Destination Counts in a Catheter`s Journey

Transcription

November 2010
Destination
Counts in a
Catheter’s
Journey
Kimberly Engel, CPC
Atlanta, Ga.
Plus:
Scribing • Biopsy • Signature Requirements • U.S. v. Stokes • PQRI
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contents
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[contents]
November 2010
In Every Issue
7Letter from the President and CEO
8 Coding News
10 Letters to the Editor
13 Letter from Member Leadership
26
Features
14 Scribing: A Very Old and Up-to-date Profession for Coders
Jim Strafford, CEDC, MCS-P
16 Understand Medicare Physician Supervision Requirements
G. John Verhovshek, MA, CPC
20 Why the New Signature Requirements Emphasis?
Lynn S. Berry, PT, CPC
22 Report Transforaminal Epidural Injections With Precision
G. John Verhovshek, MA, CPC
26 In the Journey Through Vessels - Code Destinations, Not Waypoints
Kimberly Engel, CPC
28 Op Reports Show How to Code Selective Catheter Placement
Nancy G. Higgins, CPC, CPC-I, CIRCC, CPMA, CEMC
30 Registries May Offer Advantages for PQRI Reporting
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC
34 U.S. v. Stokes: Compliance Implications for the Average Physician
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CHCC, CRA
Education
Online Test Yourself – Earn 1 CEU
go to www.aapc.com/resources/
publications/coding-edge/archive.aspx
12Synergize Your Local Chapter
Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC
44Experience Is the Best Teacher
Ken Camilleis, CPC, CPC-I
46Don’t Change the Code
Pam Brooks, CPC, PCS
People
25 KUDOS
38 Newly Credentialed Members
50 Minute With a Member
Coming Up
CPT® 2011
43 Bundled or Separate Biopsy Depends on Circumstances
Vicarious Trauma
Springfield Regional Conference
Brad Ericson, CPC, COSC
48 Consult Your Payer for Consult Guidelines
Lindsey H. Daly, MSHA, CPC
On the Cover: Kimberly Engel’s, CPC, travels start at the Cartersville Airport in Atlanta, Ga.,
ES
CH A NG
G
COMIN
JA N . 1
Distinguish 78 from 58, 79
Customer Complaints
and much like the selective catheter’s journey through blood vessels, it’s the destination, not the
journey, that matters. Cover photo by Connie Locklear (www.locklearphotos.com).
www.aapc.com
November 2010
3
Serving 98,000 Members – Including You
Serving AAPC Members
The membership of AAPC, and subsequently the readership of Coding Edge, is quite
varied. To ensure we are providing education to each segment of our audience, in
every issue we will publish at least one article on each of three levels: apprentice,
professional and expert. The articles will be identified with a small bar denoting
knowledge level:
APPRENTICE
Beginning coding with common technologies, basic anatomy and
physiology, and using standard code guidelines and regulations.
PROFESSIONAL
More sophisticated issues including code sequencing, modifier
use, and new technologies.
EXPERT
Advanced anatomy and physiology, procedures and disorders
for which codes or official rules do not exist, appeals, and payer
specific variables.
November 2010
Chairman
Reed E. Pew
[email protected]
President and CEO
Deborah Grider,
CPC, CPC-I, CPC-H, CPC-P, COBGC, CPMA, CEMC, CPCD, CCS-P
[email protected]
Vice President of Marketing
Bevan Erickson
[email protected]
Vice President, Business Development
Rhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTC
[email protected]
Directors, Pre-Certification Education and Exams
advertising index
Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC
[email protected]
Katherine Abel, CPC, CPMA, CPC-I, CMRS
[email protected]
American Medical Association .............p. 24
www.amabookstore.com
Vice President, Post Certification Education
American Society of Health
Informatics Managers . ....................... p. 41
http://ashim.org
Director of Editorial Development
Central Florida Health Alliance .......... p. 43
www.CFHAlliance.org
Brad Ericson, MPC, CPC, COSC
[email protected]
Danielle Montgomery
[email protected]
Coding Conferences LLC .................... p. 9
www.CodingConferences.com
The Coding Institute, LLC .............p. 11, 15
www.SuperCoder.com
CodingWebU . ...................................... p. 51
www.CodingWebU.com
Contexo Media .................................... p. 2
www.contexomedia.com
HeathcareBusinessOffice LLC ............ p. 19
www.healthcareBusinessOffice.com
Ingenix . ............................................... p. 47
www.shopingenix.com
Medicare Learning Network® (MLN)...... p. 42
Official CMS Information for Medicare Fee-For-Service Providers
www.cms.gov/MLNGenInfo
NAMAS/DoctorsManagement ............ p. 52
www.NAMAS-auditing.com
PMIC ................................................... p. 5
http://PmicOnline.com
David Maxwell, MBA
[email protected]
John Verhovshek, MA, CPC
[email protected]
Directors, Member Services
Senior Editors
Michelle A. Dick, BS
[email protected]
Renee Dustman, BS
[email protected]
Production Artist
Tina M. Smith, AAS Graphics
[email protected]
Advertising/Exhibiting Sales Manager
Jamie Zayach, BS
[email protected]
Address all inquires, contributions and
change of address notices to:
Coding Edge
PO Box 704004
Salt Lake City, UT 84170
(800) 626-CODE (2633)
© 2010 AAPC, Coding Edge. All rights reserved. Reproduction in whole or in part, in any
form, without written permission from the AAPC is prohibited. Contributions are welcome.
Coding Edge is a publication for members of the AAPC. Statements of fact or opinion
are the responsibility of the authors alone and do not represent an opinion of AAPC,
or sponsoring organizations. Current Procedural Terminology (CPT®) is copyright 2009
American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
values or related listings are included in CPT®. The AMA assumes no liability for the data
contained herein.
CPC®, CPC-H®, CPC-P®, and CIRCC® are registered trademarks of AAPC.
Volume 21 Number 11
November 1, 2010
Coding Edge (ISSN: 1941-5036) is published monthly by AAPC, 2480 South 3850 West, Suite B. Salt
Lake City, Utah, 84120, for its paid members. Periodical postage paid at the Salt Lake City mailing office
and others. POSTMASTER: Send address changes to:
Coding Edge c/o AAPC, 2480 South 3850 West, Suite B, Salt Lake City, UT, 84120.
4
AAPC Coding Edge
CODING &
COMPLIANCE
bO O ks, fO r M s A N d s O f t wA r E
2011
AAPC MEMBERS SAVE 25%–50%
ON ALL PMIC PUBLICATIONS!
Order your 2011 coding and
compliance books with PMIC by
November 30th for a chance to
win a brand new smart car.
It’s
to order from PMIC.
1-800-MED-SHOP • PmicOnline.com
www.ProfitableUse.com
When Meaningful Use is not enough.
letter from the president and CEO
Analyze Your
AAPC Membership’s Value
Unlike family and friends, material possessions can often be replaced. Perhaps that is
why we sometimes take them for granted.
We forget that insurance only covers the
face value of our assets, and much of what
we possess holds far more value than the
original price tag.
Can You Put a Price
on Your AAPC Membership?
Your AAPC membership, regardless of the
credential(s) you hold, has tremendous value
in the health care industry. AAPC credentials are the “gold standard” of our industry
and AAPC education and services outmatch
others in our field and can't be replaced.
There are three membership types: individual, student, and corporate (which varies by
number of members). Let’s look at what is
included in your membership and the yearly
value of these services:

Coding Edge magazine subscription 12
issues ($99.95)

Free ICD-10 resources including the
implementation Benchmark Tracker
(www.aapc.com/memberarea/ICD10/
Default.aspx), the ICD-10 Code
Translator (www.aapc.com/ICD-10/
codes/index.aspx), articles, and other
tools helpful for implementation
($500.00 value)

Member savings for code books ($122.90
and more on code book bundles)

ICD-10 Connect newsletter (www.aapc.
com/resources/publications/icd-10-connect-subscribe.aspx ) ($25.00)

Billing Insider newsletter (www.aapc.
com/resources/publications/billinginsider-subscribe.aspx ) ($25.00)

Free continuing education units (CEUs)
in Coding Edge ($120.00 per year)

Local chapter meetings/networking
opportunities along with CEUs ($90.00)

National and regional conferences (sav
ings of approximately $200.00 more
than conferences in the industry)

Low cost webinars and workshops
($50.00 savings over other organizations)
Here are some AAPC member benefits you
cannot put a price on:

Lobbyist representation in Washington

AAPC representative on the CPT® Edi
torial Panel

AAPC EdgeBlast

AAPC News and Updates (news.aapc.com/)

Access to member forums

Access to Members Savings Benefits
connection (www.aapc.com/resources/
member-benefits.aspx ) (savings on
name brand stores, items, and services
from 5-20 percent)

Member savings on other resource
materials, which varies by publication
(10-20 percent)

Grocery coupons and more (savings vary)
AAPC membership is priceless. You can’t
put a price on knowledge, networking,
and building friendships. I hope you are as
proud as I am to be a member of AAPC.
We will continue to expand services to you
in the coming years and hope you take
advantage of what AAPC has to offer.
Let’s Give Thanks
On a final note, it’s the time of year to
count your blessings and give thanks for all
that is irreplaceable. Take time to be kind
to those you hold most dear, and extend a
helping hand to others. Set aside some quiet
time and share it with a friend who brings
you special joy.
Until next month, my friends.
Sincerely,
Deborah Grider,
CPC, CPC-H, CPC-I, CPC-P, CPMA,
CEMC, COBGC, CPCD, CCS-P
AAPC President and CEO
www.aapc.com
November 2010
7
coding news
coding news
Coordination and Maintenance Committee
meeting, which only recently were finalized.
The changes go into effect Oct. 1.
Here is a key to the changes:
 = New  = Revised Deleted
New text in revised codes is underlined
Deleted text in revised codes is crossed out
Neoplasms: Neoplasm of Uncertain
Behavior of Endocrine Glands and Nervous System
 237.79 Other neurofibromatosis
Rationale: This code joins 237.73
Schwannomatosis as a new code effective Oct.
1. Neurofibromatosis (NF) describes a set of
distinct genetic disorders that cause tumors
to grow along certain nerves. NF also can
affect the development of non-nervous tissues such as bones and skin and is recognized in ICD-9-CM by subcategory 237.7
Neurofibromatosis. There is fifth digit specification for type 1 (von Recklinghausen’s
disease) and type 2 (acoustic neurofibromatosis). Schwannomatosis (237.73) recently
was recognized as a distinct (although rare)
form of NF, in which patients have multiple
Schwannomas on cranial, spinal, and peripheral nerves; however, they do not develop
vestibular tumors and do not go deaf as in
the type 2 NF.
The American Academy of Neurology recommended the new code for “other” neurofibromatosis to be reported with 237.79
(NOT 237.78).
Special Symptoms or Syndromes, Not
Elsewhere Classified
New ICD-9-CM Changes,
Effective Oct. 1
Additional changes have been made to
ICD-9-CM that were not available at the
time the Coding Edge article “ICD-9-CM for
2011 Aimed at Diagnostic Specificity” was
written for the September issue.
The Centers for Disease Control and Prevention (CDC) discussed changing specific
diagnosis codes at the March ICD-9-CM
8
AAPC Coding Edge
listing. Continue to report fluency disorder
as a late effect of cerebrovascular accident
with 438.14 Late effects of cerebrovascular
disease, fluency disorder. These revisions, supported by the American Speech-LanguageHearing Association (ASHA) and the
American Psychiatric Association (APA),
better capture the nature and description of
fluency disorder.
Specific Delays in Development: Speech
or Language Disorder
 315.35 Childhood onset fluency disorder
Rationale: Code descriptors have been
modified to distinguish adult onset fluency
disorder (see revised code 307.0), childhood
onset fluency disorder, and fluency disorder
subsequent to brain lesion or disease (such as
neurologic disorders or late effects of traumatic brain injury—see new code 784.52
below). Codes 307.0 and 315.35 include stuttering and/or cluttering, as explained by new
“includes” notes in the ICD-9-CM tabular
listing. Continue to report fluency disorder as
a late effect of cerebrovascular accident with
438.14. These revisions, supported by the
American Speech-Language-Hearing Association (ASHA) and the American Psychiatric
Association (APA), better capture the nature
and description of fluency disorder.
Influenza Due to Certain Identified
Influenza Viruses
488.0 Influenza due to identified avian influenza virus
 488.01 Influenza due to identified avian
influenza virus with pneumonia
 488.02Influenza due to identified avian
influenza virus with other respiratory
manifestations
 307.0 Stuttering Adult onset fluency disorder
disorder, childhood onset fluency disorder
(see new code 315.35), and fluency disorder
subsequent to brain lesion or disease (such as
neurologic disorders or late effects of traumatic brain injury—see new code 784.52
below). Codes 307.0 and 315.35 include stuttering and/or cluttering, as explained by new
“includes” notes in the ICD-9-CM tabular
 488.09Influenza due to identified avian
influenza virus with other manifestations
488.1 Influenza due to identified novel H1N1
influenza virus
 488.11Influenza due to identified novel H1N1
influenza virus with pneumonia
influenza virus with other respiratory
manifestations
Project1:CodingEdge Ads 8/13/10 12:03 PM Page 1
coding news
influenza virus with other manifestations
Rationale: Codes 488.0 and 488.1 do not
provide additional code specification under
category 487 Influenza. Codes 488.0 and
488.1 were expanded to match the codes at
487. This allows for greater specificity and
consistent coding of all forms of influenza
with pneumonia. A review also has occurred
for all ICD-9-CM tabular instructional
notes related to categories 487 and 488.
Symptoms Involving Head and Neck:
Other Speech Disturbance
784.52 F
luency disorder in conditions classified
elsewhere
disorder (revised code 307.0), childhood onset
fluency disorder (new code 315.35), and fluency disorder subsequent to brain lesion or
disease such as neurologic disorders or late
effects of traumatic brain injury (784.52).
Fluency disorder as a late effect of cerebrovascular accident continues to be reported
438.14. These revisions, supported by the
American Speech-Language-Hearing Association (ASHA) and the American Psychiatric
Association (APA), better capture the nature
and description of fluency disorder.
Need for Isolation and Other
Prophylactic or Treatment Measures
 V07.51Prophylactic uUse of of selective estrogen receptor modulators (SERMs)
 V07.52Prophylactic uUse of aromatase inhibitors
 V07.59 P
rophylactic uUse of other agents affecting estrogen receptors and estrogen levels
 V07.8Other specified prophylactic
or treatment measure
Rationale: Descriptor wording has been
modified to represent better the intent of
the codes, to include treatment as well as
prophylactic (preventive) measures.
You can find a summary of the March
9-10 ICD-9-CM Coordination and
Maintenance Committee meeting agenda
and discussion at: www.cdc.gov/nchs/data/
icd9/TopicpacketforMarch2010.pdf.
Access the resulting ICD-9-CM tabular
addenda effective Oct. 1 on the CDC
website: www.cdc.gov/nchs/data/icd9/
icdtab10add.pdf.
Find the resulting addenda list of
ICD-9-CM Index to Diseases changes,
effective Oct. 1, at: www.cdc.gov/nchs/data/
icd9/icdidx10add.pdf.
 V07.9Unspecified prophylactic or treatment
measure
www.aapc.com
November 2010
9
letters to the editor
Letters to the Editor
Cyclops Lesion: A Complication
of Anterior Cruciate Reconstruction
I have several comments and questions regarding the article
“Arthroscopic Gems: Hints for Accurate Coding” (Coding Edge
September 2010, pages 26-28):
In 2004, the American Academy of Orthopedic Surgeons (AAOS) defined areas of the shoulder similar to
compartments of the knee. AAOS defined those areas as
glenohumeral, acromioclavicular, and subacromial. This
information would have been a good addition to the reference on shoulder arthroscopic procedures.
When referencing the open procedures 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute, 23412
Repair of ruptured musculotendinous cuff (eg, rotator cuff) open;
chronic, and 23420 Reconstruction of complete shoulder (rotator)
cuff avulsion, chronic (includes acromioplasy) versus arthroscopic
29827 Arthroscopy, shoulder, surgical; with rotator cuff repair,
I am not sure that 23420 should fall into this category
because 23420 is a reconstruction, rather than a repair procedure of the rotator cuff.
The author indicates that the open procedures “differentiate
between whether the tear is acute or chronic or how many
tendons are repaired.” I do not note the number of tendons
in any of the listed codes. Code 23420 does state “complete;” however, I have never found a reference as to “complete” meaning all four tendons. If such a reference exists,
where can I find it?
Lastly, when referencing debridement of a cyclops lesion,
the author states that this lesion occurs after total knee
replacement procedures. The cyclops lesion develops as a
complication after anterior cruciate reconstruction, not commonly after total knee replacement procedures.
Ruby O’Brochta-Woodward, BSN, CPC, CCS-P, ACS-OR
It is true that the AAOS Coding, Coverage, and Reimbursement
Committee recognizes three “areas” or “regions” of the shoulder
(the glenohumeral joint, the acromioclavicular joint, and the
subacromial bursal space), and that these areas are clearly separate; procedures done in one area should not influence coding
in a different area. I agree that the AAOS is a good reference;
however, the article was not meant to be an exhaustive study
of arthroscopy coding. My objective was to offer a general (i.e.,
applicable to private and federal payers) “hints and tips” article
for newer coders; therefore, I decided to use only American
Medical Association (AMA) references and those AAOS coding
concepts the AMA has incorporated. Medicare recognizes the
AMA as the source of information for correct use of CPT® codes
for all providers except hospitals. The AMA receives input from
the AAOS, but does not necessarily adopt all of their concepts—
hence my inclusion of AMA endorsed concepts (knee compart10 AAPC Coding Edge
Please send your letters to the editor to:
[email protected].
ments) and omission of those not “ratified” by the AMA via
publication (shoulder areas/regions).
I also took into consideration that excision of osteophytes and
coplaning of the distal clavicle (i.e., involving the acromioclavicular joint) generally are considered as included in a procedure
primarily aimed at the subacromial space (29826 Arthroscopy,
shoulder, surgical; decompression of subacromial space with partial
acromioplasty, with or without coracoacromial release). This scenario,
on the surface, would seem to contradict the AAOS guidance
cited above. I felt that a thorough explanation of why this scenario is not necessarily at odds with AAOS advice would take
the article away from my objective. I decided to emphasize that
the shoulder arthroscopy codes involve two separate joints.
As to the question on the number of tendons being a criterion
for code selection for rotator cuff repair/reconstruction, please
note this excerpt from the February 2002 CPT® Assistant: “Code
23420 describes a repair of a complete shoulder (rotator) cuff
avulsion, referring to the repair of all three major muscles/tendons of the shoulder cuff.”
Your last statement is correct. Unfortunately, I noticed this error
only after publication. A cyclops lesion is a complication of anterior cruciate ligament reconstruction. The article should read,
“Debridement of cyclops lesion after anterior cruciate ligament
repair/reconstruction and of adhesions after total knee replacement are common conditions for which arthroscopic lysis of
adhesions is performed.”
Denis Rodriguez, CPC, CIRCC, CASCC, CCS
Are Skin Codes Appropriate for
Surgical Reconstruction?
The July 2010 Coding Edge offered conflicting advice as to
whether it’s appropriate to use 15002-15431 when material such
as acellular dermal allograft are used for abdominal wall reconstruction during compartment separations, hernia repairs, etc.
“Tie Up the Loose Ends of Surgical Wound Coding,” page 33,
advises that skin replacement and skin substitution codes are
not appropriate when the materials are used for closing the myofascial layers of a wound, and that an unlisted procedure code
should be reported instead.
“Expose the Layers of Abdominal Wall Reconstruction,” page
45, employs 15330 Acellular dermal allograft, trunk, arms, legs;
first 100 sq cm or less, or 1% of body area of infants and children and
+15331 Acellular dermal allograft, trunk, arms, legs; each additional
100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary
procedure) to report the use of allograft materials overlaying and
strengthening the closure of the rectus and/or fascia.
Which is correct?
Melissa Crabtree, CMA, CPC
letters to the editor
A quick look at AAPC message forums will confirm that this
is a much-debated topic (AAPC members may view an example
at: www.aapc.com/memberarea/forums/showthread.php?t=121).
The lack of clarity is not coincidental: Neither the AMA nor the
Centers for Medicare & Medicaid Services (CMS) provide specific,
direct coding advice for skin grafts and substitutes used in “non
integumentary” circumstances (e.g., for abdominal reconstruction).
A conservative approach would advocate reporting an unlisted
procedure code. As “Surgical Wound Coding” author Terri
Brame, MBA, CPC, CPC-H, CPC-I, CGSC, CHC, notes:
CPT® codes are procedure-based, not product-based, and applying AlloDerm® (to cite one example) to the integument clearly is
a different procedure than applying the same product to rectus
and/or fascia. It may mean more time and work to submit the
claim, but reporting an unlisted procedure code in this case
most closely follows CPT® conventions.
Reporting 15002-15431 during surgical repair/reconstruction
does have its advocates. To cite one example, Dr. Raymond
Javenicus, an American Society of Plastic Surgeons representative to the AMA CPT® Advisory Committee, published an
article in the April 2006 Plastic Surgery News advocating 15330
for skin graft to close the abdominal cavity (www.lifecell.com/
downloads/Ap06CPTCornerAbWallRecon.pdf).
“It almost always depends on the carrier and what rules they
choose to follow,” explains John Bishop, PA-C, CPC, CGSC,
CPRC, author of the “Abdominal Wall Reconstruction” article,
who also notes that many clinical and coding resources agree
with Dr. Janevicius’ position.
The bottom line: Ask your payer for guidance, in writing. If the
payer will allow 15002-15431 to report surgical reconstructions,
be sure to do so. If you are absent such explicit payer consent,
stick with an unlisted procedure code.
Sleep Apnea Coverage Receives Praise
I want you to know how much I appreciated the two-article
format for sleep apnea in the August 2010 issue (“Sleep Apnea:
The Not So Silent Bed Partner” and “Monitor Disturbances in
Sleep Study Coding”). Presenting an entire article as a clinical
piece with an entire article as a coding piece was great. I hope
you’ll do this more in the future.
I also commend Dr. I. A. Barot for his candid assessment of the
state of our medical environment, which he describes as physicians treating the numbers along with patient demands for
instant resolution of symptoms. In his words, “The long-term
result of this approach ... has included overzealous expenditure
of health care dollars, increasing utility of already over-stretched
resources.” Until Americans take responsibility for their health
by eating a proper diet and exercising, we will continue to sink
farther and farther into the health care abyss we’ve created.
Marti Bailey, MT (ASCP), CPC
www.aapc.com
November 2010
11
AAPCCA
Synergize
Your Local Chapter
Bring your chapter together
and activate success with
these officer resources.
Local chapter officers are leaders working
to synergize local chapters. Creating an
inspiring vision for your local chapter is
important; you must empower, inspire, and
energize your members, building a team by
encouraging initiative and involvement.
Giving your chapter direction, setting goals,
and having confidence wins respect and
trust from members. Always be enthusiastic
and create a positive meeting environment.
Delegate authority and be open to new ideas;
believe in the creativity of others. Communicate openly and honestly, giving the
guidelines set out by AAPC and outlining
what the next year will hold for members.
Be willing to discuss, listen, and support.
Involve everyone to facilitate a team
approach and create unity within the chapter. Coaching chapter members brings out
the best. Having fun is a big element and
should be a goal.
Tools to Boost Chapter Enthusiasm
There are many resources available on
AAPC’s website (www.aapc.com) to assist
you in handling next year’s challenges. Using
these resources provides the energy you need
to keep members excited and engaged:
Local Chapter Handbook
Forms
Meeting Ideas
Proctoring Information
CPC® Review Tools
May MAYnia Details
Best Practices
Local Chapter Code of Conduct
Coder of the Year
Request a Visitor
The local chapter handbook provides you
with guidance on how to operate the local
chapter efficiently and effectively. In the
12 AAPC Coding Edge
By Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I, CEMC
forms section you can request AAPC
Bucks, and download continuing education
unit (CEU) certificates, seminar certificates,
local chapter meeting attendance forms,
quarterly meeting reports, and local chapter
speaker agreements.
AAPC’s website helps you improve your
meetings and attendance. This is where
Great resources for speakers are local
medical carriers and other carriers. These
meetings often have great attendance. The
AAPC forum is another way to get ideas
for chapter meeting speakers or roundtable
discussions. Encourage members to bring
their most difficult coding issues and work
on them as a group.
Be a member of the AAPCCA Board of Directors.
Applications are at www.aapc.com.
other chapter officers share their ideas with
AAPC and the AAPCCA Board of Directors. There are an absentee ballot, ballot
education request, meeting agenda, refreshment donation schedule, rewards points
schedule, scholarship application, and a vote
count sheet.
Mix It Up
Make sure meetings are a good mix of education, networking, and fun:
Education—Organize the education section of the meeting to maintain your membership and keep them involved.
Professional Medical Coding Curriculum
(PMCC) instructors need to earn continuing teaching units (CTUs) to maintain
instructor status and they can earn these by
speaking at your meetings. AAPC has presentations that can be given by local chapter officers. Some of these include “E/M
Auditing;” “Communication or Bust;” and
“Maximize Reimbursement.”
Proctoring examinations is a key role for
local chapters. Administering exams correctly protects the integrity of the certification process. The responsibility placed on
officers as proctors is very serious. Providing education to officers and members who
assist ensures the process is done properly.
Networking—Have members network
with physicians, compliance officers, and
coding specialists presenting at your local
meetings. Use other chapter officers as
speaker resources.
You can even request a visit from AAPC,
if it has been at least three years since the
chapter has had a visit. Ask for this visit at
least six months in advance of the meeting.
The chapter can sponsor an AAPC seminar
or conference.
Fun—Coding games are a great icebreaker
for any meeting and a fun networking
opportunity. AAPC’s website provides links
to sites with games.
May MAYnia should be added to every
chapter’s plans. Your educational speaker
brings the membership and other health
care professionals to your chapter. May is
the month to spotlight on your chapter.
AAPC awards prizes to the chapter with
the most guests and to the chapter with the
highest number of attendees.
The Rest Is Up to You
As soon as elections are finalized, meet and
brainstorm. Get organized, plan your meetings, speakers, exams, and post them on the
AAPC website for all to view. Consider synergizing your chapter and with the combined
effort you’ll realize the sky is the limit.
Lynn Keaton-Cockrell, CPC, CPC-H, CPC-I,
CEMC, a member of the AAPCCA Board of Directors, is president of LCA Medical Consulting.
Lynn has more than 25 years of experience in
the health care industry. She provides PMCC
training through Columbia State Community College and provides consulting services to Hickman Community Health Services (part of Saint
Thomas Health Services). She has provided coding workshops
for the Tennessee Medical Association. Lynn serves as president
of the Professional Coders of Columbia, Tenn. and the Cahaba
Physician Outreach and Education Committee for Tennessee.
letter from member leadership
Get Excited About Coding
I am passionate about coding. I get excited
when I see how AAPC affects coders. The
biggest thrill for me is when I train and
hire coding professionals who beam with
certification pride. They know the importance of coding, hard work and dedication,
setting goals, and the value of their coding
education.
Find Your Talents
I started out as a radiology technologist.
When I became involved in radiology
coding, it was a natural transition for me.
I was good at it and that was where my
coding passion began. Since then, I have
earned several AAPC credentials including the Certified Interventional Radiology
Cardiovascular Coder (CIRCC™) credential.
Currently, I own a physician billing company and consult on radiology, interventional radiology, and orthopaedics. I also
train coders, give presentations, and serve as
president on the AAPC National Advisory
Board (NAB).
I never dreamed my coding passion would
take me to where I am today.
Find Your Passion
You may not be as enthusiastic about interventional radiology coding as I am, but
you may have expertise or enjoy working in
another health care area. There are so many
areas of coding that you can branch out
into (interventional radiology cardiovascular
coding pun intended). You can give your
passion and expertise credibility in the medical industry by earning AAPC credentials
for the particular area(s) that excites you:

