September 2011

Promote Healthy HRA Coding Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC

Plus: I&D • 2012 ICD-9-CM • Diverticulitis • Shared Visits • Find Jobs

Contents

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[contents]

September 2011

In Every Issue 7 Letter from the Chairman and CEO 8 Coding News 11 Letter from Member Leadership

26 Features 18 Differentiate Intestinal Diverticula, Diverticulosis, and Diverticulitis

Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P

21 Just Released: ICD-9-CM Updates Increase Neoplasm Specificity

G.J. Verhovshek, MA, CPC

26 Know What HRA Services Are Included in Preventive Medicine Counseling

Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC

34 Avoid Common I&D Mishaps

Sarah W. Sebikari, MHA, CPC

36 Document Shared Visits for Optimal Reimbursement

Sarah Todt, RN, CPC, CPMA, CEDC

41 Two Codes Confuse Monoclonal Antibody Injection Reporting

G.J. Verhovshek, MA, CPC

43 Three Tidbits Help You Code Lesion Biopsy and Removal

Brenda Chidester-Palmer, CPC, CPC-I, CEMC, CASCC, CCS-P

48 Review Your HIPAA Compliance Now

Marcia L. Brauchler, MPH, CPHQ, CPC-P, CPC-H, CPC-I

On the Cover: Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC, Salt Lake City, is getting a workout keeping up with what health risk assessment (HRA) services are supposed to be included in preventive medicine counseling. Cover photo by Kelli Bramble of Sprout Photo (http://sprout-photo.com).

12 Letters to the Editor

Special Features Online Test Yourself – Earn 1 CEU

Go to: www.aapc.com/resources/ publications/coding-edge/archive.aspx 14 Project AAPC 15 Find Jobs on AAPC’s Website 16 Opportunities for Coders

Education 38 Newly Credentialed Members 46 Be a Successful Coding Instructor

Coming Up • 2011 Salary Survey • Burn Coding • Stress Management • Nashville Regional Conference • Clinical Trials www.aapc.com

September 2011

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Serving 106,000 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]

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

APPRENTICE

PROFESSIONAL

EXPERT

September 2011

Vice President of Finance Korb Matosich [email protected]

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

Vice President of Marketing Bevan Erickson [email protected]

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

Vice President of ICD-10 Education and Training Rhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTC [email protected]

advertising index

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Director of Member Services Danielle Montgomery [email protected]

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

CaseCoder, LLC.............................................10 www.casecoder.com

Managing Editor

CodingWebU..................................................30 www.CodingWebU.com

John Verhovshek, MA, CPC [email protected]

Executive Editors

Contexo Media...............................................20 www.contexomedia.com



Michelle A. Dick, BS [email protected]

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Advertising/Exhibiting Sales Manager

Medicare Learning Network® (MLN)...............5

Address all inquires, contributions and change of address notices to: Coding Edge PO Box 704004 Salt Lake City, UT 84170 (800) 626-CODE (2633)

Official CMS Information for Medicare Fee-For-Service Providers (http://www.cms.gov/MLNGenInfo)

NAMAS/DoctorsManagement.................. 6, 52 www.NAMAS-auditing.com The American Society of Health Informatics Managers.........................................................9 http://ashim.org The Coding Institute, LLC..............................12 www.CodingCert.com

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Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC [email protected] Katherine Abel, CPC, CPMA, CPC-I, CMRS [email protected]

Advanced Career Solutions, LLC...................42 www.CodingConferences.com

Jamie Zayach, BS [email protected]

©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.

The Coding Institute, LLC....................... 25, 47 www.SuperCoder.com

Volume 22 Number 9

ZHealth Publishing, LLC..................................2 www.zhealthpublishing.com

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.

AAPC Coding Edge

September 1, 2011

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Letter from the Chairman and CEO

Look Out Medicare Providers, It’s the Perfect Storm

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ecently, President Obama signed the Congress’ Budget Control Act that raised the U.S. debt limit. Most Americans decried the difficulty of getting the debt ceiling increased and just wanted Congress to “fix” the problem, and to fix it their way: Some wanted tax increases, some wanted expenditure cuts, some wanted cuts but only in certain areas, etc. Congress had the same difficulty deciding where to make necessary budget cuts. Medicare might be a target.

SGR and Budget Control Threaten Medicare Cuts Within health care, another “perfect storm” is brewing. Under current law, the sustainable growth rate (SGR) formula promises a scheduled 29.5 percent reduction to Medicare Part B reimbursement rates on Jan. 1, 2012. That’s a big cut. Without change, the current formula is estimated to reduce payments to providers by $300 billion over the next 10 years. Washington agrees that the SGR formula needs to be fixed to avoid this drastic cut to providers. Almost everyone agrees that the financial structure of Medicare is unsustainable. The challenge is for Congress to come up with an alternative payment methodology that will fairly compensate physicians, while fulfilling its other goal to reduce Medicare expenditures.

Debt Ceiling Bill Allows Medicare Cuts On a separate but related track, the recently passed Debt Ceiling Bill establishes a new Joint Congressional Committee to create cost cutting legislation. This new committee will be composed of 12 members—

three each to be named by the leaders of both parties in each chamber (i.e., there will be three Republicans and three Democrats from both the House of Representatives and the Senate). The committee’s majority is required to send a proposal back to both houses of Congress, where it must receive a yea or nay vote. The committee must develop legislation that achieves at least $1.5 trillion in future deficit reduction by Thanksgiving. The committee’s legislation will be guaranteed a House and Senate vote, without amendments, by Dec. 23. This law allows the committee to make cuts in the Medicare program, as well. If the committee does not report legislation that achieves $1.5 trillion in deficit reduction, or Congress fails to enact the committee’s recommendations, automatic cuts, or “sequestration,” will be triggered, forcing across-the-board spending cuts—including cuts to the Medicare program. Under the new law, any such cut to Medicare, which would come from payments to providers and insurance plans, would be limited to less than 2 percent of the program’s cost. No Medicare benefit cuts or increases in Medicare beneficiary costs are included in this bill.

Your friend,

Reed E. Pew Chairman and CEO

A Shovel Won’t Help A severe winter storm will come this January if Congress doesn’t override the SGR formula threatening severe pay cuts to Medicare reimbursement rates and fails to reach its deficit reduction goal. The result of these two legislative failures could mean a 31.5 percent cut in Medicare payments to physicians, leaving the Medicare program neck deep in snow.

www.aapc.com

September 2011

7

Coding News Medicare Recertification May Delay Your 5010 Compliance

The Centers for Medicare & Medicaid Services (CMS) held its first National 5010 Testing Day June 15. Shortly after, Medicare administrative contractors (MACs), including TrailBlazer, Highmark, and NHIC, Corp., began posting the top 10 submission errors specific to their respective jurisdictions. The results should serve as a lesson and a wake-up call for organizations that have not yet begun testing version 5010 compliance standards. MACs sliced and diced the data in several ways, listing 5010 submission errors by state, or comparing Medicare Part A claims to Part B claims, for example. A few errors that occur consistently nationwide include: • The billing provider’s submitter was not approved for electronic claim submissions on behalf of the billing provider • Missing or invalid National Provider Identifier (NPI) or tax ID • Duplicate submissions • Invalid billing address or ZIP code information Act Now to Correct Errors “If you want to correct address errors, you need to begin now,” says Rhonda Buckholtz, CPC, CPMA, CPCI, CENTC, CGSC, COBGC, CPEDC, vice president of ICD-10 education and training at AAPC. The 5010 standard doesn’t allow for post office (P.O.) boxes, she explains. The billing address must be a physical location, and requires a nine-digit ZIP code. “Anytime you change your ‘pay to’ address—as providers currently using P.O. boxes will have to do—you must revalidate your Medicare credentials,” Buckholtz continues. “Credentialing changes don’t happen overnight. If your credentials and billing address aren’t updated by January, you will be in a world of hurt.” CMS is stating that it does not process claims via the address; however, be sure that you are credentialed correctly. For some payers, a letter outlining any changes might be sufficient. Other plans may require tedious paperwork. “If providers don’t test early, they could suffer significantly when 5010 takes effect because it could take months to get credentialing errors fixed,” Buckholtz says. To prevent your payments from drying up, Buckholtz recommends that all Health Insurance Portability and Accountability Act (HIPAA)-covered entities conduct external testing to ensure timely compliance. The version 5010 compliance date is Jan. 1, 2012. The new standard is being implemented in two levels: 8

AAPC Coding Edge

• Level I requires covered entities to test throughout the year, and to schedule testing as early as possible, to ensure sufficient time for corrective actions and re-testing. • Level II requires covered entities to complete endto-end testing with each of its trading partners, and be able to operate in production mode with the new versions of the standards. National 5010 Testing Days are an opportunity for trading partners to test compliance efforts with the benefit of real-time help desk support and direct, immediate access to MACs. These CMS-sponsored testing days do not preclude trading partners from testing transactions immediately with their MAC.

Big Payment Cuts for SNFs in 2012

CMS announced in a July 29 final rule that it will cut Medicare skilled nursing facility (SNF) Prospective Payment System (PPS) payments by 11.1 percent, or $3.87 billion, in 2012. The 2012 rates correct an unintended spike in payment levels and better align Medicare payments with costs. “CMS is committed to providing high quality care to those in skilled nursing facilities and to pay those facilities properly for that care,” said CMS administrator Donald M. Berwick, M.D. “The adjustments to the payment rates for next year reflect that policy.” CMS is cutting payments to get back the estimated increased reimbursement in 2011 that resulted from unintended changes in SNF Medicare billing for therapy (following changes in how Medicare paid for therapy). CMS recalibrated its payment structure through resource utilization groups (RUGs) to correct the incentives that led to billing for higher-cost therapies. CMS also tightened SNF rules in timing of allocating group therapy to help reduce future overbilling. According to CMS, the final rule also: • Clarifies circumstances when SNFs must report breaks of three or more days of therapy • Eliminates the distinction between facilities regularly furnishing therapy services on a five or seven day basis for purposes of setting the date for the End of Therapy (EOT) Other Medicare Required Assessment (OMRA) • Streamlines procedures for documenting situations involving a brief interruption in therapy, where therapy resumes without any change in the patient’s RUG-IV classification level

Coding News • Introduces a new Change of Therapy (COT) OMRA to capture those changes in a patient’s therapy status that would be sufficient to affect the patient’s RUG-IV classification and payment, even though they may not increase to the level of a significant change in clinical status • Provides for the allocation of a therapist’s time for group therapy (defined in the rule as a single therapist leading four patients in a common activity) to ensure that Medicare payments better reflect resource utilization and cost for these services, and specifically that the therapist’s time is being appropriately counted and reimbursed • Discusses the impact of certain provisions of the Affordable Care Act, and announces that proposed provisions regarding ownership disclosure requirements set forth in the Affordable Care Act will be finalized at a later date

In response to the pay cuts, the not-for-profit nursing home association LeadingAge said, “We are appalled that the [CMS] chose to implement an 11.1 percent across-the-board rate cut for skilled-nursing facilities in one year. We believe that any across the board cut is unwarranted and problematic, and one of this magnitude is unprecedented.” The 2012 recalibration reduced payments by $4.47 billion or 12.6 percent, but that change was partially offset by the update of 1.7 percent, or $600 million, according to CMS. The update reflects a 2.7 percent inflation increase and was reduced by 1 percentage point through a productivity adjustment mandated by last year’s Affordable Care Act. For further information, see www.cms.hhs.gov/center/snf. asp. A copy of the final rule is available in the Federal Register, which may be viewed online at: www.ofr.gov/OFRUp​ load/OFRData/2011-19544_PI.pdf.

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September 2011

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Letter from Member Leadership

Learn in the Classroom and Beyond

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ith fall here and my children returning to school, education has been on my mind—specifically, continuing education in the medical coding and billing field. Let’s look at a few ways you can further your education. Whether you select a particular subject to study just because it interests you, or because you are seeking certification in relation to your current or potential future position, there are many opportunities for you to receive the education you need. In addition to AAPC’s online and self-study courses, there are webinars, workshops, and conference sessions. Depending on your needs, you may learn formally through structured courses in a classroom environment, or less formally through networking and researching with others in our field.

Make the Most of Your Educational Opportunities In a formal classroom setting, it’s important to get the most out of your learning experience. Opportunities to maximize the knowledge you take home occur not just during the lesson itself, but during the assigned question and answer (Q&A) time, and during the networking time before and after formal instruction. Take Advantage of Q&A Time Instructors and presenters deliberately leave time during sessions and classes to address questions. Typically, this time is set at the end, but may be allowed during the class or session, as well. Use this designated time to your benefit, as well as for others attending. When raising a question, use common courtesy. Be aware of the restricted time frame the presenter and attendees have for questions and the material being presented. A prepared class or audience is appreciated; however, an instructor or presenter can become distracted by questions asked out of

context during the presentation (e.g., 15 slides back) or by repeats of the same question. If you don’t feel your question was answered completely, be courteous towards both the speaker and other attendees and save your question for the end of the presentation. Share your knowledge or expertise to help others. If you are in a class or presentation when a question or issue arises that you have worked through in the past, share your hard-earned knowledge and/or solution with others in attendance. Networking Is an Informal, Invaluable Benefit Besides the career opportunities that networking brings, there is the enjoyment of building a community of individuals who can help you find answers, provide feedback, and understand and speak your language. If you are in the classroom environment, look to the person next to you as an opportunity to continue sharing and gaining coding knowledge. Although formal education is an excellent way to obtain generalized knowledge regarding a specific topic in a relatively short time, networking can continue to be an education source throughout your life. To gain further insight into the coding world, build your network in both directions by taking advantage of the thoughtprovoking questions a new coder brings forth, and by finding the answers you’re looking for from experts. Networking is about building long-term relationships and creating lasting, positive impressions to boost confidence and conquer the next coding challenge.

What’s New with ICD-10 at AAPC? Before I sign off for this month, I’d like to address a need that members have expressed in regard to ICD-10-CM. During my past

year’s ICD-10-CM implementation presentations, I found that many of our members want to begin preparing themselves for using the ICD-10-CM code set. Although it is too soon for in-depth code set training, it is a perfect time to expand your knowledge of anatomy, physiology, and pathophysiology that will be necessary to accurately use the new coding system. AAPC’s ICD-10-CM Anatomy and Pathophysiology curriculum is a great place to start. Members can download all 14 modules for just $149.95. Each module is worth 1 CEU. Go to www.aapc.com/ICD-10/anatomy-pathophys​ iology.aspx to learn more. Best Wishes,

Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P President, National Advisory Board www.aapc.com

September 2011

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Letters to the Editor Remember Modifier 25 Requirements, Initial Inpatient Coding I have additional information as it relates to a couple of articles that appeared in the July 2011 issue: Regarding “Eliminate Infusion Confusion” (pages 20-23), I’d like to address the issue of physicians performing evaluation and management (E/M) services on the same day as chemotherapy, specifically as it applies to physician-owned centers. Providers must understand that to report a separate E/M code in addition to the chemotherapy administration, a significant, separately identifiable E/M service (apart from the chemotherapy) must be documented in the medical record. Only then may a separate E/M service be reported, appended with modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service. Concerning “Hospitalists: Focus on Coding, Billing, and Documentation” (pages 42-46), I’d like to remind readers of the need to perform and bill an initial inpatient service when a patient goes from observation to inpatient status on a different day. I normally see the initial observation service reported, but I hardly ever see providers of

Please send your letters to the editor to: [email protected] any type performing and charging for the initial inpatient encounter. Per the Medicare Claims Processing Manual, section 30.6.8.D, the physician may not bill an initial observation care code for services on the date that he or she admits the patient to inpatient status; however: “If the patient is admitted to inpatient status from hospital outpatient observation care subsequent to the date of initiation of observation services, the physician must bill an initial hospital visit for the services provided on that date. The physician may not bill the hospital observation discharge management code (99217) or an outpatient/office visit for the care provided while the patient received hospital outpatient observation services on the date of admission to inpatient status.” Jules Enatsky, RT, BSN, CPC-H Senior Consultant, J.A. Thomas & Associates

Complete ICD-9-CM Coding Crucial to HCC Reimbursement I appreciated reading the article published in July on Hierarchical Condition Categories (HCCs), “Complete ICD-9-CM Coding Is

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AAPC Coding Edge

Letters to the Editor Crucial to HCC Reimbursement,” on page 41. I work in a part of the industry that deals with HCCs, and I am always curious to read what my peers have to say about it. I would like to offer clarification to Jacqueline Nash-Bloink’s, MBA, CPC-I, CPC, CMRS, article—especially for any coder that may assume they are potentially due additional reimbursement for improved coding. Ultimately, coders should always be assigning diagnosis codes based on their highest levels of specificity and accuracy, especially in light of, and in preparation for, ICD-10 (which is quickly approaching). Coders should understand that there are several different relationship models that network physicians can have with their Medicare Advantage Organization(s) (MAO). The models include fee-for-service (FFS), capitated, staff, and mixed services. In terms of coding better to get the best possible reimbursement, Ms. Nash-Bloink’s article applies to coders employed by providers who typically have staff model contracts executed with their MAO(s). This relationship can and will vary from one MAO to another. Coders employed by providers who have FFS model contracts in place with their MAO(s) will not see an increase in reimbursement for better coding because these “relationships” are based on either contractual agreements or on fee schedules. Under the FFS model, a health plan’s network providers’ payments are not directly affect-

ed by ICD-9-CM coding. Coders, however, should always adhere to the Official ICD-9-CM Guidelines for Coding and Reporting, and should ensure that their physicians’ documentation practices always support assignment of all appropriate ICD-9-CM codes. Jennifer M. Oravecz, CPC

Watch Out for Acronym Confusion The article “Complete ICD-9-CM Coding Is Crucial to HCC Reimbursement” (July, page 41) used the acronym “MCC” in reference to managed care companies. Several readers pointed out that these organizations are more commonly referred to as “MCOs” (managed care organizations), while the acronym “MCC” generally is used to indicate “major complication or comorbidity.” Note, as well, that many MCOs that offer Medicare Advantage health insurance plans (formerly, Medicare Part C) refer to themselves as Medicare Advantage Organizations (MAOs) or Medicare Advantage Plans. Coding Edge

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September 2011

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AAPCCA By Freda Brinson, CPC, CPC-H, CEMC

Project AAPC: Compassion Is Contagious When it comes to giving, our members’ response is overwhelming. There’s a lot of good in this world and, for members of AAPC, we need not look any further than right here in our own organization to find it. Nestled in between 5010, ICD-10 implementation, the Centers for Medicare & Medicaid Services (CMS) Quarterly Updates, and the fast-approaching ICD-9-CM and CPT® changes for 2012, is Project AAPC.

