November 2011

Hernia Repair in Five Easy Steps

Melissa Brown, RHIA, CPC, CPC-I, CFPC

Plus: E/M Outliers • Exemption • Nashville Conference • Hot Buttons • FESS

Contents

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[contents]

November 2011

In Every Issue 7 Letter from the Chairman and CEO 9 Kudos 11 Letter from Member Leadership 12 Coding News

Special Features 16 Features 20 Demystify the Physician Fee Schedule

G.J. Verhovshek, MA, CPC

24 Why Your Practice Should Care About E/M Outliers

Mary LeGrand, RN, MA, CPC, CCS-P

26 FESS Up! You Need a Sinus Surgery Refresher

Laurette Pitman, RN, CPC-H, CGIC, CCS

30 Code Fat Albert’s Hernia Repair in Five Easy Steps

Melissa Brown, RHIA, CPC, CPC-I, CFPC

34 ICD-10 Testing, Testing ... One, Two, Three

Julia Croly, CPC, CPC-P, CPC-I

36 Deal with Difficult People by Managing Hot Buttons

Dana Lightman, Ph.D.

42 I Take Exception with That!

Maryann C. Palmeter, CPC, CENTC

46 For CPC-As, Mentors Are a Must

Suzi Morrow, CPC

48 Since When Is “Give Less Weight” an Audit Protocol Standard?

Robert A. Pelaia, Esq., CPC, CPCO

On the Cover: If you’d like to push your hernia coding to a higher level, Melissa Brown, RHIA, CPC, CPC-I, CFPC, of Jacksonville, Fla. can walk you through the process, one step at a time. Cover photo by Jon M. Fletcher (www.jonmfletcher.com).

Online Test Yourself – Earn 1 CEU

Go to: www.aapc.com/resources/ publications/coding-edge/archive.aspx 16 Nashville Regional Conference 36 Added Edge 42 Featured Coder 46 Coder’s Voice 48 Legal Edge

Education 14 AAPCCA: Have YOU Attended a Chapter Meeting Lately? 38 Newly Credentialed Members 34 ICD-10 Road Map

Coming Up • 2012 CPT® • AAPC’s ICD-10 Plan • OB Ultrasound • Pediatric Neurosurgery • Tubal Sterilization www.aapc.com

November 2011

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Serving 107,000 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:

Chairman and CEO Reed E. Pew [email protected]

Vice President of Finance and Strategic Planning

Beginning coding with common technologies, basic anatomy and physiology, and using standard code guidelines and regulations.

APPRENTICE

PROFESSIONAL

EXPERT

November 2011

Korb Matosich [email protected]

Vice President of Marketing

More sophisticated issues including code sequencing, modifier use, and new technologies.

Bevan Erickson [email protected]

Vice President of ICD-10 Education and Training

Advanced anatomy and physiology, procedures and disorders for which codes or official rules do not exist, appeals, and payer specific variables.

Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC [email protected]

advertising index

Directors, Pre-Certification Education and Exams Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC [email protected] Katherine Abel, CPC, CPMA, CPC-I, CMRS [email protected]

American Medical Association......................51 www.amabookstore.com

Director of Member Services Danielle Montgomery [email protected]

CaseCoder, LLC.............................................47 www.casecoder.com

Director of Publishing Brad Ericson, MPC, CPC, COSC [email protected]

Coding Institute, LLC........................12, 32, 44 www.SuperCoder.com CodingWebU..................................................19 www.CodingWebU.com Complete Medical Solutions..........................13 www.gemstool.com

Managing Editor John Verhovshek, MA, CPC [email protected]

Executive Editors

Michelle A. Dick, BS [email protected]



Tina M. Smith, AAS [email protected]

Renee Dustman, BS [email protected]

Production Artists Renee Dustman, BS [email protected]

Contexo Media...............................................23 www.contexomedia.com

Advertising/Exhibiting Sales Manager

HealthcareBusinessOffice, LLC.....................29 www.HealthcareBusinessOffice.com

Address all inquires, contributions, and change of address notices to:

Ingenix is now OptumInsightTM, part of OptumTM.............................................10 www.shopingenix.com Medicare Learning Network® (MLN)...............6 Official CMS Information for Medicare Fee-For-Service Providers

http://www.cms.gov/MLNGenInfo American Society of Anesthesiologists...........2 www.asahq.org/Shop-ASA NAMAS/DoctorsManagement.................. 5, 52 www.NAMAS-auditing.com

Jamie Zayach, BS [email protected]

Coding Edge PO Box 704004 Salt Lake City, UT 84170 (800) 626-CODE (2633) ©2011 AAPC, Coding Edge. All rights reserved. Reproduction in whole or in part, in any form, without written permission from AAPC is prohibited. Contributions are welcome. Coding Edge is a publication for members of AAPC. Statements of fact or opinion are the responsibility of the authors alone and do not represent an opinion of AAPC, or sponsoring organizations. Current Procedural Terminology (CPT®) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein. CPC®, CPC-H®, CPC-P®, CPCOTM, CPMA®, and CIRCC® are registered trademarks of AAPC. Volume 22 Number 11

November 1, 2011

Coding Edge (ISSN: 1941-5036) is published monthly by AAPC, 2480 South 3850 West, Suite B. Salt Lake City, Utah, 84120, for its paid members. Periodical postage paid at the Salt Lake City mailing office and others. POSTMASTER: Send address changes to: Coding Edge c/o AAPC, 2480 South 3850 West, Suite B, Salt Lake City, UT, 84120.

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AAPC Coding Edge

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Letter from the Chairman and CEO

The Importance of Time This is an inspirational story written by Bob Perks© www.bobperks.com, which has been paraphrased. It had been some time since Jack had seen Mr. Belser next door. College, girls, career, and life itself got in the way. In fact, Jack moved clear across the country in pursuit of his dreams. There, in the rush of his busy life, Jack had little time to think about the past and often no time to spend with his wife and son. He was working on his future and nothing would stop him. Over the phone, his mother told him, “Mr. Belser died last night. The funeral is Wednesday.” Memories flashed through his mind like an old newsreel as he sat quietly remembering his childhood days. “Jack, did you hear me?” “Oh sorry, Mom. Yes, I heard you,” he replied. “It’s been so long since I thought of him. I’m sorry, but I honestly thought he died years ago,” Jack said. “Well, he didn’t forget you. Every time I saw him, he’d ask how you were doing. He’d reminisce about the many days you spent over ‘his side of the fence’ as he put it,” Mom told him. “I loved that old house he lived in,” Jack said. “You know, Jack, after your Father died, Mr. Belser stepped in to make sure you had a man’s influence in your life,” she said. “He’s the one who taught me carpentry. I wouldn’t be in this business if it weren’t for him. He spent a lot of time teaching me things he thought were important. Mom, I’ll be there for the funeral,” Jack said. As busy as he was, he kept his word. Jack caught a flight home. Mr. Belser’s funeral was small and uneventful, as he had no children of his own and most of his relatives had passed away. The night before he had to return home, Jack and his mom stopped by to see Mr.

Belser’s old house next door. Standing in the doorway, Jack paused for a moment. It was like crossing over into another dimension, a leap through space and time. The house was exactly as he remembered, and each step held memories … Jack stopped suddenly. “What’s wrong, Jack?” his mom asked. “The box is gone,” He said. “There was a small gold box he kept locked on top of his desk. I must’ve asked him a thousand times what was inside. All he’d tell me was, ‘The thing I value most.’” Everything about the house was exactly how Jack remembered it, except for the box. Someone from the Belser family must’ve taken it. Two weeks after Mr. Belser died, Jack returned home from work to discover a note from the Post Office in his mailbox alerting him to a package. He retrieved it the next day. It looked like it had been mailed decades ago. The handwriting was difficult to read but the return address, “Mr. Harold Belser,” caught his eye. In the car, Jack ripped open the package to find the gold box and an envelope. In the envelope was a note that read, “Upon my death, please forward this box and its contents to Jack Bennett. It’s the thing I valued most in my life,” and a small key. Heart racing, Jack carefully unlocked the box. Inside he found a beautiful gold pocket watch. Running his fingers over the finely etched casing, he unlatched the cover. Inside was engraved, “Jack, thanks for your time! - Harold Belser” The thing Mr. Belser valued, Jack realized, was Jack’s time. He held the watch for a few minutes, and then called his office and cleared appointments for the next two days. “Why?” his assistant, Janet, asked. “I need some time to spend with my son,” he said. “Oh, by the way, Janet, thanks for your time!”

Your friend,

Reed E. Pew Chairman and CEO

www.aapc.com

November 2011

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NE Become a Certified Professional Compliance Officer Voluntary Today, Mandatory Tomorrow – The Patient Protection and Affordable Care Act will mandate compliance programs as a condition of enrollment in Medicare and Medicaid. Become a leader in your practice by demonstrating your knowledge of compliance and help your practice meet this requirement.

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Learn more at:

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AAPC Coding Edge

W

KUDOS

Please send your Kudos to: [email protected]

Kudos

Rhonda Buckholtz in The Wall Street Journal You know you’re in the big league when you make it into The Wall Street Journal. On Sept. 13, WSJ published, “Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way,” a lighthearted article about the detail that ICD-10-CM will bring to diagnosis codes. In the article, our vice president of ICD-10 training, Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, mentions one of the more obscure codes, V91.07XA Burn due to water-skis on fire, initial encounter, and contemplates how an accident like this is possible: “Is it work-related?” she asks. “Is it a trick skier jumping through hoops of fire? How does it happen?” Before the day was over, national and local print and broadcast media picked up the story, which included background information Rhonda had provided and interviews with federal officials.

Brinson Named Humanitarian Freda Brinson, CPC, CPC-H, CEMC, compliance auditor for St. Joseph’s/Candler in Savannah, Ga., received this year’s St. Joseph’s/Candler Lientz Award. Brinson, who volunteers at a number of St. Joseph’s/Candler’s Angels of Mercy events and serves on the AAPCCA board of directors, exemplifies the health system’s mission of “Rooted in God’s love, we treat illness and promote wellness for all people.” She received the award because of her work ethic, compassion, volunteerism, and leadership. Congratulations, Freda!

Chapters Popping Up All Over Congratulations and thanks to the new chapters that dedicate their time to helping coders and their profession. We welcome the following new chapters: Aberdeen, S.D.

Laramie/Cheyenne, Wyo.

Arcata, Calif.

Manhattan, Kan.

Athens, Ga.

Marion, Ohio

Aurora, Ill.

Mitchell, S.D.

Beaumont, Texas

Norfolk, Neb.

Brainerd, Minn.

Santa Barbara, Calif.

Cumming, Ga.

Savannah, Tenn.

Hamilton, N.J.

Sharon, Pa.

Idaho Falls, Idaho

Staten Island, N.Y.

Kingman/Havasu City, Ariz.

Tawas City, Mich.

London, Ky.

Warrenton, Va. www.aapc.com

November 2011

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Letter from Member Leadership

Thankful for AAPC W hen asked, “What are you thankful for?” most reply in the usual manner: family, friends, and good health. This month, however, let’s explore this topic and look at what our AAPC family has brought to each of us, its members, for which we are thankful.

A Heartfelt Story of Thanks I’d like to share a story about one of our members, Casey Henry, CPC. Like many professional medical coders, Casey didn’t grow up wanting to be a coder. “I didn’t know what coding was,” she admits. Casey’s journey to medical coding began while studying fine arts in college. To make ends meet as a student, Casey accepted a position filing and retrieving medical records at Carle Foundation Hospital, located in Urbana, Ill. While working in this position, Casey was introduced to medical coding through “coders who loved their job,” she said. Casey completed her bachelor’s degree in fine arts at the University of Illinois, married, and moved to southern Illinois. But she had difficulty finding employment in her field during trying economic times. This led to getting a dead-end job in manufacturing; needing state assistance to support her family; returning to the Urbana area; and, changing her career. Finding a Home with AAPC Hoping to return to Carle, Casey contacted her former manager and was informed that the requirements for working in the medical records department had changed during her absence. She would need to be credentialed as an outpatient coder to work in the department. With the desire to move toward her dream of a stable and rewarding career, Casey began researching credentialing organizations and decided that AAPC was the best fit for her. When asked what drew her to AAPC, Casey said, “They were more accessible, and easier to work and communicate with. I really felt like they wanted me to succeed, it was like a family.” As a sin-

gle mom, the availability of taking medical coding classes online allowed her the flexibility to continue education and obtain certification. Her local chapter network has also been very supportive. “They made me feel at home right away,” she said. While preparing for her Certified Professional Coder (CPC®) exam, Casey again applied for a position with Carle Foundation Hospital, this time in the clinical coding department. She was hired after completing her studies, but before taking the CPC® exam. She passed the exam, and remains there happily working for the physician side of Carle, Carle Physician Group. When asked where she sees her future as a medical coding professional, Casey said, “I’m glad I became certified before ICD-10-CM went into effect, I plan to continue learning and eventually become a ‘go to’ person.” Casey Gives Thanks In the spirit of this article, I asked Casey who and what she is thankful for regarding her career. Her response: “It’s not a single person that I am thankful for—my parents David and Cathy Owens, for their support and persistence to keep going when I was frustrated and discouraged. I also personally thank AAPC for changing my life.” She added, “I now have a rewarding career and continue to learn more everyday. AAPC has opened up doors for me that I never would have expected. Thank you very much!”

Thankful Realization at Conference While attending the regional conference this past September in Nashville, Tenn., I reconnected with long-time friends and made a few new ones. As usual, we spent most of our time discussing how we began in this industry, the many changes we’ve seen, where we believe health care is headed, and our role as coders, billers, managers, teachers, and consultants in the future. During these discussions, one point consistently came to the forefront of every conversation: None of us would be where we are

in our careers and life without AAPC, its members, and their support. Thanks for another great conference.

Express Your Thanks During this Thanksgiving season, while you are considering what you are thankful for, remember to share with your family, friends, fellow AAPC members, and colleagues the many blessings they bring into your life. Best Wishes,

Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P President, National Advisory Board

www.aapc.com

November 2011

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Coding News Use Revised ABN by Nov. 1 Providers (including independent laboratories, physicians, and practitioners) and suppliers now have until Nov. 1 to begin using the revised Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131. The original implementation date was Sept. 1, but the Centers for Medicare & Medicaid Services (CMS) extended the mandatory use date to Jan. 1, 2012 to give providers and suppliers more time to transition to using the new form, and to use up stockpiles of old forms. The revised form replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007). The latest version of the ABN has a release date of March 2011 printed in the lower-left corner. All ABNs with a release date of March 2008 that are used on or after Jan. 1 will be invalid. The ABN should be used in situations where Medicare payment is expected to be denied. Skilled nursing facilities (SNFs) should use the revised ABN form when services are expected to be denied under Medicare Part B only. Download the revised ABN at www.cms.gov/BNI/02_ABN.asp, available now for immediate use.

AMA Releases CPT® 2012 Category II Codes The American Medical Association (AMA) has released new and revised CPT® Category II codes, effective Jan. 1, 2012. Category II codes are supplemental tracking codes used for performance measurement (e.g., the Physician Quality Reporting System, www.cms.gov/PQRS/). Category II codes are not required for correct coding and should not be used in place of Category I codes. They describe clinical components that may: typically be included in evaluation and management (E/M) or clinical services; result from clinical laboratory or radiology tests and other procedures; or identify processes intended to address patient safety practices or services reflecting compliance with state or federal law. For 2012, four Category II codes are deleted and replaced by newer codes: • 4002F Statin therapy, prescribed (CAD) is deleted and replaced by 4013F Statin therapy prescribed or currently being taken (CAD). • 4006F Beta-blocker therapy prescribed (CAD, HF) is replaced by 4008F Beta-blocker therapy prescribed or currently being taken (CAD, HF).

Coding Institute’s Expert Staff Provides a Lowdown on ICD-9 2012 Changes October 1 is less than a month away – if you feel you’re still not up to speed on the ICD-9 2012 code changes, here’s a great way to stay on top - SuperCoder’s free webinar ‘ICD-9 2012: Top Changes’. Presented by a trio of the Coding Institute’s expert staff - Jen Godreau, Leesa A. Israel and Mary Compton, this 30-minute webinar will walk you through:  2 details make the difference between 4 new and revised Pelvic Fracture codes  Ditch 997.4 for new code range for Gastric Band Complication  Terms that’ll land you the correct Pulmonary Embolism code  How to accurately code Unspecified Dementia  7 new codes that improve Glaucoma tracking.  And More! Plus, SuperCoder subscribers also stand to take home 0.5 AAPC-approved CEUs after attending the conference.