Certified Professional Coder (CPC®)

Certified Professional Coder-Hospital (CPC-H®)

Certified Professional Coder-Payer (CPC-P®)

Certified Interventional Radiology
Cardiovascular Coder (CIRCC®)

Certified Professional Medical Auditor (CPMA™)

Certified Ambulatory Surgical
Center Coder (CASCC™)

Certified Anesthesia and
Pain Management Coder (CANPC™)

Certified Cardiology Coder (CCC™)

Certified Cardiovascular and
Thoracic Surgery Coder (CCVTC™)

Certified Dermatology Coder (CPCD™)

Certified Emergency
Department Coder (CEDC™)

Certified Evaluation and
Management Coder (CEMC™)

Certified Family Practice Coder (CFPC™)

Certified Gastroenterology Coder (CGIC™)

Certified General Surgery Coder (CGSC™)

Certified Hematology and
Oncology Coder (CHONC™)

Certified Internal Medicine Coder (CIMC™)

Certified Obstetrics
Gynecology Coder (COBGC™)

Certified Orthopaedic
Surgery Coder (COSC™)

Certified Otolaryngology Coder (CENTC™)

Certified Pediatrics Coder (CPEDC™)

Certified Plastics and Reconstructive
Surgery Coder (CPRC™)

Certified Rheumatology Coder (CRHC™)