What Exactly Is Project AAPC? The idea for Project AAPC was conceived in 2009 by former AAPC Chapter Association (AAPCCA) Board Chair Jill M. Young, CPC, CEDC, CIMC. As Jill watched the devastating footage from the Haiti earthquake, she was moved to reach out, to do something, and Project AAPC Local Chapters Aiding People in Crisis (Project AAPC) was born. Your AAPCCA board began finding ways to get local chapters involved and raise money to be presented as one great big donation at the 2010 national conference.

Disaster Relief Inspires Kindness The creativity of some local chapter members was truly inspiring. Some held yard sales, some had bake sales, and others just asked their members for donations. As conference drew near, you could feel the excitement building. And then, just before conference in late April, the unthinkable happened: Nashville was flooded and our conference had to be moved to Jacksonville. Behind the scenes, so much was going on to make changes for over 2,000 registered attendees. Once again, AAPCCA was filled with compassion. We asked our members to consider donating the funds collected by Project AAPC to the American Red Cross for disaster relief in our country’s Nashville area. The response and support from our AAPC members was overwhelming. It was truly an outpouring of love. The Red Cross was presented with a $13,086.74 check, all of which was donated by members. 14

AAPC Coding Edge

Helping Those in Need For 2011, the focus of Project AAPC shifted to a cause that hits close to home for everyone: hunger. The statistics of Americans going to bed hungry is staggering. Coders wanted to help as before, so local chapters thought of ways to raise money, help out at food shelters, and hold canned food drives. Unfortunately, once again, another natural disaster occurred: the earthquake and tsunami that hit Japan. Our heartstrings were plucked into action, and at our 2011 AAPC national conference in Long Beach, attendees were given the choice of donating to hunger relief through Feeding America, or donating to the Japan Tsunami Relief. The final numbers for Project AAPC was $3,596.82 for Feeding America and $1,484.54 for Japan Tsunami Relief—that’s awesome!

Find Out How You Can Help Your AAPCCA board is already making plans for Project AAPC at this fall’s regional conference in Nashville and for 2012. Local chapter members can start now by making plans on how to help raise funds. Alternatively, you can make personal contributions directly to Project AAPC. Contact any AAPCCA board member to find out how. Every member of AAPC can be proud to say, “We are the largest and most caring medical coding organization in the world!” We reach out to our neighbors in need, we pray for relief for those who suffer, and our generous gifts can be found in the collection box at our national conferences. We have many rules and guidelines when it comes to our coding world, but we also have compassion and treat others as we want to be treated. We are coders. We are caring. We are aiding people in crisis. We are AAPC. 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. Freda has 30 years of health care experience. She was the 2008 AAPC Networker of the Year and chapter president when Savannah was named 2008 AAPC Chapter of the Year.

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

Added Edge

By Brad Ericson, MPC, CPC, COSC

Now Find Scores of Jobs on AAPC’s Website This one-stop search makes it easy to manage your job hunt.

W

ith the newly enhanced job search resources at www.aapc.com, it’s easier than ever to find the coding, billing, auditing, or compliance job you are looking for. The free service, accessed via the “Jobs” tab on the main page of the AAPC website, allows members to simplify the job hunt through the power of the Internet. Start your search at www.aapc.com/medical-cod​ ing-jobs and take advantage of this AAPC member benefit. You can select, refine, and save your search. You can also set up a job search profile so the AAPC website remembers what you are looking for. You will then receive job alerts by email when new jobs matching your criteria are posted. “There are thousands of coding jobs out there, but they’re hard to find,” Bevan Erickson, vice president of marketing at AAPC, said. “We’ve designed this tool to better aggregate all jobs posted online and have given our members the power to search and be alerted of the specific positions they are most qualified for.” He shared a story with Coding Edge about a recently Certified Professional Coder –

Apprentice (CPC-A®) member who contacted AAPC saying she was still seeking a job. Using AAPC’s job search tool, he was able to find hundreds of jobs in her area, including one in her town that specified the CPC-A® credential for the open position. Jobs can be sorted by relevance, date, or distance from a specific ZIP code. Results can be saved and posted on members’ log-in screens with daily, bi-weekly, or monthly email alerts scheduled. More than one search based on criteria can be saved, and members can manage their saved searches and alerts when logged in. “This is another example of how AAPC seeks to help its members better,” Danielle Montgomery, director of membership services, said. “Members who are just entering their careers told us they need help finding that first job. We hope this one-stop search will make it a lot easier. I hope all members try it and every job seeker takes advantage of this tremendous member benefit.” Brad Ericson, MPC, CPC, COSC, is director of publishing at AAPC.

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September 2011

15

Professional

Hot Topic

By Michael Stearns, MD, CPC, CFPC

Opportunity Opens for Coders in the Digital World You are in a position H to safeguard accurate medical data capture within electronic exchanges.

ealth care organizations are encouraged by the U.S. government to accelerate their adoption of health information technology (HIT), including electronic health records (EHRs). There is significant evidence that improvements in health care’s quality and cost-effectiveness are tied to HIT use, and in particular, to discrete data. To be useful in clinical care, this information must be stored in the form of codes that accurately and completely represent clinical conditions, results, procedures, and devices. We’ll explore the emerging opportunities for coding professionals who are in a position to assist clinicians with an understanding of how to capture and use clinical code information.

Consider the Possibilities There are three potential coding professional roles that are tied to the rapidly expanding role of HIT in clinical care. We’ll explore: • how the information captured from EHRs can be coded accurately for clinical use • how this information, used by clinical HIT systems, is designed to exchange data between health care organizations • how this information is used by other clinical systems • necessary quality controls to protect patients from medical errors related to inaccurate or incomplete information Resource Tip: Other EHR opportunities for coding professionals, such as how they can help providers reduce their risk of a negative audit through calculating evaluation and management (E/M) codes can be found in the article “EHRs Pose Challenges, Provide Opportunities” of June 2009’s Coding Edge.

EHRs use templates or similar tools that often can store codified information, making it easy for clinicians to simply click on a clinical expression that automatically generates a code to represent that concept. This information is necessary to submit claims, but now it also will be used for clinical decisions. Codified data is used within EHRs to support automated clinical decision support tools, such as when the patient has a disease that is a contraindication for use of a specific medication, and the EHR alerts the physician before the medication is prescribed. It also is used to manage patient populations by assessing what preventative interventions (e.g., immunizations) are needed, and compliance with treatment guidelines (e.g., blood pressure control). With a greater dependency on codified data for automated use in patient care, information stored as codes needs to be as accurate and complete as possible. In most systems this information is stored as ICD-9-CM codes, which were not designed for use in clinical information systems and have the potential to introduce inaccuracies that could lead to patient safety issues. ICD-10-CM offers a number of advantages, but may have certain limitations related to its origins in ICD-9-CM. 16

AAPC Coding Edge

Hot Topic

Knowing the challenges associated with ICD-9-CM, ICD-10-CM, and SNOMED CT® codified data capture within EHRs is a skill set in demand right now.

To overcome these limitations, other terminologies, such as Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT®) will become more common in the near future. For example, the U.S. government already allows for the use of SNOMED CT® as an alternative to ICD-9-CM for the electronic submission of patient problem lists for data exchange. The World Health Organization (WHO) is considering altering the structure of ICD-11, slated for release in 2015, to better align more closely with SNOMED CT®’s features. Coding professionals will have the dual role of helping practices capture information in EHRs that meets both administrative and clinical needs. Knowing the challenges associated with ICD-9-CM, ICD-10-CM, and SNOMED CT® codified data capture within EHRs is a skill set in demand right now.

What the Future Holds The next phase in the clinical data lifecycle is its submission to health information exchanges (HIEs). HIEs are networks that allow health care organizations to share information within communities. Currently, the primary tool used to share clinical information is the Continuity of Care Document (CCD), which is a clinical summary of the patient’s problems, medications, allergies, recent labs, and other relevant information. It can contain codified or free text information; however, in the future codified data will largely replace free text. CCDs can be stored within the HIE and accessed by health care providers who have appropriate permission. Data from multiple patients can be abstracted from CCDs and used for population health initiatives, such as how well providers are managing diabetic patients in a geographic region. For these key health care initiatives to be effective, the data submitted to an HIE must be as accurate and complete as possible. Coding professionals know the nuances of how codes represent clinical information, and have the opportunity to expand their role as data stewards as health care becomes increasingly dependent on information shared through HIEs.

Another role for coders will be to ensure the data received by an EHR from an HIE or another EHR is accurate and complete. This will become an important patient safety issue because clinical decisions may be made based on the accuracy of this information. For example, if a patient has been diagnosed with chronic pelvic pain, for which there is no specific ICD-9-CM code, the information may be received as the “closest match” ICD-9-CM code (e.g., 789.04 Abdominal pain left lower quadrant). Those without coding knowledge would have difficulty understanding how code description information might not be accurate or complete. Practices will need clinical data gatekeepers to prevent medical errors that could occur if inaccurate data is received and used by an EHR.

What You’ll Need to Know As a coding professional, take advantage of emerging opportunities in health care and benefit from knowing how information is captured as codified data and used in EHRs, shared and used within HIEs, and imported and used by other systems. Getting to know SNOMED CT® and mapping efforts between ICD-9-CM, ICD10-CM, and SNOMED CT® can make you more valuable to many health care organizations. You have mastered converting clinical information into codified data, and HIT depends upon access to accurate and complete data stored as codes that can be easily processed and managed by computer systems. This has created a unique opportunity for you to play an essential role in improving the quality and efficiency of health care through the expanded use of information technology. Michael Stearns, MD, CPC, CFPC, is a board certified neurologist. He has 15 years of experience in clinical and academic medicine, and over 14 years of experience in HIT and has been a certified coding professional (CPC ® ) since 2006. Dr. Stearns served as the international director of SNOMED CT® during its formation. He has presented and testified at several national meetings on medical terminology, EHRs, coding, and genomic medicine. Dr. Stearns is the president and CEO of e-MDs, an EHR company, and the board president of the Texas e-Health Alliance, a non-profit policy and advocacy organization.

www.aapc.com

September 2011

17

Apprentice

Feature

By Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P

Differentiate Intestinal Diverticula, Diverticulosis, and Diverticulitis When accurate diagnosis coding pressure builds, look at location and hemorrhaging for each.

Diverticula are small “pouches” that poke through the muscle wall of the intestines, generally due to pressure within the intestine. They occur most frequently in the sigmoid colon (where internal pressure is highest), and are common in older patients (at least half of individuals over age 60 have diverticula, according to estimates). The condition of having intestinal diverticula is called diverticulosis. Appropriate diagnosis coding for diverticulosis depends on the precise location of the diverticula and whether there is mention of hemorrhage (bleeding). Diverticulosis

w/o mention of hemorrhage

w/ mention of hemorrhage

Small Intestine

562.00

562.02

Colon

562.10

562.12

Diverticulitis Is Diverticulosis, with a Difference Diverticulitis occurs when the intestinal diverticula become inflamed and/or infected. Diagnosis coding is similar to that for diverticulosis, based on location and whether hemorrhage is documented: Diverticulitis

w/o mention of hemorrhage

w/ mention of hemorrhage

Small Intestine

562.01

562.03

Colon

562.11

562.13

Transverse Colon Diverticula (Diverticulosis)

Inflamed Diverticulum (Diverticulitis)

Ascending Colon

Descending Colon

Cecum

Appendix Sigmoid Colon Rectum

18

AAPC Coding Edge

Note: A similar condition, called duodenitis (535.6x; a fifth digit is required to specify either with or without obstruction), may occur in the duodenum. Although this article covers only intestinal diverticula, diverticula may develop in any hollow organ, such as the esophagus, stomach, bile ducts, ureters, bladder, etc. Diverticulitis may lead to complications, such as intestinal abscess (e.g., 569.5 Abscess of intestine) and fistula (e.g., 569.81 Fistula of intestine, excluding rectum and anus). In addition, 569.82 Ulceration of intestine may be associated with diverticula, as may 569.83 Perforation of intestine.

Treatment Options Diverticulosis and mild diverticulitis often are treated conservatively with recommended changes in diet, the use of over-the-counter pain medi-

Feature

More severe cases of diverticulitis with acute pain and complications may require a hospital stay, and may be treated with intravenous antibiotics and/or several days without food or drink to allow the colon to rest.

cations, and possibly bed rest. Physician counseling and management are part of any evaluation and management (E/M) services provided. More severe cases of diverticulitis with acute pain and complications may require a hospital stay, and may be treated with intravenous antibiotics and/or several days without food or drink to allow the colon to rest. Once again, physician management is part of any inpatient E/M services billed. In extreme cases, surgery may be required. For example, emergency surgery may be necessary if peritonitis (567.xx) is present. The most common surgical treatment for emergency left-side complicated diverticulitis is the Hartmann type procedure (open, 44143 Colostomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure), or laparoscopic, 44206 Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure)). The diseased segment of the bowel is removed and an end colostomy is formed (the end colostomy may be reversed when the patient has made a recovery). Primary anastomosis is not performed due to the risk of infection. If the risk of infection is minimal but surgical treatment is required, the surgeon may perform colonic resection with primary anastomosis (open, 44140 Colectomy, partial; with anastomosis, or laparoscopic, 44204 Laparoscopy, surgical; colectomy, partial, with anastomosis). In this case, the diseased portion of the bowel is removed, and the two resulting ends are reconnected (anastomosis).

Until Sure, Stick with Signs and Symptoms Physicians cannot report “rule out” diagnoses. That means unless a definitive diagnosis of diverticulosis/diverticulitis has been established, you must report signs and symptoms only. Diverticulosis often is asymptomatic, and may be discovered incidentally as a result of an exam for other conditions. For example, diverticulosis often is diagnosed during a colonoscopy (e.g., for cancer screening). Symptoms, when apparent, include lower abdominal pain, bloating, blood in stools, and constipation. Diverticulitis is a more serious condition, the most common symptom of which is abdominal pain (which may be severe and sudden, or worsening over time), cramping, nausea, vomiting, fever, chills, and changing bowel habits.

Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS-P, CCS, is the manager of compliance education for a large university practice group. She is the long-time consulting editor for General Surgery Coding Alert, and has presented at five AAPC national conferences.

Why “Roughing It” Is Good for You The underlying cause of diverticulosis is believed to be a low-fiber diet. Fiber is the part (sometimes called “roughage”) of fruits, vegetables, nuts, and grains that the body cannot digest. Fiber may be either soluble (which takes on a jelly-like consistency as it moves through the intestinal tract) or insoluble (which passes through the body almost unchanged). Both types of fiber absorb liquid and add bulk to stool, which helps to prevent constipation and straining. For most individuals, a high-fiber diet is superior to a low-fiber diet. A high-fiber diet is good not only for the intestines, but also is hearthealthy (soluble fiber is linked to lower cholesterol levels) and may

help to control body weight. The American Dietetic Association recommends consuming 20 to 35 grams of fiber each day. Individuals with bowel disorders, such as Crohn’s disease or severe diverticula, may require a low-fiber diet, however. Lack of exercise also may be associated with increased risk for diverticulosis, whereas the benefits of regular exercise are well documented. So, trade your cookie for a carrot, and take a walk while you’re at it. Your colon will thank you!

www.aapc.com

September 2011

19

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19003

Apprentice

Feature

By G.J. Verhovshek, MA, CPC

Just Released: ICD-9-CM Updates

Increase Neoplasm Specificity

Plus, significant other changes make way for more precise diagnosis reporting.