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AAPC Coding Edge

Coding News • 4009F Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed (HF, CAD, CKD), (DM) is replaced by 4010F Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed or currently being taken (CAD, HF). • 4275F Hepatitis B vaccine injection administered or previously received (HIV) is replaced by 4149F Hepatitis B vaccine injection administered or previously received (HEP C, HIV) (IBD). Several dozen new codes have been added in clinical areas such as angina, tobacco use, neuropsychiatric symptoms, and more. For a full list of revisions to Category II codes (as well as a sneak peak at some 2013 codes), see “Update to List of Category II Codes” dated Sept. 14, 2011.

Don’t Jump the Gun When Delivering DMEPOS Refills Effective Oct. 31, 2011, suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) submitting claims for items or services provided to Medicare beneficiaries shouldn’t be too hasty to dispense refills. CMS Change Request (CR) 7410 modifies the number of days a supplier

can contact the beneficiary prior to dispensing a refill and the number of days it can deliver a DMEPOS product prior to the end of the product’s usage. For DMEPOS refills, suppliers must contact the beneficiary prior to dispensing the refill. Do this to ensure the refilled item is necessary and to confirm any changes or modifications to the order. CR 7410 mandates,“contact with the beneficiary or designee regarding refills should take place no sooner than 14 calendar days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 10 calendar days prior to the end of usage for the current product.” See CR 7410 (www.cms.gov/transmittals/downloads/R389PI.pdf) for more information.

New Online Application Fee Collection Process through PECOS Medicare Learning Network (MLN) Matters® Special Edition (SE) article 1130 changes Medicare’s online application payments process and affects providers and suppliers. See MLN Matters® SE1130 (www.cms.gov/MLNMattersArticles/Downloads/ SE1130.pdf) for details.

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AAPCCA

By Freda Brinson, CPC, CPC-H, CEMC

Have YOU Attended a Chapter Meeting Lately? It’s not your grandma’s local chapter meeting.

I

have been a member of AAPC for 15 years, but I have not always been a local chapter meeting attendee. In fact, I came up with many excuses not to attend: • It’s not a convenient time for me. • I have too much work to do. • I need to get home and feed the kids. • I have a paper due in a few days. • My favorite program comes on TV at that time. • I don’t know anyone there. • It’s boring. • It takes too long to get there. • There is never a speaker talking about my specialty. The excuses are endless. I’m sure you could probably add a few of your own to the list. What if you put aside those excuses and preconceived notions (factual or illusory), and attended a local chapter meeting? What do you suppose would happen?

Walking in, Here’s What You’d Find Speaking from experience, here’s a typical scenario: Prior to the meeting start time, the secretary, treasurer, and president-elect are preparing a table with the sign-in sheets and pens. The member development officer is poised at the door, ready to greet members with a smile and a kind word as they arrive. Chapter volunteers are setting up the meal table (Yes, my chapter has a meal at every meeting.); and, the president and education officer are at the front of the room, making last-minute preparations for the call-to-order and the speaker presentation. There is excitement in the air as members enter the room and take their seats. Members exchange greetings and join in conversations about another unbelievable denial or an operative note unlike anything ever seen. It’s apparent that these folks are not just individuals attending a meeting, but friends and colleagues enjoying each other’s company.

As the Meeting Begins … You hear the local chapter president call the meeting to order. It’s exactly the time specified on the agenda because officers are conscientious of your time, and conduct chapter meetings professionally. Members are welcomed and local chapter officers are introduced. New members and guests are acknowledged and newly certified 14

AAPC Coding Edge

members congratulated. Announcements of upcoming educational opportunities are shared as well as other chapter business.

Onto Education When the presentation starts, there is something valuable to be learned from every speaker. It may not apply to your current position, but tomorrow is a new day with new challenges. Years ago, I came so close to skipping a local chapter meeting because I didn’t see why I would ever need to know how to code a liver transplant. I talked myself into going (it was during my lunch, so at least I would have food), and it turned out to be one of the most interesting lectures I’ve ever attended. The lecture had nothing to do with me, my job, or anything I might code, but it was so new to me I was like a sponge, wanting to absorb all the information I could. You never know what topics will excite you at a local chapter meeting.

Time to Network I love organizing and encouraging networking at local chapter meetings. Believe it or not, I used to sit in the back of the room, trying not to make eye contact with others. I’d pretend to read whatever I had in front of me (over and over), rather than actually talk to those around me. That was me four years ago. I’m still not a Chatty Cathy with the gift for gab, but I’m now able to talk with attendees at my local chapter meeting because I have found something we have in common: We all want to share and learn from each other. Four years ago, I knew the names of maybe five fellow chapter members. Since getting involved with my chapter and stepping out of my comfort zone to become a chapter officer, I’m proud that I can name every single person at our meetings. I can now spot a new member or guest at 20 yards away—that’s exciting!

Become Part of the Excitement If you have attended a chapter meeting that wasn’t exciting, I challenge you to get involved and make your chapter exciting. If you think the topics at your chapter meetings aren’t interesting or don’t apply to you, step out of your comfort zone and recruit a speaker or present a topic that interests you. Become committed and willing to share with your fellow members.

Social Media Ain’t Got Nothing on a Chapter Meeting In this age of immediate, fast-paced information, it’s a pleasure to walk into a local chapter meeting, shake hands with real-live members, look each other in the eyes, and talk face-to-face.

AAPCCA

AAPCCA Quick Tip

We Want You!

Years ago, I came so close to skipping a local chapter meeting because I didn’t see why I would

The AAPCCA is accepting applications for five new board members, and one of those spots could be filled by you.

ever need to know how to code a liver transplant.

We want you, if: ✓✓ You can’t wait to get to the next chapter meeting ✓✓ You have a great meeting idea to share ✓✓ You find yourself seeking out new members to welcome at meetings ✓✓ You drive home thinking of ways to improve chapter attendance ✓✓ You mentor CPC-As

You may have 1,000 friends on Facebook, and you may follow 1,000 people more on Twitter, but this doesn’t compare to the feeling you get when you attend a local chapter meeting. Some things just cannot be replaced, and networking and learning with fellow members of your local chapter are two of those things. Attend a local chapter meeting; and when you do, let me know about it. I’d love to hear from you.

If this sounds like you, take the time to fill out an application and contact the AAPCCA Board of Directors (BOD) member in your region for more information. —AAPCCA Vice-chair Angela Jordan, CPC

AAPCCA Handbook Corner Correction

Freda Brinson, CPC, CPC-H, CEMC, serves on the AAPCCA Board of Directors and is compliance auditor for St. Joseph’s/Candler Health System in Savannah, Ga. She has 30 years of health care experience. Ms. Brinson was 2008 AAPC Networker of the Year and chapter president when Savannah was named 2008 AAPC Chapter of the Year.

In the October issue, “Handbook Quick Tip: Know Officer Attendance Requirements” was written by Susan Edwards, CPC.

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www.aapc.com

November 2011

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Nashville Conference a Smashing Success AAPC regional gathering provides sweet music for coders. By Michelle A. Dick

“For a regional conference, it was AWESOME!” exclaimed Judy A. Wilson, CPC, CPC-H, CPC-P, CPC-I, CANPC, CMBSI, CMRS, as she compared the 2011 AAPC Regional Conference in Nashville, Tenn. to the national conferences she has attended. “The attendees who I met had nothing but good remarks about the conference.” The atmosphere compared to a national conference and its caliber of speakers was top-notch, according to AAPC National Advisory Board (NAB) President-elect David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCS, RCC. Although he has never been to a regional conference prior to Nashville’s, Dunn said, “As far as the program, the keynote, and the speakers, it felt like any national conference I’ve been to.” Here’s what the conference offered:

An Attentive, Friendly Smile David Zielske, MD, CIRCC, CPC-H, CCC, CCS, RCC, can’t “say enough about the professional, warm, and friendly AAPC staff and volunteering members.” As a speaker and attendee, Zielske said he has “always been greeted with a smile and genuine interest, which makes a speaker comfortable and welcome at conference.” And the hospitality and professionalism didn’t end there. Zielske said, “The attendees were knowledgeable about the subject matter, attentive, and interactive during the talks. I didn’t catch anyone snoozing, even after the lunch break!” As an AAPC Chapter Association (AAPCCA) Board of Directors member, Brenda Edwards, CPC, CPMA, CPC-I, CEMC, knows the goal at conference “is to make everybody feel welcome.” Throughout the conference, whenever she saw someone who AAPCCA helped check in at registration, she would say “Hi!” and have a nice conversation.

16

AAPC Coding Edge

The most important benefit you can get out of attending conference is networking, and this conference was full of it.

A Grand Location in Nashville Nashvillians Dunn and Zielske were thrilled when they heard the regional conference would be in Nashville. Dunn said, “When the 2010 national conference was cancelled due to the flood disaster and moved to Jacksonville, I was disappointed that we couldn’t have it here.” He added, “So, when I found out the regional conference was here, I was excited and worked very hard to help Melanie Mestas, conference director, and AAPC CEO and Chairman Reed Pew in any way I could to get the best speakers.” Zielske may be a little biased about the location since he lives there, he said, “but still, the topics were timely and pertinent, and the presenters were outstanding. After a few days of rain at the start of the week, even the weather cooperated.” For those who traveled to attend, such as Wilson, who is from Virginia, there was a lot to do outside of conference, too. “What is there not to like about the Gaylord Opryland Resort? It was beautiful and you could shop, eat, rest, workout, etc.,” Wilson said. The Nashville location lent itself “for some fun time—like getting Grand Ole Opry tickets on sale,” said Wilson; and, the resort was “close enough to see some of the sites of Nashville—you just needed good walking shoes.”

Hot Spot for Physician Speakers “The conference had a strong contingent of Nashville physician speakers, including Melanie Dunn, MD, who delivered an outstanding Ob/Gyn presentation, and John David Rosdeutscher, MD, a plastic surgeon who did an excellent job explaining lesion excision and wound care,” said Zielske. Other physician presentations included “the Nashville standbys” Dunn and Zielske, who “elaborated on the intricacies of vascular families and neurovascular interventional coding, respectively,” according to Zielske.

Dunn’s highlight of the conference was the speakers. “I asked a good friend of mine and neighbor in Nashville, Bill Gracey, the president and COO, Blue Cross Blue Shield of Tennessee to speak,” he said. Gracey was in the hospital side of health care for 20 years, and then went over to the insurance side. “That was probably the highlight for me, introducing Bill Gracey as the keynote speaker,” Dunn admitted. “Because he’s seen both sides of the fence, he talked about health care reform from all angles of the industry.” During his presentation, Gracey shared his perspective on health care as it stands today. “He was insightful and humorous, and his was a timely presentation,” Zielske said. Dunn asked his wife, Dr. Dunn, to speak, as well. He said, “My wife speaking, that was really funny because it was her first time speaking for AAPC and the room was really hot; she got there late from the hospital; and her computer failed five minutes before it was supposed to start. After everything got worked out, her session was successful. She enjoyed it.”

So Much to Do, So Little Time Although Edwards, an active AAPCCA board member, was busy helping attendees; gearing up for “Get 2 Know Your Local Chapter;” and presenting “The Good, Bad, and Ugly of E/M Auditing;” she found the time to see Melissa Brown’s, CPC, CPC-I, CFPC, “3D - Exploring the Human Body.” Edwards said this was her favorite presentation because, “I loved the anatomy (autopsy) since we were viewing actual bodies and not models or pictures. I benefitted from seeing the body’s organs and loved when they put dye in the GI system to ‘bring it to life.’” Wilson, an AAPCCA board member and presenter, had a hard time picking out one session as her favorite because “there were so

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November 2011

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 Left to right: Judy Wilson, Melissa Brown, Susan Edwards, and Melody Irvine  The AAPCCA table was decked-out with suggestion cards, give-away raffle tickets, door prizes, and a board member banner.

many to pick from.” She said, “I am not sure I could pick just one thing. But I will tell you, I enjoyed all the different sessions that were available.” Wilson said she was “so glad to see some of the specialty sessions like anesthesia;” and, enjoys going to sessions that she doesn’t know much or anything about, or use in her daily job. “It is a way to keep learning new things,” Wilson said.

Get to Know Your Local Chapter (G2KYLC) G2KYLC was a big hit. According to Edwards, “The biggest compliment was given to our board by Vice-president of Live Events Bill Davies when he told us the line of people at the event was for our table. Our members were that eager to know more about the local chapter board.” There was a “tremendous number of first-time attendees at conference—that was awesome!” said Edwards. The best thing about G2KYLC is the networking opportunities. Wilson said she was able to meet new networking buddies, and she “took away so much information.” She said, “I had such a great time at the Get to Know Your Local Chapter event. I got lots of information that I took back to help our chapter.”

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AAPC Coding Edge

It’s All About Networking The most important benefit you can get out of attending conference is networking, and this conference was full of it. Wilson said, “I think if I had to choose one thing as my favorite part, it would be all the networking opportunities that were available during the conference.” The great part about regional conferences is that everything is on a slightly smaller scale than national conferences. This means it’s easier to network with coders in your area. Wilson agreed, “I really enjoy regional conferences as it is usually a smaller group and you get more time to meet and network.”

Simply, Smashing Zielske wrapped up the conference best, saying, “The Nashville conference was a smashing success. AAPC espouses well the concepts of networking, education, and professionalism, and I think most attendees had an outstanding conference experience. I know I did. See y’all in Vegas!” Michelle A. Dick is executive editor at AAPC.

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Apprentice

Feature

By G.J. Verhovshek, MA, CPC

Demystify the Physician Fee Schedule Understand how Medicare payments are made by learning how to calculate them.

You probably already know that Medicare payments are based on relative value units (RVUs) assigned to each CPT®/HCPCS Level II code. But the 2011 National Physician Fee Schedule Relative Value File contains no fewer than 10 columns listing various RVUs, as shown on next page. This may leave you wondering exactly which of those RVU columns you should use, and how the Centers for Medicare & Medicaid Services (CMS) determines total payments.

RVU Totals Are the Sum of Three Parts Payment rates for individual services are based on the sum of three separate RVU categories. 1. Work RVUs “reflect the relative levels of time and intensity associated with furnishing a … service and account for approximately 50 percent of the total payment associated with a service,” according to CMS’ Medicare Physician Fee Schedule Payment System Fact Sheet (www. cms.gov/MLNProducts/downloads/MedcrephysFeeSchedfctsht.pdf). These RVUs are specifically to pay for physician effort. All work RVUs must be reviewed (and may be changed) at least once every five years. 2. Practice expense (PE) RVUs reflect the cost of non-physician labor, and expenses for building space, equipment, and office supplies. 3. Malpractice (MP) RVUs are meant to cover the cost of malpractice insurance for each procedure and service. These typically account for the smallest overall contribution to the total RVU value of a given procedure or service. MP RVUs must be reviewed (and may be changed) at least once every five years.

PE RVUs Depend on Place of Service Work RVUs and MP RVUs for a particular code are consistent across all places of service. For example, the work RVUs for 10021 Fine needle aspiration; without imaging guidance are 1.27, regardless of whether the service is provided in the physician office, an inpatient hospital, or any other health care setting. Similarly, the MP RVUs are 0.22 regardless of the place of service. Note: All RVUs in this article are based on the most recent 2011 National Physician Fee Schedule Relative Value File at press time. This file can be found on the CMS website (www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage).

Because the expense of providing a service may differ depending on where the service is provided (facility vs. non-facility), PE RVUs also may change depending on where the service is provided. To account for this, the fee schedule lists separate columns to describe “Facility” and “Non-facility” PE RVUs. The fee schedule also provides separate columns listing “Transitional” PE RVUs and “Fully Implemented” RVUs. As the CMS Fact Sheet explains, “For CY 2011, indirect cost data that are used in the calculation of PE RVUs for most specialties were updated using the American Medical Association’s Physician Practice Information Survey (PPIS) data. The PPIS is a multispecialty, nationally representative indirect PE survey of both physicians and non-physician practitioners. Its use is being transitioned over a four-year period beginning in CY 2010.” In other words, the “Transitional” RVUs reflect the current PE payment; while the “Fully Implemented” RVUs reflect what the PE RVUs will be at the end of the transition period (2014). The PE RVUs will be adjusted over each of the next three years until they reach the fully implemented amounts. 20

AAPC Coding Edge

Feature The Medicare Physician Fee Schedule lists relative value units for facility and nonfacility services.

Returning to 11021, for instance, the fee schedule lists the following PE values: Code

Transitioned Fully Non-facility PE RVUs

Implemented Non-facility PE RVUs

Transitioned Facility PE RVUs

Fully Implemented Facility PE RVUs

10021

2.7

2.77

0.58

0.64

From this example, we see that the current (transitioned) RVUs in the facility setting are 0.64; and in the non-facility setting (e.g., physician office), the current RVUs are 2.7. In 2014, these values will increase to 0.64 RVUs and 2.77 RVUs, respectively.