Certified Urology Coder (CUC™)
Follow Your Passion
Since I started my tenure, AAPC has
focused on fostering each member’s professional growth through AAPC local chapters.
Local chapters are where you can talk about
coding and help others in the coding community. They provide an outlet to discuss
the intricacies of coding and also provide a
coding community to which you can relate.
Chapters can help you develop your leadership skills by serving as an officer. Here
is where your true passion for coding can
develop into greater career possibilities.
Keep your coding passion alive by coding
daily. Even if you aren’t an in-the-trenches
coding professional, I encourage you to code
for a few hours daily. I do.
Sincerely,
Terrance C. Leone,
CPC, CPC-P, CPC-I, CIRCC
President, National Advisory Board
www.aapc.com
November 2010
13
feature
CRIBING:
A Very Old and Up-to-date
Profession for Coders
APPRENTICE
By Jim Strafford, CEDC, MCS-P
A
health care profession that is booming and can
stake a claim as being among the world’s oldest
is scribing. Scribes appear frequently in the Bible
and ancient history as “record keepers” who transmitted legal
texts and other documents. Four thousand years later, the
modern scribe also transmits legal documents such as emergency department (ED) charts and documentation for other
medical specialties.
Modern scribing has been around for several decades. In
the late 1970s, a study by the “Annals of Emergency Medicine” found that scribes who “shadow physicians” and “act
as human tape recorders” increased physician efficiency and
improved chart documentation. Why, then, has the use of
scribes only increased dramatically in the past five years
(from a handful of practices to over 500 utilizing scribe services), particularly in ED practices?
When physicians are free of hunting
down labs and performing data entry,
the focus is on patient care.
“The implementation of electronic medical records [EMRs]
in many emergency departments has required a physician
learning curve,” suggests Dr. Luis Moreno, chief medical
officer of Scribe America. “The systems often aren’t user
friendly. As a result, EMRs actually increase chart documentation time. Interacting with a computer terminal instead of
a patient is not an efficient use of a physician’s time; thus,
the need for scribes.”
Advantages of Scribes
Several additional factors have influenced the scribe boom.
These include:
•
ED overcrowding and patient throughput issues require
more efficient use of physicians’ (and other medical providers’) time.
14 AAPC Coding Edge
•
As all coders know, documentation guidelines require
an emphasis on time-consuming documentation of history/physical and medical decision making (MDM), plus
all other chart elements.
•
With recovery audit contractors (RACs) and other government and payer oversight, the importance of complete, compliant, and medical necessity-supported charts
has become critical.
“EDs must become more efficient from both a clinical and
revenue-generation perspective,” Dr. Moreno notes. “A recent
article from the Society of Academic Emergency Medicine
demonstrated that the addition of a scribe collaborator
results in an additional 24 RVUs [relative value units] during
one 10-hour provider shift. Another article, written by Dr.
Richard Bukata of Southern California, calculated that every
minute spent on documentation and not seeing the next
patient costs $18. Additional benefits, such as being able to
task the scribe to hunt down labs or relatives and perform
data entry, allow the physician to focus on higher levels of
thought relating to patient care—as well as leave at the end
of their shift instead of hours later.”
Dr. Craig Gronchewski, chairman of Princeton University
Emergency Department, does not use scribes yet, but sees
many advantages. “Burnout continues to be an issue for ED
physicians,” he notes. “A less chaotic, more efficient work
place improves the quality of work life for all providers in
the ED.”
Scribe’s Role in Medicine
The scribe shadows the physician and records all of the chart
elements that coders look for in determining evaluation and
management (E/M) levels (and procedure codes). These include
all elements of history, physical, and MDM. Scribe guidelines
emphasize that scribes are recording these elements strictly
from physician direction. Like coders, scribes cannot assume
that something was done without clear direction from the
physician. Scribes also document consults with other physicians, review old records, labs, ordered diagnostics, and find-
feature
ings. An effective scribe documents all of the elements for the
all-important MDM element of documentation.
Scribes have begun to morph into a broader role in the ED.
Scribes may visit the patient to record review of systems
(ROS), family history, social history, and past medical history. In the outpatient setting, these do not require physician
presence—but do require documented physician review (physician presence is required in the inpatient setting, according
to the Centers for Medicare & Medicaid Services (CMS)).
Overall, scribes provide a complete service to physicians,
increasing physician efficiency and job satisfaction.
Scribe companies generally hire college students interested
in a career in the medical field. “In the past, we have seen
coders and scribes as having different skills,” Dr. Moreno
admits. But he quickly adds, “We now are beginning to see
the very close relationship between scribe and coder. We
plan to increase coding training for our senior scribes. In
fact, we have begun to discuss the concept of scribes working
hand-in-hand with onsite coders. This could be an ideal situation for assuring both documentation and coding is completed in ‘real time,’ not several days later.”
Prospects for Employment
In a slow economy, there are plenty of openings for scribes.
Scribes must be on-site, and many EDs are implement-
ing their own scribe services. Openings often are posted on
scribe organizations’ websites. Scribe companies are recruiting prospects from local universities nationwide, especially
among students with some medical or mid-level training.
These companies provide classroom and on-line education—
plus hands-on experience in the clinical setting, witnessing
and recording actual patient encounters. Because turnover is
expected as scribes graduate from school, there is a constant
need for new scribes.
An effective scribe must not be squeamish at the sight of
blood and other body fluids, have the fortitude and patience
to stay on his or her feet and take constant direction from
doctors and nurses, plus have people skills and the ability to
deal with a high-intensity, chaotic environment. But for the
right coder, scribing could be a perfect fit. “We recognize
that a big change in how we view scribes may be in the creation of the scribe who also codes,” Dr. Moreno says. “That
is why we have begun to provide coding training and coding
certification for our senior personnel and trainers.”
Jim Strafford, CEDC, MCS-P, principal of Strafford
Consulting Inc., has over 30 years experience as
a consultant, manager, and educator in all phases
of medical coding, billing, compliance, and reimbursement. Mr. Strafford is a published, nationally
recognized expert on ED revenue cycle and coding
issues. www.straffordconsulting.com. He can be
reached at [email protected].
www.aapc.com
November 2010
15
feature
Understand
Medicare Physician Supervision
Dx vs. Tx rules are critical to success.
Requirements
By G. John Verhovshek, MA, CPC
EXPERT
M
edicare supervision requirements apply to outpatient services in both the hospital setting and
the physician office. Following physician supervision requirements is crucial for compliance and reimbursement. Services not meeting applicable guidelines
are considered “not reasonable and necessary,” and are
ineligible for Medicare payment; however, the rules differ
depending on the type of service(s) provided.
Note: Medicare physician supervision requirements do
not apply to hospital inpatient services. For inpatient
services, the Centers for Medicare & Medicaid Services
(CMS) defers to hospital policy and Joint Commission
on Accreditation of Healthcare Organizations (JCAHO)
standards.
For Outpatient Diagnostic Services,
a Physician Must Supervise
For diagnostic services in an outpatient setting (hospital
outpatient or physician office), only “a doctor of medicine
or osteopathy legally authorized to practice medicine in
his or her state of practice,” as defined by §1861(r) of the
Social Security Act, may act as a supervisory physician.
The 2010 Hospital Outpatient Prospective Payment
System (OPPS) Final Rule verifies, “Physician assistants,
nurse practitioners, clinical nurse specialists, and certified nurse midwives who do not meet the definition of
‘physician’ may not function as supervisory physicians for
the purposes of diagnostic tests” (Federal Register, Nov.
20, 2009; view at http://edocket.access.gpo.gov/2009/pdf/
E9-26499.pdf).
CMS recognizes three primary levels of physician supervision. In the context of outpatient diagnostic services,
these are defined as:
1. General supervision: The procedure is furnished
under the physician’s overall direction and control. The
physician must order the diagnostic test and is responsible for training staff performing the tests, as well as
maintaining the testing equipment. He or she does not
need to be present in the room during the procedure.
2. Direct supervision: The meaning of “direct supervision” varies according to the precise location at which the
service is provided:
16 AAPC Coding Edge
In the physician office, the supervising physician
must be present in the office suite and immediately available to furnish assistance and direction
throughout the procedure’s performance.
For hospital outpatient diagnostic services provided
under arrangement in nonhospital locations (such
as independent diagnostic testing facilities (IDTFs)
and physicians’ offices), the supervising physician
must be present in the office suite and immediately available to furnish assistance and direction
For services furnished directly or under arrange-
ment in the hospital or an on-campus providerbased department (PBD), the supervising physician
must be present on the same campus and immediately available to furnish assistance and direction
In any case, the physician does not need to be present
in the room during the procedure, but must not be performing another procedure that cannot be interrupted,
and must not be so far away that he or she could not provide timely assistance.
3. Personal supervision: A physician must be in attendance in the room during the procedure’s performance.
Regardless of location, if a physician personally provides
the entire service, supervision requirements are not a
concern.
Note, as well, that supervision requirements apply only
to the technical component (the actual test administration) of a diagnostic service. A physician always must
provide the professional component (reading/interpreting
of results) for diagnostic services.
Resource: Medicare physician supervision requirements
for outpatient diagnostic services are defined by CMS
Program Memorandum B-01-28, change request (CR)
850 (April 19, 2001), and may be found in Medicare’s
Internet Only Manual, 100-02 Medicare Benefit Policy
Manual, chapter 15, § 80 (www.cms.gov/manuals/
Downloads/bp102c15.pdf).
feature
If a mid-level provider administers the test without
physician supervision, the medical record should
document clearly that the service is within the
provider’s scope of practice as allowed by state law.
Fee Schedule Lists
Supervision Requirements per Code
The National Physician Fee Schedule Relative Value File
assigns a physician supervision level for all CPT® and
HCPCS Level II codes. The column labeled “Physician
Supervision of Diagnostic Procedures” contains a one- or
two-character indicator. These apply specifically to outpatient diagnostic services.
The most common indicators are:
ɶɶ • 1– Procedure must be performed under general
supervision
An example of such a procedure is the technical component of ambulatory electroencephalography (EEG), 95950
Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and interpretation, each 24 hours.
ɶɶ • 2 – Procedure must be performed under direct
supervision
Included in this category is the technical component of
many urinary studies, such as 51792 Stimulus evoked response
(eg, measurement of bulbocavernosus reflex latency time).
ɶɶ • 3 – Procedure must be performed under
personal supervision
Examples include the technical component of several
X-ray studies, for instance 70370 Radiologic examination;
pharynx or larynx, including fluoroscopy and/or magnification
technique.
ɶɶ • 9 – Concept does not apply
For instance, the concept of physician supervision would
not apply to surgical procedures such as 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy.
A “0” indicator (procedure is not a diagnostic test, or
procedure is a diagnostic test not subject to the physician
supervision policy) currently is not assigned to any CPT®
or HCPCS Level II code in the Relative Value File.
Resource: The Medicare National Physician Fee
Schedule Relative Value File is available as a free
download on the CMS website: www.cms.gov/
PhysicianFeeSched/PFSRVF/list.asp?listpage=4. Select the
most recent (last-posted) file for download.
Provider Status May Affect Supervision Level
For some services, supervision requirements depend on
the training of the provider administering the service.
Such services are identified in the Relative Value File
with the following indicators:
ɶɶ • 4 – Physician supervision policy does not apply
when the procedure is furnished by a qualified, independent psychologist or a clinical
psychologist, or furnished under a clinical
psychologist’s general supervision; otherwise
must be performed under a physician’s general supervision.
Services assigned this indicator include all central nervous
system assessments or tests in the range 96101-96125.
ɶɶ • 5 – Physician supervision policy does not apply
when procedure is furnished by a qualified
audiologist; otherwise must be performed
under a physician’s general supervision.
An example of a service assigned this supervision requirement is 92640 Diagnostic analysis with programming of
auditory brainstem implant, per hour.
ɶɶ • 21 – Procedure must be performed by a technician with certification under general
supervision of a physician; otherwise must
be performed under a physician’s direct
supervision.
Included in this category are several evoked potential
studies, including 95926 Short-latency somatosensory evoked
potential study, stimulation of any/all peripheral nerves or skin
sites, recording from the central nervous system; in lower limbs
and 95927 Short-latency somatosensory evoked potential study,
stimulation of any/all peripheral nerves or skin sites, recording
from the central nervous system; in the trunk or head.
A “22” indicator (procedure may be performed by a
technician with on-line real-time contact with physician)
currently is not assigned to any CPT® or HCPCS Level II
code in the Relative Value File.
www.aapc.com
November 2010
17
feature
To discuss this
article or topic,
go to www.aapc.com
Therapy Services Have
Unique Supervision Requirements
CMS designates several supervision categories specific
to physical therapy services. These categories assign the
required level of supervision based on the provider’s level
of training:
• 6 – Procedure must be performed by a physician,
or by a physical therapist (PT) who is certified
by the American Board of Physical Therapy
Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to
provide the procedure under state law.
• 66 – Procedure must be performed by a physician or
by a PT with ABPTS certification and certification in this specific procedure.
• 6a – Supervision standards for level 66 apply; in
addition, the PT with ABPTS certification may
supervise another PT, but only the PT with
ABPTS certification may bill.
• 77 – Procedure must be performed by a PT with
ABPTS certification, or by a PT without certification under direct supervision of a physician,
or by a technician with certification under a
physician’s general supervision.
• 7a – Supervision standards for level 77 apply; in
addition, the PT with ABPTS certification may
supervise another PT but only the PT with
ABPTS certification may bill.
Document for Success
CMS guidelines specify, “Documentation maintained by
the billing provider must be able to demonstrate that
the required physician supervision is furnished.” The
guidelines do not provide examples of appropriate documentation; however, for those services requiring personal
supervision, the physician should document, with a comment and signature, his or her presence during the test.
For services requiring direct or general supervision, the
provider performing the service should document the
physician’s direction or presence in the office, as required
by the level of supervision, and the physician should confirm with a signature.
If a mid-level provider administers the test without physician supervision, the medical record should document
clearly that the service is within the provider’s scope of
practice as allowed by state law.
18 AAPC Coding Edge
Compliance tip: Diagnostic testing requirements for
physician supervision are distinct from incident-to billing
requirements for mid-level providers. Incident-to requirements are not applicable to diagnostic testing in the
office setting. The Medicare Benefit Policy Manual, chapter
15, § 80 states, “Diagnostic tests may be furnished under
situations that meet the incident to requirements but this
is not required.”
Mid-Level Providers May Supervise Outpatient
Therapeutic Services
As outlined in the 2010 Hospital OPPS Final Rule, “All
hospital outpatient services that are not diagnostic are
services that aid the physician in the treatment of the
patient, and are called therapeutic services.” Supervision
requirements for outpatient hospital therapeutic services
are different than those for outpatient diagnostic services.
Whereas only a physician may provide supervision for
outpatient diagnostic services, nonphysician practitioners
(NPPs) including “clinical psychologists, licensed clinical
social workers, physician assistants, nurse practitioners,
clinical nurse specialists, and certified nurse-midwives,
may directly supervise all hospital outpatient therapeutic
services that they may perform themselves within their
State scope of practice,” according to the 2010 Hospital
OPPS Final Rule. The NPP must be privileged by the
hospital to perform the services he or she supervises, and
must abide by any applicable hospital physician-collaboration or supervision requirements. An NPP may not
supervise a service he or she cannot perform personally.
In other words, for therapeutic services in a hospital
outpatient setting:
A physician may provide supervision at the
required level (general, direct, or personal), or
An approved NPP may provide direct supervision
for the service, as long as the NPP legitimately may
perform the service him- or herself.
In this context, “direct supervision” may be defined:
For services provided in the hospital or on-campus
PBD of the hospital, the physician or NPP must
be present on the same campus and immediately available to furnish assistance and direction
feature
“In the hospital or on-campus PBD” includes the main
building(s) of a hospital or critical access hospital (CAH):
under the ownership, financial, and administrative
control of the hospital or CAH;
 operated as part of the hospital or CAH; and
for which the hospital or CAH bills the services
furnished under the hospital’s or CAH’s CMS
Certification Number.
For off-campus PBDs of hospitals or CAHs, the physician or NPP must be present in the off-campus PBD, and
immediately available to furnish assistance and direction
In either case, the supervising provider does not need to
be present in the room during the procedure, but must
not be performing another procedure that cannot be
interrupted, and must not be so far away that he or she
could not provide timely assistance.
There are some exceptions: Regardless of the NPP’s
scope-of-practice or other qualifications, only a doctor of
medicine or osteopathy may provide direct supervision
for cardiac rehabilitation (CR), intensive cardiac rehabilitation (ICR), and pulmonary rehabilitation (PR) therapeutic services, as outlined in the 2010 Hospital OPPS
Final Rule.
[
G. John Verhovshek, MA, CPC, is director of
editorial development/managing editor at AAPC.
]
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www.aapc.com
November 2010
19
feature
Why the New
Signature Requirements Emphasis?
Find out how it began and what holds true for 2011.
By Lynn S. Berry, PT, CPC
S
eemingly out of nowhere, providers have been barraged
with material regarding Medicare signature requirements. Why is there a new emphasis on something
that should be standard practice?
PROFESSIONAL
History in the Making
When the November 2009 Comprehensive Error Rate
Testing (CERT) Improper Medicare Fee-For-Service (FFS)
Payments Report was published, an astonishing result was
noted. Although CERT errors had been falling steadily (from
10.1 percent in 2004 to 3.6 percent in 2008), there was a
huge increase to 7.8 percent in 2009. Why?
Each year, the Office for Inspector General (OIG) conducts
an audit of the CERT process and makes recommendations.
Due to growing concern with Medicare fraud and abuse
and a greater emphasis on government efforts to recover
overpayments, the OIG performed a more extensive review
in 2008 (especially of durable medical equipment (DME)
payments) and, in 2009, conducted an independent review
of 2008 CERT findings for all claim types. As a result of
these audits, and based on the recommendations of the OIG,
the Centers for Medicare & Medicaid Services (CMS) revised
the error rate methodology for the 2009 report—instructing CERT contractors, among others, to “strictly enforce the
Medicare policies.”
The 2009 CERT report subsequently concluded, “a significant portion of the new errors found in FY 2009 were due
to a strict adherence to policy documentation requirements,
signature legibility requirements, the removal of claims history
as a valid source for review information, and the determination that medical record documentation received only from a
supplier is, by definition, insufficient to substantiate a claim”
[emphasis added].
Specifically, the following errors were found:
“Records from the treating physician not submitted
or incomplete: In the past, CERT would review available
documentation, including physician orders, supplier documentation, and patient billing history and apply clinical
20 AAPC Coding Edge
review judgment. Now, CERT requires medical records from
the treating physician and does not review other available
documentation or apply clinical review judgment.”
“Missing evidence of the treating physician’s intent to
order diagnostic tests: In the past, CERT would consider
an unsigned requisition or physicians’ signatures on test
results. Now, CERT requires evidence of the treating physician’s intent to order tests, e.g., signed orders, progress notes.”
“Medical records from the treating physician did not