T

he Centers for Medicare & Medicaid Services (CMS) has released an updated ICD-9-CM code set, effective Oct. 1, 2011. The nearly 250 changes include more than a few minor descriptor revisions, but also significant code additions. Among these, the most prominent are 40 new codes for malignant neoplasms now de-

scribed by location as “unspecified” (fifth digit “0”), “basal cell carcinoma” (fifth digit “1”), “squamous cell carcinoma” (fifth digit “2”), and “other specified” (fifth digit “9”). Ten “other malignant neoplasm” (four-digit) codes were deleted to make way for these new, more precise codes:

173.0

Other malignant neoplasm of skin of lip



173.00

Unspecified malignant neoplasm of skin of lip



173.01

Basal cell carcinoma of skin of lip



173.02

Squamous cell carcinoma of skin of lip



173.09

Other specified malignant neoplasm of skin of lip

173.1

Other malignant neoplasm of skin of eyelid, including canthus



173.10

Unspecified malignant neoplasm of eyelid, including canthus



173.11

Basal cell carcinoma of eyelid, including canthus



173.12

Squamous cell carcinoma of eyelid, including canthus



173.19

Other specified malignant neoplasm of eyelid, including canthus

173.2

Other malignant neoplasm of skin of ear and external auditory canal



173.20

Unspecified malignant neoplasm of skin of ear and external auditory canal



173.21

Basal cell carcinoma of skin of ear and external auditory canal



173.22

Squamous cell carcinoma of skin of ear and external auditory canal



173.29

Other specified malignant neoplasm of skin of ear and external auditory canal

173.3

Other malignant neoplasm of skin of other and unspecified parts of face



173.30

Unspecified malignant neoplasm of skin of other and unspecified parts of face



173.31

Basal cell carcinoma of skin of other and unspecified parts of face



173.32

Squamous cell carcinoma of skin of other and unspecified parts of face



173.39

Other specified malignant neoplasm of skin of other and unspecified parts of face

173.4

Other malignant neoplasm of scalp and skin of neck



173.40

Unspecified malignant neoplasm of scalp and skin of neck



173.41

Basal cell carcinoma of scalp and skin of neck



173.42

Squamous cell carcinoma of scalp and skin of neck



173.49

Other specified malignant neoplasm of scalp and skin of neck

173.5

Other malignant neoplasm of skin of trunk, except scrotum



173.50

Unspecified malignant neoplasm of skin of trunk, except scrotum



173.51

Basal cell carcinoma of skin of trunk, except scrotum



173.52

Squamous cell carcinoma of skin of trunk, except scrotum



173.59

Other specified malignant neoplasm of skin of trunk, except scrotum

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September 2011

21

Feature

173.6

Other malignant neoplasm of skin of upper limb, including shoulder



173.60

Unspecified malignant neoplasm of skin of upper limb, including shoulder



173.61

Basal cell carcinoma of skin of upper limb, including shoulder



173.62

Squamous cell carcinoma of skin of upper limb, including shoulder



173.69

Other specified malignant neoplasm of skin of upper limb, including shoulder

173.7

Other malignant neoplasm of skin of lower limb, including hip



173.70

Unspecified malignant neoplasm of skin of lower limb, including hip



173.71

Basal cell carcinoma of skin of lower limb, including hip



173.72

Squamous cell carcinoma of skin of lower limb, including hip



173.79

Other specified malignant neoplasm of skin of lower limb, including hip

173.8

Other malignant neoplasm of other specified sites of skin



173.80

Unspecified malignant neoplasm of other specified sites of skin



173.81

Basal cell carcinoma of other specified sites of skin



173.82

Squamous cell carcinoma of other specified sites of skin



173.89

Other specified malignant neoplasm of other specified sites of skin

173.9

Other malignant neoplasm of skin, site unspecified



173.90

Unspecified malignant neoplasm of skin, site unspecified



173.91

Basal cell carcinoma of skin, site unspecified



173.92

Squamous cell carcinoma of skin, site unspecified



173.99

Other specified malignant neoplasm of skin, site unspecified

The New York State Cancer Registry requested specific codes for basal cell and squamous cell carcinoma so these cancers could be identified easily, without a time-consuming review of medical records.

Basal cell carcinoma and squamous cell carcinoma are the most common forms of skin cancer, but are not reportable to cancer registries. The New York State Cancer Registry requested specific codes for basal cell and squamous cell carcinoma so these cancers could be identified easily without a time-consuming review of medical records. All skin neoplasms are reported by site, with category 173.9x reserved for skin neoplasms of unspecified site.

Glaucoma Gains Low-risk and High-risk Designations ICD-9-CM now differentiates low-risk versus high-risk open angle glaucoma, with the revision of 365.01 and addition of 365.05: 365.01

Open angle with borderline findings, low risk

365.05

Open angle with borderline findings, high risk

There are several types of glaucoma (primary open angle glaucoma, primary angle closure glaucoma, pigmentary glaucoma, etc.), which are caused by damage to the optic nerve and may lead to vision loss. Patients may present for treatment at different stages of the disease. The American Academy of Ophthalmology (AAO) requested the new codes to capture the stage of disease. Typically, the earlier the patient presents for treatment, the better the outcome. Also new is a code for family history of glaucoma: V19.11 Family history of glaucoma.

Saddle Up for Improved Embolism Coding Saddle emboli occur when a large clot lodges in an artery bifurcation, which causes blockage in both branches. Saddle emboli are the most severe type of emboli, and have a high mortality rate. They occur most commonly in the aorta, but may occur elsewhere. In recognition of this, ICD-9-CM has added several new codes to report saddle emboli in locations other than the aorta: 22

AAPC Coding Edge

Glaucoma

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Feature

New codes were created to report the specific, various types of air leaks and pneumothorax.

415.13

Saddle embolus of pulmonary artery

444.01

Saddle embolus of abdominal aorta

Previously, saddle emboli defaulted to the aorta. ICD-9-CM also adds V12.55 for Personal history of pulmonary embolism and 444.09 for Other arterial embolism and thrombosis of abdominal aorta.

Pneumothorax Also Gain Precision Spontaneous pneumothorax (collapsed lung) may be primary or secondary to another condition (for instance, cystic fibrosis). New codes were created to report the specific, various types of air leaks and pneumothorax. 512.81

Primary spontaneous pneumothorax

512.82

Secondary spontaneous pneumothorax

512.83

Chronic pneumothorax

512.84

Other air leak

512.89

Other pneumothorax

A patient can have a postoperative air leak without significant air in the pleural space. A patient also can have a persistent air leak that is not postoperative. Previously, postoperative air leak was reported with 512.1 Iatrogenic pneumothorax. The American College of Surgeons requested the new codes to report postoperative air leak, and primary and secondary pneumothorax.

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AAPC Coding Edge

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Feature

The National Center for Health Statistics (NCHS) proposed a new category of codes to report complications of infection or device malfunction with bariatric and gastric bypass surgery.

Bariatric Surgery Complications Now Recognized Bariatric procedures for weight loss have become increasingly common in recent years, and so has the incidence of surgical complications. The National Center for Health Statistics (NCHS) proposed a new category of codes to report complications of infection or device malfunction with bariatric and gastric bypass surgery. 539.01

Infection due to gastric band procedure

539.09

Other complications of gastric band procedure

539.81

Infection due to other bariatric procedure

539.89

Other complications of other bariatric procedure

Use All Available Resources to Keep Current The above revisions are among the more significant in the latest ICD-9-CM update, but there are many dozens of additional changes that may affect your practice. A full listing of the most recent ICD-9 changes, with full explanations, documentation tips, and more, can be found in the AAPC’s “Complete 2012 ICD-9-CM Coding Updates” (see AAPC’s website for more details). Additional ICD-9-CM changes released as subsequent addenda or errata can be found on the Centers for Disease Control and Prevention’s (CDC’s) website at www.cdc.gov/nchs/icd.htm. G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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September 2011

25

Cover Story

Professional

By Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC

Know What HRA Services Are Included in

Preventive Medicine Counseling New preventive medicine mandates call for healthy coding habits of these services.

W

ith the Centers for Medicare & Medicaid Services’ (CMS’) renewed focus on preventive medicine visits, there’s been some confusion about what is included in preventive medicine counseling and health and behavior assessments, who can bill for them, and when. The Patient Protection and Affordable Care Act of 2010 specifies that a health risk assessment (HRA) must be included as part of the preventive medicine counseling visit. This assessment includes all activities known only to an individual patient, such as smoking, physical activity, and nutritional habits. The purpose of this assessment is to allow the provider to give feedback tailored to the information collected (prior to or during the visit) to promote health, and to reduce illness and injury (see www.healthcare.gov/cen​ter/au​thorities/ title_iv_prevention_of_chronic_disease.pdf).

HRA Scenarios Provide Proper Coding Preventive medicine counseling and risk factor reduction interventions vary with age, and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter. For instance, consider the following HRA examples: Example 1: A patient and his family arrive at their family practice office to see the physician for counseling and instructions regarding the patient’s desire to start a healthy eating plan. The physician meets with the patient and his family to discuss the benefits of a healthy diet, and to discuss some of the physical changes that will accompany the diet, such as weight loss, increased energy, improved mood, and so on. The physician then recommends that the family meet with a registered dietician to outline a meal plan, and discusses how to incorporate this lifestyle into their day-to-day life. Start time: 9:30 a.m. Stop time: 10 a.m. 26

AAPC Coding Edge

Ms. Cronin knows that physical activity helps to achieve a positive health risk assessment.

Cover Story

HRA CPT® Codes

Correct coding is CPT® 99402; ICD-9 V65.49 Other specified counseling. Example 2: A patient is seen in his primary care physician’s office to discuss smoking cessation. The patient briefly speaks to Dr. Smith regarding options for quitting his smoking habit. Dr. Smith informs him of the various medications and recommends the patient review additional information on the Internet. The patient agrees. Start time: 1:15 p.m. Stop time: 1:25 p.m. Correct coding is CPT® 99406; ICD-9 V65.42 Counseling on substance use and abuse.

Behavior Change Intervention Guidance Behavior change interventions are for persons who have a behavior often considered an illness itself (such as tobacco use and addiction, substance abuse/misuse, or obesity). Behavior change services may be reported when performed as part of the treatment of condition(s) related to, or potentially exacerbated by, the behavior; or, when performed to change the harmful behavior that has not yet resulted in illness. Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up. Any E/M services reported on the same day must be distinct, and time spent providing these services may not be used as a basis for the E/M code selection. Codes 96150-96155 capture a wide range of physical health issues—from patient compliance to medical treatment, symptom management, health-promoting behaviors, health-related risktaking behaviors, and overall adjustment to physical illness. In most cases, a physician will already have diagnosed the patient’s physical health problem.

Behavioral Change Invention Examples Show Correct Code Choices Example 1: The patient is a 56-year-old female recently diagnosed with stage IV breast cancer. She is undergoing both aggressive chemotherapy and radiation treatments. She arrives at her provider’s office

99401

Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes

99402



approximately 30 minutes

99403



approximately 45 minutes

99404



approximately 60 minutes

99406

Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

99407



99408

Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

99409



99411

Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes

99412



intensive, greater than 10 minutes

greater than 30 minutes

approximately 60 minutes

These services are distinct from evaluation and management (E/M) services, and may be reported separately when performed face-to-face by providers or other qualified health care professionals as a separate encounter.

Behavior Change Interventions CPT® Codes 96150

Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment

96151



96152

Health and behavior intervention, each 15 minutes, face-to-face; individual

96153



group (2 or more patients)

96154



family (with the patient present)

96155



family (without the patient present)

re-assessment

These codes are for mental health providers to report services provided to patients with primary physical illnesses/diagnoses/symptoms. These services are offered to patients who may benefit from assessments and/or interventions focused solely on biopsychosocial factors related to the health status of the patient. Behavioral health providers use these assessments to indentify certain factors important to the care and treatment of physical health problems associated with a patient’s behavioral, cognitive, emotional, psychological, and social status. When these codes where developed almost all intervention codes used by psychologists involved psychotherapy and required a mental health diagnosis. Health/behavior assessment and intervention services focus on patients whose primary diagnosis is physical in nature. www.aapc.com

September 2011

27

Cover Story

Preventive medicine counseling and risk factor reduction interventions vary with age and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results …

Ms. Cronin is relaxing while performing a variation of Utthita Parsvakonasana (Extended Side Angle pose of Warrior Angle).

with her family for an initial health and behavioral assessment evaluation. The patient is seen initially to address issues of pain management via imagery, breathing exercises, and other therapeutic interventions; and to discuss quality of life issues, treatment options, and death and dying issues. Due to the medical protocol and the patient’s inability to travel to additional sessions between hospitalizations, a plan is developed for extending treatment at home with the patient’s husband and sister as co-caregivers. The patient’s family is seen by the health care provider for training in how to assist the patient in objectively monitoring her pain and in applying exercises learned via her treatment sessions to manage pain. Issues of the patient’s quality of life—as well as death and dying concerns—are also addressed with assistance given to the husband and sister as to how to make appropriate home interventions between sessions. Effective communication techniques with his wife’s physician and other members of his medical team regarding her treatment protocols are facilitated. Start time: 2 p.m. Stop time: 3 p.m. Correct coding is CPT® 96154 x 4; ICD-9 174.9 Malignant neoplasm of female breast, unspecified. Example 2: The patient is a 21-year-old male who is recently diagnosed as an insulin-dependent diabetic. The patient reports anxiety and pain with injections and blood glucose testing. An individual-based approach is used to address the patient’s anxiety problems. Relaxation and distraction techniques are used to address the patient’s anxiety with finger sticks and injections. The patient practices these techniques in the office with success and feels comfortable about reproducing these results on his own. Start time: 8 a.m. Stop time: 8:45 a.m. 28

AAPC Coding Edge

Correct coding is CPT® 96152 x 3; ICD-9 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled, V58.67 Long-term (current) use of insulin.

Use Caution When Combining Services For a provider treating a patient with both a physical and mental illness, reporting each service requires careful attention. This is because health and behavior codes cannot be used for psychotherapy services (addressing the patient’s mental health diagnosis), nor can they be reported on the same day as psychiatric or E/M CPT® codes. For patients that require psychiatric services (90801-90899), as well as health and behavior assessment/intervention (96150-96155), report the predominant service performed. Per CPT®, health and behavior assessment/intervention services (96150-96155) should not be reported on the same day as HRA (99401-99412). Example: The patient is a 15-year-old male who was recently diagnosed with chronic asthma and who has an existing diagnosis of bipolar I. He arrives with his family for an assessment of the patient’s emotional, social, and medical treatment related to the chronic asthma, hospitalizations, and treatments. Test results from the assessment provide information for treatment planning that includes health and behavior interventions involving a combination of behavioral cognitive therapy, relaxation response training, and visualization. The patient’s mother then discusses that the patient has been experiencing more manic type episodes, which was confirmed by the patient. The patient is currently on lithium, which has been able to reduce the frequency of the patient’s bipolar episodes. I then spend 30 minutes discussing the various medication options, benefits, and drawbacks of each medication with the patient and his mother, who agrees to try a higher dosage of lithium for now because it has worked

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Cover Story

… health and behavior codes cannot be used for psychotherapy services (addressing the patient’s mental health diagnosis), nor can they be reported on the same day as a psychiatric or E/M CPT® codes. in the past. The prescription is given to the patient’s mother with the instruction to follow up with me in three weeks. Diagnosis: Bipolar I, with mild manic episode. Please note that I spent a total of 15 minutes performing the assessment and 30 minutes discussing options of medication changes with the patient and his mother. Start Time: 10 a.m. Stop time: 10:45 a.m. Correct coding is 90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services and 296.41 Bipolar I disorder, most recent episode (or current) manic, mild. According to the guidelines, it’s appropriate to report psychotherapy CPT® code 90807 rather than 96154 because the provider spent the majority of the appointment time discussing and providing treatment for the patient’s bipolar disorder, as documented in the note.

Coordination of Care is Required CMS carriers are looking for documentation that shows coordination of care with the patient’s primary care provider, or the medical provider who is in management of the patient’s illness being addressed by the psychological assessment/intervention. For example, Cahaba Government Benefit Administrators®, LLC, requires documentation of: • Evidence of a referral to the clinical psychologist for the initial assessment and for each reassessment • Evidence of coordination of care with the beneficiary’s primary medical care providers, or medical provider responsible for the medical management of the physical illness that the psychological assessment/intervention was meant to address • The ICD-9-CM code that reflects the condition of the beneficiary and clearly indicates the reason for the service Initial assessment (96150) documentation in the medical record by the clinical psychologist must include documentation to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements: • Date of initial diagnosis of physical illness • Clear rationale for why assessment is required • Assessment outcome including mental status and ability to understand and to respond meaningfully • Goals and expected duration of specific psychological intervention(s), if recommended

Reassessment (96151) documentation must include the following elements: • Date of change in mental or physical status • Clear rationale for why reassessment is required • Clear indication of the precipitating event that necessitates reassessment Intervention service (96152-96154) documentation supporting that the intervention is reasonable and necessary must include, at a minimum, the following elements: • Evidence that the beneficiary has the capacity to understand and to respond meaningfully • Clearly defined psychological intervention plan and goals • Goals of the psychological intervention clearly stating how the service is expected to improve compliance with the medical treatment plan • The response to the intervention indicated • Rationale for frequency and duration of services • Time duration (stated in minutes) for each visit spent in the health and behavioral assessment or intervention encounter (source: www.cms.gov/medicare-coverage-database/details/lcd-details.as px?LCDId=31330&ContrId=10&ver=3&ContrVer=1&bc=AgIAAAAAAAAA&) Per CMS, you are not required to submit medical records with the claim; however, the medical record (e.g., complete nursing home record, doctor’s orders, progress notes, office records, and nursing notes) must be complete and available to the carrier upon request.

