5d20cc7a-09ad-4f19-93e0-f1a0b31e9bb5

Plus: Hospital OIG • Hearing Loss • 2013 Cardiology • Sticky POS • Double Dipping

Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA

Infuse a Dose of Coding Know-how

February 2013

Perfecting Practice & Revenue Cycle Management EDGE

EDGE

ICD-10 BRINGS BIG CHANGES. BIGGER OPPORTUNITIES.

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about 140,000 unique codes

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ICD-10= 1,000 codes

Call: 1.800.464.3649, option 1

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140,000 CODES. ACCESSIBLE IN SECONDS. Simplify ICD-10 with EncoderPro.com from OptumTM. ICD-10 will have 668% more codes than ICD-9 — but that doesn’t mean the transition has to be overwhelming. As an affordable, simplified alternative to coding books, EncoderPro.com — the industry leader for web-based coding, billing, and compliance solutions — provides one-click access to ICD-10 codes, data, and mapping tools as well as CPT® and HCPCS code sets.

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www.aapc.com February 2013 3

[contents] 7 Letter from the Chairman and CEO

9 Letter from Member Leadership

10 Kudos

12 AAPCCA

14 Letters to the Editor

14 Coding News

In Every Issue

16 Choose with Clarity Hearing Loss Equipment Codes MaritaCable-Camilleis,CPC

18 Get Busy Learning New Non-cardiac Endovascular Codes DavidZielske,MD,CPC-H,CIRCC,CCC,CCS,RCC

22 2013 Picks for HCPCS Level II G.J.Verhovshek,MA,CPC

26 Boost Your Knowledge of Lesser-used Modifiers TerriBrame,MBA,CHC,CPC,CGSC,CPC-H,CPC-I

30 Timely Tidbits: CPT® 2013 Clarifies Time-based Services G.J.Verhovshek,MA,CPC

34 Infuse Yourself with Coding Knowledge AmyLeeSmith,MBA,CPC,CPC-H,CPMA,CIA,CRMA

38 Tips Plus More Tips for Cardiology in 2013 DavidB.Dunn,MD,FACS,CIRCC,CPC-H,CCC,CCVTC

44 Know Double Dipping Etiquette G.J.Verhovshek,MA,CPC

46 Control Hospital Risk Using OIG’s 2013 Work Plan JillianHarrington,MHA,CPC,CPC-P,CPC-I,CCS-P

48 New POS Rules Get Sticky for 21 and 22 E/M Services MichaelD.Miscoe,Esq.,CPC,CASCC,CUC,CCPC,CPCO,CHCC

54 Optimize Your Patients’ Access to Care DavidJ.Moore,MD,MS

Special Features

Education

Coming Up

Contents

February 201354

29 AAPC Conference Guide

62 Minute with a Member

10 A&P Quiz

59 Newly Credentialed Members

Online Test Yourself – Earn 1 CEUGo to: www.aapc.com/resources/ publications/coding-edge/archive.aspx

44

• Hospital Candidates

• Foot Amputations

• Compliance Professionals

• Fractures

• Therapy G Codes

Features

34

22[Coding/Billing] [Auditing/Compliance] [Practice Management]

On the Cover: Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA, infuses a dose of proper drug administration coding at the Infu-sion 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).

[Coding/Billing]

4 AAPCCuttingEdge

Volume 24 Number 2 February 1, 2013

AAPCCuttingEdge(ISSN:1941-5036)ispublishedmonthlybyAAPC,2480South3850West,SuiteB,SaltLakeCityUT84120-7208,foritspaidmembers.PeriodicalsPostagePaidatSaltLakeCityUTandatadditionalmailingoffice.POSTMASTER:Sendaddresschangesto:CuttingEdgec/oAAPC,2480South3850West,SuiteB,SaltLakeCityUT84120-7208.

Serving 119,000 Members – Including You!