substantiate what was billed: In the past, CERT would
review available documentation, including physician orders,
supplier documentation, and patient billing history and
apply clinical review judgment. Now, CERT requires medical
records from the treating physician and does not review other
available documentation or apply clinical review judgment.”
“Missing or illegible signatures on medical record documentation: In the past, CERT would apply clinical review
judgment in considering medical record entries with missing
or illegible signatures.”
Subsequent to the CERT report, CMS published March 16
Transmittal 327, Change Request (CR) 6698, and MLN
Matters article MM6698 Revised (www.cms.gov/transmittals),
which outline rules for signatures and clarify how Medicare
claims review contractors review claims and medical documentation. The transmittal identified contractors that must
abide by the rules as Medicare claim review contractors (carriers, fiscal intermediaries (FIs), affiliated contractors (ACs),
Medicare administrative contractors (MACs), the comprehensive error rate testing (CERT) contractor, and recovery audit
contractors (RACs)).
The Current Rule in Effect
The current rule, outlined in CR 6698, specifies that any
services provided or ordered must be authenticated by the author
either by a hand written or electronic signature. A current exception to this is that orders for clinical diagnostic tests are not
required to be signed; however, if not signed, there must be
written evidence within the physician progress note or other
feature
To discuss this
article or topic, go to
www.aapc.com
In the past, CERT would consider an unsigned requisition or physicians’ signatures on test results. Now, CERT
requires evidence of the treating physician’s intent to
order tests, e.g., signed orders, progress notes.
such documentation containing the provider’s intent for
the clinical diagnostic test to be performed. This must be
authenticated by a handwritten or electronic signature.
CR 6698 gives further guidance for e-prescribing signature
requirements and signature dating requirements. It also provides exceptions for hospice certifications and other requirements as specified by local coverage determinations (LCDs),
national coverage determinations (NCDs), or Medicare
manuals.
CR 6698 is retroactive for the November 2010 CERT
reporting period (which includes the prior year). If you find
you have illegible signatures in any 2009 or 2010 records
requested by any Medicare review contractor, make sure a
recent signature log is attached; if you find missing signatures, make sure an attestation statement is attached (see the
Program Integrity Manual (PIM), publication 100-08, chapter
3, section 3.4.1.1 and 3.4.1.2, www.cms.gov/manuals, for
detailed instructions).
reference laboratory technicians to determine whether a test
has been requested appropriately. Potential compliance issues
would be eliminated during any subsequent Medicare audits
because a signature would always be required.
What This Means for 2011
If the proposed rule goes into effect, as of Jan. 1, 2011, every
piece of documentation written by the physician or NPP,
including any orders or prescriptions, must have an authenticated, legible signature. This includes any orders or requisitions for clinical diagnostic tests, as well as initial notes,
progress notes, daily logs, or any other document in the
medical record. You should include a printed name under the
physician’s signature so it is clear who wrote the document or
signed the order.
How does your physician signature appear on all documents?
This: _________ This:
John Whigg, MD
Or This:
Proposed Rulemaking
Pages 430-437 of the proposed rule (www.federalregister.
gov/inspection.aspx#special) provide a history of government
rulemaking regarding signatures for clinical diagnostic tests
and their reasoning for changing the current rule. The proposal now requires a physician or non physician practitioner
(NPP) to sign requisitions for clinical diagnostic laboratory
tests paid on the basis of the Clinical Laboratory Fee Schedule (CLFS) as a part of the other signature requirements.
CMS believes this will eliminate any confusion because a
physician’s signature would be required for all requisitions
and orders, thereby eliminating any uncertainty:
Whether the documentation is a requisition or an
order (a semantic issue)
W
hether the type of test being ordered requires a signature, or
W
hich payment system (the MPFS or CLFS) requires a
physician or NPP signature.
CMS also says the proposed rule would make it easier for the
CR 6698 and the regulations in chapter 3, section 3.4.1.1
and 3.4.1.2 of the PIM clearly define a legible, authenticated
signature for Medicare. It cannot be a stamped signature and
or an electronic signature for prescribing narcotics (this last
requirement may change). CR 6698 outlines how the provider can appeal a ruling based on signature logs and attestation statements.
Make sure your physician and/or NPP understands these
regulations. This should help the CERT rate to go back
down, reduce the possibility of fraud and abuse, eliminate
any threats regarding this issue from MACs, CERT, or
RACs, and reduce appeals on the part of the provider—thus
improving your bottom line.
Lynn Berry, PT, CPC, had over 35 years of clinical and
management experience before beginning a new career
as a coder and auditor and later becoming a provider
representative for a Medicare carrier. She owns the consulting firm, LSB HealthCare Consultants, LLC, furnishing
consulting and education to diverse provider types. She
has held a variety of AAPC chapter offices and continues
as one of the directors of the St. Louis West Chapter.
www.aapc.com
November 2010
21
EXPERT
feature
Report Transforaminal
Epidural Injections With Precision
With OIG keeping a watchful eye on these interventions,
be sure your coding is straight and narrow.
By G. John Verhovshek, MA, CPC
A
sharp rise in reporting transforaminal
epidural injections in recent years
has prompted the Office of Inspector
General (OIG) to scrutinize these services
as part of its 2010 Work Plan (http://oig.
hhs.gov/publications/docs/workplan/2010/
Work_Plan_FY_2010.pdf). Keep yourself
out of the OIG’s crosshairs with these seven
coding tips.
1. Choose the Correct Approach
Transforaminal epidural injections (CPT®
64479-64484) are an interventional technique to diagnose or treat pain, such as pain
that starts in the back and radiates down the
leg. A long-acting steroid is injected laterally through the natural opening between
the vertebrae (the neuroforamen) to place
medication in the anterior epidural space and
target a specific spinal nerve.
The translaminar epidural approach, by con-
trast, places the medicine inside the epidural
space. Report these procedures using 6231062311, depending on the targeted spine
region (cervical/thoracic or lumbar/sacral).
2. Code by Spinal Region
Codes describing transforaminal epidural
injections are specific to the targeted spine
region (cervical/thoracic or lumbar/sacral):
64479Injection, anesthetic agent and/
or steroid, transforaminal epidural;
cervical or thoracic, single level
+64480Injection, anesthetic agent and/
cervical or thoracic, each additional
level (List separately in addition to
code for primary procedure)
64483Injection, anesthetic agent and/
lumbar or sacral, single level
+64484Injection, anesthetic agent and/
lumbar or sacral, each additional
level (List separately in addition to
code for primary procedure)
3. Report per Level, Not per Injection
The American Medical Association’s
(AMA’s) CPT® Assistant (Feb. 2000)
confirms that 64479-+64484 are to be
reported once per level targeted, “regardless
of the number of [unilateral] injections performed at a particular spinal level.” Report
additional code units only when the physician targets different levels.
Terminology alert: Although the code
descriptors specify “levels,” these injections target the area between the vertebrae
(i.e., the spinal interspace), rather than an
individual vertebra. For instance, two left
side injections at C3/C4 and two left side
injections at C4/C5 represent two levels
(although they involve three vertebrae and,
in this case, four separate injections), and
are reported 64479-LT Left side for the initial level and one unit of 64880-LT for the
second level.
4. Apply Modifiers to Specify Location
Codes 64479-+64484 describe unilateral
procedures; and because there are separate
nerves on each side of the spine, these procedures may be performed bilaterally at the
same spinal level(s). “When a transforaminal injection is performed on the opposite
side, the work may involve redraping and
positioning of the patient,” advises CPT®
Assistant (Sept. 2005). “Therefore, when
performing bilateral transforaminal epidural injections at a single spinal level, modifier 50 [Bilateral procedure] is appended to
the appropriate code(s).” As an example, the
physician provides one right side injection
22 AAPC Coding Edge
feature
and one left side injection at L1/L2. In this
case, the appropriate coding is 64483-50.
The Medicare physician fee schedule relative value file assigns 64479-+64484 a
bilateral surgery indicator of 1, so most
insurers will pay 150 percent of the standard fee for bilateral injections.
As shown by example in our third tip,
modifiers LT and RT Right side also may
be used to designate location for unilateral
injections.
5. Claim Guidance Separately
Epidural injections require imaging guidance to place the needle precisely. CPT®
Assistant (Feb. 2000) explains, 6447964484 “are performed under fluoroscopic
guidance for precise anatomic localization
to avoid potential injury to the vertebral
artery or damage to the spinal cord or
surrounding nerve roots.” CPT® further
instructs, “For fluoroscopic guidance and
localization for needle placement and injection in conjunction with 64479-64484, use
77003 [Fluoroscopic guidance and localization
of needle or catheter tip for spine or paraspinous
diagnostic or therapeutic injection procedures
(epidural, transforaminal epidural, subarachnoid, or sacroiliac joint), including neurolytic
agent destruction].”
Report a single level of 77003 per session,
regardless of the number of levels/injections
involved. Confirm in the documentation
that guidance was used, and include a hard
copy of the film in the patient record.
For example, documentation might state:
The lumbar spine was prepped and draped
in a sterile manner. The C-arm was brought
into view and the right side of the L2/L3,
L3/L4, and L4/L5 transforaminal areas were
visualized. Skin was marked and infiltrated
with 1 percent Xylocaine. 22g, 3½ inch
Quincke-type spinal needles were inserted
into the transforaminal area and were
advanced in the lateral view. In the AP
view, 2 cc of Isovue were injected revealing
adequate neurograms with medial spread.
20 mg of Kenalog with 1 cc of .25 percent
bupivacaine at each level.
In this case, report:
• 64483-RT for the initial injection
• 64484-RT for the subsequent injection
at L3/L4
• 64484-RT for the subsequent injection
at L4/L5
• 77003 for fluoroscopic guidance (C-arm)
Beware of inappropriate bundling:
Although some payers may attempt to
bundle guidance into the injection procedure, the American Society of Anesthesiologists (ASA) stresses, “Fluoroscopic guidance
is reported and valued separately from
spinal injection procedures. CPT® instructions are clear and unequivocal. Medicare
and other payers who use the CCI edits
allow the reporting of 77003 along with
codes.” For more information, view the
ASA’s memorandum at: www.asahq.org/
news/031907Fluoroupdate.pdf.
6. Establish Medical Necessity
To establish medical necessity for spinal
injections, the claim form must cite, and
documentation must support, an appropriate diagnosis. Allowable diagnoses may
vary by payer (Check with your particular
payers for specifics.); however, commonlyallowable ICD-9-CM codes to establish
medical necessity for 64479-64484 include
intervertebral disc disorders (722.x), spinal
stenosis (723.0 Spinal stenosis in cervical
region, 724.0x), post-laminectomy syndrome
(722.8x), and radiculitis (723.4 Brachial
neuritis or radiculitis NOS, 724.4 Thoracic or
lumbosacral neuritis or radiculitis, unspecified),
among others.
Transforaminal Epidurals
With Ultrasound Call for
Category III Codes
Transforaminal epidural injections may
be provided under ultrasound guidance
as well as fluoroscopic guidance. When
reporting these injections with ultrasound, do not select 64479-+64484.
Instead, rely on the following dedicated
Category III codes:
0228TInjection(s), anesthetic agent and/
or steroid, transforaminal epidural,
with ultrasound guidance, cervical
or thoracic; single level
0229TInjection(s), anesthetic agent
and/or steroid, transforaminal
epidural, with ultrasound guidance, cervical or thoracic; each
additional level (List separately
in addition to code for primary
procedure)
epidural, with ultrasound guidance, lumbar or sacral; single
level
epidural, with ultrasound guidance, lumbar or sacral; each
additional level (List separately
in addition to code for primary
procedure)
7. Observe Frequency Guidelines
Many payers will place limits on the number
of levels a physician may inject during a
single encounter, as well as the time between
procedures and the maximum number of
injections allowable over time.
As an example, the payer may state that
if there is no documented pain relief after
two injections, no further injection will be
considered medically necessary at the same
level. Or, the payer may limit reimbursement to no more than three injection series
in a calendar year. Again, check with your
individual payer for these guidelines.
[
G. John Verhovshek, MA, CPC, is director of
editorial development/managing editor at AAPC.
]
To discuss this
article or topic, go to
www.aapc.com
www.aapc.com
November 2010
23
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TOGETHER WE ARE STRONG
Laissez Les Bons Temps Rouler
("Let the Good Times Roll")
by George Dansker, CPC-A
Lafayette
Chapter wins
best table.
There was a tremendous feeling of southern hospitality at the
second annual Louisiana Coding Workshop hosted by the New
Orleans chapter, Aug. 21, at the Ochsner Brent House Conference Center as blue shirted greeters donned ICD-9-CM codes
and welcomed each of the 150 attendees. The ICD-9-CM code
numbers were for a later coding quiz.
In the foyer of the meeting room were four decorated chapter
tables (New Orleans, Covington, Baton Rouge, and Lafayette),
reflecting each chapter’s uniqueness. Keynote speaker, Marti
Johnson, director, local chapter support at AAPC, served as
judge and awarded the Lafayette chapter the prize for their
winning design.
Before getting down to serious coding business, chapter
presidents broke the ice with the skit, “Coding Circus” which
took a light-hearted look at some issues coders face daily. The
audience favorite was “The Stressed-out Coder.” The Covington
Chapter delighted the audience with a true Pepto Bismal™
version of the upset stomach.
Johnson brought participants up-to-date on “What’s Happening
at AAPC?”
Dr. Angela Parise, an obstetrics/gynecology specialist at Ochsner, spoke on “Robotic Surgery.” Other presentations included:
recovery audit contractors (RAC), Health Insurance Portability
and Accountability Act (HIPAA), Medicare, incident-to, split/
shared visits, and ICD-10-CM.
And what New Orleans party would be complete without music
and food? Songs such as “Celebration” and “The New Orleans’
Saints’ Champion Song” were crowd pleasers as was the joyful
“Second Line” celebration.
The day ended with a fun-filled and skill-testing round of “Quick
Coding Challenge.” Contestants competed to win great prizes
graciously donated by generous supporters.
What a wonderful way to keep up with coding changes, network
with colleagues, and earn 7.5 continuing education units (CEUs)
New Orleans-style! Kudos! New Orleans.
Hospitality
greeters with
Marti Johnson,
AAPC National
Office.
Covington
Chapter
performs the
Pepto Bismal™
version of an
upset stomach.
Coders
compete to win
Quick Coding
Challenge
prizes.
If you know anyone who deserves kudos, please email [email protected].
www.aapc.com
November 2010
25
cover
Upper extremity arterial orders
In the Journey
Through Vessels,
Code Destinations,
Not Waypoints
By Kimberly Engel, CPC
Here’s how to report
catheter placement from
puncture to journey’s end.
APPRENTICE
W
hen deciding the “order” of a vessel for
catheter placement, first ask yourself,
“Where did the provider access the
vessels for this catheter?” Femoral, brachial, jugular,
and iliac are common access sites; other vessels also
may be accessed.
For puncture only—that is, the provider stays in the
access vessel and never travels to another—coding
is fairly straightforward. Report either CPT® code
36000 Introduction of needle or intracatheter, vein for
a vein or 36140 Introduction of needle or intracatheter;
extremity artery for an artery.
It’s when the journey goes beyond the access point
that one may wish there was a roadmap handy.
26 AAPC Coding Edge
Lower extremity arterial orders
cover
DID YOU KNOW?
On average there are 60,000 miles of vessels in the
human body. That is 2.5 times around the equator.
Start at Home
There are several orders of vessels past the access
site. Zero order is the “home” or starting point. This
almost always is the aorta (see illustration on preceding page). If the provider goes as far as the aorta and
stops, report 36200 Introduction of catheter, aorta.
Note: Less frequently, the catheter is not advanced
to the aorta, but is advanced directly from one vessel
to another without passing through the aorta—for
example, from the common femoral to the superficial
femoral (in the same leg or ipsilateral), and perhaps
to the popliteal or beyond. For more information on
this topic, see the accompanying article “Op Reports
Show How to Code Selective Catheter Placement.”
From the aorta, the ordered vessels branch outward
like a network of streets, from highways (first order)
to boulevards (second order) to side streets (third
order) and down to alleys. The “streets” of the upper
body (above the renals), including the neck, are coded
with 36215-36218. The streets of the lower body
(renals and below) are coded with 36245-36248.
Don’t Code Until You Reach the Destination
To continue the street analogy, imagine that the catheter is a car. Once in the car (introduction of the catheter), if the provider wishes to travel any further, he
always must check in at home (the aorta). If he continues on from home, he is on a first-order street (vessel).
If he turns again, he is on a second-order vessel, and
so on. When coding this journey, report only the final
destination; all stops along the way are included.
For example, the catheter enters the right common
iliac artery. The physician drives the “car” (catheter)
into the aorta (home) and over to the left common
iliac. This would be a first order, lower body vessel,
36245 Selective catheter placement, arterial system; each
first order abdominal, pelvic, or lower extremity artery
branch, within a vascular family. You would not code
the access (36140) or the zero order aorta code (36200)
because they were along the path that had to be
taken from the puncture to the final destination.
What if the physician needs to drive further, into
another vessel, from the aorta, such as the left superficial femoral? In that case, there would be three
street names along the way. This would then be a
third-order placement, and reported 36247 Selective
catheter placement, arterial system; initial third order or
more selective abdominal, pelvic, or lower extremity artery
branch, within a vascular family.
“From the aorta, the ordered vessels branch outward
like a network of streets, from highways (first order) to
boulevards (second order) to side streets (third order)
and down to alleys.”
As a final example, the provider documents: “Right
common iliac access. Catheter advanced to the aorta.
Imaging shows normal anatomy and no disease or
defect. Catheter then advanced into the left external
carotid artery … final placement in the left internal
carotid.” The final code is 36216 Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family for a second
order, upper body vessel.
Note: All examples are based on normal anatomy.
There can be variations in the vascular anatomy that
will change the order of vessels you code.
The same coding principles illustrated above apply to
venous catheter placement outside the heart (3601036012).
Keep reading: In future articles, look for more
advanced concepts, such as how to determine vascular
families, coding for second- and third-order vessel
catheter placements beyond the initial placement,
bypass vessels, and abnormal anatomy.
Kimberly J. Engel, CPC, is owner of Decision
Medical Management Solutions, LLC, in Atlanta
(www.decisionmedicalmanagementsolutions.
com). She has been a Certified Professional
Coder (CPC®) for nearly a decade for many
specialties, and also is former coding management for Duke University Medical Center and
Aurora-Advanced, among others.
www.aapc.com
November 2010
27
cover
Op Reports Show How to Code
Selective Catheter Placement
To claim correctly consider the codes that should be assigned for these cases.
Nancy G. Higgins, CPC, CPC-I,
CIRCC, CPMA, CEMC
PROFESSIONAL
Determining correct selective catheter placement codes
is an integral part of coding
any interventional procedure.
For a better understanding,
code these two operative (op)
reports demonstrating common
coding scenarios.
28 AAPC Coding Edge
Example 1:
PATIENT: John Doe
SURGEON: John Smith
, MD
PROCEDUR E: Abdomi
na l and pelvic angiograph
y with bilateral lower
extremity runoff, selective
runoff of lef t lower extrem
ity.
INDICATIONS: Mr. Do
e is a 70-year-old gentlema
n who presents
with worsening bilateral
lower extremity claudica
tion. CT angiogram
had demonstrated severe
atherosclerotic disease of
the infrarena l aorta
but there did not appear
to be a focal high-grade
stenosis. He had bilatera l patent iliac stents and
lef t SFA occlusion.
DE SCRIPTION OF PR
OCEDUR E: The patien
t was brought to
the angiography suite and
placed on the table in sup
ine position.
We accessed the right fem
ora l site with use of a So
noSite. A Magic
Torque™ wire was advanc
ed in a retrograde fashion
under fluoroscopic
guidance. A 5-French she
ath was positioned over the
wire and the wire
and dilator were withdraw
n. A pigtail catheter was
then advanced up
to the upper abdomina l
aorta over a wire and flu
sh aortography was
performed in an AP projec
tion. The catheter was the
n brought down
to the lower abdomina l aor
ta and AP views of the pel
vis were taken.
Using a step-table techniqu
e, bilateral subtraction an
giography of the
lower extremity was perfor
med. We then exchanged
catheters for a universal flush catheter, which
was used with the Glidewir
e to select the
lef t common iliac artery.
A Glidewire was then adv
anced down to the
superf icia l femora l artery
and catheter exchange wa
s performed over
the wire for an angled tap
er catheter. Pressures in the
lef t femora l artery
distally were 80 /40. There
did not appear to be any
focal high-grade
stenosis proximal to that.
The catheter was then uti
lized to perform
selective angiography of