Sum the Parts for RVU Totals To find the total RVUs for a particular code, add together the work RVUs, MP RVUs, and the transitioned PE RVUs appropriate to your site of service (facility or non-facility). The fee schedule lists these values for you (as well as the 2014 projected totals, including the fully implemented PE RVUs). Code

Transitioned Non-facility Total

Fully Implemented Non-facility Total

Transitioned Facility Total

Fully Implemented Facility Total

10021

4.19

4.26

2.07

2.13

The difference in the total RVUs for the facility and non-facility settings is a function of the different PE RVUs assigned for each setting. If you’re billing 10021 in the physician’s office in 2011, the total RVUs on which you will be reimbursed are 4.19 (1.27 work RVUs + 0.22 MP RVUs + 2.7 transitioned non-facility PE RVUs). In the facility setting, the total RVUs are 2.07 (1.27 work RVUs + 0.22 MP RVUs + 0.58 transitioned facility PE RVUs).

GPCI Account for Regional Cost Differences The Physician Fee Schedule is a national fee schedule, but the cost of living—as well as practicing medicine and providing medical services—varies from one location to another. To account for these differences, CMS applies separate Geographic Practice Cost Indices (GPCI) to each of the three relative values (work, MP, and PE) used to calculate payment. CMS is required to update the GPCIs every three years, and to phase in changes over two years. The easiest way to find the GPCI for your location is by using the “Physician Fee Schedule Search” tool found on the CMS website (www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx). This tool allows you to search by code, locality (e.g., Baltimore, Los Angeles, Topeka, etc.), and type of information (e.g., RVUs, pricing information, or GPCI).

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November 2011

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To discuss this article or topic, go to: www.aapc.com

Feature

The Physician Fee Schedule is a national fee schedule, but the cost of living—as well as practicing medicine and providing medical services—varies from one location to another. For example, if you’re in Atlanta and want to find the GPCI for your area, you can: 1. Select “Geographic Practice Cost Index” from the “Type of Information” choices. 2. Choose “Specific Locality” from the choices under “Select Carrier/Medicare Administrative Contractor (MAC) Option.” 3. Choose “1020201: Atlanta, GA” from the “Carrier/MAC Locality” pull-down menu. 4. Click the “Submit” button. The results will show you the “GPCI WORK” for Atlanta is 1.006, the “GPCI PE” is also 1.006, and the “GPCI MP” is 0.890. The average GPCI value is 1, so we know that work RVUs and PE RVUs are paid slightly higher than average in Atlanta, while MP RVUs are paid at a lower than average rate.

plains, “The formula specifies that the update for a year is equal to the Medicare Economic Index (MEI) adjusted up or down depending on how actual expenditures compare to a target rate called the Sustainable Growth Rate (SGR).” On several occasions (including for 2011), Congress has acted to revise the CF when application of the formula would have resulted in drastic reductions to the CF. The CF for 2011 is $33.9764. Although the CF may change annually, it is the same for all places of service and localities across the nation. From our examples above, we already know the specific RVU totals for 10021 in the facility and non-facility settings in Atlanta, as well as a non-facility setting in Seattle. To arrive at a current payment amount, simply multiply these totals by the CF:

Apply the Formula to Determine Final RVUs

Atlanta, non-facility: 4.18962 RVUs x 33.9764 CF = $142.35

To determine the true, total RVUs for a procedure or service in your area, apply the following formula: (work RVUs x work GPCI) + (PE RVUs x PE GPCI) + (MP RVUs x MP GPCI)

Remember: To ensure accuracy, select the transitioned PE RVUs for your place of service (facility or non-facility). For example, if you want to determine the final RVUs for 10021 when provided in a physician office in Atlanta, apply the formula as follows: (1.27 work RVUs x 1.006 work GPCI) + (2.7 transitioned non-facility PE RVUs x 1.006 PE GPCI) + (0.22 MP RVUs x 0.890 MP GPCI) = 4.18962 RVUs

In the facility setting, the total is found by applying the same formula, but using the facility PE RVUs: (1.27 work RVUs x 1.006 work GPCI) + (0.58 transitioned non-facility PE RVUs x 1.006 PE GPCI) + (0.22 MP RVUs x 0.890 MP GPCI) = 2.0569 RVUs

To demonstrate how locality affects the GPCI amounts (and the overall RVU total), let’s consider one more example, using a Seattle physician’s office as our location. Note how the GPCI (found on the CMS lookup tool) differ: (1.27 work RVUs x 1.020 work GPCI) + (2.7 transitioned non-facility PE RVUs x 1.098 PE GPCI) + (0.22 MP RVUs x 0.785 MP GPCI) = 4.4327 RVUs

RVUs Times CF Gives You a Dollar Amount To calculate payment, you must multiply the place-of-service and locality-specific RVU total by a dollar conversion factor (CF). The CF is updated annually according to a formula specified by statute. The Physician Fee Schedule Payment System Fact Sheet ex22

AAPC Coding Edge

Atlanta, facility: 2.0569 RVUs x 33.9764 CF = $69.89

Seattle, non-facility: 4.4327 RVUs x 33.9764 CF = $150.61

For those of you who love math, here’s the entire formula we used to arrive at these figures: [(work RVU x work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF = final payment

Those of us who are less enamored with numbers can skip all the computation and simply use the Physician Fee Schedule Search tool to find payment information. If we select “Pricing Information” from the “Type of Information” pull down menu, select “1020201: Atlanta, GA” as our locality, and specify code 10021, the lookup tool will tell us the non-facility and facility price for the code—and they are, as we calculated, $69.89 and $142.35, respectively. We can also confirm that $150.61 is the correct payment for 10021 provided in the physician’s office in Seattle, and learn that the facility price in Seattle is $71.52. With a few clicks, we can just as easily determine that an endoscopic retrograde cholangiopancreatography (ERCP) (43260 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)) in a Miami facility will pay $421.49, or that radiological supervision and interpretation (S&I) of abdominal aortography (75625 Aortography, abdominal, by serialography, radiological supervision and interpretation) in Houston pays $215.66. Now, the next time you wonder about Medicare payments, you’ll know where to find them, how those payments are calculated, and exactly what all those RVU columns in the Physician Fee Schedule mean. G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

Professional

Feature

By Mary LeGrand, RN, MA, CPC, CCS-P

Why Your Practice Should Care About E/M Outliers Benchmarking provider services shows variations in practice patterns, and helps to define a practice as an outlier. Imagine an auditor looking at the distribution of evaluation and management (E/M) services for your physicians and non-physician practitioners (NPPs). What would he or she find when comparing your office’s usage pattern to other practices of the same specialty in your state? If you don’t know, you need to read on.

Benchmarking Shows How Your Practice Stacks Up To paraphrase Wikipedia, “benchmarking is comparing one’s performance metrics to industry bests, and involves management comparing the results and processes in the targets to one’s own results.” Operating under the theory of “no surprises,” sharpening your benchmarking skills should be at the top of your priority list. When benchmarking performance (whether it be for collection metrics or coding), you may discover that you are an “outlier” in some categories. Wikipedia defines an outlier as “an observation that is numerically distant from the rest of the data.” If a physician is an outlier on an E/M benchmark comparison—for instance, because he or she uses more consultation codes or more upper level codes—it’s not necessarily a bad thing. In many cases, the variation can be explained because a specialist, such as a neuro-otologist, is compared to general ear, nose, and throat (ENT) specialists due to Medicare’s specialty classifications; or, a spine surgeon who only sees patients on referral is compared to general orthopaedic surgeons. Nevertheless, being an outlier will prompt inquiring minds New to ask questions. Hopefully, you will 100% have good answers to explain the de80% viation, supported by excellent docu60% mentation.

Keep an Eye on Your Curves From any payer’s perspective, graphing code usage produces a distribution curve to use as a basis for compar24

AAPC Coding Edge

ison. This is especially true for Medicare, which paid $25 billion for E/M services (totaling 19 percent of all Medicare Part B payments) in 2009, according to the 2011 Office of Inspector General (OIG) Work Plan. Comprehensive Error Rate Testing (CERT) audits also revealed a national Medicare fee-for-service error rate for the November 2009 reporting period of 8 percent (up from 6 percent in 2008), which equates to $24.1 billion in erroneous payments (see www.cms.gov/CERT/Downloads/CERT_Report.pdf). Medicare’s recovery audit contractors (RACs), CERT contractors, and zone program integrity contractors (ZPICs) are out to recoup money paid to those outliers, and they have been successful in collecting. Knowing how you compare to other practices on a physician-to-physician basis is critical. Ignore those who tell you that your coding pattern should look like the proverbial “bell shaped curve.” Your coding should instead represent the level of care and documentation in your records. Your subspecialty or other unique aspects of your practice, your patient population, and your level of automation will influence your coding, E/M distribution, and variations from the “norm.”

Implement Benchmarking in Your Practice You can use various tools to benchmark your code use. For example, Karen Zupko & Associates’ (KZA) E&M Profile Analyzer™ (www.karenzupko.com/products/product_em.html)

Patient Office or Other Outpatient Visit

40% 20% 0%

99201 National

99202

99203 Some State

99204 Group

99205 Physician

To discuss this article or topic, go to: www.aapc.com

Feature

Ignore those who tell you that your coding pattern should look like the proverbial “bell shaped curve.” Your coding should instead represent the level of care and documentation in your records.

uses Medicare paid claims data to compare doctors in the same specialty and state with one another using a graphic format. The chart on the preceding page is an example of a benchmarking graph (with specialty and state concealed). What you see here is a physician’s distribution pattern for new patient visits that is significantly different than other members of his group. His volume and intensity of services differs from his colleagues in the state and nationally, as well. To find out why the physician’s distribution pattern deviates from others, you would: • Audit a sample of 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; medical decision making of low complexity. Verify that the medical necessity and documentation support the volume of level-III visits. If you identify any issues, address them through internal education. • Look at the other levels of service. Both the physician and practice are outliers in undercoding. Undercoding equals lost revenue to the practice, and might even raise concern that Medicare beneficiaries aren’t receiving appropriate care. The next steps include: 1. Running a frequency report for new, established, consultation, and inpatient codes by the physician. 2. Reviewing reports from the E&M Profile Analyzer, or a comparable product. The E&M Profile Analyzer, for example, allows you to access monthly or quarterly reports. 3. Using the above results to audit E/M records that represent outlier status (over- or under-utilization). 4. Making sure someone with solid qualifications performs the audit, such as a certified coder with relevant experience in your specialty. The auditor must be able to command the physicians’ attention and respect.

5. Developing an internal compliance plan (if you don’t have one), identifying both coding and billing process risks. Tip: Use the E&M Profile Analyzer, or a similar tool, as part of your internal compliance plan to pinpoint documentation reviews. Rather than pulling random numbers or types of charts, you can focus on outliers who are likely to attract an auditor’s interest.

Double Check E/M in EHRs Using an electronic health record (EHR) doesn’t mean that everything is OK with your E/M utilization. In fact, the OIG 2011 Work Plan has a special callout for EHR generated notes. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. It’s advisable to review multiple E/M services for the same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments. Never assume EHR logic is perfect—few, if any, systems can accurately calculate medical necessity; and cloning is often a significant problem. For instance, it’s a good idea to review all EHR generated 99214 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 detailed history; A detailed examination; Medical decision making of moderate complexity visits after about six weeks of use. Mary LeGrand, RN, MA, CPC, CCS-P, is a senior practice management consultant with Chicago-based KarenZupko & Associates. Ms. LeGrand specializes in E/M and surgical coding education, reimbursement analysis, and compliance/auditing. She is a coding and reimbursement expert in specialties such as orthopaedics, spine surgery, otolaryngology, and general surgery.

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November 2011

25

Expert

Feature

By Laurette Pitman, RN, CPC-H, CGIC, CCS

FESS Up!

You Need a Sinus Surgery Refresher Good documentation and a thorough understanding of anatomy and procedures will help you accurately code this service.

A

nyone who has had chronic sinus infections knows how miserable the constant headache and facial pressure can be. Fortunately for chronic sufferers, there is a minimally invasive surgical technique to help alleviate this problem. Today, functional endoscopic sinus surgery (FESS) is the primary approach used for the surgical treatment of chronic sinusitis. Familiarity with the procedure and sinus anatomy aids in the accurate selection of CPT® codes for this service.

Start with the Procedural Basics FESS is performed under direct visualization to restore sinus ventilation and normal function. Indications and ICD-9-CM codes for FESS include: • Chronic sinusitis refractory to medical treatment (473.9 Unspecified sinusitis (chronic)) • Recurrent sinusitis (473.9) 26

AAPC Coding Edge

• Nasal/sinus polyps (471.9 Unspecified nasal polyp and 471.8 Other polyp of sinus) • Sinus mucoceles (478.19 Other disease of nasal cavity and sinuses) • Foreign body removal (932 Foreign body in nose) • Epistaxis control (784.7 Epistaxis) Prior to the procedure, the physician performs a thorough history and examination, a trial of medical treatment, and a computed tomography (CT) scan (70486 Computed tomography, maxillofacial area; without contrast material). The CT scan is mandatory to identify the patient’s ethmoid anatomy and its relationship to the skull base and the orbits, along with the extent of the sinus disease. In a typical FESS procedure, the physician first identifies the middle turbinate and removes the uncinate process to expose the ethmoid bulla. The anterior ethmoid air cells are opened, leaving the bone covered with mucosa. This allows for better ventilation of the anterior ethmoid sinuses. The maxillary ostium is examined and, if it is obstructed, a middle meatal antrostomy is performed. This minimal surgery is often sufficient to improve the function of the osteomeatal complex, which improves the ventilation of the maxillary, ethmoid, and frontal sinuses. If the CT scan shows disease in the additional sinuses, the endoscope is advanced further into these areas. Additional endoscopic procedures may include sphenoidotomy, frontal sinus exploration, and removal of localized irreversible disease in the maxillary sinuses. If indicated, septoplasty and inferior turbinectomy may also be done during the surgical encounter.

Select CPT® Codes by the Treated Location Thorough and accurate physician documentation is the key to correct FESS code selection. CPT® provides multiple codes in the Sinus Endoscopy subsection to report these procedures, dependent on the sinuses surgically treated. CPT® also includes extensive instructions in this subsection, so become very familiar with these notes. CPT® codes 31231-31297 describe diagnostic and surgical endoscopic sinus procedures. All of the codes report unilateral procedures, with the exception of 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure), which specifies unilateral or bilateral in the descriptor. If any other procedure in this code range

Feature

CPT® includes extensive instructions in the Sinus Endoscopy subsection, so become very familiar with these notes.

is provided bilaterally, append modifier 50 Bilateral procedure. For unilateral procedures, anatomic modifiers RT Right side and LT Left side are used to identify the site of surgery. The surgical codes for endoscopic sinus procedures describe interventions where the sinuses are manipulated, opened, and pathologic tissues are removed. These codes always include any diagnostic inspection performed prior to or concurrently with the surgical intervention. Surgical treatment of the ethmoid sinus cells is a more common component of endoscopic sinus surgery. Because ethmoid sinuses are divided into anterior and posterior regions, CPT® has defined two separate codes for reporting these procedures. For drainage of infected mucous and removal of inflamed tissue confined to the anterior ethmoid cells, report 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior). When both the anterior and posterior regions are treated, assign 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior). Both 31254 and 31255 include removal of any polyps encountered and a middle turbinectomy. A medically necessary inferior turbinectomy may be reported separately with either 30130 Excision inferior turbinate, partial or complete, any method or 30140 Submucous resection inferior turbinate, partial or complete, any method, depending on the technique. Antrostomy generally is defined as making an opening into the maxillary sinus for drainage. This procedure commonly is performed with an endoscopic ethmoidectomy and assigned 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy for the maxillary antrostomy. A more extensive procedure, which involves removal of tissue from the maxillary sinus(es), is used to treat polyps, redundant mucous membrane, fungal debris, or bony partitions, and is reported with 31267 Nasal/sinus endoscopy; with removal of tissue from maxillary sinus. This procedure includes antrostomy, and may be performed alone or with other endoscopic sinus interventions. During frontal sinus exploration (31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus), the physician creates a permanent opening from the frontal sinus to the nose. The complexity of this procedure is determined by the site of obstruction to the outflow tract, disease within the sinus, or variations in frontal and ethmoid sinus anatomy, but the same code will always apply. The surgery focuses on removing the obstructing disease and restoring drainage.

Disorders of the sphenoid sinus are likely underreported, both because they are unusual and due to lack of recognition. Headache is the most common symptom, and may be caused by inflammation or expansile lesions of the sphenoid sinus. During sphenoidotomy, an opening is created into the anterior or front wall of the sinus to allow for improved drainage. Select 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy for this procedure. For a more extensive procedure, which would involve removal of tissue from the sphenoid sinus, assign instead 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus.

