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AAPC membe s ge spec a p c ng Be su e o men on p omo code AAPCe13

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Contents
22
[Coding/Billing]
44
[Auditing/Compliance]
54
[Practice Management]
February 2013
[contents]
34
[Coding/Billing]
In Every Issue
7 Letter from the Chairman and CEO 9 Letter from Member Leadership 10 Kudos 12 AAPCCA 14 Letters to the Editor 14 Coding News
Special Features
29 AAPC Conference Guide 62 Minute with a Member
Features
16 Choose with Clarity Hearing Loss Equipment Codes
Marita Cable-Camilleis, CPC
18 Get Busy Learning New Non-cardiac Endovascular Codes

David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
Education
10 A&P Quiz 59 Newly Credentialed Members
Online Test Yourself Earn 1 CEU
22 2013 Picks for HCPCS Level II

G.J. Verhovshek, MA, CPC
26 Boost Your Knowledge of Lesser-used Modifiers

Terri Brame, MBA, CHC, CPC, CGSC, CPC-H, CPC-I
30 Timely Tidbits: CPT 2013 Clarifies Time-based Services

Go to: www.aapc.com/resources/ publications/coding-edge/archive.aspx
34 Infuse Yourself with Coding Knowledge

Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA
Coming Up
Hospital Candidates Foot Amputations Compliance Professionals Fractures Therapy G Codes
On the Cover: Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA , infuses a dose of proper drug administration coding at the Infusion Center at Mary Immaculate Hospital (affiliated with Bon Secours Health System, Inc.) in Newport News, Va. Cover photo by Jennifer Terry Photography (www.jenniferterry.com).
38 Tips Plus More Tips for Cardiology in 2013

David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC
44 Know Double Dipping Etiquette

46 Control Hospital Risk Using OIGs 2013 Work Plan

Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P
48 New POS Rules Get Sticky for 21 and 22 E/M Services

Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC
54 Optimize Your Patients Access to Care

David J. Moore, MD, MS
www.aapc.com
February 2013
Serving 119,000 Members Including You!
Be Green!
Why should you sign up to receive AAPC Cutting Edge in digital format? Here are some great reasons: You will save a few trees. You wont have to wait for issues to come in the mail. You can read AAPC Cutting Edge on your computer, tablet, or other mobile device -anywhere, anytime. You will always know where your issues are. Digital issues take up a lot less room in your home or office than paper issues. Go into your Profile on www.aapc.com and make the change!
February 2013
Chairman and CEO

Reed E. Pew reed.e.pew@aapc.com
Vice President of Finance and Strategic Planning

Korb Matosich korb.matosich@aapc.com
Vice President of Marketing

Bevan Erickson bevan.erickson@aapc.com
Vice President of ICD-10 Education and Training

Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC rhonda.buckholtz@aapc.com
Vice President of Live Educational Events

Bill Davies, MBA bill.davies@aapc.com
Directors, Pre-Certication Education and Exams
advertising index
Affymax, Inc. and Takeda Pharmaceuticals USA, Inc.........50 www.omontys.com AHA Central Office..........................................5 www.ahacentraloffice.com American Medical Association......................11 www.amabookstore.com CodingWebU.com. ............................................8 www.CodingWebU.com Contexo Media...............................................25 www.contexomedia.com HealthcareBusinessOffice, LLC.....................29 www.HealthcareBusinessOffice.com Ingenix is now OptumTM ..................................2
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Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC raemarie.jimenez@aapc.com Katherine Abel, CPC, CPMA, CPC-I, CMRS katherine.abel@aapc.com
Director of Member Services

Danielle Montgomery danielle.montgomery@aapc.com
Director of Publishing
Brad Ericson, MPC, CPC, COSC brad.ericson@aapc.com
Managing Editor
John Verhovshek, MA, CPC g.john.verhovshek@aapc.com
Editorial and Production Staff

Michelle A. Dick, BS Renee Dustman, BS Tina M. Smith, AAS
Advertising/Exhibiting Sales Manager

Jamie Zayach, BS jamie.zayach@aapc.com Address all inquires, contributions, and change of address notices to: AAPC Cutting Edge PO Box 704004 Salt Lake City, UT 84170 (800) 626-CODE (2633)
2013 AAPC Cutting Edge. All rights reserved. Reproduction in whole or in part, in any form, without written permission from AAPC is prohibited. Contributions are welcome. AAPC Cutting Edge is a publication for members of AAPC. Statements of fact or opinion are the responsibility of the authors alone and do not represent an opinion of AAPC, or sponsoring organizations. CPT copyright 2012 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The responsibility for the content of any National Correct Coding Policy included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product. CPT is a registered trademark of the American Medical Association. CPC, CPC-H, CPC-P, CPCOTM, CPMA, and CIRCC are registered trademarks of AAPC.
www.optumcoding.com Medicare Learning Network (MLN).............41 Official CMS Information for Medicare Fee-For-Service Providers http://www.cms.gov/MLNGenInfo NAMAS/DoctorsManagement................ 15, 64 www.NAMAS-auditing.com The Physicians Practice SOS Group............24
Taking the Business of Medicine to the Next Level
www.ppsosgroup.com The Coding Institute, LLC..............................57 www.SuperCoder.com ZHealth Publishing, LLC................................21 www.zhealthpublishing.com
Volume 24 Number 2
February 1, 2013
AAPC Cutting Edge (ISSN: 1941-5036) is published monthly by AAPC, 2480 South 3850 West, Suite B, Salt Lake City UT 84120-7208, for its paid members. Periodicals Postage Paid at Salt Lake City UT and at additional mailing office. POSTMASTER: Send address changes to: Cutting Edge c/o AAPC, 2480 South 3850 West, Suite B, Salt Lake City UT 84120-7208.
AAPC Cutting Edge
E 1 0.6 1 0
2013 AHA CODING CLINIC AUDIO CONFERENCE SERIES
CODING ADVICE FROM THE CODING EXPERTS
2013 AUDIO CONFERENCE SCHEDULE
Wednesday, March 13, 2013 12:00 1:45pm ICD-10-CM and ICD-10-PCS Procedure and Diagnosis Coding for the Circulatory System Wednesday, May 1, 2013 12:00 1:45pm ICD-10-CM and ICD-10-PCS Procedure and Diagnosis Coding for Obstetrics Wednesday, July 31, 2013 12:00 1:45pm ICD-9-CM AHA Coding Clinic 2013 Update Part 1 Wednesday, August 28, 2013 12:00 1:45pm ICD-10-CM and ICD-10-PCS AHA Coding Clinic 2013 Update Wednesday, October 2, 2013 12:00 1:45pm October Surprise Topic will be Chosen by Participants Wednesday, December 4, 2013 12:00 1:45pm ICD-9-CM AHA Coding Clinic 2013 Update Part 2
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Letter from the Chairman and CEO
Heres What Really Smart People Do

AAPC offers a full spectrum of education and training programs to make you more knowledgeable in your desired area of expertise. Although you have this oasis of health care know-how to take advantage of, its up to you to make the most of it. Unfortunately, this may not be as easy as it sounds. Believe it or not, it is possible for you to get in the way of your own learning, according to Kevin Daum, an Inc. 5000 entrepreneur. In his article 5 Things That Really Smart People Do in Inc. magazine, he says most people generally assume learning comes naturally. This is not the case, however. If youre like most people who are getting older, it may take more effort to absorb fully what is said in a conversation or lecture. Daum says, I find as I get older that real learning takes more work. The more I fill my brain with facts, figures, and experience, the less room I have for new ideas and new thoughts. Plus, now I have all sorts of opinions that may refute the ideas being pushed at me. Its important to keep your head clear of your own opinion, especially because the health care world is rapidly evolving, with more information being thrown at us everyday. Learning should be constant and continuous, and your desire to learn should outweigh your desire to be right, according to Daum. To help you get through learning obstacles as you get older, he explains five ways to increase your brain power by staying open and impressionable during intellectual conversations and lectures. Ive excerpted information from Daums five steps that I found most informative in the article: ion about the information being provided . That voice often keeps you from listening openly for good information and can often make you shut down before you have heard the entire premise. Focus less on what your brain has to say and more on the speaker. You may be surprised at what you hear.
2. Argue with Yourself

If you cant quiet the inner voice, then at least use it to your advantage. Every time you hear yourself contradicting the speaker, stop and take the other point of view. Suggest to your brain all the reasons why the speaker may be correct and you may be wrong. In the best case you may open yourself to the information being provided. Failing that, you will at least strengthen your own argument.
3. Act Like You Are Curious

Some people are naturally curious and others are not. No matter which category you are in you can benefit from behaving like a curious person. Next time you are listening to information, make up and write down two or three relevant questions. Daum recommends Googling the questions or asking another person to find the answers. Either way youll likely learn more, and the action of thinking up questions will help encode the concepts in your brain, he reasons.
5. Focus on the Message Not the Messenger

Often people shut out learning due to the person delivering the material. Separate the material from the provider. Pretend you dont know the person or their beliefs so you can hear the information objectively. For Kevin Daums entire article, go to www. inc.com/kevin-daum/5-things-that-reallysmart-people-do.html. Sincerely,
4. Find the Kernel of Truth

Rarely does a concept or theory come out of thin air. Somewhere in the elaborate concept that sounds like complete malarkey there is some aspect that is based upon fact. Even if you dont buy into the idea, you should at least identify the little bit of truth from whence it came. Play like a detective and build your own extrapolation. Youll enhance your skills of deduction and may even improve the concept .
Reed E. Pew AAPC Chairman and CEO
1. Quiet Your Inner Voice

You know the one I am talking about. Its the little voice that offers a running commentary when you are listening to someone. Its the voice that brings up your own opin-
www.aapc.com
February 2013
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Letter from Member Leadership
Let AAPC Take a Piece of Your Heart
t. Valentines Day, thanks to its Hallmark card association, is typically celebrated by exchanging cards, candy, and gifts. Being the researcher that I am (and that health care coders and billers are), I was curious to find out the story behind St. Valentine, and if he truly existed. I found out how this holiday became part of American culture.
St. Valentine Represents Passion from the Heart

There are several possible explanations for the origins of St. Valentines Day, including a pagan festival, Lupercalia, and no less than three saints named Valentine. I dug deeper to learn more about each of these saints. They were noted to be heroic, sympathetic, and romantic figures fighting against constraints and for that which they held dear and believed to be right and true. One legend reveals St. Valentine as the priest who defied Claudius law for soldiers to remain unwed by continuing to perform marriages in secret. The second legend states that once imprisoned, St. Valentine fell in love with the jailers daughter and before his death sent her a letter signed From your Valentine. The third legend depicts St. Valentine as a martyr killed for attempting to help Christians break out of Roman prisons. Regardless of which of the St. Valentine legends holds true, it seems that this month, more than any other, is the time to reflect upon and pursue that which we hold near to our hearts.
AAPC members is apparent. Being a member saves me incalculable hours of work attempting to absorb the nuances of coding for psychiatry, working through nerve conduction study changes, and piecing together the elements of new evaluation and management (E/M) codes for transitional care management services. Calling on fellow AAPC members allows us to share ideas and our work load, and benefits our employers with a collaboration of many years of health care experience.
Aim Your Passion at AAPC

Whether you need to build your AAPC network or expand your existing network to include other specialties or areas of health care administration, there are several ways to accomplish this in 2013: Attend local chapter meetings, including nearby area meetings. Contact your local chapter officers regarding members who are looking to build their member network. Log in and use the AAPC member forums. Join your fellow members at AAPC regional and national conferences. Belonging to a network of colleagues brings benefits; however, it includes the responsibility of reciprocal action. Be sure to show your passion for coding by contributing your skills, knowledge, and experience to the network. The benefits of your heartfelt effort will come back to you tenfold when you receive the family experience AAPC membership offers. Best wishes,
Holding AAPC Dear to My Heart

The benefits of being an AAPC member continues to be held near and dear to me as the most valuable asset to my health care career. With so many CPT changes for 2013, the benefit of networking with my fellow
Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P President, National Advisory Board
www.aapc.com February 2013 9
A&P QUIZ
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC
Think You Know A&P? Lets See

The colon is also called the large intestine. The ileum (last part of the small intestine) connects to the cecum (first part of the colon) in the lower right abdomen. The rest of the colon is divided into four parts: The ascending colon travels up the right side of the abdomen. The transverse colon runs across the abdomen. The descending colon travels down the left abdomen. The sigmoid colon is a short curving of the colon, just before the rectum.
Test yourself to find out where your anatomy and physiology skills rank:
The physician documents that he removes a polyp found at 19 cm. What part of the colon is this considered? A. Anus B. Rectum C. Rectosigmoid D. Sigmoid The correct answer is on page 20.
Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is vice president of ICD-10 Training and Education at AAPC.
KUDOS
124 Pounds-worth of Pop Tops for a Good Cause

Louise Dowling, CPC, of the Minneapolis local chapter has a reputation for making things better in the Land of 10,000 Lakes. This year, her chapter officers handed out dozens of Ronald McDonald House (www. rmhc.com) cardboard houses for members to collect pop tops. Stepping up to the plate, Dowling offered to deliver members donations in person. After two meetings, she and her fellow chapter members collected nearly 38 pounds of aluminum tabs. Ronald McDonald House Charities provides a home away from home for families of seriously ill children receiving treatment at nearby hospitals. Many Ronald McDonald Houses work with local recycling centers to receive money for collecting tabs from aluminum cans. The charitable act hit home for Dowling
10 AAPC Cutting Edge
Photo by iStockphoto VIPDesignUSA
when she took the donation to the local Ronald McDonald House. She said, I had a little girl who looked so sick dressed up in a princess dress and tiara come up to me. She asked if I had drunk all that pop and beer by myself. We had a good laugh over that one. She gave me a hug and told me to thank the rest of those [coding] ladies for drinking so much! I went to my car and cried and laughed at the same time. The Minneapolis chapter invited attendees at Novembers AAPC state conference to pitch in and donate all of their pop tops. As a result, Dowling and her chapter collected quite a few pop tops at the event, and wound up with a 124-pound total for the year. Kudos to the charitable Dowling and her Minnesota AAPC colleagues!
ama-assn.org
Published in December
Handbook for HIPAA-HITECH Security, second edition
by Margret Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS

So much has changed since 2005 when federal regulations first required compliance with the HIPAA Security Rule. Handbook for HIPAA-HITECH Security details the new privacy and security requirements brought about by HITECH as they pertain to patients health records and medical data. This second edition of the popular AMA title Handbook for HIPAA Security Implementation presents practical and pragmatic ways to interpret the final regulations and ensure compliance. Handbook for HIPAA-HITECH Security covers such compelling topics as: The importance of information security A plan of action to achieve and maintain security Organizational relationships and documentation requirements Risk analysis (also required for meaningful use of the EHR incentive program)
Softbound, 7" 10", 256 pages CD-ROM included Also available as an E-book
Administrative, physical, and technical safeguards Business associate relationships, contracts, and agreements Web site security, remote access, passwords, social media protections, and encryption Application of security controls to thwart identity theft Breach notification requirements Additional features include: A reprinting of the final Security Rule Case studies Questions and answers A security-related glossary Policy templates and other tools on CD-ROM Customizable tables and checklists on CD-ROM
HIPAA
AFTER the FINAL RULE
Carolyn P. Hartley, MLA Edward D. Jones III Forewords by Louis W. Sullivan, MD, and Mark E. Frisse, MD, MBA, M.Sc
New for 2013
Third edition
HIPAA Plain and Simple: After the Final Rule, third edition
Order online at amabookstore.com or call (800) 621-8335.
The third edition expands upon the topics of enforcement, the accounting of disclosures, and contracts with and disclosures to business associates. New content includes migrating to operating rules and meaningful use. Softbound, 7" 10" Approx. 350 pages Also available as an E-book
Chapter Life
By Angela Jordan, CPC
Chapters Can Change Lives

Charity unites, bonds, and strengthens local chapters.
AAPCs local chapters are known for providing educational and networking opportunities for its members. Lesser known is that chapters are taking a more active role in communities, giving back through charitable work. In turn, these philanthropic endeavors are uniting members and making chapters stronger. Id like to highlight the good deeds a handful of our chapters have accomplished.
Phoenix, Ariz.
In 2002, the Phoenix chapter lost one of their members, Germaine Steudler. The following year they honored her memory by supporting Community Alliance Against Family Abuse (CAAFA), an organization Steudler helped to start. The coders still collect household goods, clothing, and money to help support the shelter throughout the year. The Grand Canyon Coders have been recognized as one of CAAFAs supporters on the charitys website (www.caafaaz.org/Supporters.html).
Minneapolis, Minn.
In 2012, the Minneapolis local chapter participated in several charitable activities; two of these activities were organized by Louise Dowling, CPC . In the spring, Louise handed out dozens of little Ronald McDonald Cardboard Houses to members to collect pop tops. Members were encouraged to drop them off at chapter meetings for her to collect and deliver back to the charity. In all, 37.6 pounds of pop tops were collected after just two chapter meetings (read Kudos on page 10 for more information). The chapter also stepped up to donate 12 blankets and 65 towels for the Hennepin County Animal Shelter.
St. Louis, Mo.

St. Louis Professional Coders (St. Louis West chapter) support a variety of causes throughout the year, several of which are charities also supported by the hospital where they meet. For example, the chapter holds canned foods drives during the year and, in August, collects school supplies for local kids in need. They have also raised money for the AAPCCA Hardship Scholarship Fund by holding raffles for an education pack, which included attendance at their local chapter seminar and lots of great reference books. At Christmas, they collect mittens, hats, and gloves for the homeless. Members have also participated in several dining out events where they are the host at a local restaurant and invite members to come and dine together. Fifty percent of the proceeds are donated to causes like St. Louis Childrens Hospital and AIDS research by the restaurant owner. They also have participated in Komen Race for the Cure, Light the Town Pink, and the MS Walk.
Cross, and the AAPC Chapter Association (AAPCCA) Hardship Scholarship Fund.
Kansas City, Mo.

The Kansas City chapter started a community project committee in 2010. Each year, they select an organization to support. Their first project was a silent auction and bone marrow drive held for Be the Match. As a result of the drive, there have been two bone marrow matches so far. In 2011, the chapter collected toys, arts and crafts supplies, medical supplies, and sporting goods for Camp Hope, a childrens cancer camp. Members also had the opportunity to volunteer at the camp. In 2012, the chapter set its sights on the local Ronald McDonald House. At each local chapter meeting members were encouraged to donate items needed on the House Wish List. Participating members names were placed in a drawing for a cookbook, given away at each meeting. Chapter members also formed a cooking team to prepare an Italian feast for the families staying at the house.
Tulsa, Okla.
Since 2005, the Tulsa, Okla. chapter (ProTulsa) has actively supported their local food bank, participating in the Backpack for Kids program, volunteering their time, collecting food items at meetings, and providing financial support. They have also collected teddy bears for local police departments and hospitals, who give them to children in abusive or other traumatic situations. In 2011, the chapter collected donations from members for the Society for the Prevention of Cruelty to Animals, the American Cancer Society, Alzheimers Association, American Red Cross, American Heart Association, and the Blood Bank of Tulsa. In 2012, ProTulsa continued their charitable work and also donated money to Project AAPC, the American Red
Gainesville, Ga.
The Gainesville, Ga. chapter supports the organization Challenged Child and Friends, which works to keep children with special needs in the mainstream by pairing them with other children in the community. At the chapters year-end party, members
photo by iStockphotohidesy
AAPCCA: Handbook Corner

By Barbara Fontaine, CPC
are encouraged to bring school supplies, learning toys, batteries, and any office supplies the organization needs.
Be All You Can Be: Consult Your Handbook

For AAPC members, being all you can be means being active, enthusiastic, and involved in an organization designed to benefit your career and personal development, and this starts in your local chapters. The Local Chapter Handbook introduction states, local chapters are essential in setting the standard of professionalism and higher education, while developing personal improvement and strong networking opportunities. You are a vital link in this mission as a member. To carry out AAPCs vision through your local chapters: Support your local chapter with your presence. Attend meetings, suggest programs, and try presenting. Per the Local Chapter Handbook, each chapter must hold at least six meetings offering continuing education units (CEUs). Present yourself as a professional, ethical member. Watch what you say and whose name you mention. If you want to share something, make it valuable. Be a networker and a mentor. Increase awareness of AAPC and its membership. The more your coworkers know and understand about our organization, the more credibility youll gain for your career and expertise. People will see you as a leader and a person to turn to when they need an answer. Fulfill your chapters needs. If your chapter needs a proctor to hold an exam, volunteer. If theres an open office position, fill it. The Local Chapter Handbook states that chapters with monthly attendance over 40 members should have both an education officer and a member development officer. Challenge yourself and volunteer to help. Partake in AAPC online forums. Tune into your chapter by using the Forum Tools button at the top of your chapter forum to subscribe. Its easy and comes right to your inbox.
Helping Across America