the lef t lower extremity.
FINDINGS OF THE DI
AGNOSTIC EX AMIN
ATION: There was
atherosclerotic disease inv
olving the entire infrarena
l segment from the
renal arteries to the bifurc
ation ; however, this did no
t appear to result
in a focal high-grade steno
sis. There were duplicated
renal arteries on
the right. The lef t renal
artery did not demonstrate
any
signif icant
stenosis. Bilateral commo
n iliac stents were patent
.
Th
e
lef
extremity runoff demonstr
t lower
ates a patent common fem
ora l artery. The
superf icia l femora l artery
is occluded at its origin.
Despite the fairly
rapid filling of the profun
da femoris, there was ver
y poor distal runoff
and ver y slow filling of the
above-knee poplitea l segme
nt on that side.
On the selective angiogra
ms, we were able to identi
fy
thr
ee-vessel
runoff. Dista lly, there is
a short focal dissection in
the proximal superf icia l femora l artery that do
es not appear to be flow
limiting. The superficial femora l artery appear
s patent down to the popli
tea l segment. He
appears to have three-ves
sel runoff preser ved on the
right.
cover
Example 2:
PATIENT: Jane Doe
SURGEON: John Smith, MD
PROCEDURES PERFORMED: Left femoral angiogram by antegrade access, left angioplasty and stent of superficial femoral artery.
DESCRIPTION OF PROCEDURE: The patient was brought to the
angiography suite where both groins were prepped and draped in the
usual manner. Skin overlying the left common femoral artery was infiltrated with 1 percent Xylocaine. Left common femoral artery was cannulated with a 21-gauge perc needle in an antegrade manner. The wire
was confirmed to be in the superficial femoral artery. The micropuncture sheath was then exchanged for a 5-French sheath. The 5-French
sheath in place, angiographic images were acquired of the left superficial femoral artery. She was noted to have a total occlusion at the level
of the adductor canal as well as other multiple, relatively minor stenoses.
The vessel was reconstituted at the level of the adductor canal. Popliteal
artery is widely patent. Anterior tibial and posterior tibial arteries are
patent, although there is some mild atherosclerotic disease at the tibioperoneal trunk. A 5-French sheath was then exchanged for a 6-French
sheath. With 6-French sheath in place, the lesion was crossed using
a subintimal dissection technique. The superficial femoral artery was
reentered well above the knee joint. The lesion was angioplastied with
a 5 mm x 40 mm angioplasty balloon. Residual occlusion remained so
a decision was made to place a stent. A 6 x 150 mm Viabahn stent was
then deployed across the diseased segment. The stent was then angioplastied with a 6 x 40 Powerflex balloon that did not adequately expand
the stent through its proximal portion. A 6 x 40 Dorado balloon was
then used to complete the angioplasty proximally. Follow-up angiography revealed some contour irregularities in the distal component of the
stent deployment. This area was then covered with a 5 mm x 5 cm Viabahn extension. Completion angiography showed the stent to be widely
patent. I showed excellent flow through the stent. The angiogram shows
the popliteal artery and proximal tibial vessels were unchanged from the
preprocedure angiograms. The patient tolerated the procedure without
difficulty and was returned to the holding area in satisfactory condition.
This report indicates the catheter was introduced
at the right femoral artery, advanced to the aorta,
then to the left common iliac, and finally to the left
superficial femoral artery. The correct catheter placement code is 36247 Selective catheter placement, arterial
system; initial third order or more selective abdominal,
pelvic, or lower extremity artery branch, within a vascular
family because the superficial femoral artery is considered a third-order branch and the code assignment
is based on the final destination of the catheter.
To help with your coding, you may refer to the
CPT® Appendix L , which shows the assignment of
branches to first, second, and third order for various vascular families, assuming the starting point
is the aorta. From this appendix, we can follow the
progression from common iliac to superficial femoral. The appendix indicates that this is a third-order
branch, confirming the correct catheter placement
code is 36247.
Through various vendors, including Z Health
Publishing (www.zhealthpublishing.com) and Medical
Assets Management (www.medicalassetsmanagement.
com), you can obtain color diagrams that show codes
for various catheter placements by vessel. When using
such a diagram, you also can determine, at a glance,
36247 is the appropriate code.
In example 2, the catheter is introduced at the left
common femoral artery and advanced in an antegrade fashion to the left superficial femoral artery.
This case differs from the first one because the aorta
was not crossed, and the catheter was moved down
the leg from one branch to another.
Here, CPT® Appendix L is not as easy to use. Recall
that Appendix L assumes the starting point for the
catheterization is the aorta. In this case, the catheter
was not moved to the aorta—so that assumption
does not hold true. But you can still use the appendix if you
are careful with your interpretation. The appendix indicates
that if the catheter is in the common femoral and is moved
to the superficial femoral, the catheter has moved from one
branch to a different branch. If we consider the common femoral as the starting point, the superficial femoral artery would
be a first-order branch. This scenario would support the use of
36245 Selective catheter placement, arterial system; each first order
abdominal, pelvic, or lower extremity artery branch, within a vascular family for the catheter placement.
Note: If you have access to color diagrams (as mentioned
above), you will find them to be more intuitive when coding a
case such as this.
To sum it up, you can determine the correct catheter placement
code by always considering the location of the starting point,
whether the catheter was advanced to the aorta, and the final
destination of the catheter.
Keep reading: In future months, we will consider the other
codes that should be assigned for these cases, and will look at
other op reports and their coding.
Nancy G. Higgins, CPC, CPC-I, CIRCC, CPMA,
CEMC, is a senior compliance specialist with
Carolinas Healthcare System. She has over 20
years of experience in the health care industry
and is the immediate past president of AAPC’s
Charlotte, N.C. Chapter. Nancy was recently
named 2009 Coder of the Year by AAPC. She
can be reached at: [email protected].
www.aapc.com
November 2010
29
feature
Registries May Offer Advantages
for PQRI Reporting
By Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC
EXPERT
Look at your
reporting
options and
find out how
your EP can
benefit most.
30 AAPC Coding Edge
E
ligible physicians (EPs) who wish to participate in the Physician Quality Reporting Initiative (PQRI) may use one of three methods
to report quality measures. They may report:
1. To the Centers for Medicare & Medicaid
Services (CMS) on their Medicare Part B
claims,
2. Through a qualified PQRI registry, or
3. To CMS via a qualified electronic health
record (EHR) product.
Of these, the third option is the “easiest,” but
works only if you already have a compliant EHR
system up and running. As well, only a limited
subset of measures may be reported via EHRs (10
in 2010, and up to 22 in 2011), leaving those EPs
whose patient population isn’t described by the
available measures subset out of luck.
EPs may pursue more than one reporting option
during a reporting period, but of the remaining two
options, certain EPs may find registry-based reporting offers important advantages over claims-based
reporting. In my experience, using a registry is a
piece of cake, and not at all as complicated as working with claims-based submissions.
For example, depending on the length of the
reporting period the EP chooses (six or 12 months),
registries offer more flexible (and potentially easier
to achieve) reporting options. A well designed and
supported registry also will alert you to potential
reporting mistakes; whereas, claims-based reporting requires you to “get it right the first time”
(claims may not be resubmitted for the sole purpose of correcting PQRI reporting errors). Finally,
registry-based reporting may occur retroactively:
For instance, measures for 2010 may be entered
into the registry anytime up to Jan. 31, 2011. In
contrast, claims-based PQRI reporting and submission of the actual claim must occur simultaneously.
Here’s the catch: Registry-based measures are different from claims-based measures, and apply to a
narrower patient population. As such, not all EPs
can take advantage of registry-based reporting.
Registry-based vs. Claims-based Reporting
Claims-based reporting encompasses 175 individual
quality measures, plus four measures that together
comprise the Back Pain measures group. The measures are weighted toward primary care, but an EP
of almost any specialty will find several measures
that may apply to his or her patient population.
Registry-based reporting, in contrast, relies entirely
on measures groups, of which there are only 13 in
2010 (one measures group will be added for 2011). A
measures group is four or more individual measures
related to a clinical topic having a common patient
population defined by diagnosis and/or encounter
codes. In 2010, these measures groups are:
 Diabetes Mellitus
 Chronic Kidney Disease (CKD)
 Preventive Care
 Coronary Artery Bypass Graft (CABG)
 Rheumatoid Arthritis (RA)
 Perioperative Care
 Back Pain
 Hepatitis C
 Heart Failure (HF)
 Coronary Artery Disease (CAD)
 Ischemic Vascular Disease (IVD)
 HIV/AIDS
 Community-Acquired Pneumonia (CAP)
A complete list of measures groups, as well as
qualifying CPT® patient encounter codes, ICD-9-CM
codes, and measures group-specific intent HCPCS
Level II G-codes may be found at:
feature
Ideally, in future years, CMS will increase the
number of measures groups to apply more
broadly across specialties, thereby making it
easier for more EPs to participate in PQRI.
www.cms.gov/PQRI/15_MeasuresCodes.
asp#TopOfPage. Select the link, “Getting Started
with 2010 PQRI Reporting of Measures Groups,”
near the bottom of the page.
These measures groups are skewed heavily in favor
of primary care and cardiology, and EPs with these
focus areas most easily would qualify for PQRI
incentives under registry-based reporting. But an
ear, nose, and throat specialist (ENT), to cite an
example, likely would find that her patient population wouldn’t support registry-based reporting
adequately—simply because the ENT would not be
treating or tracking patients for the available measures groups.
To cite another example: The perioperative care
measures group seems tailor-made for general
surgeons but you must be careful. The measures
group applies only to specific CPT® codes (as listed
in the aforementioned Getting Started with 2010
PQRI Reporting of Measures Groups document). If
the surgeon is not performing procedures reported
using the applicable CPT® codes, the perioperative
care measures group will not apply.
Ideally, in future years, CMS will increase the
number of measures groups to apply more broadly
across specialties, thereby making it easier for more
EPs to participate in PQRI. For a fair system, every
specialty should be able to use a registry.
Using a Registry
To become qualified, registries must meet certain
technical and other requirements specified by
CMS. A list of approved registries may be found
on the CMS website www.cms.gov/PQRI/20_
AlternativeReportingMechanisms.asp#TopOfPage:
Select the “Qualified Registries for PQRI
Reporting” link near the bottom of the page). Use
only a CMS-approved registry. The registry will
charge you a nominal fee per doctor to process and
submit your information to CMS. For instance,
the registry with which I am most familiar,
PQRI Wizard, charges $299 per doctor, and will
negotiate reductions in the per-doctor charge for
groups of 10 or more physicians.
Note: I use PQRI Wizard in my examples because
I have used this system most often to assist clients in submitting their PQRI data. Talk to your
vendor: Any worthwhile registry should offer competitive pricing and functionality.
As an example of how a registry works, PQRI
Wizard uses a questionnaire for each measure’s
group that is available to their clients in Adobe
PDF. The questionnaire mirrors the submission that you must complete when entering each
patient. The specific CPT® and ICD-9-CM codes
applicable to each measures group is listed on the
questionnaire for that measures group. The system
automatically tracks patients by reported CPT®
codes, constantly updates your PQRI reporting
status, and lets you know when you have collected
sufficient data for submission.
For instance, under the group measures reporting guidelines (when submitting for a 12-month
reporting period only), if the EP reports on all
applicable measures within the selected measures
group for a minimum sample of only 30 unique
patients who meet patient sample criteria for the
measures group, the EP is eligible for PQRI incentives (of the 30 unique patients, 28 may be nonMedicare Part B patients, ages 18 and above). A
quality registry will monitor your progress to be
sure you meet PQRI requirements (total number of
patients and quality measures, etc.), and will alert
you if there are missing or inconsistent data. This
allows you to correct information so that information submitted to CMS is perfectly clean, thereby
ensuring payment of your PQRI bonus.
www.aapc.com
November 2010
31
feature
To discuss this
article or topic,
go to www.aapc.com
Learn PQRI Basics
For example, in one group that I worked with,
there was a problem with the date the diagnosis
first was made. PQRI Wizard contacted the client
and asked them to go into the database and check
the accuracy of the information. As such, both my
client and the registry were making sure that the
data submitted to CMS was appropriate, and a payable PQRI submission was made. Be sure your registry provides similar audits and feedback, so that
you can enjoy the same successes.
Although registry-based PQRI reporting may apply
more narrowly than claims-based reporting, it also
may be applied with a greater level of success. The
ease of using a registry, and the high rate of success and payment, suggest that if you can find a
measures group that applies, registry-based PQRI
reporting may be to your benefit. You will find the
cost per physician is absorbed in labor savings, the
Medicare incentive, and the knowledge that you
will be successful.
Resource: CMS provides a “decision tree” to help you
decide if registry-based (or claims-based) PQRI reporting is
for you. Find it at: www.cms.gov/PQRI/Downloads/2010_
GettingStartedwithPQRIReportingofMeasuresGroups_020510_
FINAL_2.pdf
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H,
CPC-P, CPC-I, CHCC, is president of CRN
Healthcare Solutions and senior coder and
auditor for The Coding Network. She is consulting editor for Otolaryngology Coding Alert
and has spoken, taught, and consulted widely
on coding, reimbursement, compliance, and
health care-related topics nationally.
32 AAPC Coding Edge
If you’re not already participating in PQRI, you probably
should be. PQRI offers medical providers an opportunity
to earn incentives of up to 2 percent of their total estimated Medicare Physician Fee Schedule-allowed charges
for covered professional services within a reporting
period. Although PQRI reporting is not mandatory, based
on the trends we have seen with other CMS-sponsored
programs (such as e-scribing and the adoption of EHRs),
it’s safe to bet that providers who do not take part in
PQRI will, at some time in the future, face reduced Medicare payments.
It’s now too late to participate in PQRI for 2010, but you
shouldn’t lose your opportunity for 2011. Information
for PQRI eligibility may be found on the CMS website
(www.cms.gov/pqri/). From this site, you can view a list
of applicable quality measures, a list of frequently-asked
questions (http://questions.cms.hhs.gov/app/answers/
list: Type “PQRI” in the “search” box.), and additional
information to help you get started with the program.
PQRI offers options for individual EPs and group reporting. A list of individual Medicare EPs is available at www.
cms.gov/PQRI/Downloads/EligibleProfessionals.pdf.
EPs are not just physicians (e.g., doctors of optometry
and chiropractic), but also mid-level providers such as
physician assistants (PAs), clinical psychologists, and
more, as well as physical and occupational therapists
(PTs and OTs). Individual EPs do not need to sign up or
preregister to participate in the PQRI. Program requirements and measure specifications differ from year to
year, and EPs are responsible for ensuring they use the
PQRI documents for the correct program year.
Requirements for group reporting differ from those for
individual reporting. You may find specifics on the CMS
webpage given above, or by going directly to www.
cms.gov/PQRI/22_Group_Practice_Reporting_Option.
asp#TopOfPage.
Another year has passed.
Have You Begun?
ICD-10 Will Change Everything.
ICD-10 will be one of the largest changes health care has ever experienced. Systems, policies, procedures,
payments, submissions and documentation will all change.
No matter your role in the process, we have a training solution for you:
• Implementation Training
• Fundamentals of ICD-10
• ICD-10 Summarized in a Series of 15-Minute Webinars
For more information, visit AAPC.com/ICD-10
or call 1-800-626-2633
coding compass
U.S. v. Stokes:
Compliance Implications for the Average Physician
Failure to take corrective action can be perceived as admission of guilt.
By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CHCC, CRA
I
n a recent unpublished Sixth Circuit opinion,
United States v. Stokes, 2010 WL 3245536 (6th
Cir. 2010), the court affirmed the conviction
of a health care provider on 31 counts of health
care fraud. Dr. Robert W. Stokes, a licensed,
board certified dermatologist, became the target
of a federal investigation in 2001. Federal agents
looked at Stokes’ billing practices to determine
whether he up-coded certain outpatient surgical procedures. In particular, it was alleged that
Stokes frequently billed shaved excisions as more
costly full-thickness excisions, and billed less
complex closure techniques as expensive adjacent
tissue transfers. Stokes also was alleged to have
billed for both an office visit and a surgical procedure on the same day by indicating he treated
surgical patients for impetigo. Stokes defended
the charges on the basis of mistake; that is, he
was unaware he did anything wrong and, in fact,
believed his billing to be accurate.
Prior to trial, the government notified Stokes of
its intention to use as evidence correspondence and
audit notifications he received prior and subsequent
to the start of the government’s investigation. This
evidence fell into two general categories:
(1) letters from insurance providers addressing
relevant billing rules and questioning Stokes’
above-average surgical billings; and
(2) documents and testimony concerning audit
notifications that Blue Cross Blue Shield of
Michigan (BCBSM) sent to Stokes in 2000 and
2002.
This evidence was meant to show Stokes was aware
of relevant billing rules and, as such, his intent was
to defraud.
Although Stokes attempted to exclude this evidence, the trial court rejected his motion by con34 AAPC Coding Edge
cluding the “evidence of prior warnings is relevant
to the defendant’s knowledge and intent.” The
court, in affirming the conviction, determined the
admission of this evidence (which normally would
be excluded as hearsay) was proper because it was
not presented as proof that his billing was wrong
or fraudulent, but instead was offered to prove
the physician had known about the false Medicare claims at issue. The underlying assumption
was the communications and audit notices from
BCBSM contained sufficient information to notify
Stokes that he was doing something wrong, that
the carrier’s conclusions were accurate, and that
the billing rules for BCBSM and Medicare were
the same. It also assumed that Stokes actually saw
these notices.
Be Aware of Carrier Notifications
If the government’s theory about the case and the
assumptions drawn above are accurate, this decision
is significant to providers in the current post-payment audit climate. Consider the following scenarios
as a means of demonstrating how Stokes may affect
the average physician:
Scenario No. 1
You receive a request for records on a single patient
or a small number of patients. The carrier concludes that services were miscoded. The services
were coded correctly and the reason for the determination was a misunderstanding about the contents of the documentation. Although you disagree
with the result, the refund amount demanded is
small, the decision is made that it is not worth
arguing about, and the money is refunded. Because
you are a mid-size physician group, the issue is
handled through the compliance/billing department—the physicians don’t like to be bothered
with these things, are not advised, and, therefore,
have no knowledge of the issue.
coding compass
The underlying assumption was the communications and
audit notices from BCBSM contained sufficient information
to notify Stokes that he was doing something wrong, that
the carrier’s conclusions were accurate, and that the billing rules for BCBSM and Medicare were the same. It also
assumed that Stokes actually saw these notices.
Scenario No. 2
Your office receives written correspondence about
use of a certain code. The correspondence includes
coding policies that are unique to that carrier. They
are reviewed by your billing/compliance staff. After
review, the information is filed and the physician
never sees it.
Scenario No. 3
A carrier posts a provider alert on its website identifying potential errors pertaining to a service you
bill. According to the provider alert, you are billing
incorrectly, but neither the provider nor the staff
sees the alert.
Determine the Risks
Now let’s apply the court’s reasoning in Stokes to
determine what kind of risk is created in each
scenario:
Compliance Risk No. 1
Your acceptance of the audit result and its conclusions without objection or appeal would be
construed in a subsequent matter as agreement
with the carrier’s conclusions. Even though the
physician had no actual knowledge of the issue,
the physician would be charged with knowledge
of the error (the legal term is “constructive knowledge”). Based on the holding in Stokes, the government could then demonstrate knowledge of the
error in a subsequent investigation, making the
chances of being accused of similar, future fraud
allegations more likely.
There is an unfortunate presumption in the holding of Stokes that coding and documentation
rules are universal. Once again, because you did
not respond to the correspondence, the conclusion would be that you agreed with the carrier’s
concerns. Based on the outcome of Stokes, those
policies may be applied to billings to another
carrier (even though that carrier may not have a
similar coding policy). The failure to take corrective action could be construed as willful conduct