February 2013

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Medicare Learning Network® (MLN) ............41Official CMS Information for Medicare Fee-For-Service Providers http://www.cms.gov/MLNGenInfo

NAMAS/DoctorsManagement ............... 15, 64www.NAMAS-auditing.com

The Physicians Practice SOS Group® ...........24Taking the Business of Medicine to the Next Level www.ppsosgroup.com

The Coding Institute, LLC .............................57www.SuperCoder.com

ZHealth Publishing, LLC ...............................21www.zhealthpublishing.com

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 won’t 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.

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Chairman and CEOReedE.Pew

[email protected]

Vice President of Finance and Strategic PlanningKorbMatosich

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Vice President of MarketingBevanErickson

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Vice President of ICD-10 Education and TrainingRhondaBuckholtz,CPC,CPMA,CPC-I,CGSC,COBGC,CPEDC,CENTC

[email protected]

Vice President of Live Educational EventsBillDavies,MBA

[email protected]

Directors, Pre-Certification Education and ExamsRaemarieJimenez,CPC,CPMA,CPC-I,CANPC,CRHC

[email protected],CPC,CPMA,CPC-I,CMRS

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Director of Member ServicesDanielleMontgomery

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Director of PublishingBradEricson,MPC,CPC,COSC

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Managing EditorJohnVerhovshek,MA,CPC

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©2013AAPCCuttingEdge.Allrightsreserved.Reproductioninwholeorinpart,inanyform,withoutwrittenpermissionfromAAPCisprohibited.Contributionsarewelcome.AAPCCuttingEdgeisapublicationformembersofAAPC.State-mentsoffactoropinionaretheresponsibilityoftheauthorsaloneanddonotrepresentanopinionofAAPC,orsponsor-ingorganizations.

CPT®copyright2012AmericanMedicalAssociation.Allrightsreserved.

Feeschedules,relativevalueunits,conversionfactorsand/orrelatedcomponentsarenotassignedbytheAMA,arenotpartofCPT®,andtheAMAisnotrecommendingtheiruse.TheAMAisnotrecommendingtheiruse.TheAMAdoesnotdi-rectlyorindirectlypracticemedicineordispensemedicalservices.TheAMAassumesnoliabilityfordatacontainedornotcontainedherein.

Theresponsibilityforthecontentofany“NationalCorrectCodingPolicy”includedinthisproductiswiththeCentersforMedicareandMedicaidServicesandnoendorsementbytheAMAisintendedorshouldbeimplied.TheAMAdisclaimsresponsibilityforanyconsequencesorliabilityattributabletoorrelatedtoanyuse,nonuseorinterpretationofinforma-tioncontainedinthisproduct.

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E 1 0.6 1 0

For more information or to register: www.ahacentraloffice.com/2013audioconferences or 800/775-7654

2013 AHA Coding CliniC Audio ConFerenCe SerieS

Coding AdviCe from the Coding experts

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

2013 Audio ConferenCe sChedule

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register for 3 Audio Conferences, receive 50% off 4th conference registration.

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• Online lectures • At your own pace• Online discussion with other students

YOUR NEXT CAREER STEP?PRACTICE MANAGEMENT


AAPC offers a full spectrum of education and training programs to make you more knowledgeable in your desired area of ex-pertise. Although you have this oasis of health care know-how to take advantage of, it’s up to you to make the most of it. Unfor-tunately, 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 you’re 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 re-fute the ideas being pushed at me.” It’s 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 ev-eryday. Learning should be constant and continuous, and your desire to learn should “outweigh your desire to be right,” accord-ing to Daum. To help you get through learning obstacles as you get older, he ex-plains five ways to increase your brain power by staying “open and impressionable” dur-ing intellectual conversations and lectures. I’ve excerpted information from Daum’s five steps that I found most informative in the article:

1. Quiet Your Inner Voice“You know the one I am talking about. It’s the little voice that offers a running com-mentary when you are listening to someone. It’s the voice that brings up your own opin-

ion about the information being provided …. That voice often keeps you from listen-ing 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 speak-er. You may be surprised at what you hear.”