Telehealth Services Require Modifiers In 2010, CMS included 96150-96152 and G0425-G0427 into their distant site telehealth services for individual health and behavior assessment and intervention (HBAI) services. Effective Jan. 1, 2010 these codes are valid when billed for services furnished to beneficiaries in hospitals or skilled nursing facilities (SNFs), and properly reported with the corresponding interactive telehealth modifiers GT Via interactive audio and video telecommunication systems and GQ Via asynchronous telecommunications system. These changes allow the providers to retain the ability for providers to furnish and bill for consultations performed via telehealth. As always, the best practice is to check with your region’s specific payer policies prior to reporting any of these services to verify that they are covered and learn of any qualifying factors that may apply. Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC, is AAPC’s CEU vendor department manager.

www.aapc.com

September 2011

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Will Your Documentation Documentation dissection highlighting the increased specificity required to code for ICD-10-CM: Subjective: CC: Patient presents with c/o cough HPI: 34-year-old female presents for establishment; moved from another state. She states that for 2 weeks she has had a productive cough. She states her chest hurts when she coughs but denies fever/chills. Type 2 diabetes with retinopathy: 7-8 years. Inconsistently following recommended diet. Patient takes Ace Inhibitor. Glucose. Patient reports at last eye exam the physician noted some macular edema and this is confirmed via medical records. Last flu shot: December, 2009. Current Meds: Glyburide 5 mg 1 po bid: Aetas 45 mg 1 PO qd Allergies: Aspirin, Bee sting Personal Habits: Cigarette Use: Current cigarette smoker - 10-12 cigarettes daily for 20 years. Alcohol: Denies alcohol use. Drug Use: Denies drug use. Reviewed and updated. Objective: BP: 130/82. Pulse: 72 T; 96 9. Ht: 62" 5'2" WT: 212 lb. BMI: 38.8 Exam: Const: Appears well and comfortable. Appears stable in weight although morbidly obese. No signs of distress. ENMT: Auditory canals normal. Tympanic membranes: effusion. Nasal mucosa is pink and moist. Dentition is in good repair. Posterior pharynx shows irritation, but no exudate or redness. Resp: Respiration rate is normal. No wheezing. Auscultate mildly decreased airflow. Lungs are clear bilaterally. Skin: Skin is warm and dry Assessment #1: Diabetes Mellitus w/o complications Type lI with retinopathy and macular edema Plan: Microalbumin.is elevated. Will reck in 6 mo and then eval if still up, Cont. to watch diet and weight. Mod. Daily exercise would help. Meds: Onetouch Ultra Test Strips bgm bid dx: DM II Glyburide 5 mg 1 po bid Aetas 45 mg 1 PO qd Metformin 1,000 mg 1 po bid Immunizations: Administered: H1N1 Vaccine Administration. Administered: Influenza Virus split 3 yrs and above for intramuscular use. Administered: Pneumococcal vaccine 2 yrs or older Assessment #2: Upper Respiratory Infections Acute, viral Plan: Will treat empirically - Increase fluids w/ hot tea and rest. If no relief, follow up in one week. Assessment #3: Nicotine addiction Plan: Encouraged to quit and educated on ill effects of nicotine dependence, patient will consider cessation. Assessment #4: Obesity, morbid Plan: We discussed need for diet and exercise and that obesity is due to overeating and inactivity. Needs to reduce her caloric intake. She will make another attempt at healthy eating.

ICD-10-CM Codes E11.311

Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

Z79.4

Long term use of insulin

Z23

Immunization

J06.9

Upper respiratory infection, unspecified

F17.210

Nicotine dependence, cigarettes, uncomplicated

E66.01

Morbid (severe) obesity due to excess calories

Z68.38

Body Mass Index (BMI) 38.0-38.9

Be Ready for ICD-10? Specificity In ICD-10-CM the type of tobacco product being used is part of the code choice selection and documentation should include this.

Clinical Support Documentation BMI is coded secondarily to obesity and documentation needs to include BMI for proper code choice selection.

Combination Codes Diabetes Mellitus codes are now combination codes that include manifestations requiring documentation of any manifestations as well as the type of DM.

Insulin Use Long term use of insulin is coded for any Type 2 diabetic patient on insulin. Documentation will need to include usage of insulin for those patients requiring it.

Simplification Immunization coding is simplified in ICD-10-CM and currently there is only one code available for Immunizations and Inoculations. Documentation will still be important as specificity will be required in order to assign the appropriate procedure code.

Type Documentation for upper respiratory infections needs to include acute, chronic, due to streptococcal or viral NOS in order to assign the most appropriate code choice selection. Documentation will need to support these code choice selections.

Cause In ICD-10-CM Obesity is classified due to drug, excess calories, and then further divided by morbid and severe. Documentation must include all elements in order to select the most appropriate code.

Z68.38

E11.311

One of the largest problems following the October 1, 2013 implementation date for ICD-10 will be documentation insufficient to support the specificity required for the new ICD-10 code sets. We believe a behavioral change in documentation habits for most providers will be necessary—and now is the time to start preparing.

Z79.4

Request a Documentation Evaluation at: aapc.com/icd-10evaluation

J06.9

F17.210

E66.01

www.aapc.com | 1-800-626-2633

Apprentice

Feature

By Sarah W. Sebikari, MHA, CPC

Avoid Common I&D Mishaps 1. Identify the I&D Site Proper identification of the site requires the coder to be familiar with anatomy. 2. Identify the Abscess, Cyst, Hematoma, or Seroma An abscess contains pus and is usually left to drain. A cyst is removed together with its epithelial lining. Hematoma is a collection of blood outside a blood vessel. A seroma is a collection of serum in the body, producing a tumor like mass. 3. Differentiate Between Simple and Complicated I&D Some I&D procedures in the CPT® book are identified as either “simple” or “complicated.” For example:

Choose codes wisely because the wrong code may equal lost revenue or an audit. Incision and drainage (I&D) is a minor surgical procedure that usually can be performed in the office setting by a physician, nurse practitioner (NP), or physician assistant (PA). I&D is a common procedure for an abscess or cyst that may contain pus/purulence. It is performed by first locally anesthetizing the area surrounding the abscess. A scalpel or needle is then inserted into the skin and the purulence is drained. CPT® classifies I&D in different sections of the book based on anatomic site. Among the most common codes/categories are: • abscesses, 10060-10061 • cysts, 10080-10081 • hematoma, 10140 • complex wounds, 10180 Under-coding I&Ds may lead to revenue loss, while over-coding can trigger an audit. To code I&Ds appropriately, follow three simple steps: 34

AAPC Coding Edge

10080

Incision and drainage of pilonidal cyst; simple

10081



complicated

It is important for physicians to document precisely and differentiate whether a simple or complicated procedure was performed. A simple I&D includes drainage of the pus or purulence from the cyst or abscess. The physician leaves the incision open to drain on its own, allowing for healing with normal wound care. A complex I&D includes placement of a drainage tube to allow for continuous drainage or packing to facilitate healing. In certain cases, tissue excision, primary closure, and/or Z-plasty may be required.

Examples Light the Way to Proper Coding When coding, it’s important to identify the correct section to use in CPT®. The following examples show that it is easy to consider coding only from the integumentary system using procedures codes 1006010180, yet the procedure may be more appropriately described in a different section. The examples below are true scenarios where the coder/physician has inappropriately assigned the wrong procedure code. As you will see, the difference in reimbursement may be minimal on an individual basis, but the impact is tremendous when the error is repeated multiple times. Example A A patient with an infected right eyelid abscess, swollen and tender, is examined. After informed consent, the area is injected with 0.2 cc of 2 percent Lidocaine. An incision is made with a No. 18 needle to allow good drainage. The patient is given ciprofloxacin for postoperative measure. In this case, 67700 Blepharotomy, drainage of abscess, eyelid appropriately represents the procedure, although the coder had chosen 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single.

Feature

… it is easy to consider coding only from the integumentary system using procedures codes 10060-10180, yet the procedure may be more appropriately described in a different section.

CPT® code

Fully Implemented RVU

Medicare Reimbursement

CPT® code

Fully Implemented RVU

Medicare Reimbursement

67700

7.45

$253.12

69005

6.43

$213.37

10060

3.33

$108.72

10061

5.49

$181.43

Difference

4.12

$144.40

Difference

0.94

$31.94

Note that the relative value units (RVUs) are higher for the correct code (67700) than for 10060: $144.40 is a substantial amount to lose if this is a frequently-performed procedure. Hypothetically, if a provider performs 10 of these procedures every month, a total of $1,444 is lost on a monthly basis for one procedure, and $17,328 is lost annually. In practices where physician salary is based on the number of patients seen or procedures performed, under-coding would reduce the physician’s income considerably. Note: All Medicare reimbursement rates are copyright 2011 by Ingenix OptumInsight. RVUs are as per the Center for Medicare & Medicaid Services’ (CMS) 2011 National Physician Fee Schedule Relative Value File. Example B After receiving a signed, informed consent by the guardian, a 12-year-old boy undergoes I&D of an infected hematoma in the right external ear canal. Following adequate anesthesia of the overlying hematoma’s skin, a No. 15 blade is used to make an incision into the hematoma and express purulence. Patient tolerates the procedure well and is instructed to continue with an antibiotic and follow up within a week. In this case, the correct code is 69000 Drainage external ear, abscess or hematoma; simple. The coder instead chose 10060, which would lead to lost revenue. CPT® code

Fully Implemented RVU

Medicare Reimbursement

69000

5.50

$182.45

10060

3.33

$108.72

Difference

2.17

$73.73

If the physician had documented that a drain or packing was placed or applied to the area, it would be appropriate to code 69005 Drainage external ear, abscess or hematoma; complicated. The difference in revenue is shown here:

Example C A patient with an infected Bartholin’s cyst undergoes I&D after appropriate prepping and anesthesia is performed. The area is packed with Betadine gauze and sutured in place. The patient is placed on doxycycline. The appropriate CPT® is 56420 Incision and drainage of Bartholin’s gland abscess. Note that placement of drain is included in the procedure and not separately coded. There is no separate procedure code for a complex I&D of Bartholin’s cyst. CPT® code

Fully Implemented RVU

Medicare Reimbursement

56420

3.55

$124.35

10060

3.33

$108.72

Difference

0.22

$15.63

Reporting 10060 incorrectly in this case would lead to lost revenue. Although a difference of $15.63 may seem negligible, if the provider performs this procedure on a daily basis, over time the impact will be enormous.

Communicate for Success The significance of communication between the provider and codercannot be ignored. When documentation is not clear and precise, always clarify with the rendering physician before choosing a code. Educating the physicians on proper documentation will save the practice from unnecessary appeal process, amending documentation, and rebilling. It will also help you pick the accurate code for appropriate reimbursement. Physicians are usually focused on the clinical aspect of providing care and many times are unaware of the confusion improper documentation may cause. Keeping open lines of communication through education, and tying documentation to quality of care, may help them understand its significance. Sarah W. Sebikari, MHA, CPC, is senior coding analyst with Premier Health Care Exchange, a health care cost management company. She has been in the health care field for nine years, and a certified coder for seven years, with experience spanning from multiple-specialty physician to outpatient coding and reimbursement.

www.aapc.com

September 2011

35

Professional

Facility

By Sarah Todt, RN, CPC, CPMA, CEDC

Document Shared Visits for Optimal Reimbursement When billing these services, be sure documentation abides by payer requirements and state and employer rules.

W

hen you think of health care professionals, you generally think of physicians. It’s important, however, to be aware that other providers, such as non-physician practitioners (NPPs), also report services. These services may result in different payment rates, depending on the payer and documentation within the record. For example, services reported to the Centers for Medicare & Medicaid Services (CMS) are paid at 85 percent of the physician fee schedule when reported by mid-level providers such as nurse practitioners (NPs) and physician assistants (PAs). When the physician is directly involved and documents appropriately, the services are typically paid at 100 percent of the Medicare fee schedule.

Scope of Practice Determines NPP Billing Eligibility NPPs include NPs and PAs. NPs include acute care nurse practitioners (ANP), certified registered nurse practitioners (CRNP) and family nurse practitioners (FNP), to name a few. PAs include physician assistant-certified (PA-C) and registered physician assistantcertified (RPA-C) professionals. NPPs are credentialed providers that may perform many of the same 36

AAPC Coding Edge

functions as physicians. State and employer rules dictate the amount of supervision required and the scope of practice. Scope of practice information and supervisory requirements by state may be found on the American Academy of Physician Assistants website: www.aapa. org/advocacy-and-practice-resources/state-government-and-licensing. CMS indicates that NPPs are authorized to bill Medicare for services based on their own Unique Physician Identification Number (UPIN)/Provider Identification Number (PIN). Services reported by NPPs must meet the general supervision rules, and must be within the scope of practice for the state in which the billing NPP practices. The transmittal also reiterates that the services reported must be medically necessary. Medicare Carriers Manual Part 3-Claims Process, Transmittal 1776, section 15501 (www.cms.gov/transmittals/downloads/r1776b3.pdf) gives specific instruction regarding the reporting of an evaluation and management (E/M) visit shared between an NPP and a physician. • In the office/clinic setting, incident-to instructions should be followed to determine who should bill for the service. • In the hospital inpatient/outpatient/emergency department (ED) setting, the shared service may be reported under the physician’s UPIN when certain criteria are met:  The NPP and physician must belong to the same group practice.  The physician must provide a face-to-face portion of the service.  The documentation should demonstrate a meaningful interaction, specifically, more than a social salutation. Reviewing the NPP’s documentation and co-signing the record is not sufficient for reporting the visit as a shared service.

Shared Services Must Show Physician Involvement To properly report E/M services when NPPs are involved in the care of a patient with a physician, it’s essential to apply the shared visit documentation instructions as outlined in Transmittal 1776. As a

Facility

Shared services need clear documentation showing the physician’s involvement in the care of the patient in addition to the work performed by the NPP.

coder, you are necessary in the identification and proper reporting of services shared between an NPP and a physician. Shared services need clear documentation showing the physician’s involvement in the care of the patient in addition to the work performed by the NPP. The services of the NPP and physician may be performed independently and documented separately. A physician’s co-signature—or simply a review of the NPP’s documentation—will not support a shared visit under Medicare guidelines. The following situations illustrate when it is appropriate to report services under the physician’s UPIN: A PA sees a patient on the medical-surgical floor of the hospital and documents a note supporting an E/M service. Later that day, a physician from the same group practice sees the same patient and also documents a note supporting an E/M service. The service meets the shared visit requirements and may be reported under either the PA’s or the physician’s UPIN. In a second example, an NP sees and evaluates a patient in the ED. The NP identifies a potentially high-risk disease process. She discusses the case with one of the ED physicians, who then sees the patient, performs an exam, and documents a note clearly indicating a face-to-face encounter with a portion of the physical exam documented. This meets the shared visit requirements, and may be reported under the physician’s UPIN.

Critical Care May Not Be Shared The shared service concept does not apply to critical care. NPPs may provide and bill for critical care services when all of the requirements have been met for CPT® 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service), in addition to three other requirements:

1. The service provided must be within the scope of practice and licensure requirements for the state in which they practice. 2. Both NPs and PAs must meet the collaboration, physician supervision requirements, and billing requirements. 3. PAs must meet the general physician supervision requirements. The critical care service should reflect the NPP’s E/M of the patient, and not a split/shared/combined service between a physician and a qualified NPP. Typically, such services may be reported under the NPP’s UPIN. For example, a patient arrives at the ED with a complaint of chest pain. A PA initially evaluates the patient, performing a full cardiac work-up. The patient is having a suspected acute myocardial infarction. The NPP performs the majority of the care for the patient and documents 35 minutes of critical care time. The attending physician provides a review of the record and quick evaluation of the patient. A shared visit note is documented; however, the physician did not provide 30 minutes of care. Although there was a shared visit note, this visit would be reported appropriately under the NPP’s UPIN as critical care services. The critical care may not be a split/shared service. For additional information, refer to MLN Matters MM5993, Revised Critical Care Visits and Neonatal Intensive Care (99291-99292), available online at: www.cms. hhs.gov/MLNMattersArticles/downloads/MM5993.pdf. Sarah Todt, RN, CPC, CPMA, CEDC, is the director of quality and education at LogixHealth, an ED-specialized provider of coding, billing, and end-to-end revenue cycle services for top hospitals, officebased practices, and EDs nationwide. Ms. Todt is a registered nurse who specialized in emergency medicine and critical care. She served on the AAPC National Advisory Board (NAB) and the ED specialty exam steering committee, and presented on ED reimbursement topics.

www.aapc.com

September 2011

37

newly credentialed members Adam Anderson, CPC Aleksandra Alston, CPC Alexandrina Brockington, CPC Alisha Holder, CPC Allen D. Stroud, CPC Allison Naugher, CPC Allison Sims, CPC Amanda Patacsil, CPC Amanda Riley, CPC Amanda Slunecka, CPC Amber Martindale, CPC Amber P Amburn, CPC Ameneya Phillips, CPC Amy Hartwig, CPC Amy Joanne Coffee, CPC Angela M Bowman, CPC Angela Marie Pommarane, CPC Anita Faye Fox, CPC Anita Mayer, CPC Anita Regler, CPC Ann C McGarvey, CPC Anna Singh, CPC Anna Trieu, CPC Avula Pavani, CPC Ayesha James, CPC Barbara Ann Harber, CPC Barbara Jean Austin, CPC Barbara Karger, CPC Barbara Kreisler, CPC Barbara Paige, CPC Barbara Ruth Johnson, CPC Basta Suryakala, CPC Becky Jeske, CPC Belinda Denise Bush, CPC Beth Morrow, CPC Beth S McDorman, CPC Brandy Elaine Buchanan, CPC Brenda B Redfern, CPC Brenda Cramer, CPC Brett Gottlieb, CPC Briana Wilson, CPC Brishon Vasher, CPC Carl Reinhardt, CPC Carleen Hall, CPC Carmen M. Jones, CPC Carol Althoff, CPC Carol Lynn Dunbar, CPC Carolyn C Assell, CPC Carrie Duncanson, CPC Carrie Kreft, CPC Carrie Smith Christy, CPC Casey Pierce, CPC Catherine Julia O’Neil, CPC Cathleen M Aplin, CPC Cathy Hatmaker, CPC Chanda Lynn Miller, CPC Charity M. Campbell, CPC Charles J Salas, CPC Charmaine Finney, CPC Cherise Marie Hassell, CPC Cheryl L Flood, CPC Cheryl Rasbach, CPC-P Chris Kuebelbeck, CPC Christina Anne Hamel, CPC Christina J McLain, CPC Christina Pittman, CPC Christine W Rayburn, CPC Christopher Jason Halk, CPC Cindy Finnegan, CPC Cindy Rowlee, CPC Clarissa Ilustrisimo, CPC Colleen Flores, CPC Courtney Kinney, CPC Courtney Spielman, CPC Crystal S Hudson, CPC Cynthia D Thompson, CPC Danni Jo Duell, CPC Darlene Nunez, CPC Dawn M Mckee, CPC Dawna Moore, CPC Deanna Beth Zanoskar, CPC Deanna Steinebach, CPC Debbie Cohen, CPC-H Debbie Magill, CPC Deborah Lynn Nowakowski, CPC