In 2010, AAPCCA founded Project AAPC Chapters Aiding People in Crisis (Project AAPC) to encourage chapters to help those affected around the world by natural disasters. Little did we know a flood of historical proportions would hit Nashville, Tenn. and the surrounding area. AAPC members came together, however, and raised over $13,000, which was donated to the American Red Cross in Nashville for flood relief. In 2011, Project AAPC added a second charity, Feeding America, which supports food banks nationwide. Thanks to the fundraising efforts of our chapters and the generosity of members, Project AAPC has donated over $17,000 to the American Red Cross and over $6,700 to Feeding America. Chapters that donated to Project AAPC sold snacks at meetings, held silent auctions, raffled quilts, and asked members to donate their coffee or soda pop money for a day. Donation jars were also a popular choice for collecting funds.
Mail donations for Project AAPC to: Project AAPC, c/o Local Chapter Department 2480 South 3850 West Salt Lake City, UT 84120
Read the AAPC Local Chapter Handbook for more good advice and soon you will be on your way to becoming all you can be.
AAPCCA: Mentoring
By Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CPPM, CPC-I, CANPC, CMRS
Chapter Mentoring Program Launches

At the 2012 AAPC Regional Conference in Chicago, the AAPC Chapter Association (AAPCCA) proudly launched the Chapter Mentoring Program. Mentoring is a very rewarding endeavor that does not require you to have mentor experience to make a difference in someones life, and it doesnt take a lot of time to be effective. Sometimes its as easy as sending an email to see how your mentee is doing, answering a coding question, or referring him or her to a person who can help. Learn an unfamiliar area of our business Seek assistance in getting organized Resolve difficult workplace situations Mentoring isnt a daunting taskits fun! Youll make new friends with whom you have a lot in common. Do you remember the first person who believed in you and shared with you his or her knowledge and skills? You could be that person for someone else. Give a little of your time to help someone in need of a mentor, or sign yourself up to be a mentee.
Chapters Unite to Support a Cause

Whether its raising funds for a charity or filling a need in the community, members who come together for the greater good experience positive change and personal growth within their chapter. Helping others is contagious and its one bug your chapter should be anxious to catch! Designate in the memo area of your check whether you would like the donation to go to the American Red Cross or to Feeding America.
Angela Jordan, CPC, is managing consultant at Medical Revenue Solutions, LLC. She has 10+ years experience with health care providers and has worked as a coding and compliance manager of a large physician network and HCA. Ms. Jordans experience includes surgery, orthopaedics, ENT, emergency medicine, laboratory, radiology, inpatient, outpatient, family practice, oncology, pain management, and other specialties. She is the AAPCCA Board of Directors chair, representing Region 5 Southwest, and has served as Kansas City chapter president.
Mentoring Program Benefits Everyone Involved

The goals of the Chapter Mentoring Program are: To provide a one-on-one opportunity in an area or specialty To promote networking To encourage relationships within and beyond the local chapter level To improve an existing mentoring program, if your chapter already has one in place
Its Easy to Get Started

If you are interested or wish to have your chapter involved, please go to the AAPC website at http://static.aapc.com/ppdf/ChapterMentoringPro gram1.pdf for upcoming information about the Chapter Mentoring Program guidelines. AAPC provides step-by-step online instructions to help chapters form a successful mentoring program. If your chapter adopts this program, we would really love to hear from you. You may contact your regional representatives to share your success stories. The following members of the Mentoring Task Force helped develop this new opportunity: Melissa Corral, CPC; Roxanne Thames, CPC, CEMC; Amy Bishard, CPC, CPMA, CEMC; Susan Edwards, CPC, CEDC; Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC, along with AAPC liaisons Marti Johnson; Danielle Montgomery; and Heidi Larsen.
You can be a mentee, too. Everyone has an area that needs improvement, so heres an opportunity to get help from experts in the field. Becoming a mentee provides an opportunity to: Expand your knowledge in a certain field or specialty
www.aapc.com
February 2013
13
Coding News
Ambulance Inflation Factored for 2013
The 2013 Ambulance Inflation Factor (AIF) has been released and went into effect Jan. 1. The Social Security Act (section 1834(l)(3) (B)) figures a yearly payment update based on the Urban Consumer Price Index (CPI-U) percentage increase for the 12-month period ending with June of the prior year. Prospective payment system and fee schedule update factors are adjusted by changes in economy-wide productivity, which are equal to the 10-year average of private, nonfarm business MultiFactor Productivity (MFP) annual changes. Medicare Part B coinsurance and deductible requirements apply to payments under the ambulance fee schedule. For 2013: MFP is 0.9 percent CPI-U is 1.7 percent AIF is 0.8 percent (The Affordable Care Act says the CPI-U is reduced by the MFP to get the AIF, even if it leads to a negative update.) See Centers for Medicare & Medicaid Services (CMS) transmittal 2620 for more information: www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/Downloads/R2620CP.pdf. Here are few examples of changes made to CMS MSN message verbiage:
Message No. 18.13

Original text This service is not covered for beneficiaries under 50 years of age. New text This service isnt covered for people under 50 years old.
Message No. 18.22

Original text This service was denied because Medicare only allows the one-time initial preventive physical exam with an electrocardiogram within the first six months that you have Part B coverage, and only if that coverage begins on or after January 1, 2005. New text This service was denied because Medicare only allows the Welcome to Medicare preventive visit within the first 12 months you have Part B coverage.
Message No. 29.22

Original text The amount listed in the You May Be Billed column assumes that your primary insurer paid you. If your primary insurer paid the provider, then you only need to pay the provider the difference between the amount the provider can legally charge and the amount the primary insurer paid. See note (__) for the legal charge limit. New text If your primary insurer paid the provider, you need to pay the provider the difference between the limiting charge amount and the amount the primary insurer paid your provider. For a compete list of easier-to-read MSN messages, refer to change request (CR) 8106 at www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/Downloads/R1161OTN.pdf. You can implement and use the new MSN messages effective Feb. 18, 2013.
Medicare Summary Notices in Plain English, Please

To keep up with the Plain Writing Act of 2010, which requires federal agencies to use clear language on all documents intended for the public, CMS recently redesigned their Medicare Summary Notice (MSN) to revise outdated, complicated, and obsolete messages to plain language messages so Medicare beneficiaries can easily understand them.
Letters to the Editor
Please send your letters to the editor to: letterstotheeditor@aapc.com
Calculating Credits Owed

In the December issue, Manage Four Key Revenue Cycle Metrics (pages 33-34), the author advises you to, Determine your total current receivables, and then subtract any credits. Credits are funds owed by the practice to others. They offset receivables, so subtract credits from receivables. Otherwise, days in A/R will appear overly optimistic. A reader questions whether subtraction is the right way to describe this accounting function because, technically, credits are a negative number. To clarify, here is an example of what the author meant:
Receivables: $67,901 Credit Balance: - $4,521 (this is a negative number because it is money owed) Gross Charges: $587,857 (Total Receivables - Credits) / (Gross Charges / 365 Days) = Days in Accounts Receivable (A/R) or [$67,901 - (-$4,521)] / [$587,857 / 365 Days] = Days in A/R or $72,422 / $1,611 = 44.95 Days AAPC Cutting Edge
14
AAPC Cutting Edge
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Coding/Billing
By Marita Cable-Camilleis, CPC
Choose with Clarity Hearing Loss Supply Codes

With so many devices to choose from, knowing whats out there is key to proper reimbursement.
ou would think that someone who has a vested interest in audiology would be an authority on the subject. While attending a four-day National Hearing Loss Association of America (HLAA) Convention in Providence, R.I., June 21-24, 2012, however, I quickly realized that there is no such thing as too much information, and that I had a lot more to learn. Id like to share with you some valuable tips for reporting hearing-assistance technology supplies that I picked up at the convention so that you, too, may code hearing loss equipment with clarity.
Many Aid Choices, Many Code Choices

Most familiar hearing aid HCPCS Level II codes are classified to V5030V5267, but many prosthetic implant/hearing assist supply codes also fall into categories L8613L8629 and L8690L8693. For example, new sound processor devices for cochlear implants and cochlear bone-anchored hearing aid (BAHA) implants are reported with L8614 Cochlear device, includes all internal and external components and L8690 Auditory osseointegrated device, includes all internal and external components, respectively. Replacement implants are reported with L8619 Cochlear implant, external speech processor and controller, integrated system, replacement and L8691 Auditory osseointegrated device, external sound processor, replacement. Bonus tip: Report surgical implantation of cochlear implants with CPT 69930 Cochlear device implantation, with or without mastoidectomy. For BAHA, 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy or 69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy. When implants are placed in both ears, you may append modifier 50 Bilateral procedure. A child under the age of five would wear a headband for BAHA (or Ponto Pro) without surgery. In other examples for different body locations, HCPCS Level II code
V5095 Semi-implantable middle ear hearing prosthesis is for Vibrant Soundbridge (VSB), a semi-implantable electromagnetic hearing aid. Another middle ear implant, called Envoy Esteem, is fully implantable with no external components. This implant is also coded like the VSB semi-implant with CPT 69799 Unlisted procedure, middle ear. For an in-the-mouth (ITM) device called SoundBite, used for bone conductive loss, report L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code. According to Consumer Reports (How To Buy a Hearing Aid, July 2009), you cannot truly compare hearing aids because no two people have the same kind of hearing loss (type, severity, and configuration). With so many hearing aidsclassified as monaural, binaural, and bilateralit is easier to keep track of them using a chart, like the one shown in Table A . If a patient is diagnosed as having unilateral hearing loss and one deaf ear, a choice of bilateral contra-lateral routing of signals (BICROS) may be appropriate. Contra-lateral routing of signals (CROS) is used when a patient has one ear with normal hearing and one deaf ear. One side of chart has the body-location variable and the other side lists hearing loss diagnosis variables mixed with manufacturers variables. Some hearing aids may be adjusted for high and/or low frequency hearing losses.
V5298 Describes Aids NOC

Several increasingly popular hearing aids are not yet specifically described by HCPCS Level II codes, such as receiver-in-the-canal or receiver-in-the-ear (ITE) devices. A small version of ITE is called half shell. Slim-tubing behind the ear (BTE) devices without ear molds are called open fit or over the ear; they are also called mini-BTE aids. These new hearing aids have microphones located in the ear, rather than on the hearing aid itself, and create a more natural sound and less wind noise. The newest, smallest completely in-the-canal (CIC) devices are called mini-CICs or invisible in the canals. If these new hearing aids are not classified, they could be coded as V5298 Hearing aid, not otherwise classified.
Alternate Hearing Assistance Technologies

Photo by iStockphoto Eldemir
Not all assistive listening devices are specifically coded because of multi-functionality. Captioned telephones such as CapTel and CaptionCall may be included in the HCPCS Level II code V5274 Assistive listening device, not otherwise specified, or simply reported with V5268 Assistive listening device, telephone amplifier, any type. These
To discuss this article or topic, go to www.aapc.com
Coding/Billing: Hearing Loss
codes may also include hearing aid compatible smartphones. A modern digital hearing aid may have the ability to be controlled remotely by the patients cell phone. Some assisted listening devices have not yet been coded because they are geared more toward groups, rather than individuals. One example is the increasingly popular looping system that is more common in Great Britain and Scandinavia. In this setting, an electromagnetic wire is looped around a room (or a ticket booth) to the speaker microphone, so anyone nearby can turn on the telecoil (t-coil) switch of his or her custom-made hearing aid (or cochlear implant) to hear the speaker more clearly. Approximately 69 percent of all hearing aids have a t-coil, which can be turned on for hearingaid compatible phones with optional neck loops plugged in. T-coils (including related batteries, feedback-suppression capability, and directional microphones) are not currently specified in HCPCS Level II codes for hearing aids. Even a non-deaf person can hear better with a headphone and inductive loop receiver, which picks up signals from a loop system
Table A
CONDUCTIVE LOSS: MIXED LOSS:
while cutting off background noise. There are also personal loops just for television, which may be reported with V5270 Assistive listening device, television amplifier, any type.
New Receivers, Transmitters, and Microphones

For 2013, the descriptor for V5267 Hearing aid or assistive listening device/supplies/accessories, not otherwise specified was revised and new codes V5281V5290 were added to accommodate personal FM/DM auditory devices, which are most often used with hearing aids to improve the signal-to-noise ratio. This allows the listener to better hear in the presence of background noise. FM/DM auditory devices direct sound from a transmitting device (FM/DM transmitter) via a frequency or digitally modulated signal to a receiving device (FM/DM receiver), which may be coupled to a hearing device. A complete FM/DM system typically consists of a transmitter and a receiving device. If the receiver is built into a new hearing aid, you may report V5288 Assistive listening device, personal FM/DM transmitter assistive listening device for the transmitter only.
Another system creates a public addresstype system with a wireless microphone, transmitting sound to receivers attached to loudspeakers and/or to those attached to hearing aids. For example, Inspiro is an FM transmitter for teachers to wear in the classroom, and the DynaMic is a cordless microphone designed to be used with it. To combine all three components (receiver(s), transmitter, and microphone), use V5281 Assistive listening device, personal FM/DM system, monaural, (1 receiver, transmitter, microphone), any type for one receiver or V5282 Assistive listening device, personal FM/DM system, binaural, (2 receivers, transmitter, microphone), any type for two receivers (one for each ear). Personal amplifiers (V5274), such as Pocketalkers, are useful when FM systems, infrared systems, and hearing loop (or induction loop) systems are not available.
Marita Cable-Camilleis, M.Ed., CPC, is treasurer of HLAAs Cape Cod chapter. She has severe hearing loss and has worn hearing aids since the age of three. She has done considerable research in the field of audiology.
TYPE OF HEARING AID OR IMPLANT

AIR BONE SENSORINEURAL
CONTRALATERAL ROUTING OF SIGNAL CROS
BILATERAL CROS
DIGITAL PROGRAM
DIGITAL
BICROS
ANALOG
ANALOG
PROGRAM
DIGITAL
DISPOSABLE
SITE ON BODY
In the Mouth (ITM) Inner Ear: Cochlear Implant Middle Ear: Semi-implant (VSB) Completely In the Canal (CIC) In the Canal (ITC) L9900 L8690 L8691 L8614 L8619 V5095 V5242* V5248** V5243* V5249** In the Ear (ITE) V5050* V5130** Behind the Ear (BTE) V5060* V5140** Body Worn V5030* V5040* V5100*** V5120** In Eyeglasses Hearing Aids Not Classified Key: * = monaural ** = binaural V5070 V5080 V5150 V5298 *** = bilateral V5190 V5230 V5180 V5220 V5247* V5253** V5170 V5210 V5244* V5250** V5245* V5251** V5246* V5252** V5254* V5258** V5255* V5259** V5256* V5260** V5257* V5261** V5262* V5263** V5262* V5263** V5262* V5263** V5262* V5263**
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February 2013
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Coding/Billing
By David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
Get Busy Learning New Non-cardiac Endovascular Codes

2013 CPT changes for interventional radiology are extensive; heres where to start.
he American Medical Association (AMA) was very busy last year, creating 74 new interventional radiology, endovascular, cardiac chamber, and coronary arterial interventional codes for 2013, while deleting 32 codes for many of the same types of procedures. Well focus on the chest drainage procedures and non-cardiac endovascular codes changes, which include retrieval of intravascular foreign body and thrombolysis.
Takeaways:
The AMA created 74 new interventional radiology, endovascular, cardiac chamber, and coronary arterial interventional codes and deleted 32 codes for many of the same types of procedures. These include intravascular FB removal and thrombolysis services. Differentiate separate from bundled thrombolysis services.
2013 Breathes New Life into Chest Drainage Codes

Non-vascular interventional radiology codes 32421 and 32422, which described needle or catheter-drainage of chest fluid, have been deleted for 2013, replaced with 32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance and 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance. The old codes allowed for separate reporting of image guidance (e.g., 76942, 77002, 77012), when performed. The new codes describe chest drainage by a needle or catheter that is removed at the end of the procedure. Code 32554 is used when imaging guidance is not necessary; while 32555 is for procedures with imaging guidance. Two additional codes for percutaneous chest drainage by placement of non-tunneled chest drainage catheters are 32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance and 32557 Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance. Imaging guidance includes any combination of fluoroscopy ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). Code 32551 Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure) has been revised, and now represents an open placement of a chest tube (usually for empyema, traumatic hemothorax, or pneumothorax). These tubes are placed without imaging guidance. There is no change to the tunneled chest tube placement code (32550 Insertion of indwelling tunneled pleural catheter with cuff ), which allows separate reporting of 75989 Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation for image guidance during placement.
One Code Describes Intravascular FB Removal

A single code now describes retrieval of an intravascular foreign body (FB): 37197 Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed replaces 37203 and 75901. The procedure requires placement of a catheter and retrieval device or snare to the location of the foreign body. Make certain to report the appropriate catheter placement code (3601036012 for venous; 3601336015 for the right atrium and pulmonary artery; 36200 for the aorta; 3624536248 for selective vessels below the diaphragm; and 3621536218 for selective vessels above the diaphragm) for the retrieval. Example 1: Patient is a 40-year-old with fractured central venous access catheter noted on the chest X-ray. The catheter tip is in the main pulmonary artery. Via right femoral vein approach, a retrieval device is advanced into the right atrium. Snare is placed around the catheter tip in the pulmonary artery and the catheter is retrieved and slowly removed from the body. Proper coding is:
36013 Introduction of catheter, right heart or main pulmonary artery for catheter placement
37197 for retrieval of the foreign body
Note: Usually, a diagnostic angiogram is not necessary because broken catheters, lost coils, stents, and other intravascular foreign bodies are easily visible with fluoroscopy. Contrast injections are mostly used for guidance, as needed.
Coding/Billing: Endovascular
Thrombolysis Now a Per Date Service

Percutaneous non-coronary catheter directed thrombolysis is now a per date of therapy procedure, for coding purposes. Thrombolysis infusion, follow-up angiography, and catheter exchanges performed on a single date of therapy (12 a.m. to 11:59 p.m.) are described by a single code. Code 37211 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day describes the initial date of treatment for arterial thrombolysis, while 37212 Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day describes the initial day for venous thrombolysis. If the infusion continues past the initial day, 37213 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed is used for arterial or venous thrombolysis on the subsequent day(s) of therapy. Use 37214 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic thera-
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py, including follow-up catheter contrast injection, position change, or exchange, when performed; cessation of thrombolysis including removal of catheter and vessel closure by any method for the final day of therapy, when the infusion is concluded. If an infusion is three days or longer, 37213 will be repeated for each additional day that is not the initial or final day of treatment. Code 37213 cannot be reported the same day as 37211, 37212, or 37214. For a single day of therapy, only 37211 or 37212 may be reported for the thrombolysis. Do not report 37214 the same day as 37211 or 37212. Example 2: A 62-year-old patient has an ischemic right leg. Via left femoral arterial puncture, a contralateral sheath is placed into the right external iliac artery. Diagnostic angiography reveals acutely thrombosed right femoral-popliteal bypass graft with chronically occluded native superficial femoral artery (SFA) (75710 Angiography, extremity, unilateral, radiological supervision and interpretation). A thrombolysis catheter is advanced into the graft (36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family) and catheterdirected thrombolytic infusion is initiated (37211). The patient is sent to ICU for monitoring. The patient is brought back later the same day. Followup imaging and catheter exchange for a longer infusion catheter is performed (no additional code because 37211 describes a single day of therapy). The patient is brought back on day two with imwww.aapc.com www.aapc.com February 2013 19
Coding/Billing: Endovascular
Thrombolysis infusion, follow-up angiography, and catheter exchanges performed on a single date of therapy (12 a.m. to 11:59 p.m.) are described by a single code.
aging performed, showing resolution of thrombus and an underlying 90 percent distal anastomotic stenosis. This is treated with a stent (37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed ). Excellent result is obtained. The sheath is removed (37214) for the final day of thrombolytic therapy. Note: If the entire procedure had been performed on a single day, you would not report 37214.
Differentiate Separate from Bundled Thrombolysis Services

Routinely, at the start of thrombolysis care, an angiographic catheter is placed near the site of thrombus and a diagnostic angiographic study is performed. Both the catheter placement and the imaging supervision and interpretation are reported; however, when intracranial thrombolysis is performed, the new cervico-cerebral codes (3622236228) bundle the catheter placement. With the change of the thrombolysis codes to date of therapy codes, there are no additional codes submitted when the patient returns to the angiography suite for follow-up imaging, or when the infusion catheter is repositioned or replaced. Do not report 75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis during thrombolytic infusion therapy because it is bundled. Catheter exchange codes 37209 and 75900 are deleted in 2013 because
Anatomical Illustrations 2012, Optuminsight, Inc.
A&P Quiz Answer

The correct answer to the quiz on page 10 is D. Many physicians document by centimeters for procedures involving the colon: Anus 0-4 cm Rectum 4-16 cm Also called the rectal ampulla, upper third is covered by peritoneum; lower third is not Rectosigmoid 15-17 cmFrom the anal verge Sigmoid 17-57 cmLoop extending distally from border of left posterior major psoas muscle Descending 57-82 cmApproximately 10-15 cm long and located behind the peritoneum Transverse 82-132 cmLies anterior in the abdomen and is attached to the gastrocolic ligament Ascending 132-147 cmApproximately 20-25 cm long and is located behind the peritoneum Cecum 150 cmApproximately 6 x 9 cm pouch covered with peritoneum
this catheter exchange is bundled with the new thrombolysis codes. Usually, after completion of the thrombolysis, an underlying cause (such as a stenosis) is identified. Treatment of that abnormality is additionally reported (e.g., angioplasty, atherectomy, stent placement). Mechanical arterial or venous thrombectomy may be reported in addition to prolonged thrombolysis infusion procedures. Codes 37184-37188 are used to describe these associated percutaneous thrombectomy procedures, when performed. Although the new codes for thrombolysis do simplify coding, it may be disappointing to the on-call physician who performs a follow-up angiogram and catheter exchange (both included with 37211, submitted earlier in the day) at 11:30 pm, and has nothing to code. Stay tuned: Next month, well review CPT 2013 changes to cervico-cerebral imaging.
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiologist and president of ZHealth Consulting and ZHealth Publishing in Brentwood, Tenn.
20
AAPC Cutting Edge
Coding/Billing
By G.J. Verhovshek, MA, CPC
2013 Picks for HCPCS Level II