from that point forward. The physician could be
charged with knowledge of this correspondence,
whether or not it was seen.
The physician could be charged with knowledge
of information in provider bulletins, in carrier
e-newsletters, and in carrier medical policies even
though they are only published on the carrier’s
website. As an example, the government requires
you to be familiar with the Centers for Medicare
& Medicaid Services (CMS) Internet-only manuals
and local coverage determinations (LCDs), which
generally are available only on the web. Regardless
of whether you saw or read these materials, you
are responsible for doing so. The government need
not prove actual knowledge of the contents of such
documents. Constructive knowledge exists when
you had an opportunity to know what these materials contained.
Knowledge is a key element of demonstrating fraudulent conduct and is often the most
difficult element of fraud for the government
to prove. Unfortunately, the holding in Stokes,
as illustrated in the aforementioned scenarios,
clearly demonstrates how knowledge can be
attributed to you.
Providers, billing staff, and compliance personnel
are encouraged to:
1. Pay attention to all carrier correspondence,
provider bulletins, and medical policies
addressing your services, especially for Medicare and carriers with which you participate.
www.aapc.com
November 2010
35
coding compass
Providers should re-think refunding money where the
amount is small and underlying assertion of error is
believed to be inaccurate.
2. Document receipt and review of the information, object in writing if you disagree, and
identify and document any limitations to the
instructions (i.e., only applicable to BCBSM).
3. Document the corrective steps taken to ensure
future compliance.
4. Re-think refunding money where the amount
is small and underlying assertion of error is
believed to be inaccurate.
Take Action and Document Your Efforts
Specific to the scenarios presented, the following
suggestions are provided to mitigate further risk:
Mitigation Technique No. 1
Submit a written objection to the audit result, even
if you agree to refund the money because it isn’t
enough to fight over. Your objection should detail
why, under the relevant contract, medical policy,
etc., the carrier’s audit conclusion is inaccurate.
Always discuss and evaluate the issue with the
billing/compliance staff and the physician. If something in the documentation led the carrier to the
wrong conclusion, the physician is in the best position to correct and apply to future cases.
There are a number of ways to mitigate this problem. Circulate the correspondence and require each
staff member, including physicians, to initial when
they have read and reviewed the material. A more
effective approach is to have a staff member review
the policy in detail and present during a periodic
compliance meeting the issue, its impact, and recommended solutions. Not only will everyone be
apprised of the issue, but documenting complianceoriented education will reduce your risk of being
subject to fraud allegations.
Similar to the issue above, circulate the informa36 AAPC Coding Edge
tion throughout the billing department and the
physicians. For this to occur, the practice first must
be aware there is information to circulate. Assign
a member of the billing or compliance staff with
the responsibility of periodically reviewing changes
to your contracted and billed carriers’ websites/
newsletters/medical policies. Raise any identified changes during a staff meeting or compliance
meeting, or circulate a copy of the notice or policy
for individual review. If addressed in a meeting,
record the identity of those attending and the issues
addressed in your compliance binder. Be sure to
follow up with any staff members who were absent
from the meeting. When circulating a copy of the
notice or policy, make sure each individual verifies
by initials or other means that he or she reviewed
the material, and place the returned copy in your
compliance binder.
The holding in Stokes makes it clear that physicians
can no longer remain aloof to billing policies or
billing issues, especially when alleged coding and
medical necessity errors are based on documentation defects. Unfortunately, compliance plans and
compliance personnel will not solve the problem
entirely. At the end of the day, all providers must
make a personal effort to understand and comply
with carrier documentation and coding rules. To
mitigate the potential of becoming a fraud target,
providers must challenge inaccurate determinations
when they occur, or take immediate corrective
action when concerns are legitimate.
Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC, is
president of Practice Masters, Inc. and the founding
partner of Miscoe Health Law, LLC, a member of the
AAPC Legal Advisory Board (LAB) and a past member
of National Advisory Board (NAB). He is admitted to the
Bar in the state of California and to practice law before
the U.S. District Courts in the Southern District of
California and the Western District of Pennsylvania. Mr.
Miscoe has nearly 20 years of experience in health care coding and over
14 years as a compliance expert testifying in civil and criminal cases.
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November 2010
37
newly credentialed members
William Nettles, CPC APO AE
Monika Place, CPC APO AE
Erika Smith, CPMA, CEMC APO AE
Cheryl Stone, CPC Jefferson AE
Diane Martel, CPC Lewiston AE
Drew C Pierce, CPC West Middlesex AE
Pamela Hartmann, CPC Athens AL
Elizabeth Ann Smith, CPC Millbrook AL
Michelle M Johnson, CPC Prattville AL
Deirdre T Odom, CPC Prattville AL
Lisa Golden, CPC Maumelle AR
Maxine Torrence, CPC North Little Rock AR
Cori Klein, CPC Pineville AR
Sara McCoy, CPC Prairie Grove AR
Martha Sims-Green, CPC Avondale AZ
Cassandra Cannizzo, CPC Buckeye AZ
Courtney Henderson, CPC, CPC-P Gilbert AZ
Maxine Jo Frusher, CPC Peoria AZ
Sandra Poquette, CPC, CPC-H Peoria AZ
Abby A Catalan, CPC, CPC-P Phoenix AZ
Julia E Huston, CPC, CPC-H Phoenix AZ
Donna M McCormick, CPC, CPC-H Sahuarita AZ
Nickie D Moreno, CPC Surprise AZ
Blanca Delgado Turitto, CPC Surprise AZ
Gloria A Alcazar, CPC Tucson AZ
Maureen E Encinas, CPC Tucson AZ
Nita E Fleisch-Fresser, CPC Tucson AZ
Melina Gutierrez, CPC Tucson AZ
Eva G Hotchkiss, CPC Tucson AZ
Gayle A Manuel, CPC Tucson AZ
William Joseph Smith, CPC Tucson AZ
Lonny M Whitaker, CPC Tucson AZ
Angie Labadie, CPC, CPMA Anaheim CA
Virginia Padilla, CPC Antioch CA
April D Napravnik, CPC Brea CA
Bethany Mckeighen, CPC Carmichael CA
Sonia Parsaee, CPC Encino CA
Monica L Witt, CPC Escondido CA
Annette M Williams, CPC Hawthorne CA
Sherry Ransom, CPC Hercules CA
Heidi Shaw, CPC Hesperia CA
Liana Rojas, CPC Inglewood CA
Jeanne Constance James, CPC La Jolla CA
Cristina Perez, CPC Lake Elsinore CA
Eugenia Estrina, CPC, CIRCC, CPMA, CCC Los
Angeles CA
Karl Wood, CPC Los Angeles CA
Lynda L Hargis, CPC Mojave CA
Christine O Canlas, CPC North Hollywood CA
Rosemary Gonzalez, CPC Port Hueneme CA
Stacey D Ruggles, CPC Ramona CA
Selina Thomas, CPC Redlands CA
Marissa L Salen, CPC Redondo Beach CA
Maria van der Veen, CPC San Dimas CA
Conrad Sinsay, CPC San Jose CA
Robin Levy, CPC Santa Ana CA
Sherri Laleh Shabestari, CPC Torrance CA
Trenelle Monique Holt, CPC Vacaville CA
Angelica Almaraz, CPC Venice CA
Karen Pivnick, CPC Norwich CT
Patricia Helen Kellogg, CPC Waterbury CT
Krista Sklodowski, CPC Hockessin DE
Beth Miller, CPC Millsboro DE
Ellisa Durrant, CPC Brandon FL
Kelly Leann Williams, CPC Brooksville FL
Eileen Stein, CPC Hernando FL
Santhosh Samuel, CPC Hialeah FL
Ana Yanez-Marrero, CPC Hialeah FL
Wendy Douglass, CPC Jacksonville FL
Tiffany Morrison, CPC Jacksonville FL
Catherine Rousseau, CPC Jacksonville FL
Ryan Austin Sweat, CPC Jacksonville FL
Laura Silva, CPC Kissimmee FL
Diane Naylor, CPC Merritt Island FL
Isirett B Aguilar, CPC Miami FL
Adriana Labori, CPC Miami FL
Jenna Martin, CPC Miami FL
Jose M Venedicto, CPC Miami FL
Edelys Lopez, CPC Miami Lakes FL
Amy Nichole Russell, CPC Orange Park FL
38 AAPC Coding Edge
Yadira Charon, CPC Orlando FL
Patricia Thompson, CPC Orlando FL
Linda Williams, CPC Orlando FL
Vanessa Conde, CPC Ormond Beach FL
Barbara Bateman, CPC Palm Bay FL
Vivian Southard, CPC Palm Bay FL
Maritza Fromer, CPC Rockledge FL
Kathryn Rovito, CPC Rockledge FL
Mary Cathy Timpano, CPC San Antonio FL
Rhonda Phillips, CPC Seffner FL
Cherice Nicole Witter, CPC, CPC-H, CPC-P, CPC-I
Seminole FL
Olga Luisa Montenegro, CPC St Petersburg FL
Sandra P Carnaroli, CPC St Petersburg FL
Karen V Moses, CPC, CPMA Atlanta GA
Margo Delois Davis, CPC Augusta GA
Deborah Ann Eason, CPC Augusta GA
Torie Lynn Thibodeaux, CPC Forest Park GA
April Dawn McLean, CPC Lawrenceville GA
Debbie Thornberry, CPC-H Marietta GA
Breezy U Houston, CPC, CPC-H Newnan GA
Dawn Sikes Morris, CPC, CPC-H Smyrna GA
Christi G Kirkland, CPC, CPMA Stockbridge GA
Karen Still, CPC, CPMA, CPC-I Stockbridge GA
Trisha Ann Rencher, CPC Pocatello ID
Eswari Raj, CPC Aurora IL
Shobana Suresh, CPC Aurora IL
Stephanie Morris, CPC Avon IL
Judy Moretto, CPC, CPC-P Bartonville IL
Kimberly Waynee Darling, CPC Charleston IL
Tin Khine, CPC Chicago IL
Stephanie Lee, CPC Chicago IL
Ruth Maletz, CPC Chicago IL
Barbara J Slade, CPC Decatur IL
Marla Sue Windlan, CPC Decatur IL
Trista Rae Green, CPC Greenup IL
Tammy L Rhoades, CPC Herrick IL
Leah Elane Lewis, CPC Mattoon IL
Katrina Lynn Thompson, CPC Mattoon IL
Dalene Mary Brandenburg, CPC Neoga IL
Shelley Lovell, CPC Neoga IL
Stefanie Jones-Anderson, CPC Peoria IL
Donna D Robinson, CPC Tinley Park IL
Carol A Collins, CPC Toledo IL
Jaimee James, CPC Toledo IL
Robin Bell, CPC-H Wheaton IL
Scott A Viera, CPC Anderson IN
Traci Borzych, CPC Chesterton IN
Christine Walker, CPC, CPC-P Columbia City IN
Marianne Smith, CIRCC Ft Wayne IN
Sheila L Miller, CPC Gary IN
Virginia L Askins, CPC Indianapolis IN
Karen S Mutchler, CPC Indianapolis IN
Lori Zander, CPC Indianapolis IN
Taunya R Andrews, CPC Kokomo IN
Kathleen M Goodwin, CPC La Porte IN
Barbara L Whitten, CPC Lake Station IN
Kimberley R Naragon, CPC Martinsville IN
Janet Hawn, CPC Noblesville IN
Jackie Grusak, CPC Union Mills IN
Joan Robbins, CPC Garnett KS
Deanna Wolken, CPC Garnett KS
Dawn Jacques, CPC Leavenworth KS
Megan Lea Stamps, CPC Bowling Green KY
Puspito Walson, CPC Florence KY
Kristi Sheets, CPC Georgetown KY
Michelle T Zakic, CPC-P Georgetown KY
Sharon Ford, CPC Hartford KY
Nisha Dave, CPC LaGrange KY
Sherri Vertrees, CPC Louisville KY
Catherine A Sharp, CPC Paducah KY
Crystal Warren, CPC-H Paducah KY
Patricia Henriott, CPC Baton Rouge LA
Hue Thi Tran, CPC, CPMA, CEMC Baton Rouge LA
Monica Martin, CPC Delhi LA
Chelsea Leigh Graham, CPC Denham Springs LA
Traci Torres, CPC, CPMA, CEMC Denham Springs LA
Mary Ellis, CPC Gray LA
Shelly Serigne, CPC Houma LA
Heather Conners, CPC Metairie LA
Misty Mouch Millet, CPC Plaquemine LA
Kim Fields, CPC Walker LA
Robert Horton, CPC Reading MA
Michelle L Mann, CPC West Springfield MA
Deepali Dinkar Birhade, CPC Mumbai Maharashtra
Senthil Kumar J, CPC Mumbai Maharashtra
Harshvardhan Sham Jadhav, CPC Mumbai
Maharashtra
Sachin Ashok Karajgi, CPC Mumbai Maharashtra
Prachi Pandurang Mahadik, CPC Mumbai
Maharashtra
Anand Dattatrey Patil, CPC Mumbai Maharashtra
Raghavendra S Pawar, CPC Mumbai Maharashtra
Nithya Shanmugam, CPC, CPC-H Mumbai
Maharashtra
Senthilkumaran Sukumar, CPC, CPC-H Mumbai
Maharashtra
Lana Berov, CPC Baltimore MD
Michele Kay Oliver, CPC Baltimore MD
Schwanna Freeman Crawford, CPC, CPMA Ft
Washington MD
Douglas Dyer, CPC Hunt Valley MD
Lisa Fogle, CPC Mt Airy MD
Judy Metros, CPC Brownville ME
Shannon Curtis, CPC Bucksport ME
Ginger Roberts-Scott, CPC W Gardiner ME
Tara Erickson, CPC Windham ME
Audra M Cook, CPC Harrison MI
Jan Schuler, CPC Northville MI
Loretta L Sacco, CPC, CPMA Pinckney MI
Helen Teresa Dowling, CPC Traverse City MI
Vicky West, CPC Independence MO
Karen Fox, CPC Nixa MO
Katherine Colbert, CPC Greenville MS
Felesha L Shavers, CPC Jackson MS
Heidi Marie Lyme, CPC Ruleville MS
Lynn Deaton, CPC, CPMA, CEMC Billings MT
Angela Hahn, CPC Concord NC
Kellie Grahl, CPC Dallas NC
Anthony Levon Fleming, CPC Durham NC
Ashley Murphrey Barrow, CPC Farmville NC
Renee Carlton, CPC Havelock NC
Denise Lillis, CPC New Bern NC
Wendy Lynn Gibson, CPC Raeford NC
LaKesha Jackson, CPC Raleigh NC
Kim Fearing, CPC Statesville NC
Tamara Bryant, CPC Williamston NC
Ellen Fitts, CPC Laconia NH
Melissa Ross, CPC Belle Mead NJ
Stacey Lyvonne Roberts, CPC Camden NJ
Cindy Alves, CPC Colonia NJ
Rebecca A Musolf, CPC Colonia NJ
Barbara Elisano, CPC Millville NJ
Marie L Rubert, CPC Bronx NY
Apexa Borsada, CPC Brooklyn NY
Lisa Marie Maslowski, CPC Buffalo NY
Peggy Brown, CPC Cambria Heights NY
Kathleen E Ross, CPC Greene NY
Joy R Bruen, CPC Oneonta NY
Ruth Brown, CPC Port Crane NY
Sandi L Berry, CPC, CPMA Richville NY
Renee M Teale, CMBS, CPC, CPMA Sidney
Center NY
Diane Sanna, CPC Staten Island NY
Dana Lodge, CPC Uniondale NY
Jeanette Gonzalez, CPC Valley Stream NY
Michele Riesen, CPC Alliance OH
Lynnette Saxby, CPC Arlington OH
Amy Beth Small, CPC Beachwood OH
Emily Morrill, CPC Cleveland OH
Amy L Crego, CPC, CPC-P Columbus OH
Tracey Vaughn, CPC Delaware OH
Janet Russell, CPC Gallipolis OH
Daniel E Nousek, CPC Lyndhurst OH
Jennifer Rohaley, CPC-H Mentor OH
Ashley Marie Smithson, CPC Mentor OH
Barbara Beres, CPC Parma OH
Amber Carlson, CPC Parma OH
Marie Roberts, CPC Racine OH
Kristen Beth Wood, CPC South Euclid OH
Sheila Luke, CPC Westerville OH
Cynthia Weston, CPC Davis OK
Shanece Williamson Howell, CPC Edmond OK
Jennifer Stingley, CPC Edmond OK
James A Collins, CPC Oklahoma City OK
Edith Davis, CPC Oklahoma City OK
Crescentia Y Woods, CPC Oklahoma City OK
Amanda Hollis, CPC Tulsa OK
Catrina Jacobs, CPC Tulsa OK
Kristie C Moorman, CPC Elkton OR
Louise Riehl Haley, CPC Rockaway Beach OR
Kristina Crouse, CPC Abbottstown PA
Shelley Sampson, CPC Brookville PA
Carol Forbes, CPC Dallas PA
Michelle Lombardi, CPC Easton PA
Lori Smith, CPC Greenville PA
Mary Lou Warso, CPC New Castle PA
Joli Fitzgibbons, CPC Red Lion PA
Kori DeFazio, CPC Reynoldsville PA
Tiffany Hopson, CPC Sharon PA
Linda Burczyk, CPC Wyoming PA
Sheryl Baker Ghent, CPC Blackstock SC
Heather Kight, CPC Florence SC
Christine Matthews, CPC Lancaster SC
Cornelia D Kyle, CPC, CPMA Mt Pleasant SC
Robert B Shaffner, CPC Myrtle Beach SC
Deborah P Hyman, CPC Pamplice SC
Gayle Grieger, CPC-H Summerville SC
Deanna Rickrode, CPC, CPMA Aberdeen SD
Shantell Christina Tramp, CPC Kimball SD
Becky Elizabeth Eichstadt, CPC Mitchell SD
Debra Marie High Elk, CPC Plankinton SD
Kelli Sue Weber, CPC Plankinton SD
Teena Gaylene Moeller, CPC White Lake SD
Vignesh D, CPC Chennai Tamil Nadu
Ranjith Kumar K, CPC Chennai Tamil Nadu
Rosanna M Cassidy, CPC Ashland City TN
Chelsea Nicole Clark, CPC Castalian Springs TN
Cheryl Bryan, CPC Centerville TN
Brandi Bellar, CPC Dickson TN
Megan Elizabeth Ford, CPC Knoxville TN
Andrea Lee Thornton, CPC Knoxville TN
Elizabeth Ann Dunn, CPC Lascassas TN
Bridget Turner, CPC Mcminnville TN
Debora Lee Richardson, CPC Memphis TN
Gerrilyn Seward, CPC-H Memphis TN
David J Calby, CPC Murfreesboro TN
Christy Talley, CPC Murfreesboro TN
Jessica Denise Doub, CPC Oak Ridge TN
Rozmin Bapat, CPC Allen TX
Elizabeth W Sowder, CPC Copperas Cove TX
Judy L Stroud, CPC Granburry TX
Rolunda Baker, CPC, CPC-H Houston TX
Carolyn Freeman, CPC Lubbock TX
Jennifer J Freeman, CPC Lubbock TX
Alisha Wright, CPC Lubbock TX
Sanya Belcher, CPC Plano TX
Roxeann Teiper, CPC Richardson TX
Dana Stiff, CPC Weatherford TX
Heidi Jones, CPC Kaysville UT
Katherine Pulley, CPC Orem UT
Geri Howard, CPC Springville UT
Peggy A Stilley, CPC, CPMA, CPC-I, COBGC West
Valley UT
Elizabeth L Vanderwarker, CPC Broadway VA
Debra S Willis, CPC Cobbs Creek VA
Julie Ann Campbell, CPC Elkton VA
S Windy Lamoreaux, CPC Grottoes VA
Tina Elizabeth Payne, CPC Luray VA
Emelie Labreeska Long, CPC Mt Solon VA
Cynthia Hall May, CPC Richmond VA
Gary Ellis, CPC Suffolk VA
Melanie T Austria, CPC Virginia Beach VA
Lynn Streeper, CPC Virginia Beach VA
Samantha Martel, CPC S Burlington VT
Linda Schoenwald, CPC Bothell WA
Leticia Corpuz, CPC-H Mill Creek WA
Gena L Rooney, CPC, CPC-P, CPMA Mountlake
Terrace WA
Stacey Lee Olson, CPC, CIRCC, CEMC Renton WA
Paula Stankevitz, CPC Green Bay WI
Toni M Mleczko, CPC La Crosse WI
LeAnn Fuhrmann, CPC Merrill WI
Jaynie Kutka, CPC Milwaukee WI
Michele M Ortiz, CPC Milwaukee WI
Ashley Simanson, CPC Slinger WI
Patricia Sonnemann, CPC, CIRCC, CPMA
Waukesha WI
Lisa McDermott, CPC Waunakee WI
Jodie Douglas, CPC Dunbar WV
Amy Michelle Brown, CPC Huntington WV
Kelly Lynn Kay, CPC Letart WV
Tracey J Poe, CPC Mathias WV
Apprentices
Hiromi Kamine Arita, CPC-A APO AE
Amber Nicole Bradford, CPC-A APO AE
Melanie Cambra, CPC-A APO AE
Tiffani Jonne Davis, CPC-A APO AE
Chona Felts, CPC-A APO AE
Gabriela Adela Fortney, CPC-A APO AE
Yulia Muenzel, CPC-A APO AE
Diji Anna Tomas, CPC-A APO AE
Alexandra Gottlieb, CPC-A Bedesbach AE
Ashlee A Huerta, CPC-A Fontana AE
Sallie Fairless, CPC-A Louisville AE
Dwaylah Breland Reehl, CPC-A Fairhope AL
Leslie Butterworth Keith, CPC-A Hoover AL
Michelle Buckner, CPC-A Huntsville AL
Paula Mintzer, CPC-A Somerville AL
Jeanetta Pate, CPC-A Paragould AR
Amanda Foster, CPC-A Apache Junction AZ
Jeannine Vierra, CPC-H-A Gilbert AZ
Marilyn M Sandy, CPC-A Glendale AZ
Roni Taylor, CPC-A Marana AZ
Elizabeth Benavidez, CPC-A Mesa AZ
Stephanie Michelle Cook, CPC-A Mesa AZ
Umadevi Thekke Kunnath, CPC-A Phoenix AZ
Lyndon Mamangun Lacson, CPC-A Sahuarita AZ
Gina Marie Crowe, CPC-A Show Low AZ
Aniam Arroyo-Noriega, CPC-A Tucson AZ
Marisa A Harris, CPC-A Tucson AZ
Carla Sue Jones, CPC-A Tucson AZ
Janelle Joseph, CPC-A Tucson AZ
Kristine J Marino, CPC-A Tucson AZ
Cathleen M Martell, CPC-A Tucson AZ
Jessica Rae Martinez, CPC-A Tucson AZ
Cynthia A. Moos, CPC-A Tucson AZ
Wendy M Moreno, CPC-A Tucson AZ
Michele L Nelson, CPC-A Tucson AZ
Barbara A Saul, CPC-A Tucson AZ
Allyn M Smith, CPC-A Tucson AZ
Francie E Tintle, CPC-A Tucson AZ
Tina M Trejo, CPC-A Tucson AZ
Janice Baugh, CPC-A Yuma AZ
David Joseph Koscinski, CPC-A Yuma AZ
Devon Melba Kalvenetta Forbes, CPC-A Nassau
Bahamas
Chantell S Rolle, CPC-A Nassau Bahamas
Russell Sundberg, CPC-A Alta Loma CA
Lisa Trubisky, CPC-A Brentwood CA
Leigh Franz-Escalante, CPC-A Campbell CA
Sonia P Bringas, CPC-A Cerritos CA
Diana Soon, CPC-A Cerritos CA
Ewanica Evans-Marshall, CPC-A Chino CA
Megan Marie Moore, CPC-A Claremont CA
Lorena Roman, CPC-A Compton CA
Christine H Tran, CPC-A Costa Mesa CA
Jeffrey Snell, CPC-A Coto De Caza CA
Vickie L Utt, CPC-A Crestline CA
Cheryl Henry, CPC-A Diamond Bar CA
Betty Siu, CPC-A Dublin CA
Bing Liu, CPC-A El Monte CA
Alina Rikhtman, CPC-A Encino CA
Benny Alan Mesa, CPC-A Escondido CA
Vickie Sciorelli, CPC-A Fairfield CA
Shamsi Nikoumanesh, CPC-A Fillmore CA
Brian Scott Jorgensen, CPC-A Fontana CA
Alyssa Montijo, CPC-A Fontana CA
Shelton Ray Welch, CPC-A Fremont CA
Lucelmina Araneta, CPC-A Fullerton CA
Ma.Elenita Vargas, CPC-A Gardena CA
Kristen Fan, CPC-A Glendora CA
Carol A Ballard, CPC-A Huntington Beach CA
Steven Herbert, CPC-A Huntington Beach CA
Loujean Kapinus, CPC-A Irvine CA
KuangChin Yang, CPC-A Irvine CA
John V Rigor, CPC-A La Palma CA
Honorio Santos, CPC-A Laguna Niguel CA
Tyler A Youderian, CPC-A Lakewood CA
Bridgette Lopez, CPC-A Lomita CA
Melissa Shumsky, CPC-A Lomita CA
Mary Walsh, CPC-A Lomita CA
Gregory Brown, CPC-A Los Angeles CA
Marvin Gomez, CPC-A Los Angeles CA
Oneika Denise Parker, CPC-A Los Angeles CA
Michelle Bustos, CPC-A Norwalk CA
Aileen A Llave, CPC-A Norwalk CA
April M Thomas, CPC-A Norwalk CA
Karina Autz, CPC-A Oakland CA
David Bliss, CPC-A Oakland CA
Gina Sandler, CPC-A Oakland CA
Warren Taylor, CPC-A Oakland CA
Maggie Vashel, CPC-A Oakland CA
Kevin Watkins, CPC-A Oakland CA
Lisa Woll, CPC-A Oakland CA
Tina Muela, CPC-A Oakley CA
Henry James Robicheaux, CPC-A Oceanside CA
Valerie Nicole Cortez, CPC-A Ontario CA
Betty Laughlin, CPC-A Orange CA
Theresa Mayer, CPC-A Orange CA
Grace Ann Rebuck, CPC-A Pinole CA
Cristina Batugal, CPC-A Pittsburg CA
Grace Kim, CPC-A Rancho Palos Verdes CA
Jayne M Groen, CPC-A Rancho Santa Margarita CA
Marie Negron, CPC-A Rolling Hills Estates CA
Erna Doctora Cruz, CPC-A San Diego CA
Michael Tyrone Ingram, CPC-A San Diego CA
Stephanie K Lean, CPC-A San Diego CA
Virginia Cordova West, CPC-A San Diego CA
Migdalia Herrera, CPC-A San Pablo CA
Than Aung, CPC-A San Pedro CA
Jane I Wang, CPC-A Sierra Madre CA
Bamidele (Dele) Olufunmilola Grillo, CPC-A South
San Francisco CA
Teresita Almeda, CPC-A Torrance CA
Yaeko Mihara, CPC-A Torrance CA
Angelica Oreta, CPC-A Torrance CA
Kristy Payne, CPC-A Torrance CA
Elizabeth Smith, CPC-A Torrance CA
Chara Perez, CPC-A Turlock CA
Marsha Diy, CPC-A Tustin CA
Elpidio Javier, CPC-A Valencia CA
Lynn Ledesma, CPC-A Valencia CA
Donna Marie Peters, CPC-A Yorba Linda CA
Vicki L Boisen, CPC-A Loveland CO
Denise Dawn Kelley, CPC-A Loveland CO
Elizabeth Rebaleati, CPC-A Loveland CO
David Scott Russell, CPC-A Loveland CO
Christine Ann Webb, CPC-A Loveland CO
Carrie B Giesler, CPC-A Windsor CO
Bonita Camire, CPC-A Beacon Falls CT
Daisy Tali Martinez, CPC-A Bridgeport CT
Robyn Chase, CPC-A Bristol CT
Theo W Pawlowski, CPC-A Broadbrook CT
Elissa Genereux, CPC-A Brookfield CT
Laura V LaPointe, CPC-A Coventry CT
Catherine C Wood, CPC-A Coventry CT
Eileen Pendl, CPC-A Cromwell CT
Carolanne Rowe, CPC-A Danielson CT
Jacqueline Doris Cormier, CPC-A East Hartford CT
Megan Hope Obrero, CPC-A East Hartford CT
Deborah A Parlos, CPC-A East Windsor CT
Nicole Desiree Laymon, CPC-A Glastonbury CT
Michael Stein, CPC-A Glastonbury CT
Kristen Tobias, CPC-A Griswold CT
Kasy A Reyes, CPC-A Hartford CT
Tracey LaForge, CPC-A Manchester CT
Susan Levine, CPC-A Manchester CT
Lisa Nisula, CPC-A Manchester CT
Carol Lynn Phillips, CPC-A Manchester CT
Laura Kristin Gulliksen, CPC-A Marlborough CT
Patrice C Smart, CPC-A Marlborough CT
Maureen Gradzewicz, CPC-A Meriden CT
Gail VanDerLinden, CPC-A Middletown CT
Shannon Santos, CPC-A Naugatuck CT
Dee-Anna Sybal, CPC-A New Britain CT
Meg Jane Scarneo, CPC-A New Fairfield CT
Brenda Wilson, CPC-A New Haven CT
Rajmonda Xhaxho, CPC-A Newington CT
Madeline Medina, CPC-A South Windsor CT
Kristin Ruthen, CPC-A South Windsor CT
Johanna Lawry, CPC-A Tariffville CT
Dawn Seitz, CPC-A Terryville CT
June Cameron, CPC-A Thomaston CT
Shawn Murowsky, CPC-A Thomaston CT
Debra Ann Anderson, CPC-A Tolland CT
Nancy Randall, CPC-A Uncasville CT
Marsha A Alexson, CPC-A Vernon CT
Lisa C Gardiner, CPC-A Vernon CT
Amy Wessell, CPC-A Vernon CT
Sarah Femia, CPC-A Wallingford CT
Padmaja Seshadri, CPC-A Weatogue CT
Ashlie Hernandez, CPC-A West Hartford CT
Crystal Marie Antolini, CPC-A Willington CT
Laurie Ann Caetano, CPC-A Windsor CT
Doreen Tracey Hicks, CPC-A Windsor CT
Laurie A Sheahan, CPC-A Wolcott CT
Allison Melchiorre, CPC-A Claymont DE
Jennifer Sutton, CPC-A Wilmington DE
Melanie Taylor, CPC-A Apopka FL
Luisa E Hassen, CPC-A Brandon FL
Christy A Torres, CPC-A Brandon FL
Christina Zibers, CPC-A Cape Coral FL
Renee Moore, CPC-A Clermont FL
Walda Gonzalez, CPC-A Coral Springs FL
Kimberly Cunningham, CPC-A Hernando Beach FL
Annette White, CPC-A Hobe Sound FL
Karen L Felix, CPC-A Hollywood FL
Bonita A Bope, CPC-A Homestead FL
Isbelys C De Armas, CPC-A Homestead FL
Raquel Leal, CPC-A Homestead FL
Tammy Roessner, CPC-A Houdson FL
Bhavna Jobanputra, CPC-A Jacksonville FL
Selesia Lujuana McClendon, CPC-A Jacksonville FL