38

AAPC Coding Edge

Deborah N Miller, CPC Deborah Snyder, CPC Deborah Suthers, CPC, CPC-H Debra Zenger, CPC Denise Carver, CPC Denise R McMillan, CPC Dennis Tse, CPC Desiree S Dean, CPC Diane Jean Ohlheiser, CPC Dianna Foust, CPC Donna Ford, CPC Donna Francis-Clark, CPC Donna Knowles, CPC Donna Louise Foutch, CPC Donna Young Littlejohn, CPC Dorothea Cook, CPC Dorothy R Harrison, CPC Elaine Morton, CPC Eldina Dedic, CPC Elizabeth Ann Riner, CPC Elizabeth Apicella, CPC Elizabeth Lewis, CPC-H Elizabeth Wernet, CPC Emily C Hernandez, CPC Evette Beanes, CPC Faauiga Betts, CPC Fran E Kaufman, CPC Genise Riddle, CPC Genny Lopiccolo, CPC Gillian E Sutherlin, CPC Gloria G Brady, CPC Greer Clemons, CPC Gule Rauf, CPC Hastana Rasouly, CPC Heather E Larson, CPC Heather July, CPC Heather M Carpenter, CPC Heather Morell, CPC Heidi Beth Dexheimer, CPC Heidi Hughes, CPC Heidi Kochell, CPC Holly M Gessler, CPC Ila M Callagan, CPC Jackie M Ventura, CPC Jaclyn Forbes, CPC James William Heuser, CPC James Zaffuto, CPC Jamie Lee Hartman, CPC Jamie Thompson, CPC Janean Walker, CPC Janeris Cabrera, CPC Janette Harsar, CPC Janice C Stewart, CPC Janice Mack, CPC-H Jean Ann Locurto, CPC Jean H. Toman, CPC Jeana Elaine Abbey, CPC Jenna C Fuqua, CPC Jennifer Fanduiz, CPC Jennifer Spivey, CPC Jennifer Vandehey, CPC Jeramy Reimer, CPC Jerri Rowe, CPC Jessica Aranda, CPC Jessica Roesle, CPC Jessica Theobald, CPC Jo Ann Goldman, CPC Joanne Marie Kirk, CPC Jodie Candace Holderby, CPC Jody A Young, CPC Jolly Sam, CPC Josefa Mora, CPC Joy E Hollingsworth, CPC Juanita Dyerwilkins, CPC Julie Rowden, CPC Justine Enochs, CPC Karen Dierker Longeway, CPC Karen Kohl, CPC Karen Louise Lassen, CPC Karena R Phillips, CPC Karla Saffle, CPC Kashuna Hopkins, CPC Katherine Thomas, CPC Kathleen J Gallup, CPC Kathryn L. Ross, CPC, CPC-H

Kathy Butkus, CPC-H Katie Burden-Siemers, CPC Katie Riley, CPC Katrina Duke, CPC Kavuru Sri Taruna, CPC Kayla Cassell Estep, CPC Kayla Leo, CPC Kelley Chaney, CPC Kelli Taber, CPC Kelly Hogan, CPC Kelly Rose Moses, CPC Kelly Strong, CPC Kenyaka Barnes, CPC Kerry Ralsten, CPC Kim Nichols, CPC Kimberly A. Duffany, CPC Kimberly Lynn Sampson, CPC Kosanam Shilpa, CPC Kristian Robinson, CPC Kristin D. Anguiano, CPC Kristina Stolzenburg, CPC Kristy Zimmerman, CPC, CASCC LaKeenya T Hurst, CPC, CPC-H, CPMA Lakisha Thompson, CPC Lasonia Estes Jones, CPC Laura A Mueller, CPC Laura Kudronowicz, CPC, CPC-H Lauren Craig, CPC-H Lauren Rosen, CPC Laurie Beth Sabens, CPC Laurie May, CPC Laurie Miller, CPC Laurie Newman, CPC Lawrence E Caputo, CPC Lea Ann Gay, CPC Lecia Lou May, CPC Leiza Rodriguez, CPC, CPC-H Lekhena Veasna, CPC Lena Mae Jones, CPC, CPC-H Leonor Newby, CPC LeQuanna Godley-Israel, CPC Leslie Ann Kahiona, CPC Leslie R Huguley, CPC Letitia Bowens, CPC Linda Darlene East, CPC Linda E Theroux, CPC Linda Gledhill, CPC Linda Kay Pettay, CPC Linda Wild, CPC Lindsey D’Alessio, CPC-H Lisa DiSalvo, CPC Lisa M Garcia-Hubbard, CPC Lisa Malone, CPC Loganathan Reena, CPC Lori Ann Boshnakian, CPC Lori Reitz, CPC Lucy Schwarze, CPC Lusia Zacarias, CPC Lynn Dettman, CPC Maddela Sundari Meenakshi, CPC Marendria Ikie Rashall, CPC Margaret Egolf, CPC Maria L Salas, CPC Marian Graham, CPC Mariellen Conway, CPC Marta Irene Noyola, CPC Martha Sandoval, CPC Martin Harmon, CPC-H Mary Buskirk, CPC Mary Fideldy, CPC Mary Merlak, CPC Mary Sims, CPC Maryann Douglas, CPC Marylouise Moran, CPC Melanie Hill, CPC, CASCC Melba Baur, CPC Melinda Hernandez, CPC Melissa A Roberts, CPC Melissa Grizzle, CPC Michel I Minaya, CPC Michel Tennyson-Butler, CPC Michelle B Maulding, CPC Michelle M McGuigan, CPC Miranda D Galas, CPC Misti Sellars, CPC

Misty Dawn Dupes, CPC Monique Harris, CPC Nancy Almanzar, CPC Nancy I Hagstrom, CPC Nancy Ysla, CPC Nan-Sheng Sheng, CPC Natasha Simone Spence, CPC Nicholas Delgado, CPC Nicole Engelhard, CPC Nicole Lynn Norfleet, CPC Nicole Triplett, CPC Nicole Urchike, CPC Nikki Jones, CPC Nirudi Mamatha, CPC Norma Ciovica, CPC Pamela A Lawson, CPC Pamela Benfield, CPC Pamela Halbach, CPC-P Pamela S Inoshita, CPC, CPC-H Patricia H Jackson, CPC Patricia Lopez, CPC Paul Beane, CPC, CPMA, CCPC Quincy Douglas Choice, CPC Rebecca K Catlett, CPC Rebecca Lorraine Wright, CPC Rebecca Phillips, CPC Remedios M Yutiamco, CPC-H Rena Shifflett, CPC Renae L Hedstrom, CPC Renee Jordan, CPC Reta Studnicka, CPC Rhonda L Tabor, CPC Rhonda Myrick, CPC Rose Pierce, CPC Roxana Henriquez, CPC Sabrina Colleen Anzalone, CPC, CPC-P, CPMA Sally Fuller, CPC Samuel Philip, CPC-H Sandra K Workman, CPC Sandra Monsalve, CPC, CPC-P Sandy Loving, CPC Sandy VanDyke, CPC-H Sara Sanchez, CPC Sarah Luszczyk, CPC Shaheen Davis, CPC Shannon Keenan Howard, CPC Shannon Warehime, CPC Sharon Elizabeth Guill, CPC-H Sharyn Wolfe, CPC Sherry Holladay, CPC Shirley Ann Timberlake, CPC Shivnarain Nandkishore, CPC Sonia LaShelle Banks, CPC Sonya B Reynolds, CPC Stacey Harvey, CPC-H Stefanie A Wieden, CPC Stephanie Koopmann, CPC Sunnilei Willard, CPC Susan Bejmovicz, CPC Susan D Galtelli, CPC Susan Smith, CPC-H Susanne Mansfield, CPC Suzanne Edwin, CPC Suzanne Erickson, CPC Sylvia Garcia, CPC Sylvia Lampp, CPC Tamela Dickson-Matthews, CPC Tammie Toner, CPC Tammy Jones, CPC Tammy Kramlinger, CPC Tanya Bartek, CPC Tara D Hodge, CPC Taylor Deatherage, CPC Teresa Ann Smith, CPC Teresa Carnett, CPC Teresa Clark, CPC Teri J. McIntosh, CPC Terri L Reblin, CPC Thalita Viruet, CPC Theresa Cline, CPC Theresa Marie Finn, CPC Tina Marie Davis, CPC Tisha P Mallet, CPC Tom Edward Bernhoft, CPC Toni Foy, CPC

Tonya Minish, CPC Toscha S. Reid, CPC Traci Mahaffey Horst, CPC Tristina Salko, CPC Vanessa C Hollingworth, CPC Vemula Ranganadh, CPC Vicki King, CPC Victoria (Mickey) A Sternbeck, CPC Victoria Parks, CPC Virginia M Rutschilling, CPC Virginia Norton, CPC Wendy Ellis, CPC Wendy J Dahl, CPC Wendy Monteith, CPC William J Owens, CPC Yesenia Vazquez, CPC Yvonne Kelley, CPC

Apprentices

Yvonne McManus, CPC

Abel Diaz, CPC-A Adriana Aispuro Beltran, CPC-A Adriene Denise Kenard, CPC-A Aimee LaRae Sager, CPC-A, CPC-H-A Aimee Michelle Collison, CPC-A Alejandra Munoz, CPC-A Alex Devaty, CPC-A Alexas Crossman, CPC-A Alicia Bailey, CPC-A Alisha Young, CPC-A Alison Clark, CPC-A Alison Michelle Hill, CPC-A Allyson Jean Marcum, CPC-A, CPC-H-A Alyssa Laughlin, CPC-A Amanda Beachum, CPC-A Amanda Ebersole, CPC-A Amanda Forry, CPC-A Amanda Lynn Haywood, CPC-A Amanda Renee Sturdivant, CPC-A Amanda S Rooney, CPC-A Amanda Sue Richardson, CPC-A Amber Lovel, CPC-A Amilia Bameko, CPC-A Amy B Bradley, CPC-A Amy Baumgartner, CPC-A Amy Curran, CPC-A Amy Frion, CPC-A Amy Jean Harms, CPC-H-A Amy Kammin, CPC-A Amy Swift, CPC-A Ana Hanford, CPC-A Anastasia Walle, CPC-A Andrea Biscay, CPC-A Andrea Ray, CPC-A Andrew Perring, CPC-A Angela Bouse, CPC-A Angela Foster, CPC-A Angela Joyner, CPC-A Angela K Cooley, CPC-A Angela Mullin, CPC-H-A Angela Nicole Domst, CPC-A Angela Quinlan, CPC-A Angela Sisti, CPC-A Angie Louise Workman, CPC-A Anil Ahmed, CPC-A Ann Ragan, CPC-A Anna Marecka, CPC-A, CPC-H-A Anna Williams, CPC-A Anne Kukla, CPC-A Anne-Marie Burman, CPC-A Annette Regester, CPC-A Antha Duncan, CPC-A April Jean Martin, CPC-A, CPC-H-A April Kenney, CPC-A April Seyer, CPC-A Ashley Balabanoff, CPC-A Ashley Keel, CPC-A Ashley R Scamahorn, CPC-A Ashley Veale, CPC-A Astrild Maltby, CPC-A Audrey M. Clark, CPC-A Bailey Elysse Walgenbach, CPC-A Barbara Bello, CPC-A Barbara Kemp, CPC-A Becky Tackitt, CPC-A

Newly Credentialed Members

Bernice Hurley, CPC-A Beth Barhoover, CPC-A Bethany Lesman, CPC-A Beverly Canant, CPC-A Bibi Fazia Rahman, CPC-A Bobbe R Cole, CPC-A Bobbi Deutscher, CPC-A Bobbie Harlan, CPC-A Bonique Bier, CPC-A Bonnie Lewallen, CPC-A Bonnie Lynch, CPC-A Bonnie Lynne Boggs, CPC-A Brandi Jay Calhoun, CPC-A Brandi Noonkester, CPC-A Brandon M Knous, CPC-A Brandy Osborne, CPC-A Brenda Arroyo, CPC-A Brenda J Green, CPC-A Brenda Kelly, CPC-A Brenda Thomas, CPC-A Brian Paul Conrad, CPC-A Brittany Fitzgerald, CPC-A Brittany Michelle Wilson, CPC-A Brittany Truax, CPC-A Britteny Roberts, CPC-H-A Brooke Womble, CPC-A Calvin Carlos, CPC-A Candace Nicole Horton, CPC-A Carissa Wetherbee, CPC-A Carla Dietel, CPC-A Carlette L. Gable, CPC-A Carol Ann Frye, CPC-A Carol Jean Mattison, CPC-A Carol Rustici, CPC-A Carol Sullens, CPC-A Carol Vozella, CPC-A Carole Alger, CPC-A Carolyn Conroy, CPC-A Carrie Honora Barker, CPC-A Cassandra Lynn Bagian, CPC-A Cassidy Nelson, CPC-A Catalina Marie Drewery, CPC-A Cathelyn L Spears, CPC-A Catherine D Wagner, CPC-A Catherine Silversey, CPC-A Cathie Harshman, CPC-H-A Cathleen Dickovick, CPC-A Cetera Renee Henry, CPC-A Charlene Braithwaite Lovett, CPC-A Charles Cartwright, CPC-A Cheresa R Burks, CPC-A, CPC-H-A Cheryl Ann Harlow, CPC-A Cheryl Jones Casey, CPC-A Cheryl Lohrke, CPC-A Christie Marie Ramey, CPC-A Christina Elizabeth Lupanow, CPC-A Christina Ruth Diorio, CPC-A Christine K Downes, CPC-A Christine Kenny, CPC-H-A Christopher Adam Wills, CPC-A Christopher Henry Madison, CPC-A Christopher Michael James, CPC-A Christy Black, CPC-A Christy Borgerding, CPC-A Christy D Templeton, CPC-A Christy Lee Youtzy, CPC-A, CPC-H-A Ciara Gibson, CPC-A Cindy Delsignore, CPC-A Cindy Krull, CPC-A Cindy Snodgress, CPC-A Ciro Eduardo Chiquito, CPC-A Coleen Whiteman, CPC-A Colleen F Ruby, CPC-A Colleen Herrington, CPC-A Collette Jensen, CPC-A Connie M Larson, CPC-A Connie McGregor, CPC-A Cori Rocks, CPC-A Courtney Whitley, CPC-A Crissy C Cunningham, CPC-A Crystal Woods, CPC-A Curtis Gratz, CPC-A Cynthia Borgne, CPC-A Cynthia Chester, CPC-A Cynthia Klaus, CPC-A

Cynthia Manchester, CPC-A Cynthia S St Clair, CPC-A Cynthia Smith, CPC-A Daionne Smith, CPC-A Damien Smith, CPC-A Dana Michelle Leonard, CPC-A Daniel Hardcastle, CPC-A Danielle Denae Kinsfather, CPC-A Danielle Leigh Fite, CPC-A Danielle McClanahan, CPC-A Daphne Garner, CPC-A Darman Clement, CPC-A Dave Musacchio, CPC-A David Morrow, CPC-A Davida A Bonner, CPC-A Dawn Jones, CPC-A Debbie Lada, CPC-A Deborah Daly, CPC-A Debra Dulin, CPC-A Debra Grillo, CPC-H-A Debra J Mendick, CPC-A Debra Tucker, CPC-A Dee Maras-Kowalski, CPC-A Deidra Lynne McFaddin, CPC-A, CPC-H-A Deidra Oberlin, CPC-A Dejeanette Nicole Jenkins, CPC-A Delfin Lagsub Lardizabal III, CPC-A Denise Dobbin, CPC-A Denise Levin, CPC-A Denise Szakal, CPC-A Denise Zitney, CPC-A Diana Taylor, CPC-A Diane Hakes, CPC-A Diane Hartley, CPC-A Diane Lynn Johnson, CPC-A Diane M Swanson, CPC-A Diane R Irving, CPC-A Dianna Louise McCarthy, CPC-A Donna Cimino, CPC-A Donna James, CPC-A Donna Jean Lane, CPC-A Donna Leal, CPC-A Dorcas Lardizzone, CPC-A Doylene Gambrell, CPC-A Duane Callicoat, CPC-A E Mischka Hylton-Maxwell, CPC-A, CPC-P-A Ebonye Dortche, CPC-A Eda-Marie DiMassa, CPC-A Edward Wayne Conway, CPC-A Elga Camacho, CPC-A Elise Moore, CPC-A Elizabeth Ann Brennan, CPC-A Elizabeth Baron, CPC-A Elizabeth K Bucholz, CPC-A Elizabeth Lea Hakes, CPC-A Elizabeth Leslie, CPC-A Elizabeth Monetza, CPC-A Ellen Cavalier, CPC-A Ellen Walker, CPC-A Elon Abrams, CPC-A Elysia Dudley, CPC-A Emily Ilene Forshey, CPC-A Emily Pace, CPC-A Erica Lynn Malcott, CPC-A Ericia Nicole Wisdom, CPC-A Erika Emily Blackburn, CPC-A Erika Toni Street, CPC-A Erin Comben, CPC-A Erin M King, CPC-A Erin Marie Klokkenga, CPC-A Essie Carver, CPC-A Eva Stratton, CPC-A Faheem Raza, CPC-A Faith Yarborough, CPC-A Fatima Moledina, CPC-A Felicia A Green, CPC-A Felicia Murray, CPC-A Fonda Gail Fogle, CPC-A Francesco Autera Jr., CPC-A Francoise Hurly, CPC-A Frank Hoffman, CPC-A Frank Scandariato, CPC-A Frederick Carson, CPC-H-A Georgiana Redmon, CPC-A Geraldine K Moloney, CPC-A