Stereotactic Navigation Calls for Additional Coding An important component of FESS is the use of the stereotactic computer assisted navigation (61782 Stereotactic computer-assisted (navigational) procedure; cranial, extradural). This image guidance provides for the navigation and localization of high-risk anatomical areas adjacent to the sinuses, such as the optic nerve. In its guidelines for “Intraoperative Use of Computer Aided Surgery,” the American Academy of Otolaryngology gives the following examples as indications for use of the navigational system: • Revision sinus surgery • Distorted sinus anatomy • Extensive sino-nasal polyposis • Pathology involving the frontal, posterior ethmoid and sphenoid sinuses • Disease abutting the skull base, orbit, optic nerve or carotid artery • Cerebrospinal fluid (CSF) rhinorrhea or conditions where there is a skull base defect • Benign and malignant sino-nasal neoplasms Clinical coding example: A 56-year-old male with a history of chronic sphenoid sinusitis presents with chronic headaches. A CT scan shows opacification in the sphenoid sinus and bilateral ethmoid sinus disease. Findings: Polyps and pus in the sphenoid sinuses were seen, along with green thickened debris in the lateral aspect of the right sphenoid sinus. Mucosal swelling in the ethmoid air cells and osteitic bone was noted. Maxillary sinuses were free of disease. Procedure: The patient is taken to the operating room (OR) and www.aapc.com

November 2011

27

Feature

Learn Your Way Around the Sinuses The paranasal sinuses are air-filled pockets located within the bones of the face and around the nasal cavity. There are four pairs, each named for the bone in which it is located: {{

Maxillary sinuses - located in the cheekbones under the eyes

{{

Ethmoid sinuses - 6-12 small sinuses per side, located between the eyes

{{

Frontal sinuses - located in the forehead

{{

Sphenoid sinuses - behind the ethmoid sinuses, near the middle of the skull

Frontal Sinus

Nasal Cavity and Middle Turbinate

Sphenoid Sinus

Each of these sinuses has an opening, called an ostium, connecting it to the nose In the lateral wall of the nose are the superior, middle, and inferior turbinates. Each turbinate is a rounded projection that extends the length of the nasal cavity. The inferior turbinate (the largest of the three) runs parallel to the floor of the nose. The middle turbinate is part of the ethmoidal bone and projects from the lateral wall of the nasal cavity. It is just above the middle meatus into which the anterior ethmoid cells open. The middle turbinate and the middle meatus together represent the key area of the nose, known as the osteomeatal complex (OMC). The superior turbinate, located above the middle turbinate, is the smallest of the turbinates and is not commonly associated with significant sinus disease. The nose also contains the nasal septum, which divides it into two nasal cavities. The most common diagnosis involving this anatomic area is a deviated septum (ICD-9-CM 470 Deviated nasal septum), in which the top of the cartilaginous ridge leans either to the left or the right, causing an obstruction of the affected nasal passage. The condition can result in poor drainage of the sinuses.

Ethmoid Air Cells (Sinus)

Superior Turbinate

Middle Turbinate

Inferior Turbinate

Maxillary Sinus Illustrations © Ingenix OptumInsight

general anesthesia is induced. The LandmarX image guided head frame is placed on the patient’s forehead and her anatomy is calibrated to within 2 mm accuracy. The right side of the nose is addressed first. Via transethmoid approach, a sphenoidotomy is created. Polyps and pus are found within the sinus. The microdebrider is used to remove polyps and diseased mucosa. Pus is irrigated. Total right ethmoidectomy was then performed under image guided assistance. Air cells were seen along the skull base and some osteophytic bone. This was all removed. The left side was addressed and identical procedures were carried out. The sinus cavity was then irrigated with dilute hydrogen peroxide and suctioned clear. Afrin pledgets were placed into the nasal cavity and tied in front of the columella. Sponge and needle count was accurate. The patient was then awakened from general anesthesia, extubated, and transferred to the recovery room in stable condition. 28

AAPC Coding Edge

CPT® code assignment for this example includes: • 31255-50 for the documentation of the bilateral total ethmoidectomies • 31288-50 for the sphenoidotomy with removal of polyps and tissue from the sphenoid sinuses • 61782 for the LandmarX navigational procedure

Use Dedicated Codes for Balloon Sinuplasty CPT® 2011 established three codes to report endoscopic dilation of the sinus ostia. Code 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa describes endoscopic dilation of the maxillary sinus ostium, either transnasally or via the canine fossa. Both CPT® and the National Correct Coding Initiative (NCCI) consider 31295 to be an inclusive component of 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy and 31267 Nasal/sinus endoscopy, surgical, with

To discuss this article or topic, go to: www.aapc.com

Feature

Disorders of the sphenoid sinus are likely under-reported because they are unusual and due to lack of recognition. maxillary antrostomy; with removal of tissue from maxillary sinus. Do not report 31295 separately when performed on the same sinus as either 31256 or 31267. To report balloon dilation of the frontal sinus ostium, turn to 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation). Instructional notes indicate this code is not reported with 31276 when performed on the same sinus. Finally, for balloon sinuplasty of the sphenoid sinus ostium, report 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation). Per CPT® instructions, do not report 31297 with 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium),

31287, or 31288 when performed on the same sinus. CPT® guidelines that accompany 3129531297 indicate that fluoroscopy, if used, is an inclusive component of these codes and should not be separately reported. Also, as with the other endoscopic sinus procedure codes, these codes report unilateral procedures unless otherwise specified. Clinical coding example: A 66-year-old patient with chronic maxillary sinusitis who has failed medical management presents for bilateral balloon dilation of the maxillary ostium. The patient is taken to the OR, where general anesthesia is administered and an intranasal vasoconstrictive agent is injected. Using the endoscope, a guidewire is introduced transnasally into

the right maxillary ostia. A balloon is then passed over the guidewire and introduced into the maxillary ostia. The position of the guidewire and balloon are confirmed via endoscope. The balloon is inflated, which displaces bone and mucosa and results in dilation of the right maxillary ostia. The balloon is then deflated and removed. The procedure is repeated in the left maxillary ostia. The documented procedure is reported as 31295-50. Laurette Pitman, RN, CPC-H, CGIC, CCS, is an outpatient consultant for Laguna Medical Systems, the coding and compliance service area of Springfield Service Corporation. She has over 30 years’ experience in the health care field, including ED and OR nursing, coding, and DRG and APC auditing. For more information, go to www.lagunamedsys.com or contact Ms. Pitman at [email protected].

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November 2011

29

Apprentice

Cover Story

By Melissa Brown, RHIA, CPC, CPC-I, CFPC

Code Fat Albert’s HERNIA REPAIR in 5 Easy Steps Push your hernia coding to where it belongs, with the experts.

Hiatal Hernia Diaphragm Epigastric Hernia

Incisional Hernia Umbilical Hernia

Inguinal Hernia

Illustrations © Ingenix OptumInsight

30

AAPC Coding Edge

Comedian Bill Cosby tells an entertaining story about being the center of attention after he gave himself a hernia lifting a heavy sewer lid. The punch line involves what happens when Fat Albert—the cartoon character voiced by Cosby—gets a hernia of his own. As I listened to the story with my kids recently, my coder brain kicked into gear. What kind of hernia did he have? How would you code the repair? In the process of satisfying my curiosity, I found some great information to share about hernias. A hernia occurs wherever an internal body part pushes beyond a confining wall into an area where it doesn’t belong. There are many types of possible hernias; however, let’s focus on the hernia types addressed in CPT® codes 49491-49659. These codes are classified by hernia type, with additional classifications for episode, clinical presentation, and patient age. Although there are many approaches to surgically repairing a hernia, they share a common theme. Generally, an incision is made over the hernia, and the hernia sac is dissected from any surrounding structures. The contents are examined for viability and returned to their original site, if appropriate. Depending on the size of the hernia sac, the sac may be ligated and resected. The muscle tissue is repaired and the incision is closed. A mesh or other prosthetic may be used for reinforcement of the muscle wall.

1. Identify the Type of Hernia To select an appropriate repair code, first identify the types of hernias described in 4949149659. Inguinal Hernia (49491-49525, 4965049651): An inguinal hernia is a very common hernia that occurs when abdominal contents (such as the intestines) protrude through the inguinal canal due to a weak point in the lower abdominal wall. These are commonly referred to as groin hernias because they appear just above the leg crease, close to the pubic area. CPT® code selection does not differentiate between direct (superficial inguinal ring) and indirect (deep inguinal ring) inguinal hernias.

Cover Story

When the contents of the hernia sac return to their normal location spontaneously or by gentle manipulation, the hernia is considered reducible.

Lumbar Hernia (49540 Repair lumbar hernia): Not to be confused with the lumbar disk hernia, lumbar hernias are rare hernias occurring through defects in the parietal abdominal wall in any area of the lumbar region (between the last rib and the iliac crest where the transverse muscle is covered by the latissimus dorsi). Femoral Hernia (49550-49557): Femoral hernias are visible in the upper part of the thigh near the groin. They are often hard to distinguish from inguinal hernias on examination alone, although they typically occur lower in the groin (near the inner thigh). Incisional (49560-49568, 49654-49657): When the hernia occurs at the site of a previous abdominal surgery (incision), it is called an incisional hernia. The incision for surgery creates an area of weakness, making it prone for herniation. These hernias may appear weeks, months, or even years after the surgery. Ventral (49560-49568): Ventral means front (from Latin, meaning belly), so a ventral hernia is one that occurs anywhere on the abdomen. Ventral hernias commonly occur along the midline of the abdominal wall. Epigastric (49570-49572): These are similar to the umbilical hernia, but are situated higher between the breastbone and the belly button (picture the six pack abdominal muscles area). Epigastric hernias are typically made up of fat rather than internal organs. Epigastric hernias are not synonymous with hiatal hernias. Hiatal hernias occur when part of the stomach protrudes up into the chest through a weakness in the diaphragm at the hiatus. Umbilical (49580-49587): Umbilical hernias are most often seen in infants, at or near the bellybutton. This area has a natural weakness from the blood vessels of the umbilical cord, presenting a prime location for a hernia. It is possible for the area of weakness to persist through adulthood; these types of hernias are not limited to pediatric patients. Spigelian (49590 Repair spigelian hernia): The spigelian hernia is sometimes referred to as a lateral ventral hernia. These hernias occur laterally along the outer edge of the six-pack abdominal muscles in the spigelian fascia. These hernias occur between the muscles of the abdominal wall and are difficult to detect due to little outward evidence of swelling. Omphalocele (49600-49611): This birth defect occurs when the infant’s abdominal wall does not develop properly. The intestine or

other abdominal organs remain outside the abdomen, through the umbilicus, and is covered only by a thin layer of tissue.

2. Define the Episode of Care To report hernia repair appropriately, you must often know the episode of care. An initial hernia is one that has not been previously repaired. A recurrent hernia is one that appears at the site of a previous hernia repair. This can happen if the incision site weakens, or if there is infection or improper healing of the wound. The conditions that caused the original hernia (for example, obesity or nutritional disorders) may persist and encourage the development of a recurrent hernia.

3. Verify the Clinical Presentation Another factor that determines correct coding is clinical presentation of the hernia. When the contents of the hernia sac return to their normal location spontaneously or by gentle manipulation, the hernia is considered reducible. While moving the contents may make the hernia appear smaller or disappear, the weakened tissue still needs to be repaired to avoid recurrence of the hernia. When the herniated tissue becomes trapped and cannot be pushed back (reduced), the result is an incarcerated hernia, also called a strangulated hernia. Incarcerated hernias are more worrisome because they run greater likelihood of becoming strangulated, which happens when the blood supply to an incarcerated hernia is cut off. These types of hernias are dangerous due to the risk of gangrene when tissues die.

4. Determine Patient Age According to instruction in the CPT® manual, when the patient’s age is necessary for code selection of hernia repairs, use the patient’s age at the time of the surgery. CPT® notes also help with the calculation of post-conception age, as needed, for codes 49491-49496. The notes instruct us to use gestational age at birth plus age in weeks at the time of the hernia repair.

5. Put It All Together Now that you know what to look for, apply the steps to an actual note: PROCEDURE IN DETAIL: The 12-year-old (step 4: identify patient age) male patient was prepped and draped in the sterile fashwww.aapc.com

November 2011

31

Cover Story

According to instruction in the CPT® manual, when the patient’s age is necessary for code selection of hernia repairs, use the patient’s age at the time of the surgery.

ion. An infraumbilical incision was formed and taken down to the fascia. The umbilical hernia (step 1: identify type) carefully reduced (step 3: clinical presentation) back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine. The skin was reattached to the fascia with 2-0 Vicryl. The skin was approximated with 2-0 Vicryl subcutaneous, and

then 4-0 Monocryl subcuticular stitches, and dressed with Steri-Strips and 4 x 4’s. Patient was extubated and taken to the recovery area in stable condition. Note, for Step 2: Define the Episode of Care, there is no reference to a prior repair, so this would be treated as an initial hernia. Armed with this information, we can look at codes 49580-49587. Because the patient is over 5-years-old, we narrow the selection to 49585-49587. And, because we

Maximum Advantage

know the hernia was reducible, we can select 49586 Repair umbilical hernia, age 5 years or older; reducible. Melissa Brown, RHIA, CPC, CPC-I, CFPC, is manager of reimbursement and quality improvement, University of Florida Jacksonville Physicians, Inc. She has 19 years of experience in the health care industry. Ms. Brown’s areas of expertise also include fee analysis, budgeting and Physician Quality Reporting System (PQRS). Toastmasters International awarded her its highest honor, Distinguished Toastmaster (DTM). She served as co-director of the annual “Coding on the River” convention in Jacksonville, Fla. for several years.

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ICD-10 Road Map

By Julia Croly, CPC, CPC-P, CPC-I

ICD-10 Testing, Testing ... 1-2-3 Lessen testing anxiety by following a timeline, creating a taskforce, and executing a plan. ICD-10 implementation testing can be frightening. But how often have you found that when you are prepared for a test, it’s not as bad as you originally anticipated? Such is the case with ICD-10: With careful preparation, in just three steps, you can earn an A+. As you prepare for ICD-10 testing, keep these essential goals in mind: • Testing needs to include ICD-10 and any projects underway. • Testing needs to be robust, due to the high number of code changes. • Testing needs to ensure financial neutrality. • Testing may need to ensure dual processing (e.g., both ICD-9 and ICD-10 functionality). • Testing must include considerations for trading partners. • Testing must be coordinated.

1. Create a Timeline to Begin Testing in Mid-2012 Your timeline should include several key events, such as when to begin testing. Many organizations, for example, are drafting timelines for ICD-10 implementation testing to occur from mid-2012 up to the compliance date of Oct. 1, 2013, as shown below. But there is no “one size fits all” suggested start date: The actual testing kickoff date depends on each organization. And like many organizations, you may want to segregate internal and external testing to account for vendor dependencies and the deep penetration of ICD-10 code in systems and processes.

2. Create a Taskforce Establishing a testing taskforce helps to manage the testing effort. The taskforce oversees complete, integrated testing, and forms multiple workgroups, each of which is in charge of a particular testing effort. Communication among the workgroups is essential.

Discovery/Highlevel Impact Assessment

2009

Final Rule Published

34

AAPC Coding Edge

2010

In-depth Impact Assessment

Planning and Implementation Design

2011

This effort is complex and requires a high-level test plan to address the overall requirements and the design details of subsystems and components. Test plan document formats can be as varied as the products and organizations to which they apply, but generally contain some common features, including: 1. Test coverage in defining scope and objectives 2. Identification of business areas and participants, including roles and responsibilities 3. Testing methodologies and functions to tests 4. Identifying risk factors that may jeopardize testing 5. A testing schedule In the past, testing has focused on the transaction and whether it can be initiated, received, and understood correctly. Testing in the case of ICD-10 must involve all of the aforementioned, plus validation that business rules continue to work as designed pre-ICD-10. To help your team effort, collaborate in developing test strategies, test cases, and test scripts. Workgroups should develop specific guidelines and standard operating procedures for testing, and indicate desired end results for modifications made along the way. Creating a test environment separate from production will greatly facilitate this effort. The testing effort will produce a great deal of information. Use tools to log and track your findings throughout all testing. Change logs are highly recommended to maintain control over individual changes, and to track subsequent effects of those changes. From this information, metrics can be extracted to measure and track project milestones. A risk-based approach to testing helps ensure that changes, delays, and other unforeseen obstacles can be dealt with effectively. Changes, especially to older systems, can create unforeseen bugs unrelat-

Evaluate

Testing

2012

Implementation and Integration

2013

Compliance Date

2014

2015

Gaining Value

ICD-10 Road Map

Changes, especially to older systems, can create unforeseen bugs unrelated to the ICD-10-CM/ICD-10-PCS conversion. The more robust your testing efforts, the better off you will be.

ed to the ICD-10-CM/ICD-10-PCS conversion. The more robust your testing efforts, the better off you will be.

