannerselvam, CPC, CRC
Malinda R Stanley, CPC, CPB, CPC-I
Marie Morin, CRC
Marilyn Glidden, CPC, CPCO, CPMA,
CGIC, CGSC
Marissa L Davis, CPC-A, CPB
Martha Patton, CHONC
Mary Beth Wohleber, CPC, CRC
Mary Christon, CPC, CEMC
Mary Graves, CPC, CPMA
Mary Nass, CPC, CRC
MaryJo Groome, COC, CRC
Maylene Felicia Rivero, CPC, CPMA,
CEMC
Mayra Hernandez-Rodriguez, CPC, CPMA
Megan Beasley, CPC, CPMA
Megan Sorensen, CPMA
Meghan Wilson, CPB
Melania Isabel Cristobal, CPC, CEMC
Melissa Ann Schneider, CPC, CPMA,
CCVTC, CEMC
Melissa Arnold, CPC, CPCO
Melony Eriksen, CPC, CPMA
Michael Alan Carpenter, CPC, CIRCC, CPB,
CGSC, COSC
Michael Askounes, CPB
Michelle Taylor, CPC, CPB
Miguel Fana, CPC, CPCO, CPMA
Mona Bedros, CPC-A, CRC
Monica Fell, CHONC
Mulikat Ademiluyi, CPC, CPB
Nadeth Yexenia Blake, CPC-A, CEMC
Nancy Thompson, CPC, CEMC
Neva Sue Hoffman, CPC, CEMC, CFPC
Nicholas Kreitz, CEDC
Nicolas Joye, CPMA
Nicole McGuire, CPC, CPMA
Nicole Wocelka, CPCO
Pamela Dalesandro, CPB
Pamela J Amend, CPC, CRC
Penka Dringova, CPC, CPCO, CPMA,
CCC, CEMC, CGIC, CGSC, CIMC
Peter V Rossow, CPC-A, CPMA
Piyush Sheth, CGSC
Pradeepa Thanthoni, COC, CPMA, CRC
Priyadharsini Ganapathy, CPC-9-A
Rajalakshmi Gopalakrishnan, CPC, CRC
Rebecca Holcombe, CPB
Rebekah K Stone, CPC, CPMA
Regina Hoffman, CPC-A, CPMA, CRC
Regina Kay Miller, CPC, COSC
Regina Pearson, CPB
Rene Lopez Roman, CPC, CPMA, CRC
Ricardo Clark, CPC-A, CPMA
Ricardo Jose Perez, CPC, CPMA
Risa Ann Morse, CPB
Rita Osei-Obeng, CPPM
Robbie Storla, CPB
Robin Cumbie, CCC
Robin L Zink, CPC, CPPM
Robin Slacks, CEDC
Robyn Marcotte, CPC, CPB
Rosey Rupp, CPC, CPPM
Sabira Begum Ahmed Khan, COC, CPMA
Samantha Deseth, CPCO
Samantha Steach, CRC
Samna Shameer, CPC-A, CPMA
Sandie Felice, CPC, CPPM
Sanjeevi Rengasamy, CPC, CPMA
Sara Kavanagh, CHONC
Sharon McKay, CPMA
Sharvari Upendra Patel, COC, CPC,
CPMA, CRC
Sheba Vine, CPCO
Sheila Heiman, CPC, CPMA
Sheri VerSteeg, CRC
Sherry Ellis, CPC, CPMA
Shervonne L Walker, CPC, CEDC
Shirley Lawrence, CPB
Sibylle L Friberg, CPC, CPB
Somersette Black, CPCO
Stacey Amick, CPC-A, CRC
Stacey Dodd, CPC, CPPM, CGSC, COBGC
Stacey Marie Torturica, CPC, CPMA
Stefanie Werner, CPC, COBGC
Stephanie A Hindman, CPC, CPPM
Stephanie Bartlett, CEDC
Steve Fleming, CPB
Sue Bolton, CPC, CPB
Sumana Sathar, CPC-9-A
Sumerta Ochani, COC-A, CPC-A, CPMA
Sunitha Penny, CPC, CPMA
Susan Mary York, COC, CPC, CPB
Susan Pakulski, CRC
Swathi Praveen, CPC, CRC
Tammy Comfort, CPC, CPB, CPPM
Tammy Shepherd, CPC-A, CPB, CEMC
Tara Pankus, CGIC
Taran Moffett, CRC
Tatyana Fishman, CPC, CPMA
Teresa Anne Dervie, CPC, CPMA
Teresa C Powers, CPC-A, CPMA
Theresa Chevallier, CPB
Tim Lewis Dehnhoff, CRC
Tony Pookekudiyil, CPC-A, CRC
Traci Gillispie, CRC
Tracy L Coccia, CPC-A, COBGC
Tricia Touchstone, CPC, CFPC
Varghese George, CPC, CPMA
Vickie Wertz, CFPC
Wei Xiong, CPCO
Weigong He, COC-A, CPC-A, CPC-P-A,
COSC
Wendy Willes, CEA, COC-A, CPC-A, CPB,
CPC-I, CIC
Wendy Willes, CEA, COC-A, CPC-A, CPB,
CPC-I, CIC
William Bigge, CPC, CPMA
Yanelis Trujillo, CPC, CRC
Yarianny Torres Bravo, CRC
image by iStockphoto © levoncigol
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terms and acronyms:
BP Blood pressure
CC Chief complaint
ENT Ear, nose, throat
HPI History of present illness
HTNHypertension
MDM Medical decision making