Gerry Pape, CPC-A Gilbert Eric Pierre, CPC-A Ginger Adaire Porter, CPC-A Ginger Eisenhardt, CPC-A Gladys Nunez, CPC-A Glen David MacDougall, CPC-A Gretchen A. Mayes, CPC-A Gretchen B Parisi, CPC-A Gumaro Colon, CPC-A Hank Czerwinski, CPC-A Hanna Skibniewska, CPC-A Heather Anne Adamec, CPC-A Heather Colleen Mitchell, CPC-A, CPC-P-A Heather Culbreath, CPC-A Heather Petrone, CPC-A Heather Ruth, CPC-A Heidi Hoard, CPC-A Heidi M Gates, CPC-A Helen Elizabeth Bormann, CPC-A Himani Bhatt, CPC-A Ida Glenn, CPC-A Jacqueline Mona Tyson, CPC-A Jalaire Ruth Machon, CPC-A Jami DeGrave, CPC-A Jamie Ann Kupka, CPC-A Jan S Gowett, CPC-A Jan Walshaw, CPC-A Jane Cravedi, CPC-A Jane Gray, CPC-A Janice Jones, CPC-A Janice Stewart, CPC-A Jason Braspennickx, CPC-A JayneAnn Stewart, CPC-A Jean Musto, CPC-A Jeanette F Two Bulls, CPC-A Jeanie Edwards Bozeman, CPC-A Jeannie M Wolfe, CPC-A Jenise Perez-Dorsey, CPC-A Jennifer Ann Jordan, CPC-A Jennifer Berry Caple, CPC-A Jennifer Boleyn, CPC-A Jennifer Dunkleberger, CPC-A Jennifer Etter, CPC-A Jennifer Greco, CPC-A Jennifer Haag, CPC-A Jennifer Hammonds, CPC-A Jennifer Hawkes, CPC-A Jennifer Heagle, CPC-A Jennifer Hogan, CPC-A Jennifer J Thomas, CPC-A Jennifer L Miller, CPC-A Jennifer Liesch, CPC-A Jennifer Lipscomb, CPC-A Jennifer Lynn Phillips, CPC-A Jennifer M Huntsberry, CPC-A Jennifer Marie Pires, CPC-A Jennifer Massey, CPC-A Jennifer Moorman, CPC-A Jennifer Nicole Miller, CPC-A Jennifer Nicole Payne, CPC-A Jennifer Piller, CPC-A Jennifer R Mathis-McMillin, CPC-A Jennifer Sager, CPC-A Jennifer Spencer, CPC-A Jenny Riggs, CPC-A Jessica Cochran, CPC-A Jessica Danielle Conroy, CPC-A, CPC-H-A Jessica K. Smith, CPC-A Jessica Lee Greenwood, CPC-A Jessica Pluchinotta, CPC-A Jessica Poston, CPC-H-A Jessie K Hahn, CPC-A Jim Baranowski, CPC-A Jo Ann Moser, CPC-A Joanna Farrell, CPC-A Joanne Caporaso, CPC-A Joanne Long, CPC-A Joanne Reed, CPC-A Joel Harris, CPC-A John F. Mancuso, CPC-A John Jerred, CPC-A John Kasey, CPC-A Johnny Webb Jr., CPC-A Jose Luis Abad, CPC-A Jose Roces, CPC-A

Joseph Edinger, CPC-A Josh Leidy, CPC-A Joyce Berube, CPC-A Joyce M Smith, CPC-A Juan Alonso-Echanove, CPC-A Juan Alonso-Echanove, CPC-A Judith Davis, CPC-A Judy MacDonald, CPC-A Julianna Guerra, CPC-H-A Julie L Cass, CPC-A Julie Lucas, CPC-A Julie Lyn Srebot, CPC-A Julie M Chitwood, CPC-A Julie Taylor, CPC-A June Sullivan, CPC-A Justine Valdivia, CPC-A Kandace Huff, CPC-A Kandice F Vickery, CPC-A Karen B Damon, CPC-H-A Karen Denise Hodges, CPC-A Karen Heon, CPC-A Karen Herting, CPC-A Karen Pepper, CPC-A Karen Tassan, CPC-A Karena Belshe, CPC-A Karin Bourque, CPC-A Karin Michelussi, CPC-A Karla Davis, CPC-A Kasey H Taylor, CPC-A Kate Racki, CPC-A Katherine Romberger, CPC-A Katherine Schoonhoven, CPC-A, CPC-H-A Kathleen Baer, CPC-H-A Kathleen Lynn DeLany, CPC-A Kathleen M Sherbrooke, CPC-A Kathleen Oklesson, CPC-A Kathleen R Butera, CPC-A Kathryn Boggetta, CPC-A Kathryn Ferguson, CPC-A Kathryn Pahira, CPC-A Kathy Lynn Tanner, CPC-A Kathy Self, CPC-A Katie Kus, CPC-A Katrina L Johns, CPC-A Kayla Dullum, CPC-A Kayla Nichole Napier, CPC-A Kaylee Cheney, CPC-A Kaytlin Hoyt, CPC-A Keely Cain, CPC-A Kelli McClure, CPC-A Kelly A Schaffer, CPC-A Kelly Aboosamra, CPC-A Kelly Calascibetta, CPC-A Kelly Collado, CPC-A Kelly D Price, CPC-A Kelly Evert, CPC-A Kelly Frattalone, CPC-A Kelly Hunt, CPC-A Kelly Riker, CPC-A Kelly Robinson, CPC-A Kelly Samuels, CPC-A Kelsey Templeton, CPC-A Kenneth R Pendleton, CPC-A Kerry Ann Hom, CPC-A Kevin Prouty, CPC-A Kia Yang, CPC-A Kimber Thomason, CPC-A Kimberly Allen, CPC-A Kimberly Ann Donahue, CPC-A Kimberly Ann Harp, CPC-A Kimberly Ann Kloss, CPC-A Kimberly Cushing, CPC-A Kimberly Ecker, CPC-A Kimberly Kay Pardon, CPC-A Kimberly S Chatman, CPC-A Kimberly Seegan, CPC-A, COBGC Kimberly Stewart, CPC-A Kiwanis Denise Atkins, CPC-A Kiya McConnell, CPC-A Kristen M Ottaviani, CPC-A Kristen Nicole Wilson, CPC-A Kristen Norling, CPC-A Kristie Krouse, CPC-A Kristin Barber, CPC-A Kristina Josephine Ruggirello, CPC-A

www.aapc.com

Kristy Reyes, CPC-A Lacey Ragsdale, CPC-H-A Lanitha Walters, CPC-A Larisa K Crawley, CPC-A Latasha Bennett, CPC-A Latchmin Persaud, CPC-A Latoya Green, CPC-A Laura A Diters, CPC-A Laura DeVault, CPC-A Laura J Elliott, CPC-A Laura Jean Rankin, CPC-A Laura Marie Bachman, CPC-A Lauralee Ann Oppold, CPC-A Lauren E Ezzo, CPC-A Lauren Elizabeth-Shaw Braico, CPC-A Lauren Miller, CPC-A Laurie Izzo, CPC-A Laurie L Bolte, CPC-A Laurie Madden, CPC-A Laurie Mastrosimone, CPC-A Laurie Tribfelner, CPC-A Lawrence Matthews, CPC-A Lee David Stirling, CPC-A Leigh Register, CPC-A Lelia Clark, CPC-A Leonie Esselbach, CPC-A Leonila M Jewell, CPC-A Lesa Skinner, CPC-A Leslie Ast, CPC-A Liberty Leadman, CPC-A Lillian Kim, CPC-A Linda Blum, CPC-A Linda Burrell, CPC-A Linda Foote, CPC-A Linda J Lewis, CPC-A Linda Louise Dixon, CPC-A Linda M Shady, CPC-A Linda Peay, CPC-A Linda Regan, CPC-A Linda Slagle, CPC-A Lindsay Cheser, CPC-A Lindsey A St. Lawrence, CPC-A Lindsey Ann Gatlin, CPC-A Lindsey Hansen, CPC-A Lisa Anne George, CPC-A Lisa Cantero, CPC-A Lisa Clinton, CPC-A Lisa Davila, CPC-A Lisa Ellen MacKay, CPC-A Lisa Freeman, CPC-A Lisa M Burgett, CPC-A Lisa Mahler, CPC-A Lisa Martin, CPC-A Lisa Moore, CPC-A Lisa Ream, CPC-A Lisette Andrades Busby, CPC-A Lorena Jimenez, CPC-A Lori Chandler Vowell, CPC-A Lori Collins, CPC-A Lori Lynn Epstein, CPC-A Lori Rene Holthaus, CPC-A Lori Weiss, CPC-A Louise Vadeboncoeur, CPC-A Lucile Lind, CPC-A Lucinda Perrineau, CPC-A Lucy Riddle, CPC-A Luella Clark, CPC-A Lynne Mary Kahn, CPC-A MacKenzie Miller, CPC-A Manaswini Kumaraswamy, CPC-A Margani Deepthi, CPC-A Margaret Lynne Ulatowski, CPC-A Margaret M Peskind, CPC-A Margaret Tichelaar, CPC-A Marhia McAndrew, CPC-A Maria Isabel Colon, CPC-A Maria Iwinski, CPC-A Maria Ojeda, CPC-A Maria Regacho, CPC-A Marianne Elizabeth Graham, CPC-A Marilyn M Hammond, CPC-A Marlene Frost, CPC-A Marli Tuxill Vincent, CPC-A Marsha Deem, CPC-A Martha Walter, CPC-A

September 2011

39

Newly Credentialed Members

Mary Denise Rebman, CPC-A Mary Kiely, CPC-A Mary Renee Walkup, CPC-A, CPC-P-A Marybeth Park, CPC-A Mathew Allen Narvadez Atencion, CPC-A Megan Jolly, CPC-A Megan Luce, CPC-A Megan Marsh, CPC-A Meggan Shenefield, CPC-A Meghan Elise Rogers, CPC-A, CPC-H-A Melissa Anne Smallwood, CPC-A Melissa Campbell, CPC-A Melissa Carruthers, CPC-A Melissa Crist, CPC-A Melissa Mason, CPC-A Melissa McClintick, CPC-A Melissa Small, CPC-A Mendie Elizabeth Cleveland, CPC-A Meredith A McKenzie, CPC-A Meredith Adams, CPC-A Meredith Greene, CPC-A Merikay Anderson RN, CPC-A Micaela Archuleta, CPC-A Michele Knighton, CPC-A Michele Rhea, CPC-A Michele Spiel, CPC-A Michele Suris, CPC-A Michelle A Gerome, CPC-A Michelle Ausdemore, CPC-A Michelle Bolo, CPC-A Michelle D Quinn, CPC-A Michelle Guerrero, CPC-A Michelle Hoffman, CPC-A Michelle Johnson, CPC-A Michelle Lynn Shannon, CPC-A Michelle McDonald, CPC-A Michelle Meche, CPC-A Michelle Moore, CPC-A Michelle S Pavon, CPC-A Michelle Shupe, CPC-A Michelle Talbot, CPC-A Michelle White, CPC-A Migdalia Garcia, CPC-A Misty Lingle, CPC-A Mohan Achary Gannoju, CPC-A Molly D Cunningham, CPC-A Monica Sanzo, CPC-A Monique S Carter-Walker, CPC-A Nancy Gasper, CPC-A Nancy Jewell, CPC-A Nancy Senff, CPC-A Natalie Hamrick, CPC-A Nataliya Byndas, CPC-A Nawzad Hanna, CPC-A Ngoc Son Tra, CPC-A Nichole T Foster, CPC-A Nicki Bunce, CPC-A Nicole B Williams, CPC-A Nicole Bridgette Briggs-Gary, CPC-A Nicole Donelson, CPC-A Nicole Hill, CPC-A Nicole Pringle, CPC-A Nilsa Lange, CPC-A Noreen Mary Franklin, CPC-A Norma J Carey, CPC-A, CPC-H-A Pam Mommsen, CPC-A Pamela Babcock, CPC-A Pamela Robbins, CPC-A Patricia Campbell, CPC-A Patricia Cuervo, CPC-A Patricia Dillon, CPC-H-A Patricia Elaine Ewell, CPC-A Patricia M Larsen, CPC-A Patricia Murphy, CPC-A Pauline Rounds Laselle, CPC-A Periann Palmer, CPC-A Pushpa Karri, CPC-A Quennie Bonney, CPC-A Quintina T Lee, CPC-A

40

AAPC Coding Edge

Rachael Noffke, CPC-A Rachel Kathryn Cheeseman, CPC-A Rae Ann Shearman, CPC-A Raghu R. Vats, CPC-A Ramona Liedtke, CPC-A Randi Hartman, CPC-A Rebecca Elizabeth Tomes, CPC-A Rebecca Gretz, CPC-A Rebecca L Fain, CPC-A Rebecca Lee Hooks, CPC-A Regan Dunlap, CPC-A Renee Nicole Ware, CPC-A Rhonda Gail Waller, CPC-A Rhonda Starck, CPC-A Richard LeFave, CPC-A Rita R Kichenamourty, CPC-A Robin Lee Durrell-Newcomb, CPC-A Robin S Wheeler, CPC-A Rochelle Royse, CPC-A Rocquel Graves, CPC-A Ron M. Varner, CPC-A Ron Ristau, CPC-A Rose M Kolvek, CPC-A Rose Marie Bernstein, CPC-A Rowena Ablong, CPC-A Ruth Ann Spivey, CPC-A Ruth Furnier, CPC-A RyAnn Henry, CPC-A Rylee Marie Quigley, CPC-A Sabra Brinkley, CPC-A Sabrina Dean, CPC-A Salinda Wright, CPC-A Samantha Kathleen Murray, CPC-A Samantha Trujillo, CPC-A Sandra Kay Keck, CPC-A Sandra Lynette Nolan, CPC-A Sandra Lynn Miller, CPC-A Sandra S Papajcik, CPC-A Sandra Umensetter, CPC-A Sandy Bustamante, CPC-A Sandy Lea Snarr, CPC-A Sandy Thompson, CPC-A Sara Bell, CPC-A Sara Nichole Watson, CPC-A Sarah Dowell, CPC-A Sarah F Wade, CPC-A Sarah Gafford, CPC-A Sarah White Darnold, CPC-A Sean M. Rockett, CPC-A Sean Scruggs, CPC-A Senait Mussie, CPC-A Shandoah Janco, CPC-A Shannon Nicole Cappsn Dixon, CPC-A Sharlae Rich, CPC-A Sharon Comstock, CPC-A Sharon Diane Robbins, CPC-A Sharon Gray Dumas, CPC-A Sharon Huber, CPC-A Sharon Koons, CPC-A Sharon Marie Judge, CPC-A Sharon Mcbee, CPC-A Sharyl Anne Leingang, CPC-A Shawn Philip Butz, CPC-A Shawn Stover, CPC-A Shayla Carter, CPC-A Sheela Krishnamony, CPC-A Sheena Lalita Basdeo, CPC-A Shellie Ranae Davis, CPC-A, CPC-H-A Sheree Volak, CPC-A Sheri L Anderson, CPC-A Sherri McKibbin, CPC-A Sherri Michaels, CPC-A Sherrie Peterson, CPC-A Sherrie Price, CPC-A Sherry L Lacabanne, CPC-A Sherry Loy, CPC-A Sherry Nicholson, CPC-A Sheryl Dutton, CPC-A Solveig Kristiansen, CPC-A

Stacy Lynn Hannahs, CPC-A Stacy Nicole Minor, CPC-A Stefany Cesarsky, CPC-A Stephanie Dorsey, CPC-A Stephanie Fitzgerald, CPC-A Stephanie Hudson, CPC-A Stephanie Keegan, CPC-A Stephanie Lynn Waugh, CPC-A Stephanie Mathis, CPC-A Stephanie Sharpe, CPC-A Stephanie T Baumert, CPC-A Stephen Darnell Cannon, CPC-A Stevan Barnard, CPC-A Steve Geiger, CPC-A Sue M Krysztopa, CPC-A, CPC-H-A Susan Ann O’Connor, CPC-A Susan C Francis, CPC-A Susan Cacioppe, CPC-A Susan Donna O’Keefe, CPC-A Susan E Wilson, CPC-A Susan Grove, CPC-A Susan Naiss, CPC-A Susan Powers, CPC-A Susan R Borger, CPC-A Susanne Gendreau, CPC-A Suzanna L Bailey, CPC-A Suzanne LaBombard, CPC-A Suzanne Myers, CPC-A Tammy D` Parker, CPC-A Tammy Droke, CPC-A Tammy Goldstein, CPC-A Tammy Paffhausen, CPC-A Tanda L. Gerleve, CPC-A Tanya Johnson, CPC-A Tanya L Strait, CPC-A Telane Hill, CPC-A Tennielle Marie Shumski, CPC-A Teresa Banyai, CPC-A Teresa Benter, CPC-A Teresa Kissel, CPC-A Teresa Mays, CPC-H-A Teresa Nichole Presnell, CPC-A Teri Johnson, CPC-A Terri B. Sims, CPC-A Terry Cox, CPC-A Thelma L Joiner, CPC-A Theresa B Wilson, CPC-A Theresa Booker, CPC-A Threes Toscano, CPC-A Tiffany Bobbitt, CPC-A Tiffany Crump, CPC-A Tiffany Oyler, CPC-A Tiffany R. Isom, CPC-A Tina Kiefer, CPC-A Tina Quinby, CPC-A Tina S Hall, CPC-A Tina Truelove, CPC-A Tina White, CPC-A Tolly Esser, CPC-A Toni DiMenna, CPC-A Tonya R Carroll, CPC-A Torey Delbridge, CPC-A Toula Christoulakis, CPC-A Tracey Long, CPC-A Traci M DeMus, CPC-A Traci Robnett, CPC-A Travis Smilowski, CPC-A Trevor LaChapelle, CPC-A Tricia Y Garcia, CPC-A Trina Pitsch, CPC-A Tyler Downing, CPC-A Tynesha White, CPC-A Tyrone Williams, CPC-A Vadim Chernushkin, CPC-A Vanessa Clay Harrod, CPC-H-A Vanessa Nieves, CPC-A Velecia Nichole Covington, CPC-A Vemuganti Srihitha, CPC-A Vern Avritt, CPC-A