3. Begin Testing Internal Testing After the necessary ICD-10 changes have been made, it’s time to test information technology (IT) systems and business processes. Internal testing identifies localized system glitches that may occur when creating and receiving transactions that contain ICD-10 codes. Internal testing also encompasses manual and workflow processes using diagnosis and procedure codes (in collection, reporting, or both). Every change to a system or application must be tested before it goes into production. Testing can be broken into the following categories: • Quality Assurance: This answers the question, “Do all of the changes made provide the expected outcome?” • User Acceptance Testing: This testing should be planned and executed by participants from the business area affected by the changes. These participants will sign off that the systems are functioning properly and workflow design is accurate and suitable for the purpose intended. With this effort, it’s critical there are no gaps in functionality. • Integration Testing: This combines the parts to determine if they are working together. • Regression Testing: This ensures there is no impact on previously tested results, and retests the programs to ensure there is an increase in functionality and stability. Don’t forget to test business processes not affected by ICD-10 (these may be few and far between), preferably using an automated testing tool. • Performance Testing: This is done to ensure the system provides acceptable response times, and to identify and remove all bottlenecks that may result in less-than-optimal performance. Testing system compliance through

performance testing is usually done with a large number of users. • End-to-end Testing: This involves testing the interfacing applications and the full life cycle of a claim from receipt to payment to data storage. It also tests business processes to ensure the desired outcome. Remember: Internal testing must include not only time for testing, but also remediation and retesting. External testing Organizations often depend on third-party vendors and trading partners; and with ICD-10 compliance testing, you must ensure the desired functionality is achieved and business processes are maintained. Planning and coordination are essential to external testing because such testing involves coordinating with many entities. Remediated application availability should be obtained well in advance to planning for testing activities. From the impact analysis, have a list of third-party vendor and trading partners that must be contacted to discuss testing expectations. Prioritization involves identifying those who are most critical to ensuring compliance. Scheduling follows prioritization. In case a vendor or trading partner is not ready on the agreed-upon date, flexibility and contingency planning may be necessary. Just as with internal testing, there needs to be adequate time for testing, remediation, and retesting to ensure desired functionality. The purpose of external testing is to identify any issues that must be resolved prior to the compliance deadline. Testing is just one component of ICD-10 implementation, but it’s a critical step that is often underestimated. To limit your stress and minimize operational and financial risk to your practice or facility: Understand the complexity of ICD-10 implementation; establish a timeline that includes both internal and external testing; and create a detailed plan. Julia Croly, CPC, CPC-P,CPC-I, has 25 years experience in health care insurance and works as an independent health care consultant and educator in Honolulu, Hawaii. She can be reached at [email protected].

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November 2011

35

Added Edge

By Dana Lightman, Ph.D.

Deal with Difficult People by Managing Hot Buttons Don’t let a hijacked amygdala take control of your on-the-job emotions.

C

oders sometimes function in emotionally charged situations. This environment can leave you feeling stressed, drained, and burned out. The key to taking care of your emotional needs is to take charge of your reactions. By understanding how difficult behaviors trigger hot buttons, you can choose responses that neutralize negativity, reduce personal stress, and create a more positive work environment.

When the Amygdala Attacks … When you encounter behavior you perceive as difficult, the brain registers a threat. For example, an aggressive superior can threaten your sense of security, resulting in anxiety or confusion; a judgmental peer may produce feelings of doubt; a sarcastic administrator could leave you feeling agitated. In each of these examples, a hot button has been pushed. A hot button is a personal trigger that sends an individual’s emotions plummeting. You are not at liberty to prevent the detonation. But, you are at liberty to choose how to respond to that detonation. It is this choice that determines your subsequent feelings: increased stress and agitation or calmness and well-being. Of course, not all difficult behaviors are experienced as threats. For example, you may be very adept at dealing with demanding consultants. These situations rarely rattle you. Yet, another coder may encounter this same circumstance as intimidating and threatening. Her hot button is pushed, and she becomes flooded with negative feelings. What accounts for this difference? The answer lies with the “amygdala,” an almond-shaped cluster of interconnected structures in the emotional center of the brain, the limbic region. The amygdala stores emotional memory; much of it based on early childhood experiences. Incoming signals from the senses let the amygdala scan every experience for trouble. Daniel Goleman, in his book Emotional Intelligence, explains that when the amygdala perceives a threat based on its stored emotional memory, it “reacts instantaneously, like a neural tripwire, telegraphing a message of crisis to all parts of the brain … The amygdala’s extensive web of neural connections allows it, during an emotional emergency, to capture and drive much of the rest of the brain—including the rational mind.” In other words, the neocortex, or rational part of the brain, has been hijacked by the amygdala. When the amygdala is activated, you will have a knee-jerk reaction. You are now emotionally flooded, with little access to reason. This process happens within nanoseconds, and produces responses characterized by distorted perceptions, invalidation, defensiveness, and biased judgment. It also leads to the fight-or-flight response.

Managing Your Hot Buttons The key to dealing with difficult people is to shift your focus from others’ behavior (over which you have no control), to your own response (over which there is total control). To understand why, let’s again examine the way the brain functions. 36

AAPC Coding Edge

To discuss this article or topic, go to: www.aapc.com

Added Edge

… by keeping in mind that overbearing superiors may be hijacked by their superiors, you now have an interpretation of the situation that diminishes your hot button trigger.

When threatened, the brain searches for a sense of control and autonomy. It detects that the individual is back in charge when it senses the ability to make a choice. What matters most to the brain is the perception of choice. In other words, if you have been hijacked by your amygdala you don’t have to involve the difficult person in your choices. You just have to let your brain know that there are choices to be made. One simple choice that deactivates the amygdala is to put feelings into words. Researchers have found, for example, that when people attached the word “sad” to a sad-looking face, the amygdala response decreases and response in the right ventrolateral prefrontal cortex (the part of the brain that controls impulses) increases. In practical terms, when your hot button has been pushed, you can simply acknowledge how you feel: “This is anxiety” or “This is fear.” You then can make a choice by asking yourself, “How do I choose to handle this?” In this way, you have decreased the brain activity that leads to automatic stress responses and tapped into the brain area responsible for self-control and logic. David Rock, author of Your Brain at Work, describes another strategy for regaining a sense of control: “I decide to be responsible for my mental state instead of being a victim to circumstances. In the instant that I make this decision, I start seeing more information around me, and I can perceive opportunities for feeling happier. This experience is one of finding a choice and making that choice, and it shifts what and how I perceive in that moment. The idea of consciously choosing to see a situation differently is called reappraisal.”

angry listening to your colleague “schmooze.” To lessen your anger, you can choose to see the situation through the eyes of your colleague, reappraising your initial reaction that your peer is stalling and instead interpreting your colleague’s behavior as meeting a need for comfort by talking. This type of reappraisal works well for differences in work styles, values, use of time, and cultural backgrounds. A third strategy to manage hot button reactions comes from the work of Barbara Fredrickson. Her research demonstrates that negative emotions tend to linger in your mind. In other words, once the amygdala is activated, the end result is not only negative feelings, but also a negative mood. To curtail the impact of negative emotions, Fredrickson suggests deliberately choosing to counteract negative emotions with positive ones. For example, when you’re hijacked, you might take a moment to think of a happy time, picture a loved one, or remember a pleasurable event. By choosing to replace negative feelings with positive ones, you are back in control.

Three Ways to Take Control of Your Hot Buttons

References Fredickson, B.L. (2009). Positivity: Groundbreaking Research Reveals How to Embrace the Hidden Strength of Positive Emotions, Overcome Negativity, and Thrive. New York: Crown. Goleman, D. (1995). Emotional Intelligence: Why It Can Matter More than IQ. New York: Bantam Books. Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S., Pfeifer, J. H., Way, B. M. (2007). Putting Feelings into Words: Affect Labeling Disrupts Amygdala Activity to Affective Stimuli. Psychological Science, 18, 421-428. Rock, D. (2009). Your Brain at Work: Strategies for Overcoming Distraction, Regaining Focus, and Working Smarter All Day Long. New York: HarperCollins.

How can you use reappraisal to manage hot button reactions? One technique is to find a way to interpret facts to lessen the threat. For example, by keeping in mind that overbearing superiors may be hijacked by their superiors, you now have an interpretation of the situation that diminishes your hot button trigger. Another technique is to recognize that you are not alone in your reaction to certain difficult individuals. This process of normalizing diminishes the brain’s threat arousal. Another reappraisal tactic is to look at an event from another’s perspective. For example, consider this situation: Your work style is taskoriented. You like to get a job completed as quickly as possible. Your coding colleague likes to build relationships by chatting before focusing on a task. You like to stay on task and become frustrated and

Take-away Lessons Overtaxed colleagues may be in foul moods; physicians can be rude and demanding; and consultants might challenge your decisions. Although you may understand the reasons for these over-the-top behaviors, one too many difficult encounters can push your hot button. By choosing to be “response-able”—that is, able to choose your responses—you become empowered. By choosing to stop focusing on someone else’s behavior and instead shift attention to your own response, you can experience enormous relief and personal well-being.

Dana Lightman, Ph.D., is a national keynote speaker and trainer. An expert in positive psychology, she is the creator of POWER Optimism and author of the “No More Difficult People” series. For more information, visit www.danalightman.com.

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November 2011

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newly credentialed members Abhishek Chakraborty, CPC Abimbola Idowu, CPC Adriana Keene, CPC Akila Palaniswamy, CPC Alexandra Patricia Scordilis, CPC Allison Tanksley, CPC Amanda Dorozsmay, CPC Amber Jean Hohbach, CPC Amy Burney, CPC Amy Hall, CPC Amy Lynn Jackson, CPC Amy Lynn Kiland, CPC Amy Martha Wright, CPC, CPC-H Amy Nicole Henry, CPC, CPC-H Amy Touchette, CPC Ana Rodriguez, CPC Angela Lamkin, CPC Angelica Moreno, CPC AnneMarie Troise, CPC Annie R Hughes, CPC, CPMA Anthony M Fanelli, CPC, CPC-H April L Shuler, CPC April M Jourdan, CPC Aprilan Woolworth, CPC Ashley Leanne Willis, CPC Ashley Scott, CPC Audrey Babcock-Sanders, CPC Balachandar Sorimuthu, CPC Barbara McKenna, CPC Barbara Penn, CPC Barbra Shell, CPC Becky Ann Washington, CPC Benjamin Luis Baumer, CPC Beth Barlowe, CPC Bethany Shirley, CPC Bobbi Jo Knight, CPC Bonita J. Mulvenna, CPC Bonny Merry, CPC Boonsri Dickinson, CPC Brandi Michelle Blankenship, CPC Brandie Johnson, CPC Brandie Weatherly, CPC Brenda Fons, CPC Brenda Harwood, CPC-H Brian L Podrez, CPC Brian Pollard, CPC Brittany Dolen, CPC Brooke Bernicken, CPC Brooke M Brown, CPC Bruce Schulte, CPC Bryndi McDermott, CPC Candace Greenwood, CPC Cansas Riggenbach, CPC Carla Feagle, CPC Carla Mendoza, CPC Carol Mancusi, CPC Carol Marie Wolter, CPC Carrie Brown, CPC Catherine A Caronia, CPC Chanel Burnett, CPC Charita Lynne’ Farley, CPC Charlene Witherington, CPC Charmaine Rhames, CPC Cherie Loretta Isom-Chumley, CPC Chermanda E Smith Price, CPC Cherry Simmons Hartman, CPC-H Cheryl Sandri, CPC Christie Heath, CPC-H Christina E Tucker, CPC Christine Holder, CPC Christine L Roullier, CPC Christine Rommel, CPC Claire Pryor, CPC Connie Merriman, CPC Coreen Gilbert, CPC Corrina Priscilla Urbina, CPC Cristina Flores, CPC Crystal Couture, CPC Cynthia Cooke, CPC Cynthia D Calhoun, CPC Cynthia Vanderpoest, CPC Dania Leon, CPC Daniel Calugan, CPC Daniel Fazzari, CPC Danielle Constandis, CPC

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Cori Miller, CPC-A Courtney Lynn Stidham, CPC-A Cristina Nikolopoulos, CPC-A Crystal Hill, CPC-A Crystal Lynn Clark, CPC-A Crystal Yates, CPC-A Crystal Yvonne Mata, CPC-A Cynthia Fallis, CPC-A Cynthia Garrison, CPC-A Cynthia Koscinch, CPC-A Cynthia Kottke, CPC-A Cynthia Lamano, CPC-A Cynthia Yepez, CPC-A Dagmar Taff, CPC-A Danae Stephenson, CPC-A Daniel K Koesterer, CPC-A Danielle Basta, CPC-A Danielle Jackson, CPC-A Danielle Jessie Campbell, CPC-A Danielle Kristine Seeger, CPC-A Danielle M Allen, CPC-A Danielle Mallozzi, CPC-A Danielle Michelle Olson, CPC-A Danielle Rae Williams, CPC-A Darin H. Stone, CPC-A Darla Rae Zehr, CPC-A Darla Reed, CPC-A Darlene Maloney, CPC-A Darryl Curtis, CPC-A David Danner, CPC-A David Dykstra, CPC-A David Forst, CPC-A David Howard, CPC-A David Robert Zeinert, CPC-A Dawn Best, CPC-A Dawn Marie Paulini, CPC-A Dawn Michelle Messier, CPC-A Dawn Polidore, CPC-A Dawn S Tough, CPC-A Dawn Taddeo, CPC-A Dawn Tucker, CPC-A Deanna M Lisonbee, CPC-A Debbie Flemings, CPC-A Debbie Fredrickson, CPC-A Debbie K Wright, CPC-A Deborah A Stewart, CPC-A Deborah Smith, CPC-H-A Debra Ann Neeley, CPC-A Debra Ellen White, CPC-A Debra J Sofia, CPC-H-A Debra Margaret Wade, CPC-A Debra Parker, CPC-A Debra Renee Halberg, CPC-A Debra S Wolf CPC-A, CPC-A Deepa Chandramohan, CPC-A Delia Popovich, CPC-A Denise Eckert, CPC-H-A Denise Hawkins, CPC-A Denise Ivette Ramirez, CPC-A Denise Lynn McCoy, CPC-A Denise Orin, CPC-A Denise Smith, CPC-A Dennis R. Mejia, CPC-A Desiree Rodriguez, CPC-A Desiree Straehla, CPC-A Diana Ivette Paredes, CPC-A Diana Oruci Adams, CPC-A Diane Jacquez, CPC-A Diane Kahre, CPC-A Diane Walsh, CPC-A Diane Ziegler, CPC-A Dianna Louise McCarthy, CPC-A, CPC-H-A Dianne M Clarke, CPC-A Diatrix Kinney, CPC-A Dina Leon, CPC-A Dina Buccieri, CPC-A Dollie Ann Wallace, CPC-A Dominique Katie Spiller, CPC-A Donald R Cox, CPC-A Donna Burtt, CPC-A Donna Jeanneene Rousseau, CPC-A Donna Tedone, CPC-A Dori-Lynn Coe, CPC-A Dorota Liczbinska, CPC-A Eber Fuller, CPC-H-A