NAD No apparent distress
NEC Not elsewhere classified
NOS Not otherwise specified
PFSH Past medical, family and social history
ROS Review of systems
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May 2016
65
Minute with a Member
D. Mina Monet, CPC
Medical Billing and Coding Specialist, Curative Care Network
Tell us a little bit about how you got into coding, what you’ve done during your coding career, and where you work now.
I got involved in coding when I started working as a utilization management representative
for Healthlink, an insurance company under
the WellPoint umbrella. I became familiar with
diagnosis, CPT®, and HCPCS Level II codes
when I started processing pre-authorizations
for Healthlink. While working there, I completed my associate’s degree in Health Information Technology. Several months later, a colleague I met at a networking event encouraged
me to sit for the Certified Professional Coder
(CPC®) exam. I purchased the practice exams in
May 2014 and studied them daily. In the meantime, I was hired as an anesthesia coder for Infinity Healthcare. I am thankful they hired me,
but I was paid at a lower pay rate because I wasn’t
certified. In August 2014, I passed the exam on
the first try. I began looking for coding jobs that
would pay me as a certified coder. I was hired as
the billing and medical coder at Curative Care
Network, where I work today.
What is your involvement with your local
AAPC chapter?
Although I am unable to attend chapter meetings, I always check the latest notes and minutes
from the most recent meetings on the AAPC
website.
What AAPC benefits do you like the most?
I love the member savings section on AAPC’s
website, the member magazine Healthcare Business Monthly available online, and the online forums.
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the business of healthcare, we want to know about it!
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66
How has your certification helped you?
Certification has helped me to feel proud of my
accomplishments, and it has helped me to be
paid at a much higher rate than if I wasn’t certified.
Do you have any advice for those new to coding and/or those looking for jobs in the field?
Do not be discouraged by obstacles that stand
in your way, and believe in yourself. I studied every day for two months before I sat for the CPC®
exam. I faced a lot of challenges in my life that almost made me give up. Getting certified is worth
it, so stay positive and do not be afraid of challenging yourself.
What has been your biggest challenge as a
coder?
My biggest challenge was working around people who had been coding for many years and
who had more knowledge and experience than
I did. I had to believe in myself and push past
doubt and negativity.
If you could do any other job, what would it
be?
I would be a travel agent. I love to travel, and
maybe I would be able to get free trips and travel perks.
How do you spend your spare time? Tell us
about your hobbies, family, etc.
I like to play video games and spend time with
my two boys, who are 11 and 16.
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Coding | Billing - Amazon Web Services

Transcription

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