Sandra Nichols, CPC-A Jacksonville FL
Nadine Bignall, CPC-A Kissimmee FL
Keysha Clemente, CPC-A Kissimmee FL
Adalgisa Fernandes, CPC-A Kissimmee FL
Virgen Galarza, CPC-A Kissimmee FL
Phillipa McFarlane, CPC-A Kissimmee FL
Krystal Melendez, CPC-A Kissimmee FL
Alma I Santiago, CPC-A Kissimmee FL
Betsy Santiago, CPC-A Kissimmee FL
Neha Vinay Shukla, CPC-A Lake Mary FL
Tiffiny Leshon Smith, CPC-A Lake Wales FL
Arica Ann McGraw, CPC-A Lakeland FL
Florence Hoadley, CPC-A Land-O-Lakes FL
Rachel D Moore, CPC-A Largo FL
Leandra Samuel, CPC-A Lauderhill FL
Jennifer Rebecca Perry, CPC-A Longwood FL
Robert E Fields, CPC-A Lutz FL
Marianne Fraser, CPC-A Melbourne FL
Marley Gagliardi, CPC-A Merritt Island FL
Maxine Kelly, CPC-A Miami FL
Dawn Greaves, CPC-A Miramar FL
Anita Gatlin, CPC-H-A Mount Dora FL
Ruth Nuss, CPC-A New Port Richey FL
Anthea J Lewis, CPC-A North Lauderdale FL
Donna Morgan, CPC-A North Miami FL
Ainalem Almonte, CPC-A Orlando FL
Kelly Chase, CPC-A Orlando FL
Aundrea Melvin, CPC-A Orlando FL
Heloisa Tarnan Pereira, CPC-A Orlando FL
Beatrice Vazquez, CPC-A Orlando FL
Yareliz Vazquez, CPC-A Orlando FL
Norma Young, CPC-A Orlando FL
Evelyn Zimmerman, CPC-A Orlando FL
Zeenat Lalani, CPC-A Ormond Beach FL
Julie N Adams, CPC-A Palm Bay FL
Ann Schnitzer, CPC-A Palm Bay FL
Kimberly Hollins, CPC-A Palm Coast FL
Anna Lojewski, CPC-A Palm Coast FL
Olga Hollmann, CPC-A Pembroke Pines FL
Monika Rose, CPC-A Plantation FL
Carol Harvison, CPC-A Riverview FL
Courtney Flores, CPC-A Saint Cloud FL
Chandra Howton-Riley, CPC-A San Antonio FL
Tammy Lynn Valko, CPC-A Sebastian FL
Brian Geary, CPC-A Spring Hill FL
Kandi Middleton, CPC-A Spring Hill FL
Christine Mondo, CPC-A Spring Hill FL
Angela Sancenito, CPC-A Spring Hill FL
Samantha Sancenito, CPC-A Spring Hill FL
Douglas Szymanski, CPC-A Spring Hill FL
Stephen Taylor, CPC-A Spring Hill FL
Melissa Arnold, CPC-A St Augustine FL
Aimee Powell, CPC-A St Cloud FL
John Toomer, CPC-A St Cloud FL
Hector Roxas Aguilar, CPC-A Tampa FL
Kritsia Figueroa, CPC-A Tampa FL
Gregory S Gitlitz, CPC-A Tampa FL
Demetria S Green, CPC-A Tampa FL
Debbie Perham, CPC-A Tampa FL
Tracy Shamonsky, CPC-A Tampa FL
Kelly-Noelle Wells, CPC-A West Melbourne FL
Martha Franklin Van Hoose, CPC-A Winter Park FL
Ashley Hollars, CPC-A Acworth GA
Jennifer Jo Gartrelle, CPC-A Braselton GA
Kay Walters, CPC-A, CPC-H-A Canton GA
Katie Simmons, CPC-A Cartersville GA
Erin Blair, CPC-A Cleveland GA
Regina Joan Lee, CPC-A Cumming GA
Tracy Wolfe, CPC-H-A Cumming GA
Patricia E Dixon, CPC-A Dacula GA
Kelly Massaro, CPC-A Flowery Branch GA
Julie Lowe, CPC-A Gainesville GA
Wanda Bridges, CPC-A Gray GA
Tikisha Genea Winbush, CPC-A Lithonia GA
Amy Michelle Ross, CPC-A Marietta GA
Alia Natasha Naffouj, CPC-A Martinez GA
Leslie Sargent, CPC-A McDonough GA
John Bennett, CPC-A, CPMA Milton GA
Virgil Jones, CPC-A Powder Springs GA
Heather Ebright, CPC-A Meridian ID
Isabel M Cowley, CPC-A Aurora IL
Dipty Amit Maharaj, CPC-A Aurora IL
Amy Jo Webb, CPC-A Charleston IL
Zenaida Ramos, CPC-A Chicago IL
Hannah MK Zimmerman, CPC-A, CPC-H-A Dakota IL
Casey Henry, CPC-A De Land IL
Rachel A Eichorn, CPC-A Decatur IL
Melissa M Stowell, CPC-A, CPC-H-A Dixon IL
Patti K Susan, CPC-A, CPC-H-A Dixon IL
Janice Louise Wagner, CPC-A, CPC-H-A Dixon IL
LaTreece M Nelson, CPC-A Evergreen Park IL
Dionis R Fleischer, CPC-A, CPC-H-A Freeport IL
Susan M Paonessa, CPC-H-A Freeport IL
Jessica Gail Robertson, CPC-A, CPC-H-A Freeport IL
Jeannine C Frye, CPC-A, CPC-H-A German Valley IL
Lindsey Broyles, CPC-A Hoffman Estates IL
Lori A Meyers, CPC-A, CPC-H-A Lena IL
Kenna Rene'e Robinson, CPC-A Lewiston IL
Jennifer Jeanne Thomas, CPC-A Mackinaw IL
Cindy Hall, CPC-A Mattoon IL
Pamela Jo Hoelscher, CPC-A Mattoon IL
Marlena A Kerr, CPC-A, CPC-H-A Mt Carroll IL
Terri L Raisbeck, CPC-A, CPC-H-A Mt Carroll IL
Kameke Lashae Johnson, CPC-A Peoria IL
Lajava Alise Wade, CPC-A Peoria IL
Shawn V Morales, CPC-A Riverton IL
Melissa Marie Booker, CPC-A, CPC-H-A Rockford IL
Lynn McKee, CPC-A Rockton IL
Julie Ann Brigham, CPC-A, CPC-H-A Savanna IL
Kate A Gillespie, CPC-A, CPC-H-A Sterling IL
Angie Rae Shimon, CPC-A, CPC-H-A Sterling IL
Samantha Jo Brunner, CPC-A, CPC-H-A Stockton IL
Alicia Kay Dever, CPC-A Sullivan IL
Dawn M Bailey, CPC-A Tremont IL
Michelle Lynn Eatherton, CPC-A Waterloo IL
Esther Schoen, CPC-A Corydon IN
Laura Ausderan, CPC-A Fort Wayne IN
Lisa Barker, CPC-A Fort Wayne IN
Amanda Hughes, CPC-A Fort Wayne IN
Tracy Knipstein, CPC-A Hoagland IN
Donielle Y Martin, CPC-A Indianapolis IN
Josh Vinson, CPC-A Indianapolis IN
Jo Anne Kuc, CPC-H-A Schererville IN
Jean Marie Dworniczek, CPC-H-A Valparaiso IN
Sandy Proud, CPC-A Waterloo IN
Mark Brocker, CPC-A Kansas City KS
Carol M Thurston, CPC-A Lawrence KS
Chris Schelp, CPC-A Lenexa KS
Courtney Ann Cunningham, CPC-A Manhattan KS
Karen K Gilliland, CPC-A Topeka KS
Christina Leigh Knutson, CPC-A Topeka KS
Antuan Karion Kyles, CPC-A Topeka KS
Tonya Brandenburg, CPC-A Berea KY
Sue Curtis, CPC-A Bowling Green KY
Susan Lynn Gardner, CPC-A Bowling Green KY
Peggy Aleshire, CPC-A Clinton KY
Amy Lynn Perkins, CPC-A Cynthiana KY
Veronica Decker, CPC-A Edmonton KY
Tracy Faul, CPC-A Georgetown KY
Deborah Jones, CPC-A Georgetown KY
Melissa Baldridge, CPC-A Lexington KY
Adam Cook, CPC-A Lexington KY
Lori Cooper, CPC-A Lexington KY
Danny J Elmore, CPC-A Lexington KY
Noelle K Evans, CPC-A Lexington KY
Sabrina Hall, CPC-A Lexington KY
Wendy Hightower, CPC-A Lexington KY
Denise Megge, CPC-A Lexington KY
Judy Riddell, CPC-A Lexington KY
Ben Rollins, CPC-A Lexington KY
Teresa Smith, CPC-A Lexington KY
Hattie Stonecipher, CPC-A Lexington KY
Theresa Rae Griffiths, CPC-A, CPC-H-A Louisville KY
Melissa Williams, CPC-A Louisville KY
Chad Buckley, CPC-A Midway KY
Elinor Grimes, CPC-A Nicholasville KY
Jennifer Smith, CPC-A Shelbyville KY
Tracey Amis, CPC-A West Paducah KY
Sandra Castle, CPC-A Winchester KY
Alicia Danos, CPC-A Baton Rouge LA
Kim Freeman, CPC-A Bogalusa LA
Paige Pertuis, CPC-A Bush LA
Missy Fitzpatrick, CPC-A Destrehan LA
Carl Dexter Hurst, CPC-A New Orleans LA
Alison Morse, CPC-A Ayer MA
Audrey Sowell, CPC-A Granby MA
Julia Fabian, CPC-A Lawrence MA
Rose Bednar, CPC-A Millbury MA
Diane Rollins, CPC-A Northborough MA
Deborah Stanley, CPC-A Rutland MA
Lorna Christiansen, CPC-A Webster MA
Ronda J Burns, CPC-A West Boylston MA
Mark Laserte, CPC-A Worcester MA
Ron Cicio, CPC-A Baltimore MD
Colleen Rhine, CPC-A Baltimore MD
Annellen Moore, CPC-A Bowie MD
Janeice Gail Kelly, CPC-A Carl Junction MD
Kristen Trombero, CPC-A Chuchville MD
Kassia Jamison, CPC-A Columbia MD
Lisa Moore, CPC-A Crofton MD
Linda Tolliver, CPC-A Easton MD
Maria Stabosz, CPC-A Glen Burnie MD
Marian Tucker, CPC-A Laurel MD
Leandra Osei, CPC-A Silver Spring MD
Beth Anders, CPC-A Street MD
Celeste Mariano-Perrigo, CPC-A Berwick ME
Kymberly York, CPC-A Carmel ME
Carol E Hill, CPC-A Denmark ME
Carmen C Gagnon, CPC-A Kennebunk ME
Heather Barnes Adams, CPC-A Limington ME
Catherine Elizabeth Hanson, CPC-A Livermore ME
Michelle Poulin, CPC-A Saco ME
Joseph Duclos, CPC-A Shapleigh ME
Erin Thurlow, CPC-A Unity ME
Mandy L Brydges, CPC-A Grand Rapids MI
Catherine Ann Heatley, CPC-A Grand Rapids MI
Plereah Charmell Mayfield, CPC-A Grand Rapids MI
Dorothy Kay Popma, CPC-A Grand Rapids MI
Koyya Brandie Taylor, CPC-A Grand Rapids MI
Kari Kaye Lohman, CPC-A Jenison MI
Gabrielle Davida Mae Vanstedum, CPC-A Lake
Odessa MI
Mary Garrett, CPC-A Livonia MI
David Nichols, CPC-A Livonia MI
Tammy Lynn Kolean, CPC-A Middleville MI
Sharey J Goerke, CPC-A Newaygo MI
Mary Roussey, CPC-A Novi MI
DeTreda Buford, CPC-A Romulus MI
Heather Martz, CPC-A Roseville MI
Dawn Findley, CPC-A Traverse City MI
Debra Kraus, CPC-A Westland MI
Brenda McGee, CPC-A White Lake MI
Shawn C Simons, CPC-A Wyoming MI
Connie Louise Nielsen, CPC-A Brownville MN
Kristin Ann Jeanette Campbell, CPC-A Houston MN
Kiva Stevens, CPC-A Rochester MN
Christina Marie Staige, CPC-A Winona MN
Mary L Nestor, CPC-A Ballwin MO
Diane M Lane, CPC-A Cape Girardeau MO
Stephanie Nicole Robertson, CPC-A Chesterfield MO
Jackie Zellmer, CPC-A Creighton MO
Cynthia Michele Hooker, CPC-A Desoto MO
Sandra Lynn Shepherd, CPC-A Florissant MO
Elan Wright, CPC-A Raytown MO
LaDora L Erickson, CPC-A Senaca MO
Portia Blaser, CPC-A St Charles MO
Amy Lynn King, CPC-A St Louis MO
April Evelyn Piilani Wilkerson, CPC-A St Louis MO
Ileana Stewart, CPC-A St Peters MO
Jamie Elizabeth Green, CPC-A Sunset Hills MO
Edna Blasingame, CPC-A Ackerman MS
Robin L Rakestraw, CPC-A Blue Springs MS
Jennifer L Renfroe, CPC-A Hernando MS
Melissa J Bates, CPC-A Horn Lake MS
Kimberley G Green, CPC-A Horn Lake MS
Vicci D McCreary, CPC-A Southaven MS
Katie Elizabeth Worden, CPC-A Southaven MS
Sanda Campbell, CPC-A Aberdeen NC
Chetan Deshmukh, CPC-A Cary NC
Stephanie Bays, CPC-A Charlotte NC
Paula Chapman, CPC-A Charlotte NC
Varsha Evans, CPC-A Charlotte NC
George Holton, CPC-A Charlotte NC
Hugh Christopher Polland, CPC-A Charlotte NC
Pamela Wyatt, CPC-A Clemmons NC
Linda Jurgensen, CPC-A Durham NC
Anita E Jones, CPC-A Evergreen NC
Briana Davis, CPC-A Goldsboro NC
Amelia Perry, CPC-A Hampstead NC
Monica Brett, CPC-A Hubert NC
Aleasha Michelle Humphrey, CPC-A Jacksonville NC
Cindy Hardin, CPC-A Kannapolis NC
Jennifer Graham Burleson, CPC-A Locust NC
Jennifer Pickett Lee, CPC-A Maysville NC
Melanie Underwood, CPC-A Monroe NC
Bobbie Brown, CPC-A Mooresville NC
Robin Morrison, CPC-A Mooresville NC
Tammy Greene, CPC-A Mt Pleasant NC
Rebecca Evans, CPC-A Princeton NC
Wendy Reed Archible, CPC-A Raleigh NC
Amy O'Connor, CPC-A Richlands NC
Yvaughn Mullis, CPC-A Salisbury NC
Thomas Angel, CPC-A Statesville NC
Sherry Blevins Kilby, CPC-A Statesville NC
Lois Pelto, CPC-A Statesville NC
Sandra Wright, CPC-A Statesville NC
Scottie Mays, CPC-A Taylorsville NC
Bonni Staples, CPC-A Waxhaw NC
Connie Crissman, CPC-A Youngsville NC
Joy C Doll, CPC-A Mandan ND
Jennifer Lynn Brinegar, CPC-A Lincoln NE
Meghan Lowry, CPC-A Manchester NH
Cathy Trombetta, CPC-A Meredith NH
Ashley Margaret Yahrling, CPC-A Blackwood NJ
www.aapc.com
November 2010
39
Joanne Havlicek, CPC-A Deptford NJ
Wayne Toscano, CPC-A Egg Harbor Township NJ
Barbara Goszka, CPC-A Flemington NJ
Carolyn Joyce-Goodwin, CPC-A Flemington NJ
Devi Chidambaram, CPC-A Hillsborough NJ
Mandvi Tandon, CPC-A Jersey City NJ
Andrea Bobb, CPC-A Pennsville NJ
Daniel J Long, CPC-A Swedesboro NJ
Janet M Hall, CPC-A West Deptford NJ
Nicholas Michael Reyes, CPC-A Woodbury NJ
Tomrita Naomi Andy, CPC-A Albuquerque NM
Dianne M Crozier, CPC-A Magdalena NM
Cynthia Judge, CPC-A Amherst NY
Linda Anne Newell, CPC-A Amherst NY
Nadeen Daniel, CPC-A Brooklyn NY
Cecilia Ferrera, CPC-A Brooklyn NY
Patricia Hamilton, CPC-A Brooklyn NY
Joanna DeJesus, CPC-A Carmel NY
Susan Gonzalez, CPC-A Elmira NY
Kelly A Haynes, CPC-A Elmira NY
Kathleen R Rhodes-Riker, CPC-A Horseheads NY
Hazel Best, CPC-A Jamaica NY
Debra A Fisher, CPC-A Kingston NY
LaShonda Donetta Corey, CPC-A Liverpool NY
Alina Majewski, CPC-A Maspeth NY
Kristen E Spickerman, CPC-A Middleburgh NY
Cassandra Marie Vallee, CPC-A Niagara Falls NY
Eileen G Blair, CPC-A North Syracuse NY
Matthew Graham, CPC-A North Syracuse NY
Mary F DoKuchitz, CPC-A Oneonta NY
Jon Shobin, CPC-A Smithtown NY
Judith Giammarino, CPC-A Staten Island NY
Patricia Hewston, CPC-A Swan Lake NY
Martina Marie Delfuoco, CPC-A Syracuse NY
Kathryn Elizabeth Castaldo, CPC-A Walden NY
Kimberly Gayle Pacenza, CPC-A Walden NY
Cheryl Lynn Veith, CPC-A Walden NY
Maryann Graziadio, CPC-A Warwick NY
Courtney Lutz, CPC-A Waterloo NY
Katherine M Sears, CPC-A Webster NY
Denise A Nagode, CPC-A West Seneca NY
Amy L Ramadhan, CPC-A West Valley NY
Amy F Janke, CPC-A Akron OH
Marlena Rudd, CPC-A Batavia OH
Patricia A Sirna, CPC-A Bedford OH
Lori Dawn Sanders, CPC-A Chesapeake OH
Susan Jerge, CPC-A Columbus OH
Paddy Lyons, CPC-A Edison OH
Ladelle V Small, CPC-A Euclid OH
Elizabeth C Rothacker, CPC-A Fairview Park OH
Jo Anne Davies, CPC-H-A Gahanna OH
Jairia C Caldwell, CPC-A Garfield Heights OH
Amanda Thompson, CPC-A Grafton OH
Autumn Marie Bourgeois, CPC-A Hubbard OH
Kim Corron, CPC-A Jefferson OH
Tina M Leasure, CPC-A Lexington OH
Laura Ann Rice, CPC-A Lexington OH
Helen Elaine Bailey, CPC-A Mansfield OH
Tricia Ann Carroll, CPC-A Mansfield OH
Jennifer Circosta, CPC-A Mansfield OH
Gerald F Krupar, CPC-A Mantua OH
Pamela J Sobieski, CPC-A Mentor OH
Paula J Jablonski, CPC-A Mosury OH
Christina Louise Moody-Roudebush, CPC-A Newton
Falls OH
Christina M Spung, CPC-A Olmsted Falls OH
April Bucci, CPC-A Parma OH
Barbara Ann Messinger, CPC-A Proctorville OH
Adrienne Prince, CPC-A Richmond Heights OH
Debra Arlene Taylor, CPC-A Vandalia OH
Kathy Stevenson, CPC-A Wellington OH
Michael Hellyar, CPC-A Westlake OH
Heather Siders, CPC-A Willoughby OH
Tricia Ann Terlesky, CPC-A Youngstown OH
Felicia Jones, CPC-A Oklahoma City OK
Cherice Taylor, CPC-A Oklahoma City OK
Tina M Collins, CPC-A Aloha OR
Maureen Beatty, CPC-A Beaverton OR
Karen E Frost, CPC-A Clackamas OR
Gina Washington, CPC-A Gresham OR
Terry Keeler, CPC-A Junction City OR
Claudia Leigh, CPC-A McMinnville OR
Nancy Cummings, CPC-A Milwaukie OR
Alicia A Henson, CPC-A Milwaukie OR
Catherine Moore, CPC-A Newberg OR
Donna Lavonne Dyal, CPC-A Portland OR
Kaye Killgore, CPC-A Portland OR
Heather Kramer, CPC-A Portland OR
40 AAPC Coding Edge
Sarah Ysasaga, CPC-A Portland OR
Aumbria Caspers, CPC-A Salem OR
Virginia McEntee, CPC-A Bensalem PA
Angela Bunch, CPC-A Burnham PA
Juanita K Lehman, CPC-A Carlisle PA
Michele Savoie-Shevlin, CPC-A Carlisle PA
Marlene Stank, CPC-A Catawissa PA
Jennifer Lynn Britton, CPC-A Corry PA
Brenda Lee Jacobs, CPC-A East Springfield PA
Michaelyn R Orlando, CPC-A Erie PA
Theresa Ann Schaeffer, CPC-A Erie PA
Curtis Daniel Space, CPC-A Erie PA
Denise Tousey, CPC-A Erie PA
Sharon Irene Toy, CPC-A Erie PA
Sylvia Musser, CPC-A Hanover PA
Bert Baker, CPC-A Lancaster PA
Kori McDaniel, CPC-A Linfield PA
Melinda Dressler, CPC-A McAlisterville PA
Bill Gerry, CPC-A Norristown PA
Holly Vanvolkenburg, CPC-A North East PA
Kelly Kennelly, CPC-A Palmyra PA
Amy Renee Cross, CPC-A Saegertown PA
Joyce M Schittler, CPC-A Sinking Spring PA
April Lynn Winnies, CPC-A Spring City PA
Peggy Shaw, CPC-A Springfield PA
Mary Tucker, CPC-A Warren PA
Shannon Marie Shaffer, CPC-A York PA
Lisa L Verdi, CPC-A Westerly RI
Nellie Wade, CPC-A Campobello SC
Tammy W Bauknight, CPC-A Chapin SC
Jane Mcmanus, CPC-A Florence SC
Bregma Barrera, CPC-A Fort Mill SC
Ann Myers, CPC-A Greer SC
Vicki Carnes, CPC-A Lancaster SC
Kimberly Nicole Hopkins, CPC-A Ware Shoals SC
Nicole Siobhan Buchanan, CPC-A Waterloo SC
Carol Hansen, CPC-A Irene SD
Lyndsie Leigh Clark, CPC-A Antioch TN
Toni Wellman, CPC-A Antioch TN
Monica Homonnay, CPC-A Brentwood TN
Laurie Daugherty, CPC-A Burns TN
Shelia Monroe Flatt, CPC-A Cane Ridge TN
Deanna Suzanne Jarrell, CPC-A Chapel Hill TN
Christel Felts, CPC-A Clarksville TN
Julie Gallacher, CPC-A Clarksville TN
Felecia Ann Armstrong, CPC-A Columbia TN
Shanika Clyburn, CPC-A Columbia TN
Vickie Fuller, CPC-A Columbia TN
Debra Grate, CPC-A Columbia TN
Kathy Hodge, CPC-A Columbia TN
Diane E Jones, CPC-A Columbia TN
Edna (Nell) Lassiter, CPC-A Columbia TN
William Lorz, CPC-A Columbia TN
Sandra Simmons, CPC-A Columbia TN
Pierman Peggy, CPC-A Cornersville TN
James R Hendricks, CPC-A Gallatin TN
April Young, CPC-A Greenbrier TN
Angela Michael, CPC-A Hartsville TN
Johannson D Lynn, CPC-A Hendersonville TN
Haley McLaughlin, CPC-A Jackson TN
Carol J Carmichael, CPC-A Knoxville TN
Camille Hanggi, CPC-A Knoxville TN
Leslie Nation, CPC-A Lebanon TN
Laurie Longchamps, CPC-A Lewisburg TN
Tina Kunkelman, CPC-A Manchester TN
Traci Michele King, CPC-A Murfreesboro TN
Maima J Massaquoi, CPC-A Murfreesboro TN
Jana Beth Rich, CPC-A Murfreesboro TN
Brandon Spangler, CPC-A Murfreesboro TN
Roline Hodge, CPC-A Nashville TN
Sarah Temkin, CPC-A Nashville TN
Michelle Renee Walls, CPC-A Pulaski TN
Cathleen M Barry, CPC-A Rutledge TN
Melissa Cozze, CPC-A Spring Hill TN
Kristina Johnson, CPC-A Springfield TN
Sandra Kay Fournerat, CPC-A Thompsons Station TN
Meagan Smith, CPC-A Watertown TN
William Edward Pridgeon, CPC-A Ben Wheeler TX
Cathy Gardner, CPC-A Dallas TX
Tigist Gebreyesus, CPC-A Dallas TX
Becky Hernandez, CPC-A Dallas TX
Yvonne Sanchez, CPC-A Dallas TX
Sabine M Comstock, CPC-A Fischer TX
Janet Lee Phillips, CPC-A Ft Worth TX
Vickie Pursley, CPC-A Ft Worth TX
Karen Darden, CPC-A Garland TX
Diem Nguyen, CPC-A Grand Prairie TX
Tramekia Shondel Luster, CPC-A Jefferson TX
Linda Morgan, CPC-H-A Lampasas TX
P Kaye Marr, CPC-A Lipan TX
Sandy Ramirez, CPC-A Lubbock TX
Kalli Tidwell, CPC-A Lubbock TX
Beverly Mardis, CPC-A Mesquite TX
Jennifer Russell, CPC-A North Richland Hills TX
Vic Holmes, CPC-A Plano TX
Carissa Messenger, CPC-A Rockwall TX
Angela De Hoyos, CPC-A San Antonio TX
Virginia Leath, CPC-A Springtown TX
Cecilia Barrett, CPC-A Weatherford TX
Jami McClendon Burns, CPC-A Weatherford TX
Susan Machelle Hicks, CPC-A Weatherford TX
Tambra N Korson, CPC-A Weatherford TX
Joyce Ann Prentice, CPC-A Weatherford TX
Deborah Roller, CPC-A Wolfforth TX
Tamera Livesey, CPC-A Clearfield UT
Patricia Shermeister, CPC-A Clearfield UT
Nathan Ludwig, CPC-A Kearns UT
Lanae Peterson, CPC-A Magna UT
Ashley Griffith, CPC-A Midvale UT
Mariellen Higgins, CPC-A Murray UT
Malynda Boyle, CPC-A Ogden UT
Traci Pehler, CPC-A Price UT
Leslie M Hollingsworth, CPC-A Salt Lake City UT
Jackie Reed, CPC-A Salt Lake City UT
Rachel Roy, CPC-A Salt Lake City UT
Megan Weber, CPC-A Salt Lake City UT
Elizabeth M Weist, CPC-A Salt Lake City UT
Shrina Baumann, CPC-A Sandy UT
Debbie Johnson, CPC-A Sandy UT
Karen Goddard, CPC-A South Weber UT
Cheryl Webb, CPC-A Chesterfield VA
Kelly Dixon, CPC-A Hampton VA
Sushma Raghu, CPC-A Newport News VA
Vicki Hastings, CPC-A Norfolk VA
Jenna Marie Neff, CPC-A Petersburg VA
Jo Schilling, CPC-A Edmonds WA
Joan K Soelter, CPC-A Lynnwood WA
Tamra Vandyke, CPC-A Malden WA
Tambra L Hobbs, CPC-A Morton WA
Kate Kurfess, CPC-A Mountlake Terrace WA
Brenda Feitler, CPC-A Seattle WA
Harmony Nelson, CPC-A Spanaway WA
Vanessa Crisp, CPC-A Vancouver WA
Kathy Ackerson, CPC-A Vancouver, WA
Teri Dove, CPC-A Yakima WA
Tambra Maples, CPC-A Yakima WA
Kris M Schwier, CPC-A Bangor WI
Tamera Yoghourtjian, CPC-A Bayside WI
Lonnie S Simplot, CPC-A Black River Falls WI
Michelle Lee Butterfield, CPC-A Galesville WI
Kathy Ann Flahive, CPC-A LaCrosse WI
Erika Lyn George, CPC-A LaCrosse WI
Cheryl Jean Ihle, CPC-A LaCrosse WI
Shari L Bockenhauer, CPC-A Mindoro WI
Joan L McNulty, CPC-A Nashotah WI
Nancy Figon, CPC-A New Berlin WI
Rhyne C Roberts, CPC-A Onalaska WI
Jennifer Joy Glynn, CPC-A Onalaska WI
Andrea C Jeffers, CPC-A Onalaska WI
Jennifer Lynn Kaatz, CPC-A Onalaska WI
Tina Millard, CPC-A Oshkosh WI
Sheila Lynn Cavadini, CPC-A Rockland WI
Jennifer Marie Dols, CPC-A Sparta WI
Linda Lee Ingenthron, CPC-A Tomah WI
Brenda A Boe, CPC-A Trempealeau WI
Melanie Vonne Creamer, CPC-A Huntington WV
Beverley Ann Kimbler, CPC-A Huntington WV
Stephanie Ann Klinger, CPC-A Huntington WV
Crystal Leigh Miller, CPC-A Huntington WV
Specialties
David Nance,
CPC, CPC-H, CEDC, CEMC Ceres CA
Nicole L Kauffmann,
CEMC, CFPC Santa Maria CA
Linda Hinkle,
COBGC Vista CA
Kate Lamont,
CENTC Ft Myers FL
Theresa Karlene,
CHONC Titusville FL
Brenda L Goodrich,
CPC, CEDC Churubusco IN
Heather D Dombrowski,
CPC, CEDC Ft Wayne IN
Lena Gail Holbrook,
CPC, CCVTC Brodhead KY
Belinda Keeling,
CPC, CANPC Lafayette LA
Heather D Marean,
CPC, CPC-H, COBGC Holden MA
Lauri Williams,
CPC, CUC Shrewsbury MA
Stephanie Ann Thebarge,
CPC, CEMC New Gloucester ME
Harland Bruce Redmond,
CPC, COSC Old Orchard Beach ME
Jessica Smith,
CPCD Peru ME
Judy A Roy,
CPC, CANPC Turner ME
Melodie Alery,
COSC Grass Lake MI
Sally Wilkins,
CPC, CHONC Hickory Corners MI
Tressa M McGuire,
COBGC Pinckney MI
Christine M Bonn,
CPC, CHONC Arden Hills MN
Sue Jordan,
CPC, CGSC, CHONC Blaine MN
Rebecca Kramer,
CPC, CHONC Bloomington MN
Kimberly Dahlberg,
CHONC St Paul MN
Nancy A Frescas,
CHONC St Paul MN
Fay Arnold,
CPC, CHONC St Paul MN
Kerrie Amos,
CPC, CPEDC Blue Springs MO
Dawn Pruitt,
CPEDC Cabool MO
Hannah Rowland,
CPC, CANPC Mt Pleasant NC
Sharon M Casto,
CPC, CEDC Oakboro NC
Delores Roberson Everette,
CPC, COBGC Tarboro NC
Angie R Mangum,
CPC, CEMC Las Cruces NM
Rachel Keith,
CPC, CGSC Voorheesville NY
Desiree Easterwood,
CPC, CPRC Akron OH
Wendy Ryder,
CPC, CPC-H, CPC-I, CPEDC Hilliard OH
Rhonda Wagner-Shank,
CPC, CEMC Middletown PA
Linda Benner,
CPC, CPMA, COBGC New Cumberland PA
Karen Marie Goering,
CPC, CEMC York PA
Judy A Yauk,
CPC, CCC Ashland City TN
Susan Smith,
CGIC Chattanooga TN
Rhonda G Crouch,
CHONC Cookeville TN
Paul R Wickline,
CPC, CPC-H, CEMC Franklin TN
Kristi Terrell,
CRHC Hixson TN
Gail A Edmondson,
CPC, CEMC Pulaski TN
Crystal Tamara Hunnicutt,
CPC, CPMA, CEMC Spring Hill TN
Caroline Tuck,
CPEDC Tullahoma TN
Heather E Neal,
CPC, CGIC, CGSC, COBGC Mansfield TX
Tammie Newton,
CPC, CEDC Mansfield TX
Peggy C Anderson,
CPC, CPMA, CEMC Castle Dale UT
Kimberly C Cook,
CPC, CEMC Danville VA
Lori Ann Buchanan,
CPC, CHONC Mathews VA
Lia M Lisiecki,
CPC, CCC, CEMC Oak Creek WI
Magna Cum Laude
Sarah Wechselberger,
CPC Mountain Home AR
Ann Wooten,
CPC Mountain Home AR
Lisa Rosellen Vincent,
CPC Tucson AZ
Teresa D Walsh,
CPC Tucson AZ
John Paul Mashikian,
CPC San Diego CA
Yodchai Lapakulchai,
CPC-A Torrance CA
Agnieszka Piasecka-Senior,
CPC-A Hartford CT
Rebecca Jane Brewer,
CPC Cocoa FL
Lisa O'day,
CPC-A Hobe Sound FL
Janet Leclerc,
CPC-H Miami FL
Jay Norton,
CPC-A Alto GA
Avrom Simon,
CPC Chicago IL
Elizabeth Duncan Rich,
CPC Carmel IN
Christian J Black,
CPC Franklin IN
Debra L Hudak,
CPC South Bend IN
Tracy Linette Leslie,
CPC-A Oronago MO
Jaime Kristen O'Brien,
CPC-A Nashua NH
Denise I Schmidt-Simon,
CPC-A Mickleton NJ
Christina A Sweeten,
CPC-A Vineland NJ
Nancy Janak,
CPC West Seneca NY
Sara LeFever,
CPC-A Westfield NY
Nikki Lynn Palmer,
CPC Moore OK
Elaine Garczynski,
CPC-A Gilbertsville PA
Lisa Ludwig,
CPC-A Hanover PA
Danita Dameron,
CPC-A McKenzie TN
Cayce Gibson,
CPC-A Murfreesboro TN
Michelle M Vollmer,
CPC-A Oconomowoc WI
Questions About
Medicare Billing?
R
Official CMS Information for
Medicare Fee-For-Service Providers
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for Medicare Fee-For-Service Providers. Get nationally consistent, accurate, timely and free information that will help providers
correctly submit claims the first time. Please visit our website today.
http://www.cms.gov/MLNGenInfo
feature
Bundled or Separate Biopsy
Depends on Circumstances
Look to NCCI policy for the two-specific conditions that call for unbundling.
By Brad Ericson, CPC, COSC
A
biopsy performed on the same
date of service as a more extensive
procedure—such as an excision,
destruction, or removal—generally is
bundled into that more extensive procedure.
But, under two-specific conditions for
Medicare and most other payers, a same-day
biopsy and more extensive procedure may
be reported independently. The qualifying
circumstances are outlined specifically in
chapter 1 of the National Correct Coding
Initiative (NCCI) “General Correct Coding
Policies.”
1. “If the biopsy is performed on a separate lesion, it is separately reportable. This
situation may be reported with anatomic
modifiers or modifier 59.”
For example, the physician biopsies a lesion
on the left breast, and excises a lesion of the
right breast. Depending on payer preference
(check with your payer), you may report the
appropriate biopsy code with modifier LT