Effective Jan. 1, 2013, there are 150 changes, plus lots of quality performance measurement G code updates.
Since April 1, 2012, the HCPCS Level II code set has undergone approximately 150 individual changes, not counting those G codes used for reporting to the Physician Quality Reporting System (PQRS) or Medicare demonstration projects (more on those below). The G codes with modifiers must be reported at regular intervals for Medicare patients who receive outpatient therapy services, including: At the outset of therapy episode On or before every 10 treatment days throughout the course of therapy At the time of discharge from therapy At the time the beneficiarys condition, changes significant enough to clinically warrant a re-evaluation such that a HCPCS/CPT code for a re-evaluation or a repeat evaluation is billed Also new are two modifiers that may be used to break National Correct Coding Initiative (NCCI) edits, when appropriate. Modifiers LM Left main coronary artery and RI Ramus intermedius coronary artery alert the payer that two procedures occurred at separate sites and may be reimbursed separately, similar to modifiers LT Left side and RT Right side. Modifiers V8 and V9, previously used with dialysis revenue code lines for all end stage renal disease (ESRD) claims and all ESRD hemodialysis claims, were deactivated April 1, 2012.
New Modifiers
Among the changes are seven new modifiers for Medicare reporting, which must be appended to HCPCS Level II codes G8978-G9176 (new for 2013) to describe a functional limitation (e.g., G8981G8983 Changing and maintaining body position functional limitation ). The modifiers describe the extent of the functional limitation.
CH CI CJ CK CL CM CN
0 percent impaired, limited or restricted At least 1 percent but less than 20 percent impaired, limited or restricted At least 20 percent but less than 40 percent impaired, limited or restricted At least 40 percent but less than 60 percent impaired, limited or restricted At least 60 percent but less than 80 percent impaired, limited or restricted At least 80 percent but less than 100 percent impaired, limited or restricted 100 percent impaired, limited or restricted
New Supply Codes

As always, there has been plenty of action when it comes to drug supply codes as temporary codes transition to permanent status and new drugs are added. See Table 1 for details. And as shown in Table 2, there has been a lot of movement in codes used to describe skin substitutes.
Matching HCPCS and CPT Changes

The Centers for Medicare & Medicaid Services (CMS) designated several new HCPCS Level II codes to take the place of CPT codes for Medicare reporting. For example, since 2003, CMS has assigned coronary stent placement procedures to separate ambulatory payment classifications based on the use of nondrug-eluting or drug-eluting stents. To enact this policy, CMS created G0290 and G0291, which corresponded to CPT codes 92980 and 92981. For 2013, CPT deleted 92980 and 92981, replacing them with new, more granular codes describing coronary therapeutic services and procedures. To maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug-eluting and
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Coding/Billing: HCPCS II
Table 1
New Code Old Code Drug

A9586 C9290 C9292 C9293 C9294 C9295 C9296 J0178 C9291 C9286 C9288 Q2047 J1051 J0485 J0716 J0890 J1050 J1055 J1056 J1741 J1744 J2212 J7178 Q2045 Q2046 J7315 J7527 J9002 Q2048 J9019 J9020 J9042 Q2034 Q2049 S1090* C9289 J9020 C9287 J9001 J1680 C9279 Ibuprofen Icatibant Methylnaltrexone Human fibrinogen concentrate Aflibercept Mitomycin, ophthalmic Everolimus Doxorubicin hydrochloride Asparaginase (erwinze) Asparaginase, not otherwise specified Brentuximab vedotin Influenza virus vaccine, split virus Doxorubicin hydrochloride, liposomal Mometasone furoate sinus implant Florbetapir f18 Bupivacaine liposome Pertuzumab Glucarpidase Taliglucerase alfa Carfilzomib Ziv-aflibercept Aflibercept Belatacept Centruroides (scorpion) immune F(AB)2 Peginesatide Medroxyprogesterone acetate
Trade Name
AMYVID Exparel Perjeta Voraxaze Eleyso Zaltrap EYLEA Nulojix Anascorp
drug-eluting stents, CMS designated new HCPCS Level II C codes to parallel the new CPT codes:
HCPCS = CPT
C9600 = 92920 C9601 = 92921 C9602 = 92924 C9603 = 92925 C9604 = 92937 C9605 = 92938 C9606 = 92941 C9607 = 92943 C9608 = 92944
Caldolor IRAZYR Relistor
Consult Table 3 on the next page for a list of other new HCPCS Level II codes, some of which were created to take the place of CPT codes for Medicare reporting. Another interesting code is Q9969 Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose, which is newly established to report Tc-99m from non-highly enriched uranium (HEU) sources. TC-99m is the most widely used radioisotope for diagnosing diseased organs. For 2013, CMS will make an additional payment of $10 to cover the marginal costs associated with non-HEU Tc-99m production. In some cases, newly-created CPT codes have taken the place of now-deleted HCPCS Level II codes. For example, Category III CPT code 0308T Insertion of ocular telescope prosthesis including removal of crystalline lens replaced C9732 for ocular telescope prosthesis with removal of crystalline lens, while many pathology procedures in the range S3711-S3860 have been deleted and replaced with new CPT codes describing molecular pathology and multianalyte assays with algorithmic analysis (e.g., 81200-81408, 81500-81512, 81599, and 86152-86153). Finally, V5267 has been revised to specify Hearing aid or assistive listening device/supplies/accessories, not otherwise specified, and 10 new codes have been added to describe personal FM/DM auditory devices, which are used with hearing aids to improve the signal-to-noise ratio, allowing the listener to hear better in the presence of background noise.
Mitosol Zortress
Erwinaze
Adcetris Agriflu Imported lipodox Propel
*Medicare does not accept S codes.
Table 2
New Code Old Code

Q4119 Q4126 Q4128 Q4131 Q4132 Q4133 Q4134 Q4135 Q4136 C9366 C9368 C9369
Product
MatriStem PSMX, RS, and PSM Memoderm, dermaspan, tranzgraft, or integuply Flex HD, Allopatch HD, or Matrix HD Epifix Grafix CORE Grafix PRIME hMatrix Mediskin Ez-Derm
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Coding/Billing: HCPCS II
As always, there has been plenty of action when it comes to drug supply codes, as temporary codes transition to permanent status and new drugs are added.
HCPCS
C9733 G0452 G0453 G0454
CPT
N/A N/A 95941 N/A
Service
SPY and other non-ophthalmic fluorescent vascular angiography Molecular pathology procedure; physician interpretation and report Continuous intraoperative neurophysiology monitoring outside the operating room Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant, or clinical nurse specialist Preparation with instillation of fecal microbiota by any method Phakic intraocular lens for correction of refractive error Treatment planning and care coordination management for cancer, initial Treatment planning and care coordination management for cancer, established patient with a change of regimen
Physician Quality Reporting and Medicare Demonstration Projects

G codes in the range G8000G8999 are designated PQRS codes. Since April 1, 2012 there have been 114 code additions, 48 code deletions, and 122 code revisions to the G codes used to report quality performance measurements. Eligible professionals (EPs) who successfully report on quality measures in the PQRS are eligible for a 0.5 percent Medicare payment incentive for years 2012-2014. In 2015, EPs and groups that do not report quality data successfully will face a 1.5 percent payment reduction in Medicare payments, and a 2 percent reduction for 2016. For additional information about PQRS, visit the CMS website (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instru ments/PQRS/index.html). G codes in the range G9000G9999 are applied for Medicare Demonstration Project reporting. Since April 1, 2012, there have been 21 new codes and two code deletions in this section. For more information on Medicare Demonstration Projects, visit the CMS website (www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/ Medicare-Demonstrations.html).
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
G0455 S0596* S0353*
44705 N/A N/A
S0354*
N/A
* Medicare does not accept S codes
24
AAPC Cutting Edge
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21131
Coding/Billing
By Terri Brame, MBA, CHC, CPC, CGSC, CPC-H, CPC-I
Boost Your Knowledge of

ny coder worth his or her wage knows about modifiers 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service and 59 Distinct procedural service, but what about modifiers RR Rental (use the RR modifier when DME is to be rented) and LS FDAmonitored intraocular lens implant ? In fact, there are dozens of lesser-known modifiers that can help you report certain services more accurately.
Lesser-used Modiers
Overlooking these modiers can result in improper reimbursement.
Takeaways:
HCPCS Level I modifiers are CPT modifiers. HCPCS Level II modifiers are developed by CMS. Both can be used with CPT codes. Both types of modifiers, when appended correctly, are excellent tools with which to tell the whole story of a procedure or service. Review the full set of modifiers in their entirety to ensure proper selection.
Modifiers Come in Two Flavors

There are two levels of HCPCS modifiers. What coders usually call CPT modifiers are actually HCPCS Level I modifiers. These modifiers are always two digits, are published in the CPT codebook as Appendix A, and are maintained by the American Medical Association (AMA). HCPCS Level II modifiers are used less often, and tend to be less well known (two exceptions are modifiers LT Left side and RT Right side). These modifiers may be any combination of two alphanumeric charactersexcept for two numbers. Level II modifiers are published by the Centers for Medicare & Medicaid Services (CMS) as part of the annual HCPCS Level II update, and may be applied to either Level I (CPT) or Level II service and procedure codes.
plied, there are a few exceptions. Among the most important are modifiers 63 Procedure performed on infants less than 4 kgs and 66 Surgical team.
Modifier 63
When a surgeon performs a procedure on an infant weighing less than 4 kg (4,000 g, or approximately 8.8 lbs), you may append modifier 63 to the CPT code to inform the payer of the increased complexity of the procedure due to the patients small size. At best, this could garner increased reimbursement. Be aware, however, that most CPT procedure codes performed on small infants include the notation, Do not report modifier 63 in conjunction with ... because the CPT code has already been valued to include this increased complexity. For example, see the parenthetical notation following 33502 Repair of anomalous coronary artery from pulmonary artery origin; by ligation and 33503 Repair of anomalous coronary artery from pulmonary artery origin; by graft, without cardiopulmonary bypass.
Although so-called CPT modifiers are generally familiar and often ap26 AAPC Cutting Edge
Modifier 66
Modifier 66 is applied when three or more
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HCPCS Level I Modifiers
Coding/Billing: Modifiers
Level II includes quite a few modifiers beyond RT and LT that may be used within certain specialties to allow payment for multiple procedures that would otherwise appear to be duplicate billing.
surgeons complete parts of a procedure described by a single CPT code. Before solid organ transplantation codes were separated into codes for donor organ removal, backbench work, and recipient transplantation (e.g., the CPT section guidelines for Liver Transplantation), modifier 66 was appended to the transplant code to represent the separate surgical teams involved in each transplant stage. In the unusual situation, when there are three or more primary surgeons working on a procedure, ensure the medical necessity of multiple primary surgeons is documented. When submitting a claim with modifier 66, youll usually have to send the operative report, as well. Medicare and other payers that follow the National Correct Coding Initiative (NCCI), verify whether modifier 66 is allowed for the procedure by referring
to the Team Surgery column in the Medicare Physician Fee Schedule Relative Value File (downloadable from the CMS website: www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeeSched/PFS-RelativeVal ue-Files.html).
extensor tendon, finger, primary or secondary; without free graft, each tendon), the coder would report 26418-F7, 26418-F8, and 26418-F9.
HCPCS Level II Modifiers

Level II includes quite a few modifiers beyond RT and LT (as shown in Table A) that may be used within certain specialties to allow payment for multiple procedures that would otherwise appear to be duplicate billing. For example, a plastic surgeon may repair the extensor tendon in three fingers on the right hand following trauma. To identify which fingers were repaired and that three procedures were performed and reported with the same CPT code (26418 Repair,
Preventing or Overriding Edits

Some modifiers may be familiar to insurance specialists in the practices billing office, and are important to receiving correct payment: CC Procedure code change (use CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) is used when submitting a corrected claim to clarify the claim is not a duplicate or an attempt to double bill for the same service. For example, if a charge was found through the quality check process to have been keyed with the incorrect provider
Table A: Anatomic Level II Modifiers Eyelids

E1 Upper left E2 Lower left E3 Upper right E4 Lower right
Fingers
FA Left hand, thumb F1 Left hand, second digit F2 Left hand, third digit F3 Left hand, forth digit F4 Left hand, fifth digit F5 Right hand, thumb F6 Right hand, second digit F7 Right hand, third digit F8 Right hand, forth digit F9 Right hand, fifth digit
Toes
TA Left foot, great toe T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, forth digit T4 Left foot, fifth digit T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit T8 Right foot, forth digit T9 Right foot, fifth digit
Coronary Arteries
LC Left circumflex LD Left anterior descending RC Right coronary artery
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February 2013
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The true value of a Level II modifier (in my humble opinion) lies with the modifiers that describe unusual payment situations.
number, and the charge is resubmitted with the correct provider number, you should append the appropriate CPT code with CC appended. GD Units of service exceeds medically unlikely edit value and represents reasonable and necessary services is used to override medically unlikely edits (MUEs), when appropriate. In 2007, Medicare implemented a set of MUEs that are applied to CPT codes to prevent reimbursement for more units of a service than are typically provided, but the edits may not apply in all circumstances. For example, a Medicare beneficiary may have required a total thyroidectomy to treat thyroid cancer, reported with 60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection. Fifteen years later, the patient has a recurrence of thyroid cancer in a very small amount of retained thyroid tissue. The surgeon removes the remaining tissue, and should report the service with 60260 Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of the thyroid because the previous surgery was not technically a total thyroidectomy. But there is an MUE for total thyroidectomy because the total thyroid can be removed only once. In the case described, the second surgeon has a legitimate claim to override the MUE and to be paid for his service, and reports 60260-GD to describe the situation. You will likely have to submit an operative report and clearly document medical necessity, but the service should be reimbursed. GW Service not related to the hospice patients terminal condition is applied only for patients receiving hospice services. When a patient is in hospice care, physicians must report all services related to the hospice illness to the hospice provider. If the patient receives care for a non-related illness, append modifier GW to allow payment di28 AAPC Cutting Edge
rectly from the payer. For example, if a patient who is receiving hospice care at home for metastatic cancer is seen in a primary care office for an upper respiratory infection, the primary care office should report an evaluation and management (E/M) service with modifier GW.
Clinical Trials
Payers, particularly Medicare, often expect clinical research services to be identified on the claim with Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study and Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study. These modifiers identify whether the services are part of routine care for the patients condition (care that would have been provided regardless of the research) or care that is not routine, and is part of the research.
ing the modifiers below, always verify with the billing office whether they are appropriate. CR Catastrophe/disaster related [may currently apply to superstorm Sandy services] CS Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean up activities ST Related to trauma or injury
Teaching Physicians
Coders in academic practices are very familiar with the GC, GE, and GR modifiers, and so should coders looking to make a career move to academic medicine. These modifiers describe services provided following Medicare or U.S. Department of Veterans Affairs (VA) rules for resident and attending physicians working together:
GC
This service has been performed in part by a resident under the direction of a teaching physician This service has been performed by a resident without the presence of a teaching physician under the primary care exception This service was performed in whole or in part by a resident in a department of veterans affairs medical center or clinic, supervised in accordance with VA policy
Surgical Misadventures
When it is appropriate to report (or internally track) a surgical misadventure, the coder should append the CPT code with one of the following:
PA PB PC
Surgical or other invasive procedure on wrong body part Surgical or other invasive procedure on wrong patient Wrong surgery or other invasive procedure on patient
GE
GR
Trauma, Disaster, and Catastrophe

Services provided following a traumatic event may be reimbursed from a separate fund, qualify for increased reimbursement, or in some way alter the requirements for reporting a code. For example, some payer contracts may include a reimbursement carve-out for trauma-related services increasing the payment rate. When consider-
Miscellaneous
The true value of a Level II modifier (in my humble opinion) lies with the modifiers describing unusual payment situations. The following are just a few examples: CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission. This modifier may be used when the hospital where the procedure was performed admits
a patient after a surgery is completed rather than before. FP Service provided as part of the annual family planning program is especially valuable when the patient only has Medicaid coverage for family planning. A coder may need to append GT Via interactive audio and video telecommunication systems for telehealth services. H9 Court-ordered notes services rendered due to a court order. HJ Employee assistance program is append-
ed for services provided as part of an employee assistance program. Large sections of Level II modifiers also apply to mental health services, durable medical equipment (DME), anesthesia, etc. Hopefully, this sampling of CPT and Level II modifiers will motivate you to review the two modifier sets in their entirety, ensuring proper reporting and appropriate reimbursement for your practice.
As with any code, policies for using modifiers may differ from payer to payer. Before applying any modifier, ensure the payer accepts the modifier and adhere to any published rules for its use.
Terri Brame, MBA, CHC, CPC, CGSC, CPCH, CPC-I , is the compliance education officer for the University of Arkansas for Medical Sciences. She is a past AAPC local chapter president, and has presented at two AAPC national conferences.
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Coding/Billing
Timely Tidbits:
CPT 2013 Claries Time-based Services
When time is a key factor, follow these ve basic rules.
For 2013, the American Medical Association (AMA) updated their CPT codebook to better explain the rules for timebased codes. The revised instructions can be found in the Introduction section of the CPT Professional Edition (page xii), under the subhead Time. The guidelines stipulate thatin the absence of specific instruction to the contrary (whether in a parenthetical reference, code-range-specific rules, or the code descriptor)there are five basic rules when reporting time-based services.
Takeaways:
The CPT 2013 codebook better defines time when length of time is not mentioned in the code. Five rules help define what codes should be reported when a length of time is not specified. Proper determination for length of time helps coding accuracy and eases revenue cycle management.
1. Time Means Face-toface Time with the Patient

Time spent away from the patient is not billable unless a specific code describes the non face-to-face, time-based services; or, if coding guidelines otherwise allow for time spent away from the patient. For example, CPT provides time-based codes to report prolonged services without direct patient contact (9935899359). Time billed for these services is not face-to-face with the patient, but occur before and/or after patient care. Note that even face-toface services may allow you to count some non face-toface time, as long as it bears directly on patient care. For example, time-based critical care codes 9929199292 include time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patients care with other medical staff or documenting critical care services in the medical record. To be sure you are reporting all appropriate time, read all code descriptors and coding guidelines for the code category you are reporting.
2. A Unit of Time is Attained when the Midpoint is Passed

For example, if a code describes the first hour of service, you dont need to document a full 60 minutes to report the code. But at least 31 minutes of service (or past the midpoint of 60 minutes) must be provided and documented. If the unit of service is 30 minutes, at least 16 minutes must be documented to report the code. If the unit of service is 15 minutes (therapy codes are an example of these), eight or more minutes should be documented. The CPT codebook often provides charts with time ranges to help you report timebased services appropriately. For an example, see the Total Duration of Critical Care Codes chart within the Critical Care Services subsection of the Evaluation and Management chapter. If the minimum time to report is not met, either the service is not billable, or you should instead bill an (other) appropriate evaluation and management (E/M) service code (e.g., office visit 9921299215). For example, if fewer than 30 minutes of critical care (99291) are provided, CPT instructs you to report appropriate E/M codes. Some codes describe 24-hour services, as does 95950 Monitoring for identification and lateralization of cerebral seizure focus, elec-
Coding/Billing: Time-based Codes
To be sure you are reporting all appropriate time, read all code descriptors and coding guidelines for the code category you are reporting.
troencephalographic (eg, 8 channel EEG) recording and interpretation, each 24 hours. For these codes, at least 12 hours of service must be documented to report the code. For services lasting fewer than 12 hours, you may need to append a modifier, such as modifier 52 Reduced services.
15 minutes, so you would report 99213. If, instead, the service lasted 22 minutes, the closest reference time is the 25 minutes of 99214, and you would report that code.
4. Dont Combine the Time of Unrelated Services

When another service is performed concurrently with a time-based service, the time associated with the concurrent service should not be included in the time used for reporting the time-based service, CPT explains. Put more simply, dont count the time of an unrelated service when reporting a time-based service. For example, time spent providing separately reportable procedures or services should not be included toward critical care time (as reported using 99291, 99292). Only time spent performing services or procedures specifically within the CPT definition of critical care may be counted toward critical care time. Be aware that what counts as time varies by the kind of service provided. For instance, critical care services include floor/ unit time in addition to time spent at a patients bedside, while other time-based services do not. The requirements for critical care are different than those of standby services, prolonged services, or any other timebased service. Youll have to read section guidelines and code descriptors to know exactly what you can count as time for any given service.
3. When There Are Two Time-based Choices, Pick the Closest

CPT states this rule as, When codes are ranked in sequential typical times and the actual time is between to typical times, the code with the typical time closest to the actual time is used. The rule applies when reporting E/M services using time (rather than the key components of history, exam, and medical decision-making) as the controlling factor to qualify for a given level of servicethat is, when counseling and/or coordination of care comprises more than half the encounter. In such a case, use CPT reference times, along with patient status and place of service, to determine an appropriate E/M service level. For example, a level III established patient outpatient visit (99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity) has a reference time of 15 minutes, while a level IV service (99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity) has a reference time of 25 minutes. If counseling equaled 18 minutes, the closest reference time is that of 99213, at
port the total units of time provided continuously. For instance, if intravenous hydration is given in the time described above, you would report 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour once and +96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) twice.
Best Practices Bonus Tip