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Edward Earl Glomski, CPC-A Eileen Blouch, CPC-A Eileen T Pianka, CPC-A Ekaterina Dubrovina, CPC-A Elizabeth A Kilroy, CPC-A Elizabeth Ann Matty, CPC-A Elizabeth Appleby, CPC-A Elizabeth Brooks, CPC-A Elizabeth Burris, CPC-A Elizabeth Castano, CPC-A Elizabeth F Nigels, CPC-A Elizabeth Grayce Loycano, CPC-H-A Elizabeth Ishley, CPC-A Elizabeth Markle, CPC-A Elizabeth Rodriguez, CPC-A Elizabeth Rodriguez, CPC-A Elizabeth Rubritz, CPC-A Elizabeth Thorley, CPC-A Ella Romano, CPC-A Ellen Johnson, CPC-A Elyssa Diaz, CPC-A Emily A Snyder, CPC-A Emily Brockway, CPC-A Emily Jane Knollenberg, CPC-A Eric Quivers, CPC-A Erica Hellmann, CPC-A Erika Gomez-Wesby, CPC-A Erika Marie Adler, CPC-A Erin Drogin, CPC-A Erin Finnegan, CPC-A Erin Kathleen McNulty, CPC-A Erin Stalnaker, CPC-A Espanola Obligacion, CPC-A Estrella Rodriguez, CPC-A Evelyn G John, CPC-A, CPC-H-A Evelyn Navarro, CPC-A Fawn Provost, CPC-A Faye Ann Ramey, CPC-A Faye Harker, CPC-A, CPC-H-A Felicia Godwin, CPC-A Forrest RJ Campbell, CPC-A Frances Brocato, CPC-A Frances W Ewing, CPC-A Francisca Santiago, CPC-A Fred Gumbert, CPC-A Gail Dishman, CPC-A Gale T Sibbald, CPC-A Gayle Erickson, CPC-A Gaynelle Ducharme, CPC-A Geetha Lakshmi Rajamohan, CPC-A Geetharani Raja, CPC-A Gena Rose Vieira, CPC-A Gene Soloway, CPC-A Geneva Fonseca, CPC-A Genny Lee Wegenke, CPC-A Gertrude Dini, CPC-A Gina D’Annunzio, CPC-A Gina Lee, CPC-A Glena Butaslac Loyola, CPC-A Glenn Parker, CPC-A Gloria Flowers, CPC-A Gloria Hettinger, CPC-A Gloria Hurtado, CPC-A Gloria Martinez, CPC-A Haley Kristina Coffin, CPC-A Hannah Marie Breese, CPC-A Harmanika Kohli, CPC-A Heather Akridge, CPC-A Heather Bell, CPC-A Heather Cormier, CPC-A Heather Jo Benavides, CPC-A Heather L Carlson, CPC-A Heather Reagan, CPC-A Heidi Berman, CPC-A Heidi Smith, CPC-A Hena Merciba Davamani, CPC-A Hollie Roseman, CPC-A Holly Faust, CPC-A Holly Rudd Waters, CPC-A Ian Ko, CPC-A Ian Murray, CPC-A Ibe Lap Yan Chan Leung, CPC-A Ike Steitzer, CPC-A Iswarya Kannaiyan, CPC-A Ivania Wiese, CPC-A

November 2011

39

Newly Credentialed Members

Jackie Lou Santos, CPC-A Jackie Tryon, CPC-A Jacqueline A Morse, CPC-A Jacqueline Martinez, CPC-A Jaculin Marie Auer, CPC-A Jaime Medeiros, CPC-A Jakaira Rodriguez, CPC-A Jalisa Pearline Clark, CPC-A Janene Eyster, CPC-A Janet C Happel-Dayer, CPC-A Janet Edwards, CPC-A Janet Hobgood, CPC-A Janet Lunceford, CPC-A Janet McMahon, CPC-A Janice Abe, CPC-A Janice Aguilar, CPC-A Janice Ann Moore, CPC-A Janice Desrosiers, CPC-A Janine Cuddy, CPC-A Janna Abney, CPC-A Janna Tanelle Klinedinst, CPC-A Jasmin Yap, CPC-A Jasmine Courtney, CPC-A Jason John Pastrana, CPC-A Jayakumar Ramalingam, CPC-A Jayshree Shah, CPC-A Jean Goodwin, CPC-A Jean Lafrenaye, CPC-A Jean Marren, CPC-A Jeanette Dorn Roberts, CPC-A Jeanne Callahan, CPC-A Jeannie Mari Morgan, CPC-H-A Jeffrey Hewartson, CPC-A Jena Cruz, CPC-A Jennifer Brinkdoepke, CPC-A Jennifer June Casco, CPC-A Jennifer Kindel, CPC-A Jennifer L Guyton, CPC-A Jennifer Lyn Hartley, CPC-A Jennifer McBee, CPC-A Jennifer McComas, CPC-A Jennifer Noelle Lemongelli, CPC-A Jennifer Porter, CPC-A Jenny Conrath, CPC-A Jenny Dean, CPC-A Jenny Terrill, CPC-A Jeri L Slaughter, CPC-A Jessica Allison, CPC-A Jessica Barrington, CPC-A Jessica P Szydlo, CPC-A Jessica Pritchard, CPC-A Jessica Soncrainte, CPC-P-A Jessie Vescovi, CPC-A Jessie Williford, CPC-A Jo Honaker, CPC-A Joann Bucci, CPC-A Joann Kathryn McCabe, CPC-A Joanne Sharleen Brunson, CPC-A Jodie A. Brown, CPC-A Jody Anderson, CPC-A Joe Grosso, CPC-A Joel Manalo, CPC-A John Eapen, CPC-A John J Fingal, CPC-A Joron Armando Ross, CPC-A Jose R Santiago Torres, CPC-A Josefina Garsulao, CPC-A Josh Lieber, CPC-A Josh Mones, CPC-A Joyce Freeman, CPC-A Joyce Wilson, CPC-A Judith Bodson, CPC-A Judith Carnes, CPC-A Judy Wiles, CPC-A Judy Bibler, CPC-A Judy Elliott, CPC-A Judy Riebe, CPC-A Julie Ann Bellile, CPC-A Julie Elizabeth Phillips, CPC-A Julie Fox, CPC-H-A Julie Houchen, CPC-A Julie Rau, CPC-A Jun Starr, CPC-A Justin Cudnik, CPC-A Kadambari Murugan, CPC-A Kala R Gardner, CPC-A Kametra Hickey, CPC-A Kare Conrad Barney, CPC-A Karen Bednar, CPC-A Karen Bean, CPC-A Karen Chauvette, CPC-A

40

AAPC Coding Edge

Karen E Porter, CPC-A Karen Forster, CPC-A Karen Hillman, CPC-A Karen J Brashier, CPC-A Karen Jean Phillips, CPC-A Karen L Gibbs, CPC-A Karen L Shelly, CPC-A Karen Longo, CPC-P-A Karen Osler, CPC-A Karen Siegler, CPC-A Karen Tauxe, CPC-A Karen Yvonne Kirk, CPC-A Kari McCafferty, CPC-A Karin A Mcknight, CPC-A Karmen Izzard, CPC-A Karthi Nedunzhalian, CPC-A Karthiga Sivakumar, CPC-A Kasey Rose Shawgo, CPC-A Kashen Wood, CPC-A Katharina Henderson, CPC-A Katharine Ghaner, CPC-A Katherine Kiel, CPC-A Katherine Herring, CPC-A Katherine M Coady, CPC-A Katherine Ward, CPC-A Kathie Cawthon, CPC-A Kathleen A Sellnow, CPC-A Kathleen Casario, CPC-A Kathleen Gadomski, CPC-A Kathleen Lauren Kepler, CPC-A Kathleen Ripplinger, CPC-A Kathleen Schroeder, CPC-A Kathleen Wolf, CPC-A Kathryn (Kaylee) Lee Joy Blodgett, CPC-A Kathryn Elliott, CPC-A Kathryn(Kit) Marie Shotwell, CPC-A Kathy Bertolotti, CPC-A Kathy Blankenship, CPC-A Kathy Klekot, CPC-H-A Kathy Marie Von Arx, CPC-A Kathy Mokma, CPC-A Kathy Round, CPC-A Katie Colleen Heinz, CPC-A Katie Olson, CPC-A Katie Sleger, CPC-A Katie Woodrome, CPC-A Kaye Bole, CPC-A Kayla Gillies, CPC-A Kayla Walker, CPC-A Kaylee Ann Brown, CPC-A, CPC-H-A Kelli Macon, CPC-A Kellicia Freeman, CPC-A Kelly Hunsicker, CPC-A Kelly Mayo, CPC-A Kelly Mayo, CPC-A Keri Carter, CPC-A Kerrie Bliss, CPC-A Kevin Macaulay, CPC-A Keyona Downs, CPC-A Kim C. Dickinson, CPC-A Kim K Morgan, CPC-A Kimberly Share, CPC-A Kimberly A. Brown, CPC-A Kimberly Ann Harp, CPC-A, CPC-H-A Kimberly Ann Ramirez, CPC-A Kimberly Boege, CPC-A Kimberly D Green, CPC-A Kimberly Dawn Seeger, CPC-A Kimberly Gonzalez, CPC-A Kimberly Jean Moore, CPC-A Kimberly Kirby, CPC-A Kimberly Moon, CPC-A Kimberly Reis-Fleming, CPC-A Kimberly S Bartlett, CPC-A Kirsten Osorio, CPC-A Kissandra Walker, CPC-A Kody Farnsworth, CPC-A Krescent Mosley, CPC-A Krissie J. Carden, CPC-A Kristen Bensel, CPC-A Kristen Newell, CPC-A Kristen Rich, CPC-A Kristi Reismann, CPC-A Kristie Alicia Spillman, CPC-A Kristina Edholm, CPC-A Kristine Reto, CPC-A Kwasi Dyson, CPC-A Kyvan Tonnu, CPC-A L. Denae Carter, CPC-A La Shawn Sullivan, CPC-A LaCendra Sheppard, CPC-A

Lakshmi Devi Ravichandran, CPC-A Laquitta Moran, CPC-A Larry Lainey, CPC-A LaShonda Renee Yocum, CPC-A Latara Ford, CPC-A Latoya Francis, CPC-A Laura A Juanico, CPC-A Laura Dicicco, CPC-A Laura Matuszak, CPC-H-A Laura Rocco, CPC-A Laura Schewe, CPC-A Lauren Boggs, CPC-A Lauren Vaudo-Cynova, CPC-A Laurie McGee, CPC-A Laurie Thompson, CPC-A Leandra Payne, CPC-A LeAnne Fiske, CPC-A LeeAnne S Small, CPC-A Leigh A. Johnson, CPC-A Lesli Neebe, CPC-A Leslie Autrey, CPC-A Leslie Caskey, CPC-A Leslie Constable, CPC-A Leslie McCall, CPC-A Lesper Curry, CPC-H-A LeTecia Inez Morton, CPC-A Letha Sue Story, CPC-A Leticia Pujadas, CPC-A Linda Jones, CPC-A Linda Madsen, CPC-A Linda Nelson, CPC-A Linda Thompson, CPC-A Lindsay Caron, CPC-A Lindsay Trahan, CPC-A Linley Gibson, CPC-A Lionel Quartney Lee, CPC-A Lisa Davis, CPC-A Lisa Franco, CPC-A Lisa Garcia, CPC-A Lisa Kirkpatrick, CPC-A Lisa Kottke, CPC-A Lisa L Mccartney, CPC-A Lisa Machacek, CPC-A Lisa Marie Fancovic, CPC-A Lisa Martinez, CPC-A Lisa Whisenhunt, CPC-A Lizet Meza, CPC-A Lolita A Ham, CPC-A Loranda Thomas-Jones, CPC-A Loree A. Keeble, CPC-A Lorella June Murrow, CPC-A, CPC-H-A Lori Zohner, CPC-A Lori Farner, CPC-A Lori Hardison, CPC-A Lori Hurst, CPC-A Lori M Isner, CPC-A Lori McAlester, CPC-A Lori Villa, CPC-A Lorna Long, CPC-A Lorrae Aker, CPC-A Lorraine Ivanditto Bloss, CPC-A, CPC-H-A, CPC-P-A Lorri Hathaway, CPC-A Lorrie Mayo, CPC-A Lou Carter, CPC-A Louetta Bucher, CPC-A Louise Bugeau, CPC-A Louise Cravey, CPC-A Lucianne Bastone, CPC-A Lucy Davis, CPC-A Lynn Brown, CPC-A Lynn Gonnello, CPC-A Lynn Miller, CPC-A Lynn Schacht, CPC-A Lynne Obermeyer, CPC-A Lynwood Currin, CPC-A Lystra Brown, CPC-A M. Irma Alonzo, CPC-A Ma Fima Graciela Rafa, CPC-A Mabeth Villaflores, CPC-A Mae Lorenzo, CPC-A Maggan Andreas, CPC-A Mallory Kubota, CPC-A Manouchka M. Behrmann, CPC-A Marc Otomo, CPC-A Marcella Moon, CPC-A Margaret A Virag, CPC-A Margaret Clare, CPC-A Margaret E Kutscher, CPC-A Margaret K Norton, CPC-A Margaret Kirkham, CPC-H-A

Maria A Noeldechen, CPC-A Maria Bryan, CPC-A Maria C Paino, CPC-A Maria D’souza, CPC-H-A Maria Luisa Magana, CPC-A Maria Muncan, CPC-A Mariah Schelhaas, CPC-A Maricel Magtalas Puyat, CPC-A Marie Bernal, CPC-A Marie Dexter, CPC-A Marie Kathryn Foster, CPC-A Marie T Santana, CPC-A Marilyn Burris, CPC-A Marina Pomida, CPC-A Mariola Rapushi, CPC-A Marisa Arredondo, CPC-A Mark Dave Labitigan, CPC-A Mark S Gill, CPC-A Mark Umil, CPC-A Marlena L Levengood, CPC-A Marne Elizabeth Meeker, CPC-A Marnie Corrine Kuhn, CPC-A Marsha Burke, CPC-A Martina Mann, CPC-H-A Mary Beth Dorn, CPC-A Mary Brisson, CPC-A Mary Denise Rebman, CPC-A, CPC-H-A Mary E Robinson, CPC-A Mary Fischer, CPC-A Mary Grace Quismorio, CPC-A Mary Hurley, CPC-A Mary J Bridenstein, CPC-A Mary Margaret Angel, CPC-A Mary Niedermeyer, CPC-A Mary Orfanos, CPC-P-A Mary Pasciuto, CPC-A Mary Rutherford, CPC-A Mary Strackman, CPC-A Maureen Caldwell, CPC-A Maya S Davids, CPC-A Megan Privett, CPC-A Melanie Chaput, CPC-A Melinda Ficca, CPC-A Melinda Marcel Raiford, CPC-A Melisa Schultz, CPC-A Melissa Bellville, CPC-A Melissa Cox, CPC-A Melissa Hartman, CPC-A Melissa L Burciaga, CPC-A Melissa L Marshall, CPC-A Melissa M Olive, CPC-A Melissa Mitchell, CPC-A Melissa Moore, CPC-A Melissa Nichole Randolph, CPC-A Melissa Savage, CPC-A Mellissa Page, CPC-A Mercedes Larkin, CPC-A Meredith A McKenzie, CPC-A, CPC-H-A Merita Lohja, CPC-A Merritta J Stovall, CPC-A Meryl A Bullard, CPC-A Michael A Kusman, CPC-A Michael James Lehrke, CPC-A Michael Rhyan, CPC-P-A Michael Segur, CPC-A Michael Sim, CPC-A Michele Ann Eroh, CPC-A Michele Eferstein, CPC-A Michele Finder, CPC-A Michelle Andrews, CPC-A Michelle Axelson, CPC-A Michelle Gross, CPC-A Michelle Jensen, CPC-A Michelle Kessel, CPC-A Michelle Kuntz, CPC-A Michelle L Openbrier, CPC-A Michelle Luther, CPC-A Michelle Lynn Shannon, CPC-A, CPC-H-A Michelle O’Brien, CPC-A Michelle Pack, CPC-A Mikal Bailey, CPC-A Mindy Shaw, CPC-A Miriam Brestin, CPC-A Modupe Toyin Ogunsakin, CPC-A Molly Dee Neubauer, CPC-A Molly O’Toole, CPC-A Mona Tuccillo, CPC-A Monica Ferstadt, CPC-A Monica Jones, CPC-A Muthuselvi Veluchamy, CPC-A Myrtelina Martinez, CPC-A