Left side and the appropriate excision code
al li ance (noun)
with modifier RT Right side; or, you may
report the excision code (the “most extensive” procedure) without a modifier, and
append modifier 59 Distinct procedural service
to the biopsy code.
2. “If the biopsy is performed on the
same lesion on which a more extensive
procedure is performed, it is separately
reportable only if the biopsy is utilized
for immediate pathologic diagnosis
prior to the more extensive procedure,
and the decision to proceed with the
more extensive procedure is based on
the diagnosis established by the pathologic examination.”
In other words, if the results of the biopsy
prompt the physician to perform a more
extensive procedure, both the more extensive
procedure and the biopsy may be reported.
As an example, consider a patient with
a suspicious lesion on the forearm: If the
physician excises the lesion and sends it
to pathology, we know that the biopsy is
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knowledge of ICD-9-CM and CPT-4 coding. Minimum 4 years of coding experience in an acute care setting
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not reported separately because, as NCCI
explains, “If a biopsy is performed and
submitted for pathologic evaluation that
will be completed after the more extensive
procedure is performed, the biopsy is not
separately reportable with the more extensive procedure.”
Suppose, however, that the physician sends a
portion of the suspicious lesion for examination, and pathology confirms a malignancy.
The physician proceeds to excise the entire
lesion. In this case, because the biopsy led to
the decision to perform the more extensive
procedure, both the excision (e.g., 11603
Excision, malignant lesion including margins,
trunk, arms, or legs; excised diameter 2.1 to
3.0 cm) and the biopsy (11100 Biopsy of skin,
subcutaneous tissue and/or mucous membrane
(including simple closure), unless otherwise listed;
single lesion) may be reported separately.
NCCI instructs you to append modifier 58
Staged or related procedure or service by the same
physician during the postoperative period to the
excision code (11603), “to indicate that the
biopsy and the more extensive procedure
were planned or staged procedures.”
[
Brad Ericson, MPC, CPC, COSC, is director
of membership and publishing at AAPC.
www.aapc.com
]
November 2010
43
a coder’s view
Experience
Is the Best Teacher
PMCC instructor offers coding and billing students a taste of the real world.
PROFESSIONAL
By Ken Camilleis, CPC, CPC-I
I
was very impressed by Beverly Haynes’ article in the June
issue entitled “Become a Successful Coder in the Classroom.” As an educational consultant and billing/coding
instructor, I share many of Ms. Haynes’ sentiments. I bring to
the table more than 20 years’ experience in medical practice
management, and, before I became a professional coder, my
primary focus had been on billing and reimbursement.
Like Ms. Haynes, I have never actually worked as a coder
in a physician’s office; however, I did observe firsthand the
types of issues with which an “in-the-trenches” coder may be
faced, especially regarding quality of physician documentation and proper communication of information that impacts
the cash flow cycle. Authorizations for surgeries, primary care
physician (PCP) referrals, Health Insurance Portability and
Accountability Act (HIPAA) compliance and up-to-date
demographic data were often an issue. Being the
senior manager of an off-site billing company
made my staff and I further removed from information
sources because the medical records were not readily accessible to us to determine whether an encounter form was coded
properly.
Although we were familiar with the structure of ICD-9-CM
and CPT® manuals in terms of what services practitioners and
specialists were likely to perform for conditions, the function
of our business was essentially reduced to being a processing
house based on the “garbage in, garbage out” (GIGO) principle. We had access to Medicare bulletins and other periodic
payer publications, and we would inform the providers as we
learned of new coding regulations, deleted or changed CPT®
codes, or new reporting guidelines, and we managed our clients’ ongoing accounts receivable. Beyond that, our job, plain
and simple, was to process piles of superbills every day for a
multitude of specialties, most of which were prepared by hand
and delivered by postal mail or courier. Although we submitted the bulk of our claims electronically through a clearinghouse, it was too much bother and expense for most of our
clients to hook up with us for electronic charge capture.
Start at the Bottom
My career took a major twist in May 2006 when a “golden
opportunity” fell right in my lap. I received an unsolicited call
from the regional director of a career school chain. She was
looking for a billing and coding instructor. After 18 years as a
billing manager, I was getting more and more frustrated dealing with countless denials, delays, and underpayments because
of poor practitioner documentation and communication. I
welcomed this opportunity to bring my knowledge into the
classroom. I subsequently shut down the billing business to
become a spinoff coder and educational coding consultant.
Four years ago I didn’t know how to read a chart note, but I
went through intense training, took online courses running
the gamut from medical terminology, anatomy (hearing terms
I hadn’t studied since my eighth-grade biology class), HIPAA,
coding guidelines, and other subjects germane to coding. I
joined AAPC in the summer of 2008 and took a Professional
Medical Coding Curriculum (PMCC) course that fall. I passed
my Certified Professional Coder (CPC®) exam on Dec. 13,
2008, and I haven’t looked back.
44 AAPC Coding Edge
a coder’s view
Work Your Way Up
In the past four years, I’ve taught coding to individuals of all
ages, from numerous walks of life, with diverse careers, and
with different learning capacity. I especially enjoy teaching
new students who have no prior knowledge of medical coding,
such as a typical audience where the PMCC program begins
with the Step-By-Step book.
To grab the attention of students and make learning enjoyable, I start the first class by:
Breaking the ice with a ‘tell us about yourself and your
career goals’ to help students feel comfortable in the
classroom.
Illustrating a ‘bird’s eye view of the life cycle of a medical claim’ with an interactive demonstration involving
four to six multicolored markers, where each student
plays an integral role in the cycle, explaining the process
of the life cycle from the time the patient schedules the
appointment to when the claim gets paid and posted into
the practice management system.
Explaining how lay words like “office visit” and “low
back pain” are translated into codes like 99212 Office or
other outpatient visit for the evaluation and management of an
established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward decision making and 724.2 Lumbago.
Bask in the Glory
It really gives me a great feeling when one of my students in
this capacity says she wants to move on and pursue a career
as a coder. My mentoring has given her that impetus to move
forward. While I won’t reach everyone, I feel that each new
AAPC member especially every new CPC® or other credentialed member I’ve helped and encouraged to continue in the
coding field is a feather in my cap.
Kenneth Camilleis has over 20 years’ experience in health care, mostly as a billing specialist. For the last five years, Mr. Camilleis’
primary focus has been coding education,
mostly at local career schools. He is the
education officer for a Boston-area AAPC
chapter, and is preparing education programs
related to ICD-10.
join us at the beach
www.aapc.com/longbeach
AAPC NATIONAL CONFERENCE
www.aapc.com
November 2010
45
added edge
Don’t
Change the Code
APPRENTICE
By Pam Brooks, CPC, PCS
Take a stand when
patients are told you can
code differently.
I
was very interested to read the article, “Just Change the
Code” by Simone Tessitore, CPC, COBGC, in the May
2010 Coding Edge.
Our facility owns multiple primary and specialty care practices,
and recently this issue has come to the forefront after several
of our practice managers and customer service staff reported
patients were calling with angry demands to change codes.
When we learned patients had been told by the payers that
claims will be paid only if they are coded in a certain or different way, we knew we had to take a stand.
Inform Patients
First, we met with the president of our local medical management association. We asked him to bring this concern to
their next meeting and address it with the third-party representatives who also attend these meetings. At the meeting,
the association requested that payers caution their customer
service representatives to not suggest to patients that a claim
was denied due to the way it was coded, or insinuate that a
physician’s office simply could make a change in the code sets
to satisfy coverage limitations because, in doing so, they were
potentially requesting we commit fraud.
Second, we drafted a disclaimer to present to our patients prior
to their receiving services. (See the disclaimer above.)
Patients are expected to sign this disclaimer annually with
hope of educating them regarding our commitment to compliance, and to protect us from any potential improper billing. For
Medicare recipients, this disclaimer is also presented with an
Advance Beneficiary Notice (ABN), if appropriate.
46 AAPC Coding Edge
Sample Disclaimer
As a courtesy, we will submit your claim for all
services to your insurance company. Please remember
your individual health insurance policy is a contract
between you and your insurance company, and we are
not a party to that contract. Be aware that some of our
services may not be covered by your insurance policy. By
presenting for care, you agree that you are responsible
for all services and charges, regardless of your insurance
status. Should any provided services not be covered by
your insurance, we will not alter your claim, change
your diagnosis, or report a different service than what
was performed in order that your insurance will cover
the charge. You will be responsible for the balance.
Review Claim Denials
Errors occasionally are made with the selection of ICD-9-CM
or CPT® codes, particularly in the electronic medical record
(EMR) world, where physicians often submit these choices
without a pre-billing audit. All patient requests for claim
denial review should be performed by a certified coder to
determine if an administrative error was made, or if a claim
was denied for coverage reasons.
If an error is identified, the original documentation must
always support the correct code, and it should be noted the corrected claim was resubmitted due to an administrative error—
not specifically to meet a payer’s specific coverage guidelines.
Appending a record to support an additional diagnosis exclusively for payment reasons is inappropriate, but additions may
be made to clarify a legitimate ICD-9-CM or CPT® issue.
Discourage physicians from submitting or changing codes specifically to meet the demands of patients. It is our responsibility as
certified coders to educate our physicians on this risky practice.
Pam Brooks, CPC, PCS, is physician services coding
supervisor at Wentworth-Douglass Hospital in Dover,
N.H. She has a bachelor of science in Adult Education/
Workplace Training, from Granite State College (Concord, N.H.) and is enrolled in the MHA program at St.
Joseph’s College of Maine. She is experienced in billing,
coding, and practice management and is secretary of
the Seacoast-Dover, N.H. local chapter.
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CCI edits, helpful code descriptions, and
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Simplify your workload with one-stop, crosscoding resources. Cross Coders feature essential
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featured coder
Consult Your Payer
for Consult Guidelines
Medicare no longer accepts 99241-99255, but other payers may.
PROFESSIONAL
By Lindsey H. Daly, MSHA, CPC
Locating the appropriate contact
can be tricky as well, but by calling
provider relations you should be
directed to the right person.
As I write this, it has been over six months since the
Centers for Medicare & Medicaid Services (CMS) stopped
accepting CPT® consultation codes 99241-99245 (outpatient) and 99251-99255 (inpatient); however, not all
payers have followed suit. Many non-Medicare payers still
recognize consult codes for appropriately documented
services. If you have not done so already, you would be
wise to identify your payer consultation guidelines and
code accordingly.
Recently, I surveyed payers in my area (Colorado) and
most of them distributed a formal policy. You might
locate this information in either bulletin or online newsletter format. Often the information is difficult to locate,
however, and I’ve found contacting the payer directly is
the best way to determine the policy. Locating the appropriate contact can be tricky as well, but by calling provider relations you should be directed to the right person.
To simplify your request, be prepared to ask the contact
what the payer’s status regarding consultation code reimbursement is by referring to the CMS policy (available at
www.cms.gov/MLNMattersArticles/downloads/MM6740.
pdf). Often the provider relations contact will direct you
to the online policy for your reference. If possible, e-mail
the contact so you have additional documented information supporting the policy. Sometimes the provider
relations contact does not respond to email, and documenting the details of the phone conversation is adequate
(if not preferable).
After collecting the data, list each payer and its policy on
consultation codes. For example:
48 AAPC Coding Edge
Health Pla ns No Longer
Recognizing
Consultation Codes
Physicians’ Ally, Inc. has
phone or e-mail confirmati
on
that the following health
plans no longer recognize
consultation codes:
ɶɶ  Anthem—Medicare
For Medicare products tha
t Anthem administers onl
y,
Anthem follows Medicare
guidelines and no longer
recognizes consultation codes.
ɶɶ  Colorado Medicaid
As of April 1, 2010, Color
ado Medicaid no longer acc
epts
consultation services. This
affects CPT® consultation
inpatient CPT® codes 99251
-99255 and office/outpatie
nt
consultation CPT® codes
99241-99245.
Health Pla ns Continuing
to Recognize
Consultation Codes
Physicians’ Ally, Inc. has
phone or e-mail confirmati
on
that the following health
plans continue to recognize
consultation codes:
ɶɶ  Aetna
Since the American Medic
al Association (AMA) stil
l lists
“consult” codes as active in
CPT® 2010, Aetna and Co
finity continue to accept and
price these codes as valid
after
Jan. 1, 2010. This is subjec
t to future change, howeve
r.
ɶɶ  Anthem— Commerc
ial
Anthem is not following
Medicare’s lead on the con
sult
codes for commercial reimb
ursement. However, Anthe
m is
discussing a new fee schedu
le update for Jan. 1, 2011.
featured coder
For easy reference, refer to Table 1 for a quick-view summary of each payer’s guidelines.
Table 1: Payer Reimbursement—Summary
Payer
Status
Effective
Aetna
Accepts Consultation Codes
Anthem—Commercial
Anthem—Medicare
Does NOT Accept Consultation Codes
CHP+
Under Review
CIGNA
Colorado Access
03/05/10
Colorado Medicaid
04/01/10
Denver Health
Humana—Commercial
01/01/10
Humana Medicare (MCHMO and MCPPO) Does NOT Accept Consultation Codes
01/01/10
Rocky Mountain Health Plans
04/01/10
UnitedHealthcare—Medicare Solutions
01/01/10
UnitedHealthcare Commercial
This is the most recent information available for these payers in
Colorado. Be sure to research your specific payer guidelines; and
be aware that rules change. It is important to look for notifications
to determine when or if health plans will no longer recognize consultation codes.
Resources:
Revisions to Consultation Services Payment Policy
(www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf)
Revisions to Consultation Services Payment Policy
(www.cms.hhs.gov/Transmittals/downloads/R615OTN.pdf)
Colorado Medicaid Provider Bulletin, Reference: B1000281, March 2010
UnitedHealthcare Consultation Code Update
(www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/2010/ConsultationCode_Update.pdf)
Lindsey H. Daly, MSHA, CPC, is a health care consultant with Physicians’ Ally, Inc., where she coordinates
projects for physician group practices and practice
administrators such as practice analysis and strategic
planning, managed care contracting, government insurance contracting, and coding/chart auditing reviews.
Her experience includes administrative and financial
management and process improvement for health care
facilities in Colorado and California. She holds a Bachelor of Science in
Finance from the University of Colorado at Boulder and a Master of Science in Health Administration from the University of Colorado at Denver
and Health Sciences Center.
www.aapc.com
November 2010
49
minute with a member
Susan Curtis, RHIT, CPC, CPC-H
Medicare Risk Assessment Coder, Humana, Inc. Jackson, Miss.
Coding Edge (CE): Tell us a little bit about
your career—how you got into coding,
what you’ve done during your coding
career, what you’re doing now, etc.
Susan: In 1999, I received a Registered
Health Information Technician (RHIT)
degree. My teachers told me to get more credentials as my career advanced. I took their
advice, and have since earned Certified Professional Coder (CPC®) and Certified Professional Coder-Hospital (CPC-H®) credentials.
I began working for the University of Mississippi Medical Center (UMMC)—a large
pediatric department associated with the
Blair E. Batson Hospital, and the only children’s hospital in Mississippi. I focused on
evaluation and management (E/M) coding,
and training residents and attending physicians on those guidelines. After 18 months
50 AAPC Coding Edge
with pediatrics and becoming involved with
my local chapter, I was offered a job with
Renal Care Group at a local chapter meeting. At Renal Care Group I was the health
information manager (HIM) for 51 facilities
throughout the state. I worked closely with
Medicare and Medicaid to ensure requested
records were received and claims were paid.
After four years, they merged with another
company and I moved on to work at Mississippi Methodist Rehabilitation Hospital
where I was responsible for coding outpatient services for the hospital and their
outlying clinics. I began appropriate coding
of E/Ms and ambulatory payment classifications (APCs).
My career path eventually led to insurance
company Humana, Inc., as a Medicare risk
assessment analyst for Mississippi. I visit
our providers and review medical records for
chronic conditions, and discuss coding issues
and health care environment changes. I am
a social person so I really enjoy becoming
friends with providers and staff. I also enjoy
traveling to give seminars to AAPC members who cannot travel. You may remember
the 1957-1963 television series “Have Gun
Will Travel.” Well, I feel like “Have coding
seminar will travel.”
CE: What is your involvement level with
your local AAPC chapter?
Susan: I am active in the Jackson, Miss.
chapter and have been president-elect and
president twice. Now I am a new member
development officer. This year the Jackson
and Biloxi chapters sponsored a seminar in
Hattiesburg to assist those needing continuing education units (CEUs).
I really enjoy networking. After all, I did get
a job opportunity from one meeting. I ask all
my providers’ staff: “Are you credentialed?”
If the answer is “No,” I ask, “When are you
taking the test?” Several ask for assistance
and I give them coding training to refresh
anatomy, disease process, and coding.
CE: What has been your biggest
challenge as a coder?
Susan: Working for Renal Care Group as
a liaison between them and Medicare and
Medicaid was a wonderful learning experience but most challenging. Health care is
ever evolving and I have to keep up, training is a constant challenge in my life. My
first seminar was tense, but after I got to
know the members, I relaxed and laughed
at myself.
CE: How are you and/or your
organization preparing for ICD-10?
Susan: Humana has always supported their
coders with weekly AAPC coding conference
calls and monthly, in-house coding calls,
and it’s my understanding that all coders
will be trained by AAPC’s ICD-10 seminar. Humana sends coders to each annual
conference. At the conference in Orlando,
Fla., I met more Humana coders because we
were all taking the same break-out sessions.
Great networking!
CE: If you could have any other job,
what would it be?
Susan: I’m at the end of my career. I love
working for Humana and want to retire
with this company. If I do anything else,
it would be working with medical record
documentation, reviews, and external audits.
CE: How do you spend your spare time?
Tell us about your hobbies, family, etc.
Susan: I live on six acres and have lots of
cats and one dog. I support my son, Jeff,
while he pursues a bachelor’s degree in computer security. My daughter, Sherry, is my
accountant since my husband passed away.
The two of them keep me exercising and
bowling with Wii. Sherry hosts a monthly
“girls’ night out” where we play all sorts of
games and just have fun.
I enjoy painting; although, I’m not very
good as of yet. That learning curve really
makes it interesting.
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NAMAS
2nd ANNUAL AUDITING
CONFERENCE
December 6 and 7, 2010
A Subsidiary of DoctorsManagement
WHERE
SPEAKERS
Grove Park Inn Resort & Spa
290 Macon Ave,
Asheville, NC 28804
800-438-5800
www.groveparkinn.com
Special Room Rate - $129
Deborah Grider, AAPC President & CEO, Key Note Speaker
Shelton Hager, MD, Key Note Speaker
Shannon Smith (DeConda), Founder of NAMAS/ Coding & Auditing Dept. Director
Rhonda Burkholtz, AAPC Vice President, Business Development
The convention will be 2 days
of educational sessions. We
will cover the following:
Kevin Townsend, NAMAS Instructor/ Consultant
Melody Irvine, NAMAS Instructor/ Consultant
Specialty Options
Paula Wright, NAMAS Instructor/ Physician Educator
Radiology / Interventional Radiology
Theresa Powers, Coding & Billing Department Head
Teaching Physicians
*Credentials of speakers along with their biographies may be found on our website.
Ophthalmology
RESERVE NOW
The price for the convention is $895 for non-AAPC
members and $795 for AAPC members.
Early Bird Special — sign up by Sept 30, 2010 and receive
Dinner at the Biltmore, including transportation to and from, along
with a two hour Christmas candlelight tour of the Biltmore.
Interventional Cardiology
General Surgery
Pediatrics / Internal Med / Family Med
Psychology
General Auditing
E / M Auditing
Compliance
Diagnosis Auditing
• Includes breakfast, lunch and breaks
• Earn up to 14 CPMA Specific CEU’s
• Includes a conference book
Transportation to and from the Airport is available at an additional cost.
visit www.NAMAS-Auditing.com
877-418-5564
Hands on Auditing
Auditing From The Physician’s Point of View
Marketing Yourself
See our website for complete schedule
CEUs - 14 CPMA Specific
AAPC Approved

Destination Counts in a Catheter`s Journey

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