Whenever possible, physicians providing time-based services should report not only the total time of service, but also start and stop times. The additional detail goes a long way to support and justify your coding choices.
5 Basic Rules to Follow when Time Is a Key Factor

1. Time means face-to-face time with the patient. 2. A unit of time is attained when the midpoint is passed. 3. When there are two time-based choices, pick the closest. 4. Dont combine the time of unrelated services. 5. For continuous services, the date of service doesnt change.
5. For Continuous Services, the Date of Service Doesnt Change

Suppose you begin a time-based service at 10:30 p.m., and that service lasts until 1:30 a.m. the next day. Per CPT, For continuous services that last beyond midnight, use the date in which the service began and re-
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Cover: Coding/Billing
By Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA
Infuse Yourself with

Coding Knowledge
Tips and tricks for proper drug administration coding.
If the profuse number of Office of Inspector General (OIG) audits showing improper payments for drug claims submitted to Medicare every year is any indication, its safe to say that drug administration coding can get sticky. Proper drug administration coding requires as much precision as the services themselves. Just like clinicians learn little tricks for properly injecting drugs, however, there are several tips and tricks you can use to pick the right code every time.
Drug Administration Basics

First, remember that there are three categories of drug administration: 1. Hydration: CPT codes 96360-96361 are for pre-packaged fluids and electrolytes. These codes are not used to report infusion of drugs or other substances and are not reported by the physician in a facility setting.
34
AAPC Cutting Edge
Coding/Billing: Drug Administration
Physicians in the facility setting may not use chemotherapy codes.
2. Therapeutic/Prophylactic/Diagnostic: See Table 1 for CPT codes to report for the administration of drugs and other substances (other than hydration). Do not report these codes for chemotherapy or other highly complex drugs/biological or when fluids are used to administer the drug(s); the fluid administration is incidental hydration and is not separately reportable. These codes are not reported by the physician in a facility setting. 3. Chemotherapy or other biologic agents/complex drugs: See Table 2 on the next page for appropriate CPT codes. Chemo includes other highly complex drugs or biologic agents such as: Non-radionuclide anti-neoplastic drugs Anti-neoplastic agents provided for treatment of non-cancer diagnoses Certain monoclonal antibody agents Other biologic response modifiers
Table 1: Diagnostic/Therapeutic/Prophylactic Infusion Codes CPT Code
96360
Use of these codes typically requires advanced practice training and competency; special considerations for preparation, dosage, or disposal; and usually entails significant patient risk and frequent monitoring far beyond that of therapeutic administrations. Physicians in the facility setting may not use chemotherapy codes. Report separate codes for each method of administration when chemotherapy is administered by different techniques. Medications administered independently as supportive management of chemotherapy are reported separately using 96360, 96361, 96365, or 96379, as appropriate. Along with three categories of drug administration, there are three methods by which drugs may be administered: 1. Injection: Do not use CPT 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular for the administration of vaccines/toxoids. This code does not include injections for allergen immunotherapy. Although hospitals may report injection codes when the physi-
CPT Description
Intravenous infusion, hydration; initial, 31 minutes to 1 hour
Notes
Do not report if performed as concurrent infusion service; do not report hydration infusion of 30 minutes or less). Use for infusions of 31-90 minutes.
+96361
Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)
Report for intervals of greater than 30 minutes beyond one-hour increments; also report for secondary or subsequent service after a different initial service through same IV access. Report for IV infusions of 16-90 minutes.
96365
+96366
Report for intervals of greater than 30 minutes beyond one-hour increments; also report for secondary or subsequent service after a different initial service through same IV access. Report in conjunction with 96365, 96374, 96409, or 96413 if provided as secondary service after a different initial service is administered through the same IV access. Report only once per sequential infusion of same infusate mix (multiple drugs mixed together in one bag is one infusate mix). Report only once per encounter. Report in conjunction with 96365, 96366, 96413, 96415, or 96416. Used for infusions running at the same time via the same IV accessmust be hung in separate bags.
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+96367
photo of syringe by iStockphotoLiuhsihsiang
+96368
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February 2013
35
Table 2: CPT codes for chemotherapy administration CPT Code

96401 96402 96409 +96411
CPT Description
Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic Chemotherapy administration; intravenous, push technique, single or initial substance/drug Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
Notes
Report with 96409 or 96413.
96413
Report for infusions of 1690 minutes. Report 96361 to identify hydration as a secondary service through the same IV access. Report 96366, 96367, or 96375 to identify therapeutic infusion/injection as secondary service through same IV access.
+96415
Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug) up to 1 hour (List separately in addition to code for primary procedure)
Report in conjunction with 96413. Report for infusion intervals of greater than 30 minutes beyond one-hour increments. Report in conjunction with 96413. Report only once per sequential infusion. Report 96415 for additional hour(s) of sequential infusion.
+96417
cian is not present, physician offices may not. You may use injection codes to report non-antineoplastic hormonal therapy. 2. IV Push: CPT 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug is appropriate when intravenous (IV) push is the primary service. Add-on code +96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/ drug (List separately in addition to code for primary procedure) may be reported with 96365, 96374, 96409, or 96413 to identify an IV push of a new drug when provided as a secondary service after a different initial service is administered through the same IV access. Add-on code +96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility drug (List separately in addition to code for primary procedure) is used only when the same drug is administered twice in one encounter, but not within 30 minutes of each other. All of these IV push codes are reported for facilities only, and may be used for infusions lasting 15 minutes or less. 3. Infusion: Refer to Table 1 on the preceding page for infusion codes and their instructions. What makes your job so sticky is that these categories and methods can be combined in a number of different ways, all of which are coded differently.
Determine the Initial Service

The American Medical Association (AMA) created different codes for initial and subsequent administrations; coding guidelines state there should be only one initial code per encounter, unless two separate access sites are required. So how do you determine what the initial service is when more than one method or category of administration is provided? Although the rules vary depending on where the service is provided, the actual chronological order of administration is not important for coding. The initial code is not necessarily the first service provided. In the physician practice, the initial service is the primary reason for the visit. For example, a patient comes in for chemotherapy, but also gets an antibiotic injection and a hydration infusion to supplement the chemotherapy. The primary reason for the visit is the chemotherapy so it is the initial service. In the outpatient facility setting, there is a hierarchy to determine the initial service: 1. Chemotherapy infusions 2. Chemotherapy IV pushes 3. Chemotherapy injections 4. Therapeutic/Prophylactic/Diagnostic infusions 5. Therapeutic/Prophylactic/Diagnostic IV pushes 6. Therapeutic /Prophylactic/Diagnostic injections 7. Hydration
36
AAPC Cutting Edge
the actual chronological order of administration is not important for coding. The initial code is not necessarily the first service provided.
Table 3: Reporting infusion time Single infusion lasting: Can be coded (assuming documentation is complete):
IV push Initial hour Initial hour + 1 additional hour Initial hour + 2 additional hours Initial hour + 3 additional hours
15 minutes or less 16 - 90 minutes 91 - 150 minutes 151 - 210 minutes 211 - 270 minutes and so on
ing between 16 and 90 minutes. Only when an infusion lasts longer than 90 minutes can you code the additional hour code. Each additional hour means increments greater than 30 minutes over the initial hour. Do not include time spent keeping veins open (see Table 3 for examples).
Know Whats Included

The following services are included in all of the drug administration codes, and are not separately reportable: Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter, or port Flush at the conclusion of infusion Standard tubing, syringes, and supplies Chemotherapy administration codes also include preparation of drugs/agents and any fluids used to administer the chemotherapy.
The highest-ranking service provided is considered the initial service. For example, a patient comes into a hospital outpatient department for an antibiotic injection, but also receives a hydration infusion. The initial service is the antibiotic injection because the therapeutic injection ranks higher in the hierarchy than the hydration infusion.
Coding for Multiple Administrations

If you can bill only one initial code per patient, per date of service, per IV access site, how do you capture the work when more than one administration is provided during a single encounter? Specific codes for sequential, subsequent, and concurrent administrations account for additional services provided. Use subsequent or concurrent codes where appropriate, regardless of the administration order (e.g., first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). Before you make your code selection, its important to know time requirements and documentation rules.
Other Considerations
If a significant, separately identifiable evaluation and management (E/M) service is provided, report the appropriate E/M code with modifier 25 in addition to the infusion codes. A different diagnosis is not required; however, you cannot report 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services with infusion codes. If multiple infusions are administered, report only one initial service code, unless two separate IV sites are required. Per the Medicare Claims Processing Manual (chapter 4, section 230.2) as of 2007, only one initial service code can be reported per patient, per date of service, per separate IV access site. If there are multiple IV access sites, each site may be coded with an initial code and modifier(s), as appropriate, and must be supported by documentation in the record indicating it is medically reasonable and necessary for the drug or substance administrations to occur at separate intravenous access sites.
Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA , is a senior manager of internal audit with Bon Secours Health System, Inc., where she primarily performs coding and billing audits. She holds a bachelors and a masters degree in Business Administration with a concentration in finance from The College of William & Mary in Virginia. Ms. Smith is also a Certified Internal Auditor and certified in Risk Management Assurance.
Time Requirements
One of the biggest obstacles when coding drug administration is the common lack of documentation; start and stop times must be clearly and completely documented in the medical record by the clinician. The start time is normally well documented, but the stop time is quite often omitted. Check with your payer to see their requirements for these situations; some will accept a code for an IV push even if a stop time is not documented, while others will not. In general, an IV push code may be used for an infusion lasting 15 minutes or less (again, check with your payers for clarification). In drug administration terms, one hour means any infusion last-
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February 2013
37
Coding/Billing
By David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC
Tips Plus More Tips for Cardiology in 2013

Part 2: Catch up on reporting of ablations and newer technology procedures.
s we learned in Part 1 of this two-part series (see Changes Plus More Changes for Cardiology in 2013, page 40-43, Januarys Cutting Edge), the new year brings significant changes to cardiology coding. This month, we cover CPT coding in 2013 for transcatheter aortic valve replacement (TAVR), ventricular assist devices, electrophysiology ablations, subcutaneous defibrillators, intracardiac ischemia monitoring systems, and left atrial (LA) hemodynamic monitoring systems.
Transcatheter Aortic Valve Replacement/Implantation (TAVR/TAVI)

Codes 0256T-0259T are deleted for 2013, replaced by new codes for TAVR/TAVI. To make it easier to differentiate the services, heres a list of the new codes with abbreviated descriptors:
33361 TAVR, percutaneous femoral approach 33362 TAVR, open femoral approach 33363 TAVR, open axillary approach 33364 TAVR, open iliac approach 33365 TAVR, transaortic approach (eg, median sternotomy) 0318T TAVR, open transapical approach (eg, left thoracotomy) +33367 Cardiopulmonary bypass support for TAVR, percutaneous
peripheral arterial and venous cannulations
+33368 Cardiopulmonary bypass support for TAVR, open peripheral cannulations
+33369 Cardiopulmonary bypass support for TAVR, central (eg, aorta, right atrium, pulmonary artery) cannulations
Here are some tips for applying these new codes correctly: The only currently approved device is the Sapien valve. Its indicated for patients with severe aortic stenosis who are not surgical candidates (determined by a cardiothoracic surgeon). The three add-on codes for cardiopulmonary bypass (C-P
bypass), when performed, are also based on approach. Only one C-P bypass code is submitted during TAVR. Open femoral (34812) and open brachial access (34834) are included in the TAVR codes. Temporary pacemaker placement for rapid pacing during TAVR, as well as catheter placements and balloon valvuloplasty, are included. Swan-Ganz placement and aortic/left ventricular (LV) measurements and imaging to guide and complete the TAVR are included. If a complete heart catheterization is performed, you may report it if no prior diagnostic study was performed or a suboptimal study is documented, or if there has been a clinical change in the patient since the prior study or during the procedure. Code for other percutaneous coronary/cardiac interventions that are performed and medically indicated. You may code for ventricular assist device or intra-aortic balloon pump (33990, 33991, 33967, 33970), if performed. TAVR requires two physicians to complete the procedure. Codes 33361-33365 and 0318T Implantation of catheterdelivered prosthetic aortic heart valve, open thoracic approach,
Coding/Billing: Cardiology
TAVR requires two physicians to complete the procedure. Codes 3336133365 and 0318T require modifier 62 for physician billing.
(eg, transapical, other than transaortic) require modifier 62 Two surgeons for physician billing. For example, each physician would report 33361-62 for a percutaneous TAVR. The C-P bypass codes do not have this requirement. Example: An elderly patient with severe aortic stenosis, who is not a surgical candidate, presents for a TAVR procedure. This is performed with C-P bypass via femoral cut-downs and rapid pacing with a temporary pacer. The TAVR is performed via percutaneous approach. Correct codes would be:
33361 Transcatheter aortic valve replacement (TAVR/TAVI) with
prosthetic valve; percutaneous femoral artery approach
+33368 Transcatheter aortic valve replacement (TAVR/TAVI) with

prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure)
Note: Do not report the temporary pacemaker.
puncture and removes oxygenated blood from the left LA back to the TandemHeart device (external on patient), and then returns it into a second catheter, placed usually via the femoral artery. You may report 34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral when an open arterial exposure is performed to accommodate the larger catheters used in percutaneous VADs. Routine closure of artery is not reported separately. Removal and repositioning codes can only be used when at a different encounter. If on the same date of service but a different encounter, append modifier 59 Distinct procedural service to either 33992 Removal of percutaneous ventricular assist device at separate and distinct session from insertion or 33993 Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion.
Ventricular Assist Device (VAD)

Codes 0048T and 0050T for VAD are deleted and replaced by new, Category I CPT codes. For easy reference, here are abbreviated descriptors:
33990 Insert VAD, percutaneous, arterial access only, ie, Impella
device
33991 Insert VAD, percutaneous, both arterial and venous access

with transseptal puncture, ie, TandemHeart device
33992 Removal of VAD 33993 Repositioning of VAD
Follow these tips for proper coding: VADs are for use in patients with impaired LV function. The new aforementioned codes are for percutaneous VADs. Impella device is via arterial access only, with a single catheter that forcefully removes blood from the LV via the distal portion of the catheter and discharges it into the proximal aorta. TandemHeart device has both venous and arterial access. The venous catheter is placed into the LA via a transseptal
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February 2013
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Repositioning of a percutaneous VAD without imaging guidance is not a reportable procedure.
If VAD is placed prophylactically for an intervention and removed at its conclusion, do not report 33992. Repositioning of a percutaneous VAD without imaging guidance is not a reportable procedure. If an existing VAD is removed and replaced with a new VAD, code this as a new device placement. Do not report 33992 because the removal is bundled into the new device placement code.
Electrophysiology Ablations
Electrophysiology ablation codes 93651 and 93652 are deleted. New abbreviated versions of the codes are:
93653 Comprehensive electrophysiologic (EP) evaluation with ablation of supraventricular tachycardia (SVT)
93654 Comprehensive EP evaluation with ablation of ventricular

tachycardia
+93655 Additional ablation of discrete mechanism of arrhythmia

distinct from the primary ablation treated
93656 Comprehensive EP evaluation with ablation of atrial fibrillation via pulmonary vein isolation
+93657 Additional ablation of left or right atrium for a-fib remaining

after pulmonary isolation at same setting
Use these helpful tips for proper EP ablation coding: The five new ablation codes all include a diagnostic EP study at the time of ablation. Do not submit any combination of 93653, 93654, and 93656 together. If an additional mechanism is ablated, use add-on code +93655 or +93657. With ablation of SVT (93653), you may report mapping (+93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) or +93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)), transseptal procedure (+93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)), and LV pacing/ recording (+93622 Comprehensive electrophysiologic evaluation
including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure)), when performed. Ablation of VT (93654) includes 3-D mapping (93613) and LV pacing/recording (93622), when performed. You can report transseptal procedure (93462), when performed. Pulmonary vein isolation for a-fib (93656) includes the transseptal procedure (93462) and LA pacing/recording (+93621 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure)), when performed. You can report mapping (93609 or 93613) and LV pacing/recording, when performed. There is a gray zone regarding 93623; CPT states this code may be reported with 93656, but National Correct Coding Initiative (NCCI) Version 19.0 states not to report 93623 with any of the new ablation codes.
All claims submitted correctly!
If thats goal #1, then start with the right tools. The Medicare Learning Network (MLN) develops informational resources just for Medicare Fee-For-Service providers. Billing errors can prevent physicians from receiving timely and proper reimbursement for common medical and surgical procedures. For example, the CMS Comprehensive Error Rate Testing (CERT) Program cites that a number of errors relate to non-compliance with Medicare coverage, coding, and billing rules. Evaluation and Management (E/M) Services: Complying with Documentation Requirements is an MLN educational tool. It describes common CERT Program errors and provides information on the documentation needed to support certain claims to Medicare. More learning starts now. Visit http://go.cms.gov/EM-Services.com
Check out CMS on
Official CMS Information for Medicare Fee-For-Service Providers
Defibrillation threshold testing (DFT testing) involves induction of arrhythmia and evaluation of sensing and pacing for arrhythmia termination, as well as reprogramming as necessary.
Add-on code +93655 may be reported with 93653, 93654, or 93656, when performed. Add-on code +93657 may be reported only with 93656, when performed. Some of the parentheticals may need updating. For example, a parenthetical note instructs you to use +93622 only with 93620, but the CPT introductory section states +93622 may be added to 93653. Likewise, only 93620 may be used with 93621, per a parenthetical note following 93621. Example: A patient presents with atrial fibrillation. A complete EP study is performed, followed by a transseptal puncture under intracardiac echocardiography (ICE) into the LA. A 3-D map is created, followed by ablations performed to achieve pulmonary vein isolation. After this was done, there was evidence of continued a-fib and a decision was made to perform additional right atrial ablations. The a-fib then ceased. The correct coding in this case is:
93656 93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure)
0325T Repositioning of electrode and/or generator 0326T EP evaluation (defibrillation threshold testing) 0327T Interrogation of device 0328T Programming of device with iterative adjustments
93613 +93657
Note: Do not code for the EP study (93620) or transseptal procedure (93462); they are included in 93656.
Subcutaneous Implantable Defibrillators (S-ICD)

This year, CPT adds new Category III codes for S-ICD systems. Shortened descriptions are:
0319T Insertion of complete system 0320T Insertion of electrode only 0321T Insertion of generator only 0322T Removal of generator 0323T Removal and replacement of generator 0324T Removal of electrode 42 AAPC Cutting Edge
This is a newer type of defibrillator for treatment of arrhythmias that is totally implanted in the subcutaneous tissues, including the defibrillating lead. To apply the above codes, follow these tips: The generator and one lead are placed subcutaneously. This allows for easier insertion over traditional transvenous insertion of electrode, and results in fewer potential complications, such as venous stenosis and infected leads within the heart because the lead is in the subcutaneous tissues. This system does not allow pacing, as in a conventional defibrillator. To report removal of an existing subcutaneous lead and generator plus replacement with a new system, report 0322T, 0324T, and 0319T. At generator end of life, report replacement with 0323T when the depleted generator is removed and a new generator is inserted. Use the repositioning code 0325T when performed repositioning of an electrode and/or generator occurs at a different encounter than at the original insertion. Defibrillation threshold testing (DFT testing) involves induction of arrhythmia and evaluation of sensing and pacing for arrhythmia termination, as well as reprogramming as necessary, and is reported with 0326T. Report 0327T and 0328T at a different encounter than at the original placement for interrogation or programming of S-ICD (this is not DFT testing).
Intracardiac Ischemia Monitoring Device (IMD)

Also new for 2013 are Category III codes (with our abbreviated descriptions) for IMD:
0302T Insertion of complete system, or removal and replacement
of both device and electrode
The removal of an existing IMD system and replacement with a new system is reported by the single code
Left Atrial Hemodynamic Monitor

Intravascular electrode leads in subclavian vein Pulse generator (pacemaker) in subcutaneous pocket
Finally, youll find new Category III codes for left atrial hemodynamic monitor. Easier-to-follow abbreviated descriptions are:
0293T Insertion of LA hemodynamic monitor, complete with module and pressure sensor lead
0294T Insertion of pressure sensitive lead at time of insertion of

pacing cardioverter-defibrillator
Pacing electrode lead
Defibrillation electrode lead
0303T Insertion of electrode only, or removal and replacement of

electrode
0304T Insertion of device only, or removal and replacement of device
0305T Programming of device with iterative adjustment 0306T Interrogation of device 0307T Removal of IMD system
This system monitors LA pressures to identify changes in patients with heart failure to allow potential earlier treatment. Tips to apply these codes correctly include: You may use the above codes alone, or when inserted into combination-type defibrillator devices. Transseptal code 93462 is bundled with these codes, as is ICE (93662). Use 0294T with 33230 Insertion of pacing cardioverterdefibrillator pulse generator only; with existing dual leads, 33231 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple lead, 33240 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead, 33262-33264 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator , and 33249 Insertion or replacement of permanent pacing cardioverterdefibrillator system with transvenous lead(s), single or dual chamber.
David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC, is vice president of ZHealth. He oversees physician coding and instructs ZHealth educational programs, and contributes to Dr. Zs Medical Coding Series. A graduate of Texas A&M University, he completed his M.D. at the University of Texas, his surgical residency at Scott & White Hospital, and his vascular surgery fellowship at Baylor College of Medicine. A diplomat of the American Board of Surgery, Dr. Dunn is also certified in vascular surgery. He is a fellow of the American College of Surgeons and a member of the Southern Association for Vascular Surgery. He is president-elect of the AAPC National Advisory Board.
IMD (AngelMed Guardian system) consists of an electrode placed into the right ventricle and a device. It monitors electrocardiogram signals for acute ST elevation changes and warns the patient via vibratory and auditory alerts. This allows the patient to potentially seek earlier treatment of impending ischemic events. Consider these tips when applying the above codes: The removal of an existing IMD system and replacement with a new system is reported by the single code, 0302T. Report codes 0305T and 0306T at a different encounter than at original placement for interrogation or programming of IMD.
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February 2013
43
Auditing/Compliance
Know Double Dipping Etiquette