Verna Wilson, CPC-A Vicki J Bourg, CPC-A Vickie Pierce, CPC-A Victoria D Hardin, CPC-A Victoria L de Charmoy, CPC-A Victoria L de Charmoy, CPC-A Vita Ingold, CPC-A Vivian E Donahoe, CPC-A Vivian Kim, CPC-A Wanda Bushey, CPC-A Wendy Boyd, CPC-A Wendy Lee Byerley, CPC-A, CPC-H-A Wendy Livingston, CPC-A Wendy M Rosson, CPC-A Wendy McDaniel, CPC-A Wendy Michelle Lawrence, CPC-A Wendy Sedlacek, CPC-A Wilhelmina B Bennett, CPC-A Willadean R Cole, CPC-A William Hanson, CPC-A William Thomas, CPC-A Yahira Cook, CPC Yecelia Montalvo, CPC-A Yen-Chun Chen, CPC-A Yolanda D Stevenson, CPC-A Yvonne Harris, CPC-A

Specialties Alaina Michelle Boncher, CPC, CPMA Angela Angela Sue Niemi, CFPC Angela Joyce Heil, CPC, CEMC, COBGC Angela M Miller, CPC, CPMA, CEMC Anna Maria Alberghini, CPC, CPC-H, CPC-P, CPMA Annabelle Garcia-Wurtz, CPEDC Cathy Regina Smith, CPC, CEMC Darcey Bub, CASCC Darlene Johnson Lovett, CPC, CPMA Dawn G. Baca, CPC, COBGC Deanna Anderson, CPC, CEMC Deborah A Messinger, CPC, CPMA Deborah Felisky, CIRCC Denise A DiMauro, CPC, CPC-H, CPMA Dilbri Nunez, CPC, CGSC Ellen Risotti, CPC, CEMC, CFPC Emily Palmer, CPC, COBGC Gisele M Lessard, CPC, CEMC, CPEDC Greydis Maleta, CPC, CPMA, CGIC Holly Doyle, CPC, CEMC Iman Khella, CPC, CGIC Jan M Yoder, CPC, CPC-P, CEMC Jarod Rybacki, CPC, CPMA, COSC Jeanette Seesholtz, CPC, CIRCC Jennifer Redline, CPC, CPMA Jody Amos, CPC, CEMC Josephine Yakowec, CPC, CIRCC Julie Lynn Harman RN RCC, CPC, CIRCC Kara Woods, CPC, CFPC Kathleen Stark, CIRCC Kathy Walker, CPMA Kim L Christensen, CPMA Kimberly A Cologgi, CPC, COSC LaTrece Michelle Freeman-Baker, CPC, CPCO, CPMA Laurene Ann McAuley, CPC, CPMA, CEDC Linda Davis Montgomery, CRHC Linda R Melville, CRHC Lisa C Williams, CPC, CEMC Lynn Hefflefinger, CPC, CEDC Marilyn Johnson Jackson, CPC, COBGC Mary B Cremers, CPC, CHONC Mary McGhee, CEMC Melissa Baker, CPC, CPMA Merrilyn T Schroeder, CPC, CPMA Michelle Fruth, CPC, CPMA Michelle T Zakic, CPC-P, CPMA Nera Kathleen Benton, CPC, CPMA

Olivia Price, CPC, CCC Raeann Kelemen, COBGC Rebecca Kramer, CPC, CEMC, CHONC Rebecca Lynn Shoemaker, CRHC Regina (Jeannie) M Ryder, CPC, CEMC Richard White, CIRCC Robbiejean Miller, CPC, CPC-H, CPMA Roxanna Menger, CPC, CEMC Sandi Rabenberg, CFPC Sandra A Steele, CPC, CPMA, CEDC Sandra Lorena Rodriguez, CPC, CPC-H, CPMA Sandra Terrell Jones, CPC-A, CEMC Shannon Menzer, CPC, CEMC Sharon A Shover, CPC, CEMC Sharon A Stotsky, CRHC Stephanie Jordan, CPC-A, COBGC Stephanie M Elliott-Ring, CPC, CPMA Susan L DeLancy, CPC, CEMC Susan Mary Sadlocha, CPC-A, CANPC Suzanne Santellanes, CPC, CPMA Svetlana Rozinski, CPC, CUC Tamara L Martinson, CPC, CEMC Tammie Costello, CPC, CPMA Tara Davis, CUC Tonya Likisha Stevens, CPC, CPMA Toyomi T Korde, CPC, CPC-H, CPMA Trina Haney, CPC, CPMA Wanda Hamrick Rogers, CGSC Wendy L Owens-Frierson, CPC, CPCO, CPC-I

Magna Cum Laude Alexis Leah Gee, CPC Amy Elizabeth Tripp, CPC-A Amy Reed, CPC-A April Woznicki, CPC-A Ashley Alexandra Tohill, CPC Cammie Lindner, CPC Catherine Mercado Foster, CPC-A Chris Honkala, CPC Christie Plummer, CPC Courtney A Stark, CPC-A Davaryne Diaz, CPC-A Dawn Eldredge, CPC-A Debra B. Bashlor, CPC Dorinda Ann Novak, CPC Elizabeth Bumgarner, CPC-A Jacqueline Dunleavey, CPC-A Jenny A Hirschfeld, CPC Jillian DiFilippo, CPC-A Kelly A Pierson, CPC Kristy Read, CPC-A Lara Eastmer, CPC Larissa K Vodicka, CPC-A Laura Kissinger, CPC Laura Matheny Talley, CPC Leslie Hines, CPC-A Lisa M Luma, CPC Lori K Carbonell, CPC Lynda Meiliea Chambers, CPC Micah King, CPC-A Michelle Lynn Garner, CPC Nancy M Steinke, CPC, CPC-H Nancy Prose, CPC-A Nathalie Woodhouse, CPC Patricia Herrick, CPC Pauline Bryant, CPC-A Rachel Obenschain, CPC Richard Anthony Loechinger III, MD, CPC Sarah E Ibero, CPC-A Sarah Maria Matton, CPC Sharon L Long, CPC-A Tammy Lynn Miller, CPC Theresa Marie Irlbeck, CPC Tiffany C. Harris, CPC Ume Ume, CPC Viswanatha Juvvala Reddy, CPC

Expert

Hot Topic

By G.J. Verhovshek, MA, CPC

Two Codes Confuse Monoclonal Antibody Injection Reporting Determine whether 96372 or 96401 is the correct code to use.

S

everal threads in an AAPC online forum, as well as inquiries from Coding Edge readers, have questioned whether 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular or 96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic is correct to report monoclonal antibody injections. To find an answer, let’s first review what CPT® says about each of these codes. CPT® defines a therapeutic, prophylactic, or diagnostic injection (96372) as requiring “direct physician supervision” and, typically, “special consideration to prepare, dose or dispose of … practice training and competency for staff who administer infusions, and … periodic patient assessment.” Administration as reported using 96401 is a more involved service, requiring “advanced practice training and competency for staff who provide these services … and commonly … significant patient risk and frequent monitoring,” as well as other considerations (such as frequent changes in the infusion rate). The greater intensity of 96401 is reflected in a significantly higher non-facility relative value unit (RVU) total of 2.01, versus 0.68 RVUs for 96372. The greater intensity of 96401, as compared to 96372, is a function of the type of drug(s) administered during each service. CPT® parenthetical instructions direct the use of 97372 for “non-antineoplastic hormonal therapy injections,” excluding injections for allergen immunotherapy (95115-95117). Code 96401 may be used for a variety of drugs, including:    non-radionuclide anti-neoplastic drugs    anti-neoplastic agents provided for treatment of noncancer diagnoses    certain monoclonal antibody agents and other biologic response modifiers CPT® does not specifically identify those “certain monoclonal antibody agents and other biologic response modifiers” that would qualify under 96401.

Since 2006, the Centers for Medicare & Medicaid Services (CMS) has allowed reporting 96401 for non-chemotherapy monoclonal antibody agents and biologic response modifiers, as spelled out in the Medicare Claims Processing Manual, chapter 12, section 30.5.D. Unlike CPT®, CMS provides examples of such drugs, to include infliximab, rituximab, alemtuzumb, gemtuzumab, and trastuzumab, as well as leuprolide acetate and goserelin acetate. The manual goes on to state, however, “The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes. Local carriers may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare.” In other words, CMS does not require that carriers recognize 96401 for all monoclonal antibodies. And, third-party payers are free to ignore either CMS or CPT® instruction. The bottom line is: Whether you should report monoclonal antibodies using 96372 or 96401 is almost entirely at the payer’s discretion, and may vary from one specific drug to another. Under CPT® guidelines, those drugs that require a more substantial level of service should qualify for 96401, and drug manufacturers often offer advice as to correct coding—but the only way you can be certain you are coding correctly is to check with your payer. If your payer does not have a formal policy regarding a certain drug, ask for its coding directions in writing. G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

www.aapc.com

September 2011

41

4th Annual 2012 Medical Coding Update and Reimbursement Conference

CODINGC N December 1-3, 2011 • Buena Vista Palace, Orlando, FL

Join industry experts in this much-anticipated multi-specialty conference that will provide you the tools you need in correcting codes from the start, avoiding claim denials, maximizing your productivity and increasing your practice’s bottom-line.

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Registration Fees Main Conference Sessions .............................................. $995 Pre-Conference Workshop .............................................. $400

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Alumni Discount Participants of any previous Coding Conferences event get an additional $30 OFF! Call 1-866-251-3060 to speak to a Conference Specialist today. *Main Conference & Workshop Bundle

Professional

Featured Coder

By Brenda Chidester-Palmer, CPC, CPC-I, CEMC, CASCC, CCS-P

Three Tidbits Help You Code Lesion Biopsy and Removal As always, careful review of the documentation is necessary for correct coding, as well. When documented by a physician, the simple statement “removal of lesion” can lead to many different coding choices. To choose the correct code, you will need three precise pieces of information: 1. The type of lesion 2. The location of the lesion 3. The exact service performed (e.g., biopsy or excision) Lesion, mass, and lump are common terms physicians use when planning a biopsy or excision. Lesions can be benign or malignant, cysts or tumors, or even warts or skin tags. In most cases, you will not know if a lesion is malignant or benign until the pathology report is final. Waiting for the path report is key to proper code selection.

Biopsy Occurs for Pathology Exam Only A biopsy removes only part of a lesion for study by a pathologist. An excision or removal, by contrast, eliminates the entire lesion/neoplasm. The removed lesion also will be sent to the pathologist for biopsy. Physicians often will document, “removed and biopsied a lesion.” This does not mean you may bill both a biopsy and an excision. Rather, the biopsy will be included in the excision and is not separately reportable. For example, the physician removes what appears to be a benign lesion from the arm. She sends the tissue to pathology to be sure it is not cancerous. In this case, you would report the proper excision code and the correct pathology (ICD-9-CM) code, but not the biopsy procedure code. CPT® 11100-11101 describe biopsy, or taking of a specimen for pathologic purposes only. The intent is not to remove the entire lesion or area, although the total lesion may be removed, at times. Other biopsy codes throughout the surgery subsections are not for biopsy of lesions, but for biopsy of actual muscle, or a part of the lip.

For example: 20200

Biopsy, muscle; superficial

20205



40490

Biopsy of lip

40808

Biopsy, vestibule of mouth

50200

Renal biopsy, percutaneous, by trocar or needle

deep

Many physicians use the term “shave biopsy.” This can be confusing when coding because there is not a CPT® with this exact verbiage. Your choices include 11100-11001 (biopsy) or the 11300-11313 shave excision codes. Careful review of the documentation and/or query of the physician is necessary for correct coding.

Removal Can Occur by Various Methods Removal can occur by freezing with liquid nitrogen, shave excision, excision, or destruction—basically, any form of removal that the physician performs. Ligature strangulation is a removal technique used mainly on skin tags. The physician loops suture material into a circle, places the circle over the pedicle, and pulls tight to sever the skin tag. Correct www.aapc.com

September 2011

43

Featured Coder

Physicians often will document, “removed and biopsied a lesion.” This does not mean you may bill both a biopsy and an excision. CPT® codes for this type of removal are 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions and +11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure). Note that 11200 and +11201 describe skin tag removal by any method, including chemical destruction, electrosurgical destruction, or any combination of methods. In other words, skin tag removal code selection is not based on the removal type, but on the number of lesions removed. Paring or cutting (also called peeling or scraping) is a technique used for benign hyperkeratotic skin lesions, such as corns or calluses. A small spoon or ring-shaped instrument (curette), or similar sharp instrument, is used to gently scrap or pare the lesion. Bleeding is controlled by a chemical applied to the surface after removal. CPT® 11055-11057, depending on the number of lesions removed, describe this service. For example, a patient presents with painful corns on the fifth toe of her left foot and the fourth toe of her right foot. The physician pares or scrapes off the corns in several layers. The correct code is 11056 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions because two corns are removed.

Shave excision is not a full thickness dermal removal, but involves a transverse incision or horizontal slicing to remove the lesion just to the level of the skin. This removal technique does not require suture closure of the defect. Chemical or electrocauterization of the wound is included to control the bleeding. Code selection is based on anatomic location and size: • 11300-11303 (trunk, arms, or legs) • 11305-11308 (scalp, neck, hands, feet, genitalia) • 11310-11313 (face, eyelids, nose, lips, mucous membranes) Measurement should include the lesion only; margins are not included in this type of removal. For example, a patient presents with a 1.0 cm benign lesion on the right wrist, which has been irritated by his watchband. The physician injects the area with Lidocaine and makes a transverse incision to remove the lesion to the skin level. Chemical is applied to control bleeding. In this case, the correct code is 11301 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm.

Table A Electrofulguration

Electrodessication

Electrocoagulation

Electrosection

Does not touch lesion

Lesion touched with electrode

Deeper tissue destruction

Cuts tissue

Distance of 2-3 mm

Bursts are longer (2-4 sec)

Lesion may not be touched

Solid state current

Short bursts (2-3 sec)

Current intensity slightly increased

High current

Simultaneous hemostasis

Deep necrosis

Delayed healing

Table B Destruction Codes – Benign/Other

Destruction Codes – Malignant

17000-17004 Premalignant lesions (AKs)

17260-17266 Trunk, arms or legs

17106-17108 Cutaneous vascular proliferative lesions

17270-17276 Scalp, neck hands, feet, genitalia

17110-17111 Benign lesions other than skin tags or cutaneous vascular lesions

17280-17286 Face, ears, eyelids, nose lips, mucous membrane (Lesion ranges are by cm, beginning from 0.5 cm to over 4 cm)

17250 Chemical destruction granulated tissue

Table C Benign

Malignant

11400-11406 Trunk, arms, or legs

11600-11606 Trunk, arms, or legs

11420-11426 Scalp, neck, hands, feet, genitalia

11620-11626 Scalp, neck, hands, feet, genitalia

11440-11446 Face, ears, eyelids, nose, lips, mucous membrane

11640-11646 Face, ears, eyelids, nose, lips

44

AAPC Coding Edge

Featured Coder

Coding Lesion Ablations Destruction means ablation: The lesion is completely destroyed, leaving nothing to send to pathology. This form of removal can be used on benign and malignant lesions, as well as warts, condylomata, or other lesions. Destruction can be performed by several methods: • Currettage is performed using a spoon shaped instrument to scrape or scoop out the lesion in pieces. This technique can be performed alone, or with chemical or other types of destruction. • Chemical destruction involves applying chemicals directly (by brush, swab, or injection) to a lesion. Typically, the chemicals used are liquid nitrogen (LN2), trichloracetic acid, cantharidin (on warts), and salicylic acid. Chemical destruction is used when the lesion is sure to be benign, or for malignant lesions when the cancer is known to be in-situ (not spread to surrounding tissues). • Electrosurgical destruction is a general term that encompasses the different procedures using electrically generated heat. There are many types of electrosurgery, as seen in Table A on the preceding page. • Lasers can be used to destroy lesions or warts, but this is not the preferred method. Coding for destruction of lesions is not based on the method of destruction. Instead, it is based on the type and location of the lesion(s), and how many are being destroyed. Under the Destruction subheading in CPT®, there are two categories: Benign or Premalignant Lesions and Malignant Lesions, Any. As shown in Table B, codes are specific for lesions in certain anatomical sites. If there is not a code in a specific section, you would instead use codes from the integumentary section. For example: 30117

Excision or destruction (eg, laser), intranasal lesion; internal approach

40820

Destruction of lesion or scar of vestibule of mouth by physical methods (eg laser, thermal, cryo, chemical)

45190

Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach

Differentiate Skin vs. Soft Tumor Excision Surgical excision requires an incision, several types of which you may see documented in the procedure or operative note (e.g., longitudinal, elliptical, or transverse). The incision, or approach, tells us whether this was a skin lesion or a deeper mass (different CPT® codes describe a lesion on the skin versus a mass in the soft tissue). You also need to know the size of the lesion(s). In coding for skin lesion removal, there are codes for benign lesions and malignant lesions (as shown in Table C). These are further divided by size of the excision and anatomical location.