Nancy Ann Spicer, CPC-A Nancy C Greenwood, CPC-A Nancy Krogman, CPC-A Nancy Oconnell, CPC-A Nancy Osorio-Ramos, CPC-A Nancy Trevizo, CPC-A Nancy Walker, CPC-A Nanette Benvegnu, CPC-A Nani Alexander, CPC-A Natalie Iwamoto, CPC-A Natalie Valenzuela, CPC-A Natasha Milligan, CPC-A Natisha Threatt, CPC-A Navnit Mangat, CPC-A Nekeesha L Slaughter, CPC-A Nela Rusu, CPC-A Nelson Mark Braslow, CPC-A Nichole Iwema, CPC-A Nicole Bilotti, CPC-A Nicole Dillon, CPC-A Nicole Englehart, CPC-A Nicole Frett, CPC-A Nicole Shanta Pearson, CPC-A Nicole Telaya Ingram, CPC-A Nicole Washburn, CPC-A Nieve Garcia, CPC-A Niki Peterson, CPC-A Niki Schloemer, CPC-A Nikia Charles, CPC-A Nikki Leatherberry, CPC-A Nikki Lynn Cooley, CPC-A Nina E Lopez, CPC-A Nisha Chhetri, CPC-A Oralia Alaniz-Luras, CPC-A Pacee Allred, CPC-A Paige Elaine Branan, CPC-A Paige Olivia Forth, CPC-A Paige Vanderheyden, CPC-A Pam Mahoney, CPC-A Pamela Helms, CPC-A Pamela J Stanton, CPC-A Pamela Jean James, CPC-A Pamela Montgomery, CPC-A Patrice Schettle, CPC-A Patricia Ann Vavra, CPC-A Patricia Ann Wright, CPC-A Patricia Beebe, CPC-A Patricia Claybaugh, CPC-A Patricia Crump, CPC-A Patricia Garcia, CPC-A Patricia Hale, CPC-A Patricia Jean Keene, CPC-A Patricia Marie Peterson, CPC-A Patrick Emmer, CPC-A Patti Johnson, CPC-A Patty Obrien, CPC-A Paula Heitzenrater, CPC-A Peggy Bussie, CPC-A Peggy Meadows, CPC-H-A Peggy Powell, CPC-A Philip Jenkins, CPC-A Phyllis Adams, CPC-A Pilar Uribe, CPC-A Pura Toste-Oliver, CPC-A Pura Toste-Oliver, CPC-A Rachel A Grady, CPC-A Rachel Eden Bach, CPC-A Rachel Kellie, CPC-A Rachel S Friedland, CPC-A Rachel Tomlinson, CPC-A Randy Shiflett, CPC-A Raquel Canio, CPC-A Rebecca Cumley, CPC-A Rebecca Ewan, CPC-A Rebecca M Breckenridge, CPC-A Rebecca Moore, CPC-A Regi Mathew, CPC-A Rene Drouin, CPC-A Rene’ Perez, CPC-H-A Rhonda L Adams, CPC-A Richard Evans, CPC-A Ricki Lee Shafferkoetter, CPC-A Rita Smith, CPC-A Robert Manolakas, CPC-A Robert Williams, CPC-A Roberta Schultz, CPC-A Robin Roberts, CPC-A Robin Cathey, CPC-H-A Robin Coleen Williams, CPC-A Robin Johnson, CPC-A Roger Walter Hallin, MD, CPC-A

Newly Credentialed Members

Ronda Lee, CPC-A Rose M Kolvek, CPC-A, CPC-H-A Rowena Catamura Sundaram, CPC-A Roxana Gonzalez, CPC-A Roxanne Lopez, CPC-A Russell Scruggs, CPC-A Ruth Parrott, CPC-A Ruth Pyeatt-Herrera, CPC-A Ryan Arnold, CPC-A Sabrina Kay Baetje, CPC-A Samantha Patterson, CPC-A Samina Blackmon, CPC-A Sandeep Kaur Gill, CPC-A Sandra Bunke, CPC-A Sandra Happel, CPC-A Sandra Revueltas, CPC-A Sandy Szarek, CPC-A Sangeetha Pandarinathan, CPC-A Sara Rawson, CPC-A Sarah Bane, CPC-A Sarah Blejski, CPC-H-A Sarah Bowman, CPC-A Sarah Collins, CPC-A Sarah E Towles, CPC-A Sarah F Lee, CPC-A Sarah F Wade, CPC-A, CPC-H-A Sarah Moore, CPC-H-A Saritha Pichandi, CPC-A Saron Pye, CPC-A Sathiaraj Kuppusamy, CPC-A Saul Amezquita-Ruelas, CPC-A Selena Sutherland, CPC-A Sendilnathan Sambandhamoorthy, CPC-A Shadrack O. John, CPC-A Shanika Monique Linzy, CPC-A Shaniqua Adams, CPC-A Shannon J Cantwell, CPC-A Shannon Kinnel, CPC-A Shannon Konkler, CPC-A Shannon LoCicero, CPC-A Shannon Michelle Medlock, CPC-A Shari L Gilman, CPC-A Sharon Aharon, CPC-A Sharon B Hill, CPC-A Sharon Grant, CPC-A Sharon Janet Huff, CPC-A Sharon M Doll, CPC-A Sharon Schultz, CPC-A Sharri Ann Larson, CPC-A Shauntina Chambliss, CPC-A Shawn Bethay, CPC-A Shawntel Peavey, CPC-A Sheila Hunt, CPC-A Sheila Sellars, CPC-A Sheila Warner, CPC-A Shelley A Kubesh, CPC-A Shelley Thomas, CPC-A Shelli Hopper, CPC-A Shelly A Dessauer, CPC-A Sheri Higgins, CPC-A Sheri-Ellen G Gott, CPC-A Sheron Mortensen, CPC-A Sherry Gill, CPC-A Sherry Parker, CPC-A Shirl Soder, CPC-A Shyanne Denise VanAllen, CPC-A Siana Lynn Rivera, CPC-A Simon Aubrey Steadman, CPC-A Sivachandran Senthil Arumugam Veilukandamal, CPC-A Sonja Jeanette Benton, CPC-A Spella Pal, CPC-A Stacey Arndt, CPC-A Stacey Rogers, CPC-A Staci Noble, CPC-A Staci Stephensen, CPC-A Stacy Adcox, CPC-A Stacy Matula, CPC-A Stacy Purkiss, CPC-A Stephanie Ann Erstad, CPC-A Stephanie Ann Records, CPC-A Stephanie Holdaway, CPC-A Stephanie Johnson, CPC-A

Stephanie Kay Petrie, CPC-A Stephanie Love Perry, CPC-A Stephanie Marie Rodetis, CPC-A Stephanie Mcdonald, CPC-A Stephanie Tomsick, CPC-A Stephanie Walker, CPC-A Stephanie Wunsch, CPC-A Stephany Mena, CPC-A Stephen A Mason, CPC-A Steven Rueter, CPC-A Stevie Robinson, CPC-A Subathra Murugesan, CPC-A Sue Scandrett, CPC-A Sujatha Thangadurai, CPC-A Sumana Akther, CPC-A Sumathy Kumarasamy, CPC-A Summer Harris, CPC-A Summer Joy Ramler, CPC-A Susan Davis, CPC-A Susan Kerbo, CPC-A Susan M Kolakowski, CPC-H-A Susan M. Brown, CPC-A Susan Majors, CPC-A Susan Marino, CPC-A Susan Spears, CPC-A Susan Ward, CPC-A Susan Watts, CPC-A Suzanna Metteer, CPC-A Suzanne Pierce, CPC-A Suzette Frederick, CPC-A Syeda Sawda Begum, CPC-A Tabatha Marie Pace, CPC-A Tamara Thompson, CPC-A Tammy Boston, CPC-A Tammy Sykes, CPC-A Tammy Wilson, CPC-A Tanesha Johnson, CPC-A Tangerla Burton, CPC-A Tara Estrella, CPC-A Tara L Smiddle, CPC-A Tashiika N Murdock, CPC-A Tassi Brotherson, CPC-A Tatum Ruff, CPC-A Tatyana Vasilchuk, CPC-A Taysia Hatch, CPC-A Teresa Lynne Myers, CPC-A Teri Reinemer, CPC-A Terneka Hill, CPC-A Terri Hunt, CPC-A Theresa Butera Blake, CPC-A Theresa Drew, CPC-A Theresa Littaua, CPC-A Theresa M Schuchman, CPC-A Theresa Robinson, CPC-A Thomas Austin, CPC-A Thonnya Sutherland, CPC-A Tia Chanell Robinson, CPC-A Tiffany Amelia Goar, CPC-A Tiffany Elayne Lucas, CPC-A Tiffany Ramos, CPC-A Timothy Pike, CPC-A Tina Louise Lowe, CPC-A Tina Marie Arneson, CPC-A Tina Marie Diehl, CPC-A Tizita S Garedew, CPC-A Tobie Dellinger, CPC-A Todd A Volden, CPC-A Todd Manion, CPC-A Tomika B Mustafa, CPC-A Toni Thibodeaux, CPC-A Tonya M Bryant, CPC-A Tonya Twomey, CPC-A Tracey Lynn Crum, CPC-A Traci Cromer, CPC-A Tracy Bergmann, CPC-A Tracy Foster, CPC-A Tracy Gibson, CPC-A Tracy Nicole Garner, CPC-A Tracy Price, CPC-A Tracy Wingard, CPC-A Tricia Koch, CPC-A Trina Troutman, CPC-A Trisha Jones, CPC-A

Usha Rani Kalairaj, CPC-A Valerie Black, CPC-A Valerie Leslie, CPC-A Valerie Noelle Drew, CPC-A Vanessa Clay Harrod, CPC-A Vanessa Oraciona Mangonon, CPC-A Vanessa Turner, CPC-A Vangie K Becenti, CPC-A, CPC-H-A Vannarie Nickie Heng, CPC-A Veronica Brannon, CPC-A Veronica C Crawford, CPC-A Veronica Hershey, CPC-A Victoria L de Charmoy, CPC-A, CPC-H-A Vidhya Annamalai, CPC-A Vijayalakshmi Krishnamoorthy, CPC-A Vijayalakshmi Manimozhi, CPC-A Vivian E Donahoe, CPC-A, CPC-H-A Waleska Hernandez, CPC-A Wanda Toro, CPC-A Wendy Asuega, CPC-A Wendy Ann VanDerLinde, CPC-A Wendy Flores, CPC-A Wendy Lino, CPC-A Wendy M Cox, CPC-A William Hubbard, CPC-A William Wong, CPC-A Wilma Teresa Baumgardner, CPC-A Wrentek MacGowan, CPC-A Xiomara Campos, CPC-A Xiomara Stevens, CPC-A Xshanti Lucky, CPC-A Yanitra Michelle Boles, CPC-A Yolanda Medina, CPC-A Yordanka Torres, CPC-A Yvonne Chalko, CPC-A Yvonne Marie Veilleux, CPC-A Zenobia D Jean, CPC-A Zina Washington, CPC-A

Specialties Amber Lea Cunningham-Bookout, CPC, CPMA Amy J Powell, CPC, CEDC Amy Michelle Benton, CPC-A, CPMA Andrea J Zlatkus, CRHC Angele T White, CPMA Angeli Marie Abbey, CPC, CPMA Anita Holloway, CPMA April Reynolds, CPC, CANPC Barbara Stevens, CPC, CHONC Berardino M Pala, CPC, CPMA Beth Ann Crocker, CPMA Beverley A Hill, CPC, CPC-I, CEMC Billie Price, CIMC Brandy Perkins, CPCO Brittany Stanley, CPC-A, CEDC Catherine Gray, CPC, CPC-H, CPC-I, CCC, CEMC, CGIC Catherine Marie Serfass, CPC, CEMC Christina Matsiga, CPC, CPCO Christine M Schaefer, CPC, COBGC Christopher Betley, CPC, CEMC Cindy Roberts, CPC, CPCD, CPRC Colleen Gianatasio, CPC, CPC-P, CPMA Colleen Gilli, CPC, CPMA, CEMC Courtney Gladden, COSC Cynthia A Lund, CPMA Cynthia Marie Zent, CPC, CPMA Danielle I Graf, CPC, CPCO, CIMC Darlene Dean, CEMC Deanna Saxton Rivers, CPC-H, CGSC Deborah Mullen, CPC, CPC-H, CPC-I, CGSC Debra K Ham, CPC, CEMC Dee Kelly, CPC, CPMA, CPCD Diane Sanna-Galama, CPC, CPMA Dionne Renita Clawson, CPC, CEMC Donna L Christian, COSC Donna Lee Olson, CPC, CPMA Donna Y Howe, CPC, CGIC Doris V Branker, CPC, CIRCC, CPC-I, CEMC Dytha Lynn Poole, CPC, CPMA, CANPC Edideysi Gomez, CPC-A, CPMA Eileen Rose Downs, CPC, CPMA, CEMC

Elisa C Arbeeny, CPC, CANPC Elise Clark, CPC, CEMC Geannetta Adams-Alston, CGIC Ginna Marie Guido, CPC, CPMA, CIMC Heather M Tynon, CPC, CEMC Heather Shaw, CPC, CIRCC Hillary Walsh, CEDC Ingrid R Cross, CPC, COSC Isabel C Gonzalez, CPC, CGSC James F Jenkins, CPC, COSC Jan M Lasker, CPC, CFPC Janelle Raymond, CPC, CPMA Janice M Hall, CPC, CEMC Jeanne Smith, CPC, CIMC, CPCD Jennifer A Kisting, CPC, CANPC Jennifer D Bell, CPC, CPMA Jennifer Gassert, CIRCC Jennifer Renee Parsons, CIMC Jill M Harrington, CRHC Joanie Marie Cochran, CPC, CPCO Jodi Leslie, CIRCC John Wilkinson, CPCO Juddi L Schneider, CPC, CPMA, CPC-I Julie Dove, CPC, CEMC Kadie Gibson-Karanikas, CPC, CCVTC Karen H Payne, CPC, CEMC Karen Wilder, CENTC Katarzyna Jochim, CIRCC Katherine Von Laven, COBGC Kelley Morrell, CCS-P, CPMA Kimberly Mutter, CPC, CEMC Kristin L Felty, CPC, CCC, CCVTC Lani Grone, CPC, CPC-H, CCC Laura C Allen, CPC, CEMC Laura E Hill, CPC, CPMA, CPC-I Lauren Krass, CPC, CEMC Lawena U Painter, CPC, CPMA Leanne Marie Altman, CPC, CEMC Lindsay-Anne McDonald Jenkins, CPC, CPC-H, CIRCC, CPMA, CPC-I, CANPC Lindsey Ray, CPC-A, CASCC Lusine Danielian, CPC, CEMC Lydia S Perry, CPC, CPC-H, CPC-P, CPMA Marcela Alaniz, CPC, CPMA, CEMC Maria Elena DiLeo, CPC, CPMA Maria Elena Maldonado, CPC, CPC-H, CPMA, CEDC, CEMC Melanie Lewis, CPC, CEMC Michelle E McDonald, CPC, CPMA Michelle Lynn Billings, CPC, CIMC Michelle M Bernstein, CPC, CPMA, CPEDC Michelle Tippel, CPMA Mindy D Powell, CPC, CPMA, CEMC Misty Shenna Walker, CPC, CPMA, CASCC Natalie Herrera, COBGC Oleg Korsakov, CPC, COSC Patricia E Grill, CPC, CPMA, CEMC Paulette Widmer, CPC, CPMA Priscilla Alfaro, MD, CPC, CPMA Rachael Shumate, CHONC Ramona Marie Mastrangelo, CPC, CEDC Rebecca Huffman, CPC, CEMC Rebekah M Loescher, CPC, CPMA Robert Wilson, CPC, CIRCC Rose Morales-Howland, CPMA Rosemarie Himick, CUC Sandy Fuller, CPC, CIMC Sara Barthel, CPMA Sharmilla Govindsami, CPC, CPC-H, CPMA Shelli Lynn Martin, CPC, CPC-H, CPMA, CEMC Sherry Sparham, CPCD Shirley Matlock, CPMA Somdavone Sithibandith, CPC, CPMA Stephanie Williams, CPC, CEMC Steven Knowles, CEDC Sundra S Jones, CPC, CPMA, CPC-I, CHONC Susan Marie Roelant, CPC, CPMA, CEMC Susan Miller Baker, CPC, CFPC Twila M Smith, CPC, CPMA, CEDC, CEMC, COBGC Verlene Birger, CPC, CFPC Veronica Derosier, CPC, CGIC Vicki A Workman, CPC, CPMA, CEMC Vickie L Poe, CPC, CEMC, COSC

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Vicky C Foss, CPC, CPMA Victoria Marie Whitby-Moll, CPC, CPMA Virginia G Barrett, CPC, CEMC Wendy Harrigan, CPC, CPMA Yvonne B Russell, CPC, CFPC

Magna Cum Laude

Alisa Engel, CPC-H Andrew Betterton, CPC Anna Dokko, CPC-A Ashley Staples, CPC Carol Lynn Bonacum, CPC-A Catherine Gray, CPC, CPC-H, CPC-I, CCC, CEMC, CGIC Catrina Denson, CPC Christine M Ranvik, CPC-P-A Colette Richter, CPC Courtney A Stark, CPC-A, CPC-H-A Dawn Richardson, CPC-A Donna M Padnos, CPC-H-A Elizabeth Ann McKay, CPC Elizabeth R Zak, CPC Emily Davidson, CPC-A Emily Dimberio, CPC Emily Martin, CPC-A Jaime Melissa Pearson, CIRCC Jenna Shepherd, CPC Justin Edward Baumgardner, CPC-A Kadie Allred, CPC-A Kathy Koontz, CPC-A Kathy Stopyra, CPC-A Kelly Spell, CPC Kim Moreno, CPC Kimberly F Pruitt, CPC Kimberly Pilch, CPC-A Kristen Lynn McKay, CPC Laurie Ann Nickolas, CPC-A Lee Hilliard, CPC, CPC-H Leigh Muller, CPC-A Lori K Carbonell, CPC, CPC-H Margie Reynolds, CPC Marisela Bustamante Lara, CPC Mary Tannenbaum, CPC-A Maureen Margaret Benton, CPC-A Michelle Diane Verdon, CPC, CPC-H Nina Barlow, CPC-A Pamela Dillon, CPC-A Paula J Kroes, CPC, CPC-H Rafael Abreu, CPC-H Rebecca Stephanie Enriquez, CPC-A Reed Snyder, CPC Renee Baucum, CPC-H Robbie Russaw, CPC Russ Dean, CPC Ryan Monson DC, CPC Sandra Berger, CPC Sarah E Ibero, CPC-A, CPC-H-A Sherrie Solt, CPC Sivagami Narayanan, CPC Skyler Gebhart, CPC Stacey Rubio, CPC Stephanne Turner, CPC Tammy Jones, CPC Tammy Ree, CPC-A Tara Jalazo, CPC-A Teenya Magnusson, CPC Tiffany Toburen, CPC-A Uma Munuswamy, CPC Vijayalakshmi Nammalvar, CPC Viki L Boggs, CPC-A, CPC-H-A Wendy Sartin, CPC-A

November 2011

41

Featured Coder

By Maryann C. Palmeter, CPC, CENTC

I Take Exception with That! Understand the Medicare Primary Care Center Exception.