Although its usually coding taboo, at times, its proper for legitimate recoupment.
In the coding world, the term double dip has two meanings (neither of which has anything to do with dining etiquette). You might think its never OK to double dip, but in some circumstances, you definitely shouldor risk leaving legitimate reimbursement on the table. cedure designation means 44180 is bundled to the related, more extensive procedure (44186).
Double Dip Do
The second meaning of double dip is to use a single statement in the documentation of an E/M service more than once when determining the level of service provided. Contrary to what you may have heard, this type of double dipping can be appropriate, if done correctly. First, some background: Way back in December 1997, Barton C. McCann, MD, publicly remarked that when selecting an E/M service level, you cannot use one statement to count as two elements. McCann was not just any physician: He was executive medical officer of the Health Care Finance Administration (precursor to the Centers for Medicare & Medicaid Services), and his instructions mattered greatly to coders, payers, and health care regulators. McCanns intended meaning is that you cannot use a single documented item twice within the same component of the E/M service. For instance, if the physician documents pain since last Tuesday, you cannot count that statement in the history of present illness (HPI) as timing and duration. Its one or the other, but not both. Similarly, if the physician records no back pain, you cant count that statement in the review of systems (ROS) as relevant to both musculoskeletal and neurological body systems. In other words, you shouldnt use the same statement twice within the history or within the ROS. Thats your third legitimate dont. Taken in context, McCanns pronouncement about the inappropriateness of this type of double dipping was neither sensational nor controversial. Unfortunately, his words were immediately taken out of context and applied much more broadly to re-
Double Dip Dont

The first use of double dip means to bill twice for the same item; for instance, by separately reporting a service that is included in another (already claimed) procedure. Such unbundling is prohibited, andeven if done unintentionallycan quickly land you in hot water with payers. This type of double dipping is never OK. As an example, the Medicare surgical package includes routine post-operative care, including related evaluation and management (E/M) services, within the 90-day global period of a major procedure. If you separately report an E/M visit for when the operating surgeon checks on the patients recovery (clearly a service related to the surgery), you would be double dipping on the E/M. Thats a dont. As a second example, you wouldnt report a designated separate procedure when it occurs during the same operative session and in the same anatomic area as another, more extensive procedure. For instance, if a surgeon performs laparoscopic jejunostomy (44186 Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding)) with lyses of adhesions, you cannot report 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure). Thats another dont because the separate pro44 AAPC Cutting Edge
photo by iStockphotoPannonia
Auditing/Compliance: Double Dipping
flect a meaning he never intended. Specifically, McCanns statement was interpreted to mean that a single item could not apply to both the HPI and ROS. For example, suppose a patient presents with chest pain with dyspnea. Under the mistaken interpretation of McCanns statement, you would not be able to count the documentation as location and associated signs and symptoms in the history and as relevant to the respiratory system in the ROS.
Despite McCanns clarification, the you cant use the same documented item in both the history and ROS trope spread far and wide, and was repeated so often that it has been accepted as truth.
agement Services state that you cannot count a single item in both the history and ROS. Nothing in the American Medical Association (AMA) or national Medicare guidelines says so, either. And the man who is mistakenly credited with having said it was so has publicly stated that it isnt. Any payer or auditor who continues to insist on the validity of the double dip urban myth ought to know better, and should be challenged. The Truth Part 2: As long as an item is clearly documented, you may count it in both the history and ROS. Repetition of data is not required as long as it is appropriately referred to. Returning to our earlier example of the patient with documented chest pain with dyspnea, you may count dyspnea as both an associated sign/symptom for the HPI and for respiratory ROS (but you should not count chest pain for both cardiovascular and musculoskeletal systems in the ROS). But (and this is a big but), if a patient shows up with only one complaint, you shouldnt use that single complaint for both the history and ROS. Rather, you should look for documented evidence that the physician dug deeper to find more information to assist him or her in identifying what is wrong with the patient and how to treat it (in other words, you should be sure that the physician truly did provide an ROS). For example, if the patient presents with abdominal pain, and thats all the physician documents, you shouldnt report that single item in the history and ROS. But documentation of abdominal pain, no nausea means the physician asked additional questions beyond the presenting problem, which makes using the item in both the history and ROS acceptable. Similarly, documentation of cough alone isnt sufficient to count for both history and ROS; however, cough one week, no expectoration, moderate shortness of breath provides plenty of detail to support both the history and ROS elements. The bottom line: If the physician looks beyond the presenting problem, performing additional work to expand on the problem identified in the chief complaint and HPI, you may double dip and count a single element in both the history and ROS. Doing so is not only legitimate, it may mean the difference between, for example, a level III and a level IV E/M code assignment.
Setting the Record Straight (Sort of)

McCann later disavowed the twisted interpretation of his words, writing, You ask if a single statement may be used in the history of present illness and still be counted in the review of systems without actually being written twice . it is not necessary to mention an area of history twice to meet the documentation requirements for the ROS. E/M documentation guidelines are supposed to help you find the correct level of service and not to be perceived as a burden to the physician, he concluded (see http://
ercoder.com/downloads/files/PPC_1999_DD_Clarifi cation.pdf and http://medicalnewswire.com/artman/ publish/article_6570.shtml for more).
Despite McCanns clarification, the you cant use the same documented item in both the history and ROS trope spread far and wide, and was repeated so often that it has been accepted as truth. In fact, this (mis)understanding has become one of the greatest coding urban legends. And because payers and auditors do have freedom in how they apply documentation guidelines, some have, indeed, chosen to interpret the rules to mean a single item cannot be used in both the history and ROS. The Truth Part 1: There are no requirements for documented patient information to be stated or written in any specific format. Neither the 1995 or 1997 Documentation Guidelines for Evaluation and Man-
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February 2013
45
Auditing/Compliance
By Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P
Facility
Control Hospital Risk Using
OIGs 2013 Work Plan

Let government reviews help you identify and correct potential compliance risks at your hospital.
ed Group (CMS-DRG) system to Medicare Severity-Diagnosis Related Groups (MS-DRGs). This classification system change has meant updates in billing for hospitals, as well. In this review, the OIG explains the changes in billing since 2008, and how billing in 2012, in particular, varied among different providers. They also plan to examine compliance with inpatient billing standards among hospitals. Compliance with billing standards is crucial to assigning appropriate MS-DRGs. Take this opportunity to examine billing compliance function to verify it is active and functioning well. As always, inpatient coding is an area of risk in a hospital, so be sure not to forget this area when developing your coding audit plans for the year. however, CMS will examine all services provided in that time frame. This will uncover potential issues with the three-day window, as well, which is an area that has been problematic for facilities in the past. This review provides a great opportunity for hospitals to consider the affects of potential expansion of the DRG window before it occurs. For example: Is your facility including all diagnostic and clinically related nondiagnostic services provided within the three-day window? Have wholly owned and operated physician practices been considered in any previous reviews of these types of claims? Organizations should look closely at these claims and be sure that this item is included in their audit plan for the year.
Each October, the Office of Inspector General (OIG) reports on compliance issues it plans to monitor most closely in the new year. This information provides a road map your organization can use to develop a compliance audit plan for the year ahead. In reviewing the OIGs areas of concern for hospitals, you might catch potential noncompliance in your workplace, allowing you to take corrective action to reduce risk of Medicare and Medicaid fraud.
DRG Window
The Medicare program currently bundles all outpatient services delivered three days prior to an inpatient hospital admission. The Medicare program does not pay separately for these preadmission services when they are delivered in a setting owned or operated by the admitting hospital. This policy is commonly known as the DRG window, and prior OIG work identified improper payments in the DRG window. This study was developed to analyze claims data to determine how much CMS could save if it bundled outpatient services delivered up to 14 days prior to an inpatient hospital admission into the MS-DRG payment. To evaluate these DRG window payments,
Non-hospital-owned Physician Practices Using Provider-based Status

This is a two-part review by the OIG, based on concerns from the Medicare Payment Advisory Commission. In one portion of the review, the OIG will examine the impact of non-hospital-owned physician practices billing Medicare as provider-based physician practices. The Medicare program makes additional payment to facilities for services provided in the provider-based clinic setting. Unfortunately, the beneficiary also loses out in these situations, as he or she pays a higher co-payment. In the other portion of this review, the OIG will examine which practices that bill Medicare using provider-based status meet billing requirements. Hospitals should exam-
Look Out for First-time Reviews

Several items in the 2013 Work Plan, aimed specifically at the hospital industry, are appearing for the first time. Consider each of the following items carefully.
Inpatient Billing for Medicare Beneficiaries

In 2008, the Medicare Inpatient Prospective Payment System (IPPS) transitioned from the traditional Centers for Medicare & Medicaid Services-Diagnosis Relat46 AAPC Cutting Edge
photo by iStockphotocourtneyK
Auditing/Compliance: Work Plan
Hospitals should examine their provider-based clinics to determine if they are billing properly.
ine their provider-based clinics to determine if they are billing properly. If your facility has physician practices that do not meet the criteria for provider-based clinic billing, its critical these services are not billed as provider-based. diem rate if the patient was discharged to a swing bed in another hospital. This review will allow the OIG and CMS to examine swing bed policy to determine if a change in reimbursement policies should be made. with MCC has a relative weight of 1.8803. MS-DRG 870 Septicemia with mechanical ventilation, 96+ hours has a relative weight of 5.8399. This significant difference in relative weight will obviously result in a higher payment to the facility for mechanical ventilation services. Review any clinical documentation you have for mechanical ventilation in your facility: Are there areas for improving time recording? Are the minimum standards being met for the MS-DRG grouping 96hour rule?
Compliance with Medicares Transfer Policy

Transfers have been a consistent issue in hospital billing and reimbursement for many years. This OIG Work Plan looks at transfers overall, but also reviews the effectiveness of the claims processing edits used by the Medicare administrative contractors (MACs) to identify claims subject to the transfer policies in place in the Medicare program. Under Medicare IPPS guidelines, a hospital that is discharging a beneficiary receives MS-DRG payment in full. A hospital that is transferring a patient to another acute care facility is paid a graduated per diem rate. The rate will not exceed the full MSDRG payment that would have been made if the patient was discharged from the original without being transferred. There are often issues where patients are improperly noted as being discharged instead of transferred from the original facility, and the entire MS-DRG payment is made for both facilities. The OIG is on the lookout for this sort of thing. This item should always be included in a hospital billing compliance audit plan; this is a constant risk area for most hospitals.
Payments for Canceled Surgical Procedures

From an analysis of data, the OIG has determined large occurrences of initial IPPS payment for a canceled surgical procedure, followed by a second IPPS payment for the rescheduled surgical procedure. For the initial IPPS payment, few, if any, inpatient services such as laboratory or diagnostic tests were provided by the hospitals because the surgical procedure was canceled. Medicare makes two payments to hospitals, generating two bills, unless the patient is readmitted to the hospital on the same day, in which case a single payment is made. Right now, it is not inappropriate for two bills to be made, as the OIG states in their Work Plan. Its clear, however, they are determining how much money is spent on inpatient short stays for canceled surgical procedures without significant services being provided. This could result in policy changes in the future for this type of service. This review item provides an opportunity for providers to check that documentation for these types of services is strong and concise. Have clinical documentation improvement staff members work with providers to clearly document reasons for surgical cancellations, as well as all services provided for patients. Be sure coding clearly reflects all work provided for patients during their stay.
Use the Work Plan to Your Advantage

Most of these new items in the OIG Work Plan are reviews of policies, procedures, and areas for future improvement within the Medicare program. Facilities have a great opportunity to review these areas and improve compliance internally. Take the time to review the existing items in the Work Plan, such as same-day readmissions, outlier payments, observation payments, and many of the other items continuously monitored by the OIG. These are still active reviews, and your organization may be called upon to provide information in any of these areas. The entire 2013 Work Plan can be downloaded at https://oig.hhs.gov/reportsand-publica t ions/archives/workplan/2013/WorkPlan-2013.pdf. For a peek into the areas of risk
Payments for Discharges to Swing Beds in Other Hospitals

Swing beds are inpatient beds in hospitals that can be used for skilled nursing services or acute care services. This review concerns instances when an acute care facility discharges patients from the acute care setting to a swing bed. A move from one clinical setting to another to receive additional care typically is considered a transfer. Currently, however, Medicare does not pay a reduced, graduated per
Payments for Mechanical Ventilation

When a ventilator or respirator is used to take over active breathing for a patient for 96 or more hours in the inpatient setting, certain MS-DRG payments can be changed, creating a significant increase in the payment for that particular MS-DRG. For example, MS-DRG 871 Septicemia without mechanical ventilation, 96+ hours
for physician related-items read Get a Jump on 2013 Government Reviews on pages 48-49 of Januarys Cutting Edge.
Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, serves as a clinical technical editor for OptumInsight, and has nearly 20 years of experience in the health care industry. She is a former chief compliance officer and chief privacy official. She teaches CPT coding as an approved AAPC instructor, and is a former member of AAPCs ICD10 curriculum development team. She holds a bachelors degree in health care administration from State University of New York - Empire State College and a masters degree in health systems administration from the Rochester Institute of Technology.
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February 2013
47
Auditing/Compliance
Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC
Coding Compass
New POS Rules Get Sticky for 21 and 22 E/M Services

Although it may mean denials, stay compliant when reporting inpatient transports to outpatient settings.
tient provider office for an evaluation and management (E/M) service and a procedure. The patient is still a registered inpatient and will return to the hospital at the conclusion of the visit. Should the outpatient provider report his or her E/M service using the outpatient E/M codes (9920199215) or can they use the subsequent inpatient E/M codes? Applying the new POS code reporting rule, where an outpatient E/M service is reported with POS 21 or 22, the service will be denied. Here is the relevant language from transmittal 2563, effective Oct. 11, 2012: In general, the POS code reflects the actual place where the beneficiary receives the faceto-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. And here is the specific provider instruction added to the Medicare Claims Processing Manual: Special Considerations for Services Furnished to Registered Inpatients When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irre-
e sure your place-of-service (POS) code matches the setting where the patient received the service (for faceto-face services), or the setting where the technical portion of the service was delivered (for non-face-to-face services, such as diagnostic test result interpretation). Although this may sound easy in theory, new Medicare guidance can make POS assignment tricky. In recent transmittal 2563, change request (CR) 7631, the Centers for Medicare &
Medicaid Services (CMS) clarified guidance for assigning POS codes on Medicare claims. That guidance has posed new questions that should be addressed regarding these claims. One of those questions came to light through Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P, when she used the following coding scenario to point out discrepancies when reporting in compliance to the new POS reporting rules: An inpatient is transported to an outpa-
Auditing/Compliance: Place of Service
Attempting to avoid the denial by reporting an inpatient E/M service that was not performed, especially where that code results in the physician obtaining additional reimbursement, is not recommended.
spective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility. According to this provision, I see the issue where a physician performing an E/M service in an office setting for a patient who is currently a registered inpatient at a facility (and transported to the office location) would be required to report POS 21 for any physician service or procedure performed. The problem this instruction potentially creates is that while there is a facility payment rate for an outpatient E/M service, some carriers may not process a payment for an outpatient E/M service (e.g., 9920199215) when billed with POS 21 consistent with this rule. Where payment is denied, the provider is forced to appeal and validate that reporting is accurate under the above rule, consistent with the following revised instructions to the Medicare administrative carrier (MAC): 10.6 - Carrier Instructions for Place of Service (POS) Codes (Rev.2563, Issued: Oct.11, 2012, Effective: April 1, 2013)
For purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. For example, if the physicians face-toface encounter with a patient occurs in the office, the correct POS code on the claim, in general, reflects the 2-digit POS code 11 for office. In these instances, the 2-digit POS code (Item 24B on the claim Form CMS-1500) will match the address and ZIP entered in the service location (Item 32 on the 1500 Form) the physical/geographical location of the physician. However, there are two exceptions to this general rule these are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code regardless of where the faceto-face service occurs is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 22) as discussed in section 10.5 of this chapter. So, if in the above example, the patient seen in the physicians office is actually an inpatient of the hospital, POS code 21, for inpatient hospital, is correct. In this example, the POS code reflects a different setting than the address and ZIP code of the practice location (the physicians office).* * Medicare Claims Processing Manual, Internet Only Manual (IOM), pub 100-4, chapter 26, section 10.6 (emphasis added). Although it is time consuming to appeal such denials, I have to assume that Medicare administrative contractors will eventually fix their payment systems to comply with this instruction, which is not yet updated in the processing manual on the CMS IOM website. The other option would be for the physician to go to the hospital to do the E/M and pro-
cedure work. Then, and only then, could the physician bill the inpatient codebecause only in that case is an inpatient E/M service provided. A word of caution: Nothing in the above instruction suggests or implies that it would be reasonable to interpret the change as instructing a provider to report an inpatient E/M code for an E/M service performed in an outpatient setting. It merely instructs the provider to use POS code 21 (or a more specific code, where the exact facility status is known) when the outpatient E/M service or other procedure is performed on a patient that is a current registered inpatient at a hospital. Note that the location of the service in block 32 would be the physicians office and ZIP code. I suspect carriers will reprogram their claims processing systems soon to deal with this payment problem, where it exists. Attempting to avoid the denial by reporting an inpatient E/M service that was not performed, especially where that code results in the physician obtaining additional reimbursement, is not recommended. Even if paid, the provider would have to disclose and refund the overpayment within 60 days, consistent with the reverse false claims provision of the False Claims Act and the draft implementing regulations.
Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, has a Bachelor of Science degree from the U.S. Military Academy, a Juris Doctorate degree from Concord Law School, is president of Practice Masters, Inc., and founding partner of Miscoe Health Law, LLC. He is a past member of AAPCs National Advisory Board and a current member of the Legal Advisory Board. He is admitted to the Bar in California and to practice law before the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. He has nearly 20 years of experience in health care coding and over 15 years as a coding and compliance expert testifying in civil and criminal cases. He is a national speaker and has been published in numerous national publications.
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February 2013
49
Permanent J-Code for OMONTYS (peginesatide) Injection
Effective Jan. 1, 2013
J0890
ESA administration
Consider the first once-monthly, non-EPO ESA offering less-frequent dose administration.
INDICATION AND LIMITATIONS OF USE
OMONTYS (peginesatide) Injection is indicated for the treatment of anemia due to chronic kidney disease (CKD) in adult patients on dialysis. OMONTYS is not indicated and is not recommended for use in patients with CKD not on dialysis, in patients receiving treatment for cancer and whose anemia is not due to CKD, or as a substitute for red blood cell (RBC) transfusions in patients who require immediate correction of anemia. OMONTYS has not been shown to improve symptoms, physical functioning, or health-related quality of life. increased risk for death and serious adverse cardiovascular reactions including myocardial infarction and stroke was observed. There is increased mortality and/or increased risk of tumor progression or recurrence in patients with cancer receiving ESAs. In controlled clinical trials of ESAs, ESAs increased the risk of death in patients undergoing coronary artery bypass graft surgery (CABG) and deep venous thrombosis (DVT) in patients undergoing orthopedic procedures. In 2 trials of OMONTYS (peginesatide) Injection, patients with CKD not on dialysis experienced increased specific cardiovascular events. Hypertension (see Contraindications): Appropriately control hypertension prior to initiation of and during treatment with OMONTYS. Reduce or withhold OMONTYS if blood pressure becomes difficult to control. Serious allergic reactions (see Contraindications): Serious allergic reactions have been reported with OMONTYS. Immediately and permanently discontinue OMONTYS and administer appropriate therapy if a serious allergic reaction occurs. Lack or loss of response to OMONTYS: Initiate a search for causative factors. If typical causes of lack or loss of hemoglobin response are excluded, evaluate for antibodies to peginesatide. Dialysis management: Patients receiving OMONTYS may require adjustments to dialysis prescriptions and/or increased anticoagulation with heparin to prevent clotting of the extracorporeal circuit during hemodialysis. Laboratory monitoring: Evaluate transferrin saturation and serum ferritin prior to and during OMONTYS treatment. Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20%. Monitor hemoglobin every 2 weeks until stable and the need for RBC transfusions is minimized. Then, monitor monthly. Adverse reactions Most common adverse reactions in clinical studies in patients with CKD on dialysis treated with OMONTYS were dyspnea, diarrhea, nausea, cough, and arteriovenous fistula site complication.
Reducing the burden of
In controlled clinical trials of ESAs in patients with cancer,
IMPORTANT SAFETY INFORMATION

WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE. Chronic Kidney Disease: In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks. Use the lowest OMONTYS dose sufficient to reduce the need for RBC transfusions. Contraindications OMONTYS is contraindicated in patients with uncontrolled hypertension and in patients who have had serious allergic reactions to OMONTYS. Warnings and Precautions Increased mortality, myocardial infarction, stroke, and thromboembolism: Using ESAs to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular reactions and has not been shown to provide additional benefit. Use caution in patients with coexistent cardiovascular disease and stroke. Patients with CKD and an insufficient hemoglobin response to ESA therapy may be at even greater risk for cardiovascular reactions and mortality. A rate of hemoglobin rise of >1 g/dL over 2 weeks may contribute to these risks.
Reference: Schiller B, Doss S, De Cock E, Del Aguila MA, Nissenson AR. Costs of managing anemia with erythropoiesis-stimulating agents during hemodialysis: a time and motion study. Hemodial Int. 2008;12(4):441-449.
Please see accompanying Brief Summary.
03-12-00277-A.; 24102. 2012 Affymax, Inc. and Takeda Pharmaceuticals America, Inc. All rights reserved. Affymax, the Affymax logo, OMONTYS, and the OMONTYS logo are trademarks of Affymax, Inc. and/or its subsidiaries. Takeda and the Takeda logo are trademarks of Takeda Pharmaceutical Company Limited registered with the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc.
Table 2 Adverse Cardiovascular Outcomes in Randomized Controlled Trials Comparing Higher and Lower Hemoglobin Targets in Patients With CKD
NHS (N = 1265) Time Period of Trial 1993 to 1996
CHOIR (N = 1432) 2003 to 2006
TREAT (N = 4038) 2004 to 2009
Population BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION OMONTYS (peginesatide) Injection for intravenous or subcutaneous use WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE. Chronic Kidney Disease: In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesisstimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks [see Warnings and Precautions]. Use the lowest OMONTYS dose sufficient to reduce the need for red blood cell (RBC) transfusions [see Warnings and Precautions]. INDICATIONS AND USAGE Anemia Due to Chronic Kidney Disease OMONTYS is indicated for the treatment of anemia due to chronic kidney disease (CKD) in adult patients on dialysis. Limitations of Use OMONTYS is not indicated and is not recommended for use: In patients with CKD not on dialysis because of safety concerns in this population [see Warnings and Precautions]. In patients receiving treatment for cancer and whose anemia is not due to CKD, because ESAs have shown harm in some settings and the benefit-risk factors for OMONTYS in this setting have not been evaluated [see Warnings and Precautions]. As a substitute for RBC transfusions in patients who require immediate correction of anemia. OMONTYS has not been shown to improve symptoms, physical functioning or health-related quality of life. CONTRAINDICATIONS OMONTYS is contraindicated in patients with: Uncontrolled hypertension [see Warnings and Precautions]. Serious allergic reactions to OMONTYS [see Warnings and Precautions]. WARNINGS AND PRECAUTIONS Increased Mortality, Myocardial Infarction, Stroke, and Thromboembolism In controlled clinical trials of other ESAs in patients with CKD comparing higher hemoglobin targets (13 - 14 g/dL) to lower targets (9 - 11.3 g/dL) (see Table 2), increased risk of death, myocardial infarction, stroke, congestive heart failure, thrombosis of hemodialysis vascular access, and other thromboembolic events was observed in the higher target groups. Using ESAs to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular reactions and has not been shown to provide additional benefit. Use caution in patients with coexistent cardiovascular disease and stroke. Patients with CKD and an insufficient hemoglobin response to ESA therapy may be at even greater risk for cardiovascular reactions and mortality than other patients. A rate of hemoglobin rise of greater than 1 g/dL over 2 weeks may contribute to these risks. In controlled clinical trials of ESAs in patients with cancer, increased risk for death and serious adverse cardiovascular reactions was observed. These adverse reactions included myocardial infarction and stroke. In controlled clinical trials, ESAs increased the risk of death in patients undergoing coronary artery bypass graft surgery (CABG) and deep venous thrombosis (DVT) was observed in patients undergoing orthopedic procedures. The design and overall results of 3 large trials comparing higher and lower hemoglobin targets are shown in Table 2 (Normal Hematocrit Study (NHS), Correction of Hemoglobin Outcomes in Renal Insufficiency (CHOIR) and Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT)).
Patients with CKD Patients with CKD on Patients with not on dialysis with hemodialysis with CKD not on dialysis coexisting CHF or hemoglobin < 11 g/dL with type II diabetes, not previously CAD, hematocrit hemoglobin administered 30 3% on 11 g/dL epoetin alfa epoetin alfa 14.0 vs. 10.0 12.6 (11.6, 13.3) vs. 10.3 (10.0, 10.7) All-cause mortality or non-fatal MI 13.5 vs. 11.3 13.0 (12.2, 13.4) vs. 11.4 (11.1, 11.6) All-cause mortality, MI, hospitalization for CHF, or stroke 1.34 (1.03 1.74) All-cause mortality 1.48 (0.97 2.27) 13.0 vs. 9.0 12.5 (12.0, 12.8) vs. 10.6 (9.9, 11.3) All-cause mortality, MI, myocardial ischemia, heart failure, and stroke 1.05 (0.94 1.17) Stroke 1.92 (1.38 2.68)
Hemoglobin Target; Higher vs. Lower (g/dL) Median (Q1, Q3) Achieved Hemoglobin level (g/dL) Primary Endpoint Hazard Ratio or Relative Risk (95% CI) Adverse Outcome for Higher Target Group Hazard Ratio or Relative Risk (95% CI)
1.28 (1.06 1.56) All-cause mortality 1.27 (1.04 1.54)
Patients with Chronic Kidney Disease Not on Dialysis OMONTYS is not indicated and is not recommended for the treatment of anemia in patients with CKD who are not on dialysis. A higher percentage of patients (22%) who received OMONTYS experienced a composite cardiovascular safety endpoint event compared to 17% who received darbepoetin alfa in two randomized, active-controlled, open-label, multi-center trials of 983 patients with anemia due to CKD who were not on dialysis. The trials had a pre-specified, prospective analysis of a composite safety endpoint consisting of death, myocardial infarction, stroke, or serious adverse events of congestive heart failure, unstable angina or arrhythmia (hazard ratio 1.32, 95% CI: 0.97, 1.81). Increased Mortality and/or Increased Risk of Tumor Progression or Recurrence in Patients with Cancer receiving ESAs OMONTYS is not indicated and is not recommended for reduction of RBC transfusions in patients receiving treatment for cancer and whose anemia is not due to CKD because ESAs have shown harm in some settings and the benefit-risk factors for OMONTYS in this setting have not been evaluated. The safety and efficacy of OMONTYS have not been established for use in patients with anemia due to cancer chemotherapy. Results from clinical trials of ESAs in patients with anemia due to cancer therapy showed decreased locoregional control, progression-free survival and/or decreased overall survival. The findings were observed in clinical trials of other ESAs administered to patients with: breast cancer receiving chemotherapy, advanced head and neck cancer receiving radiation therapy, lymphoid malignancy, cervical cancer, non-small cell lung cancer, and with various malignancies who were not receiving chemotherapy or radiotherapy. Hypertension OMONTYS is contraindicated in patients with uncontrolled hypertension. Appropriately control hypertension prior to initiation of and during treatment with OMONTYS. Reduce or withhold OMONTYS if blood pressure becomes difficult to control. Advise patients of the importance of compliance with antihypertensive therapy and dietary restrictions. Serious Allergic Reactions Serious allergic reactions, including anaphylactic reactions, hypotension, bronchospasm, angioedema and generalized pruritus, may occur in patients treated with OMONTYS. Immediately and permanently discontinue OMONTYS and administer appropriate therapy if a serious allergic reaction occurs. Lack or Loss of Response to OMONTYS For lack or loss of hemoglobin response to OMONTYS, initiate a search for causative factors (e.g., iron deficiency, infection, inflammation, bleeding). If typical causes of lack or loss of hemoglobin response are excluded, evaluate the patient for the presence of antibodies to peginesatide. In the absence of antibodies to peginesatide, follow dosing recommendations for management of patients with an insufficient hemoglobin response to OMONTYS therapy. Contact Affymax, Inc. (1-855-466-6689) to perform assays for binding and neutralizing antibodies. Dialysis Management Patients may require adjustments in their dialysis prescriptions after initiation of OMONTYS. Patients receiving OMONTYS may require increased anticoagulation with heparin to prevent clotting of the extracorporeal circuit during hemodialysis.
Laboratory Monitoring Evaluate transferrin saturation and serum ferritin prior to and during OMONTYS treatment. Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20%. The majority of patients with CKD will require supplemental iron during the course of ESA therapy. Following initiation of therapy and after each dose adjustment, monitor hemoglobin every 2 weeks until the hemoglobin is stable and sufficient to minimize the need for RBC transfusion. Thereafter, hemoglobin should be monitored at least monthly provided hemoglobin levels remain stable. ADVERSE REACTIONS The following serious adverse reactions are discussed in greater detail in other sections of the labeling: Increased Mortality, Myocardial Infarction, Stroke, and Thromboembolism [see Warnings and Precautions] Hypertension [see Warnings and Precautions] Serious allergic reactions [see Warnings and Precautions] Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of OMONTYS cannot be directly compared to rates in the clinical trials of other drugs and may not reflect the rates observed in practice. Patients with Chronic Kidney Disease Adverse reactions were determined based on pooled data from two active controlled studies of 1066 dialysis patients treated with OMONTYS and 542 treated with epoetin, including 938 exposed for at least 6 months and 825 exposed for greater than one year to OMONTYS. The population for OMONTYS was 20 to 93 years of age, 58.5% male, and the percentages of Caucasian, Black (including African Americans), and Asian patients were 57.9%, 37.4%, and 3.1%, respectively. The median weight adjusted dose of OMONTYS was 0.07 mg/kg and 113 U/week/kg of epoetin. Table 3 summarizes the most frequent adverse reactions ( 10%) in dialysis patients treated with OMONTYS. Table 3 Adverse Reactions Occurring in 10% of Dialysis Patients Treated with OMONTYS Dialysis Patients Treated with OMONTYS (N = 1066) 18.4% 17.4% 15.3% 18.4% 15.9% 16.1% 10.9% 15.4% 15.3% 10.9% 10.9% 10.7% 14.2% 13.2% 12.2% 11.4% 11.0% Dialysis Patients Treated with Epoetin (N = 542) 15.9% 19.6% 13.3% 19.4% 16.6% 16.6% 12.5% 15.9% 17.2% 12.7% 11.3% 9.8% 14.6% 11.4% 14.0% 11.8% 12.4%
Adverse Reactions Gastrointestinal Disorders Diarrhea Nausea Vomiting Dyspnea Cough Arteriovenous Fistula Site Complication Procedural Hypotension Nervous System Disorders Headache Muscle Spasms Pain in Extremity Back Pain Arthralgia Vascular Disorders Hypotension Hypertension Pyrexia Metabolism and Nutrition Disorders Hyperkalemia Infections and Infestations Upper Respiratory Tract Infection
Respiratory, Thoracic and Mediastinal Disorders
Injury, Poisoning and Procedural Complications
Musculoskeletal and Connective Tissue Disorders
Postmarketing Experience Because postmarketing reporting of adverse reactions is voluntary and from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Serious allergic reactions have been reported during postmarketing use of OMONTYS [see Warnings and Precautions]. Immunogenicity Of the 2357 patients tested during clinical trials, 29 (1.2%) had detectable levels of peginesatide-specific binding antibodies. There was a higher incidence of peginesatidespecific binding antibodies in patients dosed subcutaneously (1.9%) as compared to those dosed intravenously (0.7%). Peginesatide neutralizing antibodies were detected in vitro using a cell-based functional assay in 21 of these patients (0.9%). In approximately half of all antibody-positive patients, the presence of antibodies was associated with declining hemoglobin levels, the requirement for increased doses of OMONTYS to maintain hemoglobin levels, and/or transfusion for anemia of CKD. No cases of pure red cell aplasia (PRCA) developed in patients receiving OMONTYS during clinical trials. DRUG INTERACTIONS No formal drug/drug interaction studies have been performed. Peginesatide does not bind to serum albumin or lipoproteins as demonstrated in in vitro protein binding studies in rat, monkey and human sera. In vitro studies conducted with human hepatocytes or microsomes have shown no potential for peginesatide to induce or inhibit CYP450 enzymes. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C There are no adequate and well-controlled studies in pregnant women. Peginesatide was teratogenic and caused embryofetal lethality when administered to pregnant animals at doses and/or exposures that resulted in polycythemia. OMONTYS should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Administration of peginesatide by intravenous injection to rats and rabbits during organogenesis was associated with embryofetal toxicity and malformations. Dosing was every third day in rats for a total of 5 doses and every fifth day in rabbits for a total of 3 doses (0.01 to 50 mg/kg/dose). In rats and rabbits, adverse embryofetal effects included reduced fetal weight, increased resorption, embryofetal lethality, cleft palate (rats only), sternum anomalies, unossification of sternebrae and metatarsals, and reduced ossification of some bones. Embryofetal toxicity was evident in rats at peginesatide doses of 1 mg/kg and the malformations (cleft palate and sternoschisis, and variations in blood vessels) were mostly evident at doses of 10 mg/kg. The dose of 1 mg/kg results in exposures (AUC) comparable to those in humans after intravenous administration at a dose of 0.35 mg/kg in patients on dialysis. In a separate embryofetal developmental study in rats, reduced fetal weight and reduced ossification were seen at a lower dose of 0.25 mg/kg. Reduced fetal weight and delayed ossification in rabbits were observed at 0.5 mg/kg/dose of peginesatide. In a separate embryofetal developmental study in rabbits, adverse findings were observed at lower doses and included increased incidence of fused sternebrae at 0.25 mg/kg. The effects in rabbits were observed at doses lower (5% - 50%) than the dose of 0.35 mg/kg in patients. Nursing Mothers It is not known whether peginesatide is excreted in human milk. Because many drugs are excreted into human milk, caution should be exercised when OMONTYS is administered to a nursing woman. Pediatric Use The safety and efficacy of OMONTYS in pediatric patients have not been established. Geriatric Use Of the total number of dialysis patients in Phase 3 clinical studies of OMONTYS, 32.5% were age 65 and over, while 13% were age 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects. OVERDOSAGE OMONTYS overdosage can elevate hemoglobin levels above the desired level, which should be managed with discontinuation or reduction of OMONTYS dosage and/or with phlebotomy, as clinically indicated. Cases of severe hypertension have been observed following overdose with ESAs [see Warnings and Precautions]. Marketed by: Affymax, Inc. Palo Alto, CA 94304 Distributed and Marketed by: Takeda Pharmaceuticals America, Inc. Deerfield, IL 60015 OMONTYS is a trademark of Affymax, Inc. registered in the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc. All other trademarks are the property of their respective owners. PEG096 R2_BS L-DSG-1112-1
General Disorders and Administration Site Conditions
Seizures have occurred in patients participating in OMONTYS clinical studies. During the first several months following initiation of OMONTYS, blood pressure and the presence of premonitory neurologic symptoms should be monitored closely. Advise patients to contact their healthcare practitioner for new-onset seizures, premonitory symptoms, or change in seizure frequency. Allergic and infusion-related reactions have been reported in patients treated with OMONTYS.
Practice Management
By David J. Moore, MD, MS
Optimize Your Patients Access to Care

Create a schedule model that fullls patient scheduling needs, reduces no-shows, improves front staff workload, and allows provider exibility.
hinking from the health care administrators perspective, wouldnt it be nice if a patient scheduling model and throughput existed that could: Fill available schedule blocks; Decrease no-show rates; Reduce appointment handling and rescheduling workload; Enhance provider schedule flexibility; and Yield high patient satisfaction scores? Thinking from the patient perspective, wouldnt it be great if you: Got dependably an appointment when you actually needed it; Were seen reliably by your own provider; Were treated respectfully by your doctors office as being competent and capable of managing your own appointment choices; and Received regular follow-up reminders as necessary?
Take Care of Patients Who Take Care of Your Practice

Modified Open Access is a scheduling model developed in 2001 and aimed to achieve these goals of a patient-centered, sustainable, and viable practice model. The model strives to optimize care provider access and utilization through the creation and maintenance of intentionally open schedule templates at the start of each day. Originally developed by our quality improvement team, its goal is to capturein a sustainable waythe innovative care scheduling ideals of the Advanced Open Access mod54 AAPC Cutting Edge
el (as developed and described in Murray and Tantaus September 2000 publication, Same-Day Appointments: Exploding the Access Paradigm). Like its Advanced Open Access predecessor, Modified Open Access pursues: Same-day care access as the norm for a practice A uniform schedule slot time length without special acuity limitations slots are intentionally designated to average the time a practice needs per patient and to eliminate the need for special appointment handling around acuity issues An emphasis on provider-specific continuity of care The goal of Modified Open Access and Murray and Tantaus model is to make the systems first priority be to take care of the patients who are established with a practice and who ultimately are the ones who take care of the practice. As we considered implementation logistics, our team addressed the concern of how to prevent open schedules from refilling with new or transient clientele who may ultimately block out established patients. To address this concern and preserve an open and accessible schedule for established patients, Modified Open Access differs from the Murray and Tantau model in placing limits on the interval beyond same-day for when appointments may be booked. It then utilizes several simple policy tools to ensure that established patients can always get in when they call for either acute or follow-up carethese are tools to maintain the promise of established patient care access.
Offering Reliable, Limited Access Is Key

Like its predecessor, Modified Open Access achieves ready appointment access by intentionally having schedules two-thirds open at the start of any business day. Open schedules mean ready access for patients. Although it may seem counter-intuitive to pursue full schedules by intentionally opening two-thirds of a providers schedule, we found that patient throughput volume actually went up because the schedule allowed patients to see their preferred provider reliably. No-show rates markedly declined as a result of the time decrease between when the request was made to when the appointment actually occurred. To achieve and maintain an open schedule, established patients are offered and encouraged to take same-day appointments, but are limited to appointments within seven days. To make established patients access top priority, new patients are limited to same-day access only; that is, new patients (patients never before seen by the particular provider) are only offered access to a provider on a same-day basis, and only after time slots for established patient care needs are addressed on that day. Limiting new patient access, as with traditional scheduling, supports and defends established patients access.
Use Tools to Support Open Scheduling

Tool No. 1: EPPA Time A behind-the-scenes tool called the established patient priority access (EPPA) time supports priority access to established pa-
Practice Management
In a nutshell, the model strives to optimize care provider access and utilization through the creation and maintenance of intentionally open schedule templates at the start of each day.
tients. The EPPA time is an internally set time on the clock each day. Before the EPPA time of the day, only established patients are allowed access to that days appointments. After the EPPA time passes, all patients, new and established, are given equal access to remaining appointments for that same day. In our busy practice setting, the EPPA time is usually set at 11a.m., but remains flexible and can be altered as needed, even on a daily basis. Before 11 a.m., only our established patients have access to the days twothirds open schedule, giving them priority status. After 11 a.m., both new and established patients are offered any remaining slots for that day. New patients who call for appointments before the days established EPPA time are politely informed that no appointments are available at that time, and are offered a callback if an appointment becomes available after the set EPPA time. After the EPPA time, new patients have equal access to any remaining slots for the day and the call-back list also can be used to fill in remaining open slots in the days schedule. The EPPA time may be adjusted to accommodate care demand trends observed by the practice. If the schedule is not filling, you can move the EPPA time to an earlier point in the day, effectively opening up the practice to more new patients. If established patient care demand risesfor instance, due to an influenza outbreakthen you can protect more established patient slots by moving the EPPA time to a later point in the day. Central to the models success is that established patients may, at any point, book an appointment up to a week in advance, but at no point are new patients offered appoint-
ments beyond today. This not only defends and sustains the models openness, it satisfies new patient needs. We found that new patients are happy to accept or be called back for same-day appointments when they are available. Our new patient volume actually increased compared to our prior traditional scheduling model experience. Tool No. 2: Receptionist Scripts To support this method of handling care demands, receptionist phone protocol scripts were developed to aid our receptionists (see Figure A and B). Although the model protocol can be integrated into the practice management scheduling software, scripts for our receptionists remain a valuable tool for implementation and training. They are also useful for understanding the models flow of patient call handling. The scripts encourage filling of first available slots, but our patient-centered emphasis remains on accommodating established patient appointment needs, up to the allowed full weeks advanced scheduling option. The scripts also introduce the next tool developed to support keeping the same-day access promise for established patients. Tool No. 3: Pressure-valve Slots Because patient care demand can be unpredictable in both volume and at what time, pressure-valve slots are a tool that allows for a second layer of capacity. Patients, who may not lock in appointments beyond one week in advance, need assurance that when they call, they have appointment access reliably. The pressure-valve slot tool is embedded in the model to ensure established patients can count on the availability of at least one same-day access option on any day. Heres how pressure-valve slots work: They are a scheduled interval of protected appointment slots built around the usual prac-
tice closing time that become available only if the days regular appointment slots have saturated. In our busy practice, pressurevalve slots span from one hour prior to our usual closing time to one hour after that time. These pressure-valve slots are available to established patients only, and always are open at the start of the day. If during any point of the day, no regular appointment slots remain open for an established patient calling for care, the pressure valveclosed till that pointthen opens, allowing the first available pressure-valve slot only to be offered to that established patient. The next available slot is only offered to a subsequent established patient requesting care. In our experience, pressure-valve slots rarely fill past usual closing time, but the capacity beyond the usual closing time allows responsiveness to care needs and demands of established patient clientele. In our primary care setting, pressure-valve care tends to be acute, urgent, and reflects the illnesses affecting the community; however, no limits are ever placed in the schedule on the nature of care requested. As the pressure-valve slots in a day progress across the interval, patients with lower acuity care needs tend to accept more readily the two-thirds open appointment options in the subsequent days. Pressure-valve slots help to keep at least one appointment available around closing time to established patients, which honors the promise of access. Tool No. 4: Follow-up Management Protocol If appointments are not locked in beyond one week for established patients, how are follow-up appointments handled beyond one week? To address this concern, a follow-up prompt and reminder system was developed using
February 2013 55
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Practice Management
Figure A
Before ______ am
EPPA time
Hello, may I help you schedule an appointment?