Another factor in choosing the correct code for skin lesion removal is the area, or margin, around the lesion that also was excised. Add this area to the lesion size and select the code based on the total sum of the margin and the lesion. For example, the patient has a 2.4 cm malignant lesion on the upper right arm, with involvement of surrounding skin/tissue. The lesion is excised along with a 1.5 cm surrounding margin. The lesion and margin added together equal 3.9 cm, so we would choose 11604 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm. If an incision is made to remove a mass or tumor in the subcutaneous tissue or below, code from a different subsection entirely. The type of lesion/mass and where it is located are determining factors. Codes for excision are found all throughout the musculoskeletal system: neck and thorax; back and flank; abdominal wall; shoulder, upper arm and elbow area; forearm and wrist; hand and fingers; pelvis; thigh or knee area; lower leg or ankle area; and, foot and toe area. These codes are selected based on the lesion or mass being subcutaneous or subfascial and on size (< or > 2 cm). Example codes include 21011-21012, subcutaneous of face or scalp; 21013-21014, subfascial face or scalp; and, 21015-21016, radical (malignant) face or scalp. There are also codes for this type of excision throughout the surgery subsections. Some of these codes are divided based on repair type (if necessary). For example: 40810

Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair

40812



with simple repair

40814



with complex repair

For example, a patient presents with a lesion on the anterior portion of the tongue. The physician decides to remove the lesion and send to it pathology. The physician injects the area with Lidocaine, makes an elliptical incision around the lesion, and removes the lesion entirely. The area is closed with a simple suture using Vicryl. In this case, the correct code is 41112 Excision of lesion of tongue with closure; anterior 2/3. This code includes the excision and the closure, so a separate repair code would not be reported. Although outside the scope of this article, you must be sure that your diagnosis (ICD-9-CM) coding matches the CPT® codes being billed. For example, you should not bill for an excision of a cyst with a diagnosis of a malignant lesion or wart. Correct coding of both procedure and diagnosis is the key to getting correct reimbursement. Brenda Chidester-Palmer, CPC, CPC-I, CEMC, CASCC, CCS-P, has 17 years of coding and billing experience. Brenda is the principal of Palmer Coding Consultants, and former coding compliance manager for a large multi-specialty group practice in Houston. She is PMCC instructor, AAPC workshop and national conference presenter, past president of her local AAPC chapter, and a former member of the AAPC National Advisory Board (NAB).

www.aapc.com

September 2011

45

Coder’s Voice

Professional

By Jeanne Yoder, RHIA, CPC, CPC-I, CCS-P

Be a Successful Coding Instructor Tips for making an effective presentation and engaging your students.

N

ot all teachers are alike—nor are all students, classrooms, or topics. In a perfect world, the teacher is interesting and makes learning fun. Students are alert and engaged. The classroom is neither too hot nor too cold. The presentation is at the students’ level, and takes them to the next level. Plus, the class is conveniently located, priced reasonably with lunch included, and earns students continuing education units (CEUs). Perfection may be too much to ask, but there are common traits that make for an effective presentation. For those of you who are—or would like to be—a coding instructor, here are some tips and truisms to improve your odds for success: ll Introverts make excellent teachers. Teaching is not interacting with 80 of your new best friends. It is talking to one or two individuals with 78 or 79 others listening in. In my experience, most coders are introverts (as am I), so you will have something in common with many of your students. ll Start with what you know. You know all sorts of coding-related information that other coders don’t know, but would like to. Start with what you know, or would like to know. ll Build confidence. Volunteer to teach small groups, such as your AAPC local chapter. As you improve, look for other venues, but don’t limit yourself to coding meetings. I’ve presented at physician, billing, and data quality meetings, as well as at state and national coding conventions. Try video or audio conferencing, as well. ll Teaching well takes practice. After every class, determine what worked and what could be improved. Adjust your presentation for the next class, and practice it in front of a mirror. If you’re doing anything to distract students—pushing hair behind your ear, chewing your lower lip, etc.—work to correct yourself. ll Find out about your class. How advanced are they? Why are they attending, and what do they want to learn? It is easier to teach students who want to be there than those who are required to be there. ll Tell your class what to expect. Provide an agenda with your objectives and approximate times. Explain how success will be measured. Students want to know what is going to happen. It reduces stress and makes it easier for them to learn.

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AAPC Coding Edge

ll Prepare. Plan at least 10 hours of research/study for the initial hour of instruction, and four hours of research/study for each additional hour of instruction. Review your lesson plan the night before and, if possible, again before class. The more comfortable you are, the more comfortable your students will be. Be prepared to adjust the lesson based on class response. ll Test your equipment. Check the classroom, audiovisual, and your displays/exhibits in advance to be sure that everything works as planned. Remember: If you plug the toaster into the same circuit as the audiovisual equipment, and the toaster stops working, you’ll need a very long extension cord. ll Use handouts. These may be as simple as printouts of PowerPoint slides, three to a page. Handouts allow students to take notes (to reinforce learning), to look ahead (remember not to put answers in the printouts), and to judge how much longer before break. ll Begin on time. If for some reason you start late, find out from the meeting coordinator if you should give your entire presentation or adjust it to stay on schedule. If you’ve practiced your material, you know about how long each section takes. You don’t need to cover all your material, as long as you end at a logical point and let the students know what is happening. ll Begin with something the students know and build on it. Start a new concept only after you have laid the foundation. If students are puzzled, go over the same topic using a different approach. Once students grasp the concept, quickly move on. ll Use relevant, concrete examples. If you can make the examples fun, all the better. ll Keep moving along. Don’t hold up the class for one student who does not understand. Consider working with him or her during the break. ll Get students involved. The more involved students are, the more they learn and remember. Give them exercises to work on, and have them code examples. Application gives students confidence that they can do the task. By reviewing students’ work, you can assess their comprehension. Based on this, you will know if they are ready for more advanced material.

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

Coder’s Voice

If you’re doing anything to distract students—pushing hair behind your ear, chewing your lower lip, etc.— work to correct yourself. ll When using slides, use bulleted catch phrases to generate interest. “The tail wags the dog” will get more attention than “sometimes medical decisions are not based on medicine.” ll You may not succeed with all students. Some students will be distracted or unprepared. Some may be turned off by your humor even if it makes class fun for others. Some will not understand your examples, or will expect you to pronounce every medical term correctly. Make your best effort, but remember that adult students have as much responsibility for learning as you do for teaching. ll Watch other teachers. Notice how they use their voice, facial expression, eye contact, gestures, and other movements. Notice how students respond, and adopt what works.

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ll Speak conversationally. Use simple words and short sentences. These steps will start you on the path to becoming a good teacher. Other, more advanced, steps include preparing measurable objectives, organizing the presentation, limiting the material to be covered, selecting applicable teaching methods, and classroom setup. With practice, you too can share knowledge and advance your colleagues’ skills. Jeanne Yoder, RHIA, CPC, CPC-I, CCS-P, is retired from the U.S. Air Force and is now a contractor working for the TRICARE Management Activity. She presented at the 2006-2009 AAPC national conferences. Her goal is to have quality data to help make quality decisions.

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September 2011

47

Coding Compass By Marcia L. Brauchler, MPH, CPC-P, CPC-H, CPC-I, CPHQ

Review Your HIPAA Compliance Now Part 2: Update your security policies. Recent changes to the Health Insurance Portability and Accountability Act (HIPAA) mean that all health care practices and facilities should be reviewing their processes to ensure compliance. Enhancements under the American Recovery and Reinvestment Act (ARRA) of 2009 have strengthened both the Privacy Rule (see part 1 of this series, “Review Your HIPAA Compliance Now,” in the August Coding Edge,) and the Security Rule, which we’ll cover here.

ePHI Must Be Secure The Security Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting electronic personal health information (ePHI). ePHI is any protected health information that is stored, accessed, transmitted, or received electronically. Examples of electronic media are: computers, laptops, disks, memory sticks, smart phones, personal digital assistants (PDAs), servers, disk drives, network systems, email, websites, etc. Like the Privacy Rule, the Security Rule defines “confidentiality” to mean that ePHI should not be made available, nor disclosed, to unauthorized persons. The Security Rule promotes two additional goals of maintaining the integrity and availability of ePHI. Under the Security Rule, “integrity” means that ePHI is not altered or destroyed in an unauthorized manner; and “availability” means that ePHI is accessible and usable on demand by an authorized person. Flexibility for how a practice complies with the Security Rule is allowed based on the office’s size and resources. But all covered

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AAPC Coding Edge

entities must review and modify their security measures to continue protecting ePHI in a changing environment. This means: ✓✓ Identifying and protecting against reasonably anticipated threats to the security or integrity of the information ✓✓ Protecting against reasonably anticipated impermissible uses or disclosures ✓✓ Ensuring compliance by your workforce The Security Rule requires a practice to: ✓✓ Identify potential risks to ePHI ✓✓ Implement appropriate security measures to address these risks ✓✓ Document what you did ✓✓ Devise policies and procedures that outline all required steps your office will take to maintain these security measures ✓✓ Routinely assess that your office is maintaining continuous, reasonable, and appropriate security protections for your ePHI Your policies and procedures will be unique to your office—reflecting your specific business needs and risks—and are in addition to the Privacy Rules’ policies and procedures to comply with HIPAA.

Conduct a Risk Assessment As a first step, your office should conduct a security risk assessment (also referred to as a risk analysis). Areas to include in the assessment are outlined in sections 164.308, 164.310, and 164.312 of the HIPAA regulations (available at the electronic Code of Federal Regulations (e-CFR) website: http://ecfr.gpoaccess.gov). See the security standards matrix on the next page for a list of risk assessment requirements in the Security Rule. There are 18 standards and 42 implementation specifications requirements, of which 20 are “required” and 22 are “addressable.” Whereas required implementation specifications must be implemented as written, addressable implementation specifications need only be implemented as written if they are assessed as reasonable and appropriate safeguards for the practice’s environment. If an addressable specification is assessed as unreasonable, you must document why and implement an alternative, equivalent safeguard that is reasonable for your environment. In other words, addressable standards must be implemented, but offer greater flexability. Use the Security Standards Matrix to conduct a security risk assessment. The assessment should help you to identify security weaknesses or vulnerabilities of your practice’s ePHI.

Coding Compass

Subpart C of Part 164 – Security Standards: Matrix Standards Sections

Implementation Specifications (R)=Required, (A)=Addressable Administrative Safeguards

Security Management Process

164.308(a)(1)

Risk Analysis (R)

 

Risk Management (R)

 

Sanction Policy (R)

 

Information System Activity Review (R)

Assigned Security Responsibility

164.308(a)(2)

(R)

Workforce Security

164.308(a)(3)

Authorization and/or Supervision (A)

 

 

Workforce Clearance Procedure

 

Termination Procedures (A)

164.308(a)(4)

Isolating Health Care Clearinghouse Function (R)

 

Access Authorization (A)

 

Access Establishment and Modification (A)

164.308(a)(5)

Security Reminders (A)

 

Protection from Malicious Software (A)

 

Log-in Monitoring (A)

Information Access Management

Security Awareness and Training

 

Password Management (A)

Security Incident Procedures

164.308(a)(6)

Response and Reporting (R)

Contingency Plan

164.308(a)(7)

Data Backup Plan (R)

 

Disaster Recovery Plan (R)

 

Emergency Mode Operation Plan (R)

 

Testing and Revision Procedure (A)

 

Applications and Data Criticality Analysis (A)

Evaluation Business Associate Contracts and Other Arrangement

164.308(a)(8)

(R)

164.308(b)(1)

Written Contract or Other Arrangement (R)

Facility Access Controls

164.310(a)(1)

Contingency Operations (A)

 

Facility Security Plan (A)

 

Access Control and Validation Procedures (A)

Physical Safeguards

 

Maintenance Records (A)

Workstation Use

164.310(b)

(R)

Workstation Security

164.310(c)

(R)

Device and Media Controls

164.310(d)(1)

Disposal (R)

 

Media Re-use (R)

 

Accountability (A) Data Backup and Storage (A) Technical Safeguards (see §164.312)

Access Control

164.312(a)(1)

Unique User Identification (R)

 

Emergency Access Procedure (R)

 

Automatic Logoff (A)

 

Encryption and Decryption (A)

Audit Controls

164.312(b)

(R)

Integrity

164.312(c)(1)

Mechanism to Authenticate Electronic Protected Health Information (A)

Person or Entity Authentication

164.312(d)

(R)

Transmission Security

164.312(e)(1)

Integrity Controls (A)

 

Encryption (A)

www.aapc.com

September 2011

49

Coding Compass

Flexibility for how a practice complies with the Security Rule is allowed, based on the office’s size and resources, but all covered entities must review and modify their security measures to continue protecting ePHI in a changing environment.

The next step is for your practice to determine the likelihood or probability for an external threat (such as a hacker trying to access your information) to expose a weakness and potentially gain unauthorized access to your ePHI. Some examples from our client risk assessments include: the need to improve backup procedures for workstations, encryption for laptops, auditing user activity in the practice management system, or using a professional shredding service to dispose of ePHI. In most practices, human resource policies also will need to be updated to include greater pre-screening of new staff members, improved job descriptions to reflect proper access to and handling of ePHI by staff, exit interviews, and training on data security and proper use of passwords, etc. These safeguards are all part of the HIPAA Security Rule. Put in place policies and procedures for each of the standards listed in the attached Security Standards table. For example, you might want to address each of the three safeguard areas in the following ways: 1. Administrative Safeguards ✓✓ Create office-specific security policies ✓✓ Place the copier or fax within the office to limit unauthorized access or viewing ✓✓ Appoint a security officer or official ✓✓ Conduct staff training on security rules, emergency operations, and reporting of real or suspected breaches (Remember: A breach is an inappropriate use, disclosure, or access of the practice’s PHI in violation of the Privacy Rule.) ✓✓ Finalize business associate contracts with outside entities that receive PHI generated by your office to do the work you require of them 2. Physical Safeguards ✓✓ Document who has access to the office during business and non-business hours, and which staff members have keys to the office ✓✓ Use password-protected screen savers ✓✓ Implement theft controls for computers and locate servers only in secured areas ✓✓ Conduct regular data backups and store them in a secure location 3. Technical Safeguards ✓✓ Control access to your workstations by using unique log-ins and time-limited passwords for all staff members 50

AAPC Coding Edge

✓✓ Ensure that unattended computers automatically log out a user ✓✓ Appropriately dispose of ePHI by shredding or pulverizing, so the information can no longer be accessed ✓✓ Encrypt emails containing ePHI The HIPAA policies you have now or create to comply with the Security Rule should be as detailed as possible. As an example, consider the following policy to address email use in your office: Be very careful when emailing PHI. As a general rule, unencrypted email should not be used to communicate PHI because email is inherently less secure than other forms of communication, such as U.S. mail, Federal Express, UPS, or facsimile transmission. If email is used, the following safeguards should be taken: • Attachments containing PHI sent as part of an unencrypted email should be encrypted in another manner before being attached to the email. • The email message should contain a “confidentiality notice.” • Verify that email is being sent to the correct person (e.g., always double-check the email address in the “To:” field before you hit “Send.”

Important Lessons to Take with You A patient’s information—in written, electronic, or verbal form— belongs to the patient: Respect your patients’ privacy. As required by HIPAA’s “minimum necessary rule,” access only the information that is necessary to do your job. Report losses or misuses of information promptly to your privacy and/or security officer(s), so issues may be dealt with early, and harm can be mitigated. Set a protocol for confidential sending and receipt of PHI and ePHI. Question strangers who are in your work area. Never take patient information home or leave it in an unsecured place. And, always consult and comply with your office’s privacy and security policies and procedures. Marcia L. Brauchler, MPH, CPC-P, CPC-H, CPC-I, CPHQ, is a health care consultant and founder of Physicians’ Ally, Inc. She advises physicians and practice administrators on managed care contracts, reimbursement, coding, and compliance. Her firm is selling updated HIPAA policies and procedures at www. physicians-ally.com/hipaa_training.html.

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Let our experts sharpen your skill set and help refine your reimbursement process. Join hundreds of your colleagues in meeting and learning from the experts on Current Procedural Terminology (CPT), the Resource-Based Relative Value Scale (RBRVS) and Medicare payment policy. For more information or to register today, visit: www.ama-assn.org/go/symposia for the fastest and easiest way to register. Or call the AMA’s Customer Service Center at (800) 621-8335 and mention priority code EAD when registering.

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CONFERENCE TOPICS All topics are presented as they relate specifically to auditing. Some of the topics include: ICD-10 Compliance Medical Necessity Risk Management Regulatory Control Specialty-specific topics include: Pediatrics Radiology Cardiology Dermatology Emergency Medicine Interventional Radiology Chemotherapy and Infusion Therapy Many more topics!

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Two days of educational sessions in a beautiful beach setting.

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