T

he final rule for teaching physician presence and documentation requirements under Medicare Part B has been in effect since July 1, 1996. Over the years, the Centers for Medicare & Medicaid Services (CMS) has issued changes and clarifications to the rule. Most recently, CMS authorized the addition of new annual wellness visit codes G0438 and G0439 to the list of services that can be performed under the “Primary Care Center Exception” (refer to CMS Transmittal 2303, Change Request (CR) 7378, dated Sept. 14, 2011). CMS also added specific manual language (Medicare Claims Processing Manual, Pub. 100-04, chapter 12, sections 100.1 and 100.1.1 (C)) to clarify how the Primary Care Center Exception would apply when the teaching physician is supervising a resident with six months or less in an approved Graduate Medical Education (GME) residency program, as well as residents with more than six months in such a program.

Follow the General Teaching Physician Rule Services furnished by residents in residency programs are excluded from being paid as “physician services” under Medicare Part B because the Medicare fiscal intermediary, Medicare Part A, already pays teaching hospitals for the services of interns and residents, and the costs associated with the supervisory services of teaching physicians. Ordinarily, to be reimbursed under Medicare Part B, services furnished in teaching settings must meet one of the following requirements: • The service must be personally furnished by a physician who is not a resident. • The service must be furnished by a resident where a teaching physician was physically present during the critical or key portions of the service. • The service provided must be a specified service (See the Applicable Procedure Codes information box) furnished by a resident under the Primary Care Center Exception.

What Is the Primary Care Center Exception? An exception to the general teaching physician rule is sometimes referred to as the “Primary Care Center Exception,” but this exception is not limited to primary care or family practice residency programs. Per CMS, the exception could apply to 42

AAPC Coding Edge

any residency program with requirements that are incompatible with the teaching physician physical presence requirement. This is because in some residencies, the resident is the patient’s primary caregiver, and it is beneficial for the resident to see patients alone to learn medical decision-making, and to recognize his or her own limitations. Direct teaching physician involvement in these cases may negatively affect the patient-resident relationship. Some examples of residency programs most likely to qualify for the exception are: family practice, general internal medicine, geriatrics, and pediatrics. Specified services performed under the exception may be billed to Medicare Part B under the teaching physician’s provider number, without the need for the teaching physician to personally perform the service or to be physically present during the critical or key portions of the service.

Attest in Writing For the exception to apply, the center must attest in writing to the Medicare Part B administrative contractor (MAC) that the following conditions have been met: 1. The services are performed in a center that is located in an outpatient department of a hospital or another ambulatory care entity in which the time spent by the residents in patient care activities is included in determining Medicare Part A payments to the hospital. 2. The residents involved have completed more than six months of a residency program. 3. The teaching physician directs the care of no more than four residents at a time and directs the care from such proximity as to constitute immediate availability. 4. The teaching physician has no other responsibilities at the time (including the supervision of other personnel) and assumes management responsibility for those patients seen by the residents. 5. The patients seen are an identifiable group who consider the center to be the continuing source of their health care and are cognizant that services are furnished by residents under the medical direction of teaching physicians. The residents must generally follow the same group of patients throughout the course of their residency program. Centers exercising the exception must maintain records demonstrating they qualify for the exception.

Featured Coder

Teaching Physician Documentation Requirements Under the Exception

Know Procedure Code Restrictions

The teaching physician must document the extent of his or her participation in the review and direction of the services furnished to each patient. Teaching Physician Note Example I have reviewed with the resident Jane Doe’s medical history, physical examination, diagnosis, and results of tests and treatments and agree with the patient’s care as documented in the resident’s note.

Services Included Under the Exception The range of services furnished by residents under the exception includes: • Acute care for undifferentiated problems or chronic care for ongoing conditions, including chronic mental illness • Coordination of care furnished by other physicians and providers • Comprehensive care not limited by organ system or diagnosis

Under the exception, MACs may make physician fee schedule payment for reasonable and necessary, low- to mid-level evaluation and management (E/M) services, and other specified services, when furnished by a resident without the presence of a teaching physician. Refer to the Applicable Procedure Codes information box for a list of specific procedure codes that may be billed under the exception.

Append Modifiers Properly Modifier GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception must be appended to services billed under the exception. Services furnished in a primary care exception center that do not meet the requirements for the exception would revert to the general teaching physician rule for services furnished outside of a primary care exception center. Modifier GC This service has been performed in part by a resident under the direction of a teaching physician would be appended to these services.

Sample Scenarios with 4-to-1 Ratio Resident with 6 months or less in residency program.

Resident with more than 6 months in residency program.

Resident with more than 6 months in residency program.

Resident with more than 6 months in residency program.

New resident A

Old resident B

Old resident C

Old resident D

Resident with 6 months or less in residency program.

Resident with more than 6 months in residency program.

Resident with more than 6 months in residency program.

Resident with more than 6 months in residency program.

Resident with more than 6 months in residency program.

New resident A

Old resident B

Old resident C

Old resident D

Old resident E

Resident with 6 months or less in residency program.

Resident with 6 months or less in residency program.

Resident with more than 6 months in residency program.

Resident with more than 6 months in residency program.

New resident A

New resident B

Old resident C

Old resident D

Exception applies to old residents B, C, and D, but not to new resident A. Follow general TP rules for new resident A.

Apply modifier GC to charge for new resident A. Apply modifier GE to charges for residents B, C, and D.

Exception does not apply to ANY residents because the 4-to-1 ratio is exceeded. Follow general TP rules for ALL residents.

Apply modifier GC to charges for ALL residents.

Exception applies to old residents C and D, but not to new residents A and B. Follow general TP rules for new residents A and B.

Apply modifier GC to charges for ALL residents.

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November 2011

43

Featured Coder

“CMS recently provided manual guidance clarifying that teaching physicians may include residents with less than six months in a residency program in the mix of four residents under the teaching physician’s supervision.”

Become Familiar with These Key Definitions Resident

An individual who participates in an approved graduate medical education (GME) program, or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary (Medicare Part A). Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of “resident.” This status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents. This term is not applicable to medical students.

Teaching Physician

A physician (other than a resident) who involves residents in the care of his or her patients.

Teaching Hospital

A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry.

Teaching Setting

Any provider, hospital-based provider, or non-provider setting in which Medicare payment for the services of residents is made by Medicare Part A under the direct GME payment methodology or freestanding skilled nursing facilities (SNFs) or home health agencies (HHAs) in which such payments are made on a reasonable cost basis.

Physically Present

The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and performs a face-to-face service.

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Applicable Procedure Codes CPT Codes New patient office or other outpatient visit: 99201, 99202, and 99203 Established patient office or other outpatient visit: 99211, 99212, and 99213 HCPCS Level II Codes G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment G0438 Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit ®

Featured Coder

Follow 4-to-1 Ratio Rules As mentioned, the teaching physician under whose name payment is sought must not supervise more than four residents at any given time. CMS recently provided manual guidance clarifying that teaching physicians may include residents with less than six months in a residency program in the mix of four residents under the teaching physician’s supervision. The teaching physician would have to be physically present for the critical or key portions of the services furnished by the resident with less than six months in a residency program. That is, the exception would not apply in the case of the resident with less than six months in a residency program. Because the exception would not apply in this case, modifier GC would be appended to the service, rather than modifier GE. The fact that one or more of the residents has less than six months in a residency program does not affect the application of the exception to the other residents with more than six months in a residency program. The 4-to-1 ratio of residents to teaching physician must not be exceeded, in any case. Maryann C. Palmeter, CPC, CENTC, is director of physician billing compliance for University of Florida Jacksonville Healthcare, Inc., and provides professional direction and oversight to the billing compliance program at the University of Florida College of Medicine-Jacksonville. She has over 29 years of health care experience in both government contracting and physician billing. She is the education officer and two-time past president of the Jacksonville, Fla. chapter. Ms. Palmeter is AAPC’s 2010 Member of the Year, and is a member of the AAPC National Advisory Board.

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November 2011

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Coder’s Voice

By Suzi Morrow, CPC

For CPC-As, Mentors Are a Must For you, it’s an extra set of hands to rely on.

I

attended a local AAPC meeting recently in Mattoon, Ill. There were a few members who had just passed their coding certification test, so New Member Development Officer Dalene Mary Brandenburg, CPC, had everyone introduce themselves and tell where they worked. Sadly, many AAPC members in attendance were either jobless or had jobs outside of their certification’s scope. I have several friends looking for their first job as a Certified Professional Coder-Apprentice (CPC-A®), so this did not surprise me. For many CPC-As® the old adage holds true, “You can’t find a job without experience and you can’t get experience without a job.”

Internships Give CPC-As Experience I have served as mentor for two new coders who now have paid coding jobs, and I am a mentor for a third. In each case, I approached my employer to get an unpaid internship approved. I use a shadow system where the intern codes the same charts as me, and then the intern compares his or her code selection with mine. I code as I nor-

mally do and this takes very little extra time on my part. Questions are answered, instruction is given as necessary, and I watch with satisfaction as the intern learns and gains confidence, accuracy, and speed. Our interns are not paid, so only very motivated new coders are interested in this program. This is a good thing, since success is in their hands. Interns must be critical of their coding, acutely aware of any differences they find, and very eager to ask questions and learn. When a coding job opens up at the intern’s facility, he or she is at the top of the list to hire. My students know the facility, the physicians, and the routine so they are able to step right into the position. These coders are excited to learn, eager to jump into their new career, and thrilled that someone gave them a chance to do the job they worked so hard to get. If one person can carve out a few hours a month to lend a hand to a talented new coder, why can’t a large institution, physician group, outpatient clinic, or billing company do the same? If you give it some thought, I think you’ll realize that you’d be doing yourself and your facility a big favor by starting a mentor program. The cost is minimal—every CPC-A® I’ve spoken to would jump at the chance for an unpaid internship—and the reward is great.

ICD-10 Will Call for an Extra Set of Hands The transition to ICD-10 is a great time to bring enthusiastic, new coders into our workplaces. With the expected slowdown of revenue associated with ICD-10 implementation, you’ll be thankful you have the extra set of hands on which to rely. Suzi Morrow, CPC, has more than 30 years experience working in many areas of medicine including hospital-based obstetrics, emergency care, a private physician practice and, for the last 12 years, as a remote medical coder for two emergency room physician groups and a cancer treatment center. She attended Millikin University and Richland Community College.

If you give it some thought, I think you’ll realize that you’d be doing yourself and your facility a big favor by starting a mentor program. 46

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Legal Edge

Since When Is

“Give Less Weight” Ask Your Legal Questions

an Audit Protocol Standard? Question

Here is an excerpt from the Medicare Program Integrity Manual, Pub. 100-08, chapter 3, section 3.3.2.5, which addresses Late Entries in the Medical Documentation: “This section applies MACs, CERT, Recovery Auditors, and ZPICs, as indicated. A provider may discover that certain documents were misfiled or needed to be filed in the medical documentation during the process of responding to an ADR. Providers are encouraged to add to the medical record or notes file all relevant documents that were created at the time of service or within a few days of the date of service. The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the query responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO and State Agency. A query is a communication tool used between facility coding personnel and the physician and/or other health care practitioners whereby the coder obtains additional documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in a beneficiary’s health record. The process may take place concurrently (while the beneficiary is in the facility) or retrospectively (after discharge).” I find this very interesting because I have no idea what Medicare means when it instructs the Medicare administrative contractors (MACs), comprehensive error rate testing contractors (CERTs), and zone program integrity contractors (ZPICs) to “give less weight when making review determinations” to documentation created more than 30 days after the date of service. Since when did something as vague as “give less weight” become an audit protocol standard? Does anyone on the Legal Advisory Board have any insight on this? Robert A. Pelaia, Esq., CPC, CPCO Senior University Counsel for Health Affairs, University of Florida College of Medicine, Jacksonville, Fla.

Answer Here are the responses of AAPC Legal Advisory Board members: —David M. Vaughn, JD, CPC, Vaughn & Associates, LLC “I do a lot of appeal work, so I get questions about after-the-fact documentation all the time, and frankly, this rule is in line with the general rule I tell my clients: That is, at some point creating after-the-fact documentation is going to be viewed as too stale to be credible. Most of my clients can’t remember specific cases in the operating room (OR) that happened last week, much less last month, or last year. So, I’ve been telling my clients for a while that although they can add late documentation, at some point there will be a presumption that the information is too stale to be considered credible. That doesn’t mean there aren’t appeal rights to overcome the “give less weight” (whatever that means) standard. In legal speak, I view the “give less weight” standard as a presumption of non-allowability in the audit phase. I believe it will be upheld in the redetermination phase by the MAC, and the reconsideration phase 48

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Legal Edge

Ask Your Legal Questions

I concur: “Give less weight” is meaningless and likely improper. What it should demand is an assessment of credibility.

by the qualified independent contractor (QIC), but can be overcome in the administrative law judge (ALJ) phase when the doc is on the phone with the ALJ testifying under oath that he remembers this specific case. If he can’t remember this specific case, I think the presumption will be upheld. While I don’t necessarily agree with the 30-day time frame, what I do like is that there is a specified time frame. I can tell my clients, ‘You’ve got to get it documented in 30 days or else the presumption is going to be that it is too stale for you to have remembered that.’ Robert, hats off to you for bringing this to our attention.” —Michael D. Miscoe Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, Miscoe Health Law, LLC “This is consistent with the U.S. Department of Health & Human Services (HHS) Office of Inspector General/Office of Audit Services (OIG/OAS) audit process guidance regarding assessing the credibility of the information provided. Notwithstanding this provision, most ZPICs or QICs will cite the PIM Ch. 3 §3.4.1.2 (or a portion thereof) as a basis for completely ignoring supplemental information. Regardless, most ALJs will consider the information, especially where the doctor’s direct testimony is credible and the supplemental info does not conflict with information recorded contemporaneously. I concur: ‘Give less weight’ is meaningless and likely improper. What it should demand is an assessment of credibility. Note that 3.4.1.2 is contrary, indicating that the date a record was created is essentially irrelevant.” —Timothy P. Blanchard, JD, MHA, FHFMA, Blanchard Manning LLP “I think the Centers for Medicare & Medicaid Services (CMS) is off base with this instruction and that provider comments to CMS are warranted. Any valid (important point) medical record entry is entitled to full faith and credit. After all, it is backed up on the physician’s license (which could be lost if an entry were shown to have been false or fraudulent). While legitimate questions might be raised in connection with very late entries, either they are valid or they are not. There is no basis for either a sliding scale or a presumption of invalidity. As long as the authenticating physician has a sufficient present recollection of the events or observations he or she can properly make a late entry and it should be respected (given full credit normally afforded) if properly entered and authenticated. I hope providers do not just cave in and accept this. Determinations based on this instruction should be challenged in the appeal process. From time to time late entries will be necessary for almost every provider and it should not matter what triggered the conclusion that a late entry was appropriate to assure an adequate and accurate medical record.” —Julie Chicoine, Esq., RN, CPC, Senior Assistant General Counsel, Ohio State University Medical Center “I have given this some further thought and suspect that the underlying issue turns on the issue of what I think of as ‘evolving documentation’ where coders or other support staff seek supplemental (additional) documentation from providers to clarify the services rendered during a particular encounter. Documentation enhancement usually takes the form of addendums to the medical record. To me, this makes sense; though, if the contractors see too much of it—especially with one or two providers several days or even weeks after the original patient encounter, and when it follows an ADR—then it becomes suspect. This might serve as a foundation for an excellent article or presentation on documentation improvement.”

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