Yes No Have you been seen at ______ Clinic before? Yes No Patient Name? / Designated PCP? Yes We show Dr _X_ is the PCP. Would you like to see Dr _X_? Yes Offer: Earliest Available PCP regular Appointment Yes Book PCP Appointment Sometimes appts become available after _____ (EPPA time). May I put your name on our call-back list, OR you may check back with us again after____ (EPPA time). No No reg appointment left? Offer 1st Available Pressure-Valve appointment Declined Please give us a call on or near the day you want to be seen and we will get you in. address concerns
Offer PCP Appointment < 1 week
No
Figure B
After _______ am
EPPA time
Hello, may I help you schedule an appointment?

Yes No Have you been seen at ______ Clinic before? Yes Patient Name? / Designated PCP? Yes We show Dr _X_ is the PCP. Would you like to see Dr _X_? Yes Offer: Earliest Available PCP regular Appointment Yes Book PCP Appointment No address concerns
Offer any remaining: same-day + Regular Appointment slots OR May I put your name on our call-back list or you may check with us again tomorrow after _____(EPPA time)
No No reg. appointment left?
Offer 1st Available Pressure-Valve appointment Declined Offer PCP Appointment < 1 week
No
Please give us a call on or near the day you want to be seen and we will get you in.
56
AAPC Cutting Edge
Practice Management
our existing practice management software capabilities. The reminder systems foundation is based on the underlying principle: No matter what the scheduling model, it ultimately is the patients choice and decision whether to comply with the follow-up recommendations given by his or her provider. With this in mind, a three-tiered, follow-up reminder system was developed to encourage recommended return care interval compliance. The system starts with the providers recommended follow-up interval being delivered to the receptionist desk while the patient exits from an existing appointment. The first tier is a general interval follow-up card given to the exiting patient (e.g., follow up in early May). The existing patient reminder system then triggers daily batch mailing reminder cards at the providers recommend-
ed follow-up interval. After allowing a response interval, if no appointment is initiated by the patient, a final reminder is generated and sent. Although initiation of an appointment request falls into the patients hands, follow-up compliance is tracked and providers are kept aware of all patient-specific lapses.
Appointment Accessibility Shows Favorable Results

The patient-initiated access and limited advanced scheduling aspects of the Modified Open Access model resulted in 50 percent or greater reductions of no-show rates versus our prior appointment model, or other site traditional appointment model users in our system. Front office staff reported dramatically improved workloads attributed to a significant reduction in appointment
rescheduling. With no locked-in appointments beyond one week, provider schedules had a significant increase in flexibility. Most importantly, patient satisfaction with provider continuity and access has been high. Implementation challenges and caveats, as well as spin-off benefits of the model, continue to be noted, and opportunities for software-driven enhancements and streamlining still remain.
David J. Moore, MD, MS, has served in primary care community health for nearly 20 years and is an assistant professor at the University of Kentuckys Center for Excellence in Rural Health. He has served in corporate medical director and site director roles in the Universitys partner relationship with the North Fork Valley Community Health Center in Hazard, Ky. He is a graduate of Harvard University School of Public Healths Masters in Health Care Management and a graduate of Wright State University School of Medicine and Family Medicine Residency in Dayton, Ohio.
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newly credentialed members

Aida Aquino, CPC Alanna Stuart, CPC Alethea Cann-Leriger, CPC Alicia Erdman, CPC Alicia Gongora, CPC Amalraj Ignatius, CPC-P Amanda Gallawa Grifth, CPC Amanda Puzycki, CPC Amber M. Smith, CPC-H Amitha Ramakrishnan, CPC Amuthapriya Elangovan, CPC Amy Thatcher, CPC Andrew Weinfeld, CPC Angela Brooks Latta, CPC Angie Stough, CPC Anisha V S, CPC-H Ann Culp, CPC Anne Whalley, CPC Annemarie Deerr-Larmer, CPC Annette M Coffey, CPC April Marie Reynolds, CPC April Shanae Williamson, CPC Aruna Padmasuran, CPC Ashlee Dressler, CPC-H Ashley Modin, CPC Ashley Terrell, CPC Audrey Anderson, CPC Barb King, CPC-H Barbara Keim, CPC Belia Villegas, CPC Beth Gawronski, CPC Bethany Sumner, CPC Bobbi Garlow, CPC Brandy Michelle Fields, CPC Brenda L Melton, CPC, CPC-H Candace Smith, CPC, CEDC Candy Cook, CPC Carissa Cobuluis, CPC Carmen Borrero Borreli, CPC Carolyn Boston, CPC, CGIC Catherine Cichowicz, CPC Catherine Peake, CPC Catherine Porter, CPC Cathy Martin, CPC Cathy Zardas, CPC Celine Nadeau, CPC Cheryl Miller, CPC Cheryl Smith, CPC Christina Lynn Walz, CPC Christina Michelle Chrisjohn, CPC Christina Pierce, CPC Christine Burke, CPC, CPC-H Christine Roketa Johnson, CPC Christy Lashon Mansuy, CPC Cindy Rohlng, CPC Cynthia Miles, CPC Daiana Varela, CPC Dana A Sisk, CPC Danielle L McVea, CPC David S Brown, CPC Dawn B Rathburn, CPC Dawn Marie Montecalvo, CPC Dawn Thomas, CPC Dawna L Moore, CPC Deb Richards, CPC Deborah Reichardt, CPC Deborah Renee Callahan, CPC Deborah Sturgille, CPC Deborah Tasnady, CPC Debra Ann Laws, CPC Delaina Herrera, CPC Delaina Rider, CPC Delora Clarissa Carswell, CPC Diana Manger, CPC-H Dianne Rice, CPC Dionne Deemer, CPC Dionne Walker, CPC Divyabharathi Alexander, CPC Donna Krysl, CPC Donna L Davis, CPC, CPC-H Donna Satterlee, CPC Donnie Dale Clancy, Jr, CPC-H Dorian Wickham, CPC Doris Ruffner, CPC Dunia Hernandez, CPC Elaine Jacobs, CPC-P Elizaveta Bannova, CPC, CFPC Emily Woody, CPC Evangeleena Jebakumari Samson, CPC Fallon Wise, CPC Farisa Percy, CPC Farrell Turner, CPC Francine DiPaolo, CPC Gay Kyzer, CPC Gopinath Velappan, CPC Grace Frances Patricio, CPC Heather Golden, CPC Heather Ochoa, CPC, CPC-H, CPC-P, CPMA Heidi Vine, CPC Jackie Bussell, CPC-H Jackie Tuttle, CPC Jacqueline Patton, CPC James Waddick, CPC Jamie Morgan, CPC Janice-Lamiece Rose, CPC Janna Hoffman, CPC-H Jeannie Allison Whitaker, CPC Jeannie Marie Jones, CPC Jeevitha Rajkumar, CPC Jennifer A Besig, CPC Jennifer Andrews Mangham, CPC Jennifer Arnsman, CPC Jennifer Easter, CPC, CPMA Jennifer Lawson, CPC, CPC-H Jennifer Marchand, CPC Jennifer Olcott, CPC Jennifer Stamey Hannah, CPC Jennifer Swift Hardin, CPC Jermeine Criego- Benjamin, CPC Jessica Moran, CPC Jessica Valdivia, CPC Jill Marie Connor, CPC Judy Guzman, CPC Julie Madden, CPC Kanchana Natarajan, CPC Kara Morris, CPC Karen A Pietsch, CPC Karen Reese, CPC Karen Willett, CPC-H Kassandra Wells, CPC Katherine J Huprich, CPC Kathi M Wyllie, CPC Kelly Anne Tuttle, CPC Kevin Stuart, CPC Kimberly Bechtel, CPC Kiriaki Kelly, CPC Kolleen Bourland, CPC Kristy Lee Seghini, CPC Lakisha North, CPC Lashonda Wootson, CPC LaTashea Renee Huggins, CPC Laura A Ratcliff, CPC Laura Anne Henckler, CPC Laura Kuhlmann, CPC Laura Michelle White, CPC Lauri St.Cyr, CPC Laurie Stutzman, CPC, CPC-H, CPC-I LeAnn McFarland, CPC Linda Soltau, CPC, CGIC Lisa Yvette McKinney, CPC Lori Budzinski, CPC Lorraine M Morreale, CPC Lydia C Rego, CPC Lynda A Hopka, CPC Mahalakshmi Shanmugasundaram, CPC Manjula Duraivelu, CPC Maria Boyd, CPC, CPC-P Maria K Lorenzen, CPC, CPC-H Maria L Kelley, CPC Mary Anne Ciriello, CPC Mary C Grove, CPC Mary Hauser, CPC Mary Tye, CPC-H Mayoury Sirattanatray, CPC Mayra Garcia, CPC Megan Pedersen, CPC Melissa R Hawkins, CPC Melissa Sartin, CPC Michaline Juckno, CPC Michele Southerland, CPC Michelle Blessie, CPC Michelle Eline, CPC Michelle Leigh Moore, CPC Michelle Lynn Wilbur, CPC Mindy Dowd, CPC, CPMA Mistie Brock, CPC Mona L Vincent, CPC Mukesh Sarath, CPC-H Nancy Lynn Allison, CPC Naomi Martine, CPC Narmatha Arumugam, CPC Natalie Ryder, CPC Nicole C Riedel, CPC, CPC-H Noushar Shihabudeen, CPC-H Olga Tsitsugina, CPC Patricia Mulvanerton, CPC Paula Cordova, CPC Paula Jensen, CPC Priyadharsini Ramalingam, CPC-P Rachel Maria Walters, CPC Rajesh V R, CPC Ranell Ross, CPC, CPC-H Rayna Williams, CPC Rebecca Bates, CPC Rebecca Faith Hernandez, CPC Rebecca Martinez, CPC Regina A Wicker, CPC Regina Miante, CPC Reinhard W Beel, CPC Reji Krishna, CPC-H Renee Michele Wallen, CPC Reshmi Jalaja, CPC Rhonda Grayson, CPC Robbie J Hartley, CPC Robin E Nelson, CPC Robin J Ward, CPC Rosemarie Goodwin, CPC Ruby Norton, CPC Sandra Frye, CPC Sangeetha S, CPC Sarah Bass, CPC Shanna Keith, CPC Shannon Holland, CPC Sharon Pascasio, CPC Sheela Mary, CPC Sherin Ninan, CPC-H Sherry Philbrick, CPC Sheryl Williams McAdams, CPC, CPC-H, CPC-P Shiela Armesto, CPC Shirley Baldini, CPC Sonya Muse, CPC Soumya P S, CPC-H Sridhar Arumugam, CPC Stephanie Dawn Kenser, CPC Stormy Grimmer, CPC Sue Ann Cofn, CPC Sue Carney, CPC Sujitha Narayanan, CPC-H Sureko A Hamilton, CPC Susan N Edge, CPC Suzan Swain, CPC Suzanne Briggs, CPC Suzanne Link, CPC Sylvia SanMiguel, CPC Tabatha Jackson, CPC Tamiko Woodfork, CPC Tammy Jennette Scarberry, CPC-H Tammy Patterson, CPC Tatyana Vasilchuk, CPC, CPC-H Tena Siebenmorgan, CPC Teresa Rogalski, CPC Teresa Blake, CPC Teri M Starling, CPC Thara L, CPC-H Thenmozhi Sengottuvel, CPC, CPC-H Tiffany Fite, CPC Tiffany Sherese Hurd, CPC Tina D Titsworth, CPC Tina McGonigle, CPC-P Trupti Patel, CPC Veronica Glasper, CPC Vigneshkumar Rajasekaran, CPC Vinutha R, CPC, CPC-H Vishnupriya Kamaraj, CPC Wendy Mitchell, CPC Whitney Clarahan, CPC Xin Zou, CPC-H Yvonne Betancourt, CPC, CPC-H Becky Goodyear, CPC-A Becky Williams, CPC-A Belinda Strack, CPC-A Ben Dominic Palomares, CPC-A Beth Ann Teague, CPC-A Beth Taylor, CPC-A Bibin Krishnan, CPC-A Bingyi Mary Ni, CPC-A Blaine Rush, CPC-A Bonnie Oakes, CPC-A Brett L Ricketts, CPC-A Brigida Maria Johnson, CPC-A Brittany Pankow, CPC-A Brittney Poling, CPC-A Carla Jo Cushman, CPC-A Carol E Wildey, CPC-A Carol Gaumer, CPC-H-A Carolyn Sue Cloer, CPC-A Casey Smith, CPC-H-A Cecilia Colmer, CPC-A Chaithra Rama, CPC-H-A Chandanapalli Haranadh, CPC-A Charity A Rouse, CPC-A Charlene J Watkins, CPC-A Charlotte Carrow, CPC-A Cheol Lee, CPC-A Cheryl Phillips, CPC-A Chris Gamet, CPC-A Christina Mott, CPC-A Christina Webb, CPC-H-A Christine Logsdon, CPC-A Christopher Brian Glenn, CPC-A Ciera Nicole Brower, CPC-A Cindy Chieng, CPC-A Claudia Castaneda, CPC-A Colleen Palmer, CPC-A Connie Morrison, CPC-A Connie Sibley, CPC-A Conrad D Lippens, CPC-A Constance McMullen, CPC-A Corin Lee Dunn, CPC-A Courtney Cooper, CPC-A Courtney Johnson, CPC-H-A Courtney McGinnis, CPC-A Craig Russell, CPC-H-A Crystal L Grove, CPC-A Dania Serrano, CPC-A Danielle Ruiz, CPC-A Danielle Seaman, CPC-A Danny Nunez, CPC-A Danyea Kim Hankins, CPC-A Daphne Rachkoskie, CPC-A David Szeto, CPC-A Dawn C Thoma, CPC-A Dawn Callender, CPC-A Debbie Zander, CPC-A Deborah A Creek, CPC-A Deborah Job, CPC-A Debra Klump, CPC-A Deepak Babu, CPC-A Della R Canter, CPC-A Denielle Caballero Cabahug, CPC-A Denise E Torcicollo, CPC-A Denise Chase, CPC-A Denise M Blair, CPC-A Denissa Faith Grace, CPC-A Desiree Joyce Bryant, CPC-A Devonna Niree Nelson, CPC-A Devshree Narvekar, CPC-A DiAna Olguin, CPC-A Dianna Miller, CPC-A Diedre P Carter, CPC-A Dina Carangelo, CPC-A Divyashree Kumaraswamy, CPC-A
Apprentices
A H S G Dasthagir, CPC-A Abby Yip, CPC-A Adelina Kobeci, CPC-A Agnieszka Plonska, CPC-A Algin D N, CPC-A Alice A Calipes, CPC-A Alice E Johnson, CPC-A Alicia McCrudden, CPC-A Alwyn DN, CPC-A Amanda Breznau, CPC-A Amanda Hasser, CPC-A Amanda Soliday, CPC-A Ambar Solorzano, CPC-A Amrita Raveendran, CPC-A, CPC-H-A Amy Marie Meeks, CPC-A Amy Penman, CPC-A Amy Pridemore, CPC-A Andreena Marie Pulak, CPC-A Anil Singh, CPC-A Anissa Booth, CPC-A Anita Ehly, CPC-A Ann Bogari, CPC-A Ann Sweeney, CPC-A Annie Nguyen, CPC-A Antoinette Munsch, CPC-A Aranya (Joy) L Feagins, CPC-A Arlet Hopkins, CPC-A Arun Kumar Rajavel, CPC-A Ashal Mahoney, CPC-A Ashley Tucker, CPC-A Ashwini Rajan, CPC-A Barbara McQuade-Lantzy, CPC-A Barbara Rabatsky, CPC-A Barun Kumar, CPC-A Becky Banks, CPC-A
www.aapc.com
February 2013
59
Newly Credentialed Members
Donna DiStefano, CPC-A Donna Ford, CPC-A Donna Place, CPC-A Donya Carol Tucker, CPC-A Edna Gonzalez, CPC-A Edwin Johnson, CPC-A Eileen Coutras, CPC-A Elena Delgado, CPC-A Elisabeth Parker, CPC-A Elizabeth Hewett, CPC-A Elyssa Ann Luebbering, CPC-A Emily E Walk, CPC-A Esmeraldo Batingana, CPC-A Evelyn D Knott, CPC-A Farine Ali, CPC-A Francelaine Saintelus, CPC-A Gail Nadeau, CPC-A Gail Yu, CPC-A Gary Edward Anderson, CPC-A Georgeta Moise, CPC-A Georgia Dodge, CPC-A Gina Conoan, CPC-A Gina Grady, CPC-A Gina L Fulcher, RDH, CPC-A Gopalakrishnan Thangavelu, CPC-A Gowri Manohari Natarajan, CPC-A Gwendolyn Lawhorn, CPC-A Harriet Cohen, CPC-A Heather Soss, CPC-A Heather Walsh, CPC-A Heidi Stutz, CPC-A Hilary Mulligan, CPC-A Holly Hindel, CPC-A Holly Christine Wideman, CPC-A Holly Henderson, CPC-A Holly Jarvis, CPC-A Horalia Acosta, CPC-A Huiyi Miao, CPC-A Indira Mahendrada, CPC-A Inge Barth, CPC-A Jackie Rogers, CPC-A Jackie Shoun Ringersma, CPC-A Jacquelyn Broten, CPC-A Jaiganesh Palani, CPC-A James Rausch, CPC-A James W Lim, CPC-A Jamie Krajewski, CPC-A Jamie Pylman, CPC-A Jamie Schwaller, CPC-A Janet L Holdeman, CPC-A Janet Yoder, CPC-A Jayanthi Vadivelu, CPC-A Jazsmine Jacobs, CPC-H-A Jean Havel, CPC-A Jean Morris, CPC-A Jeanette Robin Weiland, CPC-A Jeanne Uhing, CPC-A Jeannette Rosas, CPC-A Jenelle Keppley, CPC-A Jennifer Haselby, CPC-A Jennifer Swank, CPC-A Jennifer Austin, CPC-A Jennifer Courtney, CPC-A Jennifer Gabriela Dejamco, CPC-A Jennifer Lyn Moore, CPC-A Jennifer Mary Baumann, CPC-A Jennifer Meade, CPC-A Jennifer Porter, CPC-A Jennifer R Fair, CPC-A Jenny Estrada, CPC-A Jenny Sexton, CPC-A Jessica Fisher, CPC-A Jessica Hathaway, CPC-A Jessica Johnson, CPC-H-A Jessica Jose, CPC-A Jessica Schroeder, CPC-A Jill Doyle, CPC-A Jill R Ammons, CPC-A Jill Vierck, CPC-A Jill Visser, CPC-A
Jing Yun Wu, CPC-A Joan Elaine Erickson, CPC-A Joan Ferguson, CPC-A Joan Keller, CPC-A John Bennett, CPC-A John Bry, CPC-P-A Jordan C Burchell, CPC-A Jordan Heath, CPC-A Jordan Strombeck, CPC-A Josette Fuselier, CPC-A Joyce Favier, CPC-A Judy Block, CPC-A Judy J Taylor, CPC-A Judy Louise Ashey, CPC-A Julia Genther, CPC-A Julianne Johnson, CPC-A Julie A Miller, CPC-A Julie Kiekhoefer, CPC-A Kakasaheb Kachole, CPC-A Kandy Nies, CPC-A Kara Scott, CPC-H-A Karen Francis, CPC-A Karen J Musslewhite, CPC-A Karen Luckeroth, CPC-A Katherine Seebeck, CPC-A Kathleen Cott, CPC-A Kathleen Johnson, CPC-A Kathryne Leah Barnes, CPC-A Kathy Hudson, CPC-A Katrina Cartwright, CPC-A, CPC-P-A Katy Niemchick, CPC-A Kayla Lee Malone, CPC-A Keelie Dalonzo, CPC-A Kelli Pekios, CPC-A Kelly Hart, CPC-A Kelly McCormick, CPC-A Kelly Mckay, CPC-A Kelly Pethtel, CPC-A Kelsey Sorensen, CPC-A Kenny M. Lee, CPC-A Keri Marie Crowley, CPC-A Kim Bair, CPC-A, CPC-H-A Kim Cioe, CPC-A Kim Eskew, CPC-H-A Kim Greening, CPC-A Kim Nguyen, CPC-A Kimberly Biagioni, CPC-A Kimberly Lynne Miller, CPC-A Kiwanna Faulkner, CPC-A Kokiladevi Gopinath, CPC-A Komala Valli Selvaraj, CPC-A Komathi B, CPC-A Kristen Palmer, CPC-H-A Kristen Theisen, CPC-A Kristi Wilson, CPC-A Kristine Claire Lefebvre, CPC-A Kristine Johnson, CPC-A Krystal LaForrest, CPC-A Krystle Lister, CPC-A Kunal Chatterjee, CPC-A Lakenia Warren, CPC-A Lalima Mehrotra, CPC-A LaRena Fitz-Gerald, CPC-A Larry Poms, CPC-A LaTosha Bridgewater, CPC-A Laura Alber, CPC-A Lauren Gail Poe, CPC-A Laurie Richardson, CPC-A Laurie Hubbard, CPC-A Lavette D Neal, CPC-A Leah Trippanera, CPC-A Leigh Willard, CPC-A Leslie Boulette, CPC-H-A Lieu Doan, CPC-A Lina Ungureanu, CPC-A Linda Hatch, CPC-A Linda Heady, CPC-A Linda Tittle, CPC-A Lindsay Owens, CPC-A Linette Navarro, CPC-A
Lisa C Smith, CPC-A Lisa Campbell, CPC-A Lisa Davidson, CPC-A Lisa Fisher, CPC-A Lisa Hendricks, CPC-A Lisa Larson, CPC-A Lisa Robinson, CPC-A Lois Widener, CPC-A Lokesh Chaluvegowda, CPC-A Lora Bolton, CPC-A Lori Brown, CPC-A Lori Deniece Wise, CPC-A Lori Hewitt, CPC-A Lori Shinault, CPC-A Lucinda Jane Waber, CPC-A Lynette Valverde, CPC-A Lynn Archer, CPC-A Lynn Klim, CPC-A Lynn Kriedeman, CPC-A M McGehee, CPC-A Machelle Beckley, CPC-A Madhusmitha Gunjate, CPC-A Mahendran Selvam, CPC-A Mansoor Thangal, CPC-A Maranda Merjudio, CPC-A Marc A Cox, CPC-A Marcia Stewart, CPC-A Marcy Mote, CPC-A Maria Kathlyn Acosta, CPC-A Maria Lynn Schuster, CPC-A Marianne Amster, CPC-A Marianne Kusbit, CPC-A Marianne Moll, CPC-A Marilyn Bernache, CPC-A Marin Smith, CPC-A Marleen Hernandez, CPC-A Mary Anna Williford, CPC-A Mary Hollingsead, CPC-A Mary Jones, CPC-A Mary L Thomas, CPC-A Mary Lou Wojciechowski, CPC-A, CCC Mary Massey, CPC-A Mary T Hathorne, CPC-A Mary Wainio, CPC-A Maryann McMillan, CPC-A Marybeth Daley, CPC-A Massiel Javier, CPC-A Maura Carty, CPC-A Meenakshi Nain, CPC-A Megan Kime, CPC-A Megan Manning, CPC-A Meghan Allen, CPC-A Melanie D Briggs, CPC-A Melinda C Severt, CPC-A Melinda Trusty, CPC-A Melissa Bouchikas, CPC-A, CPC-H-A Melissa Lulling, CPC-A Melissa Mancini, CPC-A Melonie Gibson, CPC-A Michael Dosdos, CPC-A Michael Harmon, CPC-A Michelle Blackshear Harper, CPC-A Michelle Grist, CPC-A Mirian Gonzalez, CPC-A Monica Lynn Wenzell, CPC-A Morgan Jones, CPC-A Moses John Llamas, CPC-A Mrinalini Sekhar, CPC-A Nalagonda Priyanka, CPC-A Nancy Arias, CPC-A Nancy Quach, CPC-A Nandhini Jayakumar, CPC-A Naveen Selvaraj, CPC-A Nicole Walker, CPC-A Nicole Webb, CPC-A Ninette Santa Cruz, CPC-A Ondrea Maffeo, CPC-A Orsolya Simmons, CPC-H-A Paige McSain, CPC-A Pamela Beaver, CPC-A
Pamela Klaus, CPC-A Pamela S Long, CPC-A Pamela Tarpley, CPC-A Pamela Yap, CPC-A Patricia Alvis, CPC-A Patricia McAlister, CPC-A Patricia Murrin, CPC-A Pauline Ellen Thalmann, CPC-A Pavithra Ramalingam, CPC-A Phyllis Joanne Tabano Valencia, CPC-A Prabakar Murugan Sekar, CPC-A Prabha Chandrasekaran, CPC-A Prakash Shannugam Authoor, CPC-A Prathima Vaddepally, CPC-A Prem Vinoth Kumar, CPC-A Premila Kumarankandath, CPC-A Priya Gupta, CPC-A Purvi Shah, CPC-A Rachel D Ouellette, CPC-A Rachel Garena, CPC-A Rachell White, CPC-A Raghava Danwada, CPC-A Raghuraman Sundhararaju, CPC-A, CPC-H-A Rajasekar Rajendran, CPC-A Rajitha Goli, CPC-A Rajni Kanth, CPC-A Ramesh Sampath, CPC-A Ramona Merritt, CPC-A Ravikiran Nagabhushan, CPC-A Rebecca Cox, CPC-A Rebecca Pascucci, CPC-A Rebecca Ann Holderman, CPC-A Rebecca Barton, CPC-A Rebecca Cooper, CPC-A Rebecca Palmer, CPC-A Rebekah Voorhis, CPC-A Regina Oginski, CPC-A Reginald Brock, CPC-A Regine Delus, CPC-A Rena P Lening, CPC-A Renee Diaz, CPC-A Revathi E, CPC-A Rhonda Blankingship, CPC-A Rhonda Jane Hanna, CPC-A Robert Maars, CPC-A Robert Neklesa, CPC-A Robert Pezzillo, CPC-A Robert Simonds, CPC-A Roberta A Jackson, CPC-A Rona Perez, CPC-A Ronelle Bones, CPC-A Roopa Narayanan, CPC-A Ruth Case, CPC-A Ruth James, CPC-A Sabine Parmley, CPC-A Sally Valdez, CPC-A Samantha Messer, CPC-A Samantha Blattner, CPC-A Sandeep Kumar, CPC-A Sandhya Raghavan, CPC-A Sandy Steele, CPC-A Sarah Donaldson, CPC-A Sarah Hollier, CPC-A Sarah McCauley, CPC-A Sarah Moody, CPC-A Sarah Ward Coudon, CPC-A Sargunaraj Raja, CPC-A Sasipriya Madhav, CPC-A Satheesh Kumar, CPC-A Sattie Jugmohan, CPC-A Scott Kreutzer, CPC-A Shamanthkumar Mandava, CPC-A Shandi Ann McCutcheon, CPC-A Shanmugavadivel Virudhagiri, CPC-A Shannon Kropp, CPC-A Shannon Toenyan, CPC-A Shara Franklin, CPC-A Shareen Jalaludin, CPC-A Sharlene Sorenson, CPC-A Sharon Maureen Stovall, CPC-A
Shelly Figg, CPC-A Sher Kosage, CPC-A Sherry Sawyers, CPC-H-A Sherryann Sinanan-Ali, CPC-A Shiny Anand, CPC-A Shirlee Ann Kakaruk, CPC-A Shrimathi Raghupathy, CPC-A Shweta Taneja, CPC-A Simone Mathers, CPC-A Sintoria Johnson, CPC-A Sky Boggs, CPC-A Sonia Ithier Hopkins, CPC-A Sovena Homer, CPC-A Sreekanth Reddy, CPC-A Sri Bhanu Tejaswi Thummoju, CPC-A Srinath Dachepalli, CPC-A Srinivasan Vijayan, CPC-A Stacey Morache, CPC-A Staci Kuhnhenn, CPC-A Stacie Hyla Friedman, CPC-A Stacy Burney-Jones, CPC-A Stephanie Ann Honeycutt, CPC-A Stephanie Jo Weiner, CPC-A Stephanie McPherson, CPC-A Stephen S, CPC-A Steven Graessle, CPC-A Subha Ramachandran, CPC-A Sue Sansoucy, CPC-A Suganthi Raju, CPC-A Suja Chandrapaul, CPC-A Sulochanadevi Sundararajah, CPC-A Suman Patra, CPC-A Supriya Harishchandra Bhandakkar, CPC-A Suresh Babu, CPC-A Susan Gosselin, CPC-A Susan Redmond, CPC-H-A Suvega Selvaraj, CPC-A Suzanne Greene Lenske, CPC-A Suzanne M Matz, CPC-H-A Swathi Goud Kurra, CPC-A Tabatha JK Osteen, CPC-A Tabitha Foxx, CPC-A Tamara Jane Sutton, CPC-A Tania Cuevas, CPC-A Tasha Letrease Bryant, CPC-A Tellaboina Satyabhaskar, CPC-A Tena Hill Wynne, CPC-A Teresa A Hawken, CPC-A Teresa Lyon, CPC-A Terese Mastrofrancesco, CPC-A Terri Peebles, CPC-A Tiffani Dahl, CPC-A Tiffany Miklas, CPC-A Tiffany F Valery, CPC-A Tim Varghese, CPC-A Tina Schweitzer, CPC-A Tina Miller, CPC-A Tony Vakkachan, CPC-A Tora Arlene Knowles, CPC-A Tracey Denise Holzbog, CPC-A Tricia Carter, CPC-A Troiline Frezzell, CPC-A Unia Patterson, CPC-A Valerie Ortiz, CPC-A Valorie Ann Hoffmaster, CPC-A Venece R Martin, CPC-A Venkata Rakesh Chakravarthy, CPC-A, CPC-H-A Vicki Doherty, CPC-A Victoria Slavik, CPC-A Vijayadeepa Pandiyan, CPC-A Vipin Cheriyamoothore, CPC-A Vishnu Sharma, CPC-A Wendy Gonzalez, CPC-A Yutian Galloway, CPC-A Yvonne Rosenzweig, CPC-A Zak Federer, CPC-A Zelenne I Esteves, CPC-A
60
AAPC Cutting Edge
Newly Credentialed Members
Alicia Ajon Flynn, CPC, CGSC Amanda Banks Nelson, CPC-A, CRHC Amy Joanne Coffee, CPC, CPMA Amy Michelle Benton, CPC-A, CPCO, CPMA Angela M Wilson, CPC, CENTC Angela Scott, CPC, CPMA Annette Fay Rawlins, CPC, CCC Ashley D Miller, CPC, CHONC Barbara Struve, CPC, CEDC Beth Eve Schleeper, CPC, CPCO, CEMC Bobbi Jeanette Martin, CPC-H, CPMA Brenda Lea Parker, CPC, CPC-P, CPMA Brooke Thao, CPC, CEDC Candiss A Grannis, CPC-H, CIRCC Carolyn A Grifths, CPC, CHONC Cassandra Allison, CPMA Cathy E Roberge, CPC, CPPM Cathy S Jennings, CPC, CEDC, CHONC Charles B Harvey Jr, BSN, RN, CPC, CPMA Christine M Schaefer, CPC, CEMC, COBGC Clarence Milton Stewart, CPC, CSFAC Colette Mink, CPC, CPMA Connie Moering, CPC, CPEDC Courtney Polito, CPC, CPMA, COBGC Cristina M Nicoara, CPC, CPMA, CEMC Crystal Mayer, CPC, CPMA Cynthia A. James, CRHC Cynthia Anne Owens-Muller, CPC, CPMA Cynthia S Tucker, CPC, CPMA, COSC Darla Jeanell Morrison, CPC-A, CRHC David Carr, CPC-A, CPCO Deborah Kubida, CPC, COBGC Deidre Jandeska, CCC Dena Ferrante Wilcox, CPC, CCC, CEMC Denise Dula, CPC, COSC Diana M Morehead, CPC, CEMC Dianna Schrimsher, CPC, CHONC
Specialties
Donna Beaulieu, CPC, CPMA, CPC-I, CEDC Donna Kay Ring, CPC, CPMA, CEMC Edward Johnson, CPCO Eleinys Pupo, CPC, CPMA Elizabeth Ann Cook, CPC, CASCC Elizabeth Apicella, CPC, COSC Elizabeth Frias, CPC, CPMA Erin Terrones, CFPC Fiona B Lange, CPC, CPPM Gail Acton, CPC, CPMA, CEMC Gail Vogt-McGeehan, CIRCC Gigi Georgina Price, CHONC Gloria Brogan Ph.D ACS-AN, CPC, CPMA Heather Renee Smith, CPC, CPMA Helen Marie Gerdes, CPC, CCC Holly Brown, CPC, CPC-H, CEMC Jade Harden, CPC, CEDC James Thomas Carter, CPC, CPMA Jan Turley, CPC, CPMA Jennifer Westfall, CPC, CPMA, CGSC Jennifer Young, CPC, CPCO Jill D Conley, CPC, CEMC JoAnne M Wolf, RHIT, CPC, CEMC Johnita Smith, CRHC Jonathan Robert Sanford, CPC, CPC-H, CPPM Julie Brandt, CHONC Karen Guadalupi, CPRC Kathleen M Kampe, CPC, COSC Kathleen M Sherbrooke, CPC, CANPC Kathryn J Kasper, CPC, CPCD Kellie Dress, CPPM, CPRC Kerry Beth Atkins, CPC, CPMA, COBGC Kimberly Mathews, CPC, CPPM Krista Jackson, CPC, CPCO, CPC-P Kristina S Lauer, CPC, CHONC Laurie J Hartford, CPC, CCC, COBGC Leslie Dailey, CGSC Lori Ann Gelgut BBA, CPC, CPC-H, CCVTC Lori J Lawson, CPC, COBGC
Lydia Chitwood, CPC, CCVTC Malgorzata Tyszko, CRHC Margaret Coyle, CPC, CPC-H, CHONC Marilyn Glidden, CPC, CPMA, CGIC, CGSC Marilyn Kitchens Cecil, CPC, CPMA, CPCD, CPRC Marilyn L Koerner, CPC, CHONC Mary Bort, CPC, CANPC, COSC Mary Buike, CPC, CEMC Mary Gore, CPC, COBGC Mary Rikley, CPC, CPMA Maura Macri, CPPM Melanie Cooper, CPC, CEMC Melanie Lewis, CPC, CPMA, CPC-I, CEMC Michael Lee Taylor, CPC, CPMA Nancy Flowers, CPC, CPMA Nancy L Henry, CPC, CPPM Nancy Love Weith, CPC, CCVTC Naomi A Hinton, CPC, CPMA Nicole Marie Clatterbuck, CRHC Nikki Strang, CANPC Peter Weiser, CRHC Philip G Brown, CPC, CPMA, CASCC Rachel Elaine Briggs, CPC, CPMA, CEMC Robin Erinn Bay, CPC-A, CPMA Robin Szuchman, CPCD Rodolfo P Bangilan, CPC, CPC-H, CASCC Ruth Kerekes, CIRCC RuthAnn C Hansen, CPC, CPMA Sabrina R Leichtman, CPC, CENTC Sandra Gamboa, CPC, CPMA Sandra Ebersole, CHONC Sandy Colson, CPC, CPC-H, CPMA Sebrena Atencio, CPC, CEDC Shawn Dunn, CPC, CPMA Shawn Marie Muench, CPC, CANPC Sheena Lunsmann, CPC, COBGC Stacey Lynn Wilson, CPC, COSC Sunny Triana, CPC-A, CPMA Tanika Jennings, CPC, CHONC
Tanya Baker, CPC, CPMA Tara K. Johnson, CPC, CANPC, CGIC Tasha Todd, CPC, CANPC Teresa M Berry, CPC, CIRCC Terri Brown, CPC, CGSC Thelma Mae Bishoff, CPC, CPMA Tiffany Bobbitt, CPC-A, CPEDC Tiffany Nicole Taylor, CPC, CPMA Tina Louise Daley, CPC, CCC Tracy Alise Sarver, CPC, CEMC Tracy Lee Rada, CPC, CPMA, CEMC, COSC Trista L Johnson, CPC, COSC Vandna Chaudhary, CRHC Windy Baughman, CANPC
Aleida S Padron, CPC Allegra Wheeler, CPC Amanda Briggs, CPC Aniladiv Acuna, CPC-A Anisia L Torres, CPC Ann Forrister, CPC Ann Fullerton, CPC-A Anna Wade, CPC-A Avani Hart, CPC-A Brigette Burton, CPC Charlotte Perrone, CPC-A Chitra Lakshmanan, CPC Christine Schmotzer, CPC, CPC-H, CPMA, CEMC Dale Smith, CPC Darlean Yankovich, CPC Denise G Lopez, CPC Diana David, CPC-A Diana L Hutchings, CPC-A Dolores Zaldivar, CPC Eileen Camillone, CPC Eileen OCarroll McCully, CPC-A Emilio Sanchez, CPC-A
Magna Cum Laude
Evelyn Medina, CPC Freddy Mercado, CPC Gagan T Kadahalli, CPC-A Genoveva C Prieto, CPC Gisela Miller, CPC Heidi Beggan, CPC Heidy Villiers, CPC Joe Jose Moreno, CPC Johanna Marie Novoa, CPC Julia M Serrano, CPC-A Kerry L Fulks , CPC, CEDC Komal Meisuria, CPC Kristin Jacobs, CPC Maritza Isabel Vazquez Lopez, CPC Mary Deano, CPC-A Mirella Platon, CPC-A Monica Persaud, CPC-A Norma R Romero, CPC Odalys Rodriguez, CPC Rafaela Gallo, CPC Richard Campbell, CPC-A Ronna A Pate, CPC Rosalina Cespedes, CPC Shahina Jaffer, CPC Shari Brauch, CPC Sylvia Cram, CPC-A Thomas Allen Brown, CPC Tina L Pelton , CPC, CPC-H Tonia Haralson, CPC-A Vanmathi Sivaraman, CPC William Fiala, CPC Wilmieniza Yamson Sale, CPC-A Yeima Perez, CPC Yonaicris de las Maria Plasencia, CPC-A Yuanling B Nuez, CPC
r fo w 3 Ne 201
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www.aapc.com February 2013 61
Minute with a Member
Holly Brown, CPC, CPC-H, CEMC

Quality Gatekeeper, Jacksonville, Fla.
accept a position in a cardiology office, where I worked the front desk and did patient scheduling for three years. I then moved to the billing department, entering office charges and scrubbing billed codes. Thats where I really started getting involved with coding. In 2009, I found a great 10-week class and, thanks to an amazing instructor, I passed the Certified Professional Coder (CPC) exam on the first try. In 2010, I began working for a thirdparty auditing company and I have worked there ever since. I am a quality gatekeeper who performs internal quality on all full-time and contract outpatient coders. I also train new employees and keep staff up-to-date with changes, per the client. I have been involved with AAPC and local chapters, I am more confident in my work, and it shows. Im able to network and speak with other professionals about the work they do and I have met so many incredible people in the process. Being accepted in the coding community gave me the confidence I needed to create a new chapter.
How is your organization preparing for ICD-10?

I have attended ICD-10-CM workshops and seminars, and I subscribe to email updates and articles through AAPC. I take advantage of any information that I can and practice with coding exercises to stay current with changes. My company has an ICD-10 and research development team that will train all coding and auditing personnel. The education will consist of webinars, lectures, and hands-on coding exercises. As we approach the 2014 deadline, we are ramping up education and preparing everyone for implementation.
What is your involvement with your local AAPC chapter?

I am president of the Orange Park, Fla. chapter, which was created in February 2012. With the help of many dedicated friends and other coding professionals, we have grown to over 130 members in less than a yeara huge accomplishment! The wonderful people in the chapter have received so much support from other local chapters in the area.
Tell us a little bit about your career how you got into coding, what youve done during your coding career, what youre doing now, etc.
I began working in the health care industry in 1999 as an insurance companys customer service representative, speaking to members and answering health benefit questions. After a year, I was transferred to the provider line and spoke with physician offices regarding submitted and denied claims. In 2004, I began working for a local urgent care center as a registrar, performing front desk duties and answering patients billing questions. While working at the urgent care office, I took surgical technician program classes at a local college and, upon finishing the course, began an internship at a local hospital. During the job search as a surgical tech, I realized I didnt enjoy the clinical side of health care; what I really enjoy is constantly learning and keeping up with guidelines and regulationsthe back office side of the industry. I even turned down a surgical tech position to
If you could do any other job, what would it be?

I love learning and teaching other people what I have learned. Helping others learn is what is so great about the coding and auditing field. There are constant changes and you need to keep up with the new processes and codes. If I could have any other job, it would be an educator.
What AAPC benefits do you like the most?

I love networking through AAPC. There are so many avenues for speaking with other professionals. I enjoy the convenience of the forums. If I have a coding question, I can easily scroll until I find my answer or ask a new question and get a timely response. I have met several members who are always helpful and send any information after researching. Local chapter meetings are another great way to meet other professionals and to find jobs and externships for newly certified members. Local chapters open so many doors.
How do you spend your spare time? Tell us about your hobbies, family, etc.
I have been married for five years to Josh, with whom I love to spend time and travel. We enjoy going to the movies and being with family and friends. We also enjoy going to Disney World, which is only a short two hour and 30 minute drive for us. We bought annual passes two years ago and take advantage of it every chance we get. I am super excited the AAPC National Conference is at Disney World this year! I might bring my husband with me, so he can enjoy some Disney time while I attend the conference. We have a 7-year-old cocker spaniel who keeps us busy when were home.
What has been your biggest challenge as a coder?

The biggest challenge for me was finding confidence to speak to others about coding. I have always been on the quieter side and I considered my past jobs as work, not a career. Since
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Special Conference Pricing$695 www.NAMAS-auditing.com 877-418-5564

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