2. Argue with Yourself“If you can’t quiet the inner voice, then at least use it to your advantage. Every time you hear yourself contradicting the speak-er, 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 your-self to the information being provided. Fail-ing that, you will at least strengthen your own argument.”

3. Act Like You Are Curious“Some people are naturally curious and oth-ers 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 rec-ommends Googling the questions or ask-ing another person to find the answers. “Ei-ther way you’ll likely learn more, and the ac-tion of thinking up questions will help en-code the concepts in your brain,” he reasons.

4. Find the Kernel of TruthRarely does a concept or theory come “out of thin air.” Somewhere in the elaborate concept that sounds like complete malar-key there is some aspect that is based upon fact. Even if you don’t 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. You’ll enhance your skills of deduction and may even improve the concept ….”

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 don’t know the person or their beliefs so you can hear the information objectively.” For Kevin Daum’s entire article, go to www.inc.com/kevin-daum/5-things-that-really-smart-people-do.html.Sincerely,

Reed E. Pew AAPC Chairman and CEO

Here’s What Really Smart People Do

LetterfromtheChairmanandCEO

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St. Valentine’s Day, thanks to its Hall-mark card association, is typically celebrated by exchanging cards, can-

dy, and gifts. Being the researcher that I am (and that health care coders and billers are), I was curious to find out the story be-hind St. Valentine, and if he truly existed. I found out how this “holiday” became part of American culture.

St. Valentine Represents Passion from the HeartThere are several possible explanations for the origins of St. Valentine’s Day, includ-ing 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 per-form marriages in secret. The second leg-end states that once imprisoned, St. Val-entine fell in love with the jailer’s 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 leg-ends 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.

Holding AAPC Dear to My HeartThe benefits of being an AAPC member continues to be held near and dear to me as the most valuable asset to my health care ca-reer. With so many CPT® changes for 2013, the benefit of networking with my fellow

AAPC members is apparent. Being a mem-ber saves me incalculable hours of work at-tempting to absorb the nuances of cod-ing for psychiatry, working through nerve conduction study changes, and piecing to-gether the elements of new evaluation and management (E/M) codes for transitional care management services. Calling on fel-low AAPC members allows us to share ideas and our work load, and benefits our employ-ers with a collaboration of many years of health care experience.

Aim Your Passion at AAPCWhether you need to build your AAPC net-work or expand your existing network to in-clude other specialties or areas of health care administration, there are several ways to ac-complish 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 responsi-bility 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,

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

Let AAPC Take a Piece of Your Heart

LetterfromMemberLeadership

10 AAPCCuttingEdge

KUDOS

124 Pounds-worth of Pop Tops for a Good CauseLouise Dowling, CPC, of the Minneapo-lis 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’ do-nations in person. After two meetings, she and her fellow chapter members collected nearly 38 pounds of aluminum tabs. Ronald McDonald House Charities pro-vides a “home away from home” for fami-lies of seriously ill children receiving treat-ment at nearby hospitals. Many Ronald McDonald Houses work with local recy-cling centers to receive money for collect-ing tabs from aluminum cans. The charitable act hit home for Dowling

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 attend-ees at November’s AAPC state conference to pitch in and donate all of their pop tops. As a result, Dowling and her chapter col-lected 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!

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A&PQUIZ

Think You Know A&P? Let’s See …

By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC

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.

Published in DecemberHandbook for HIPAA-HITECH Security, second editionby Margret Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS

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So much has changed since 2005 when federal regulations rst 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 nal 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)

• 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 notifi cation requirements

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12 AAPCCuttingEdge

Chapter Life

Chapters Can Change LivesCharity unites, bonds, and strengthens local chapters.AAPC’s local chapters are known for pro-viding educational and networking oppor-tunities for its members. Lesser known is that chapters are taking a more active role in communities, giving back through charita-ble work. In turn, these philanthropic en-deavors are uniting members and making chapters stronger. I’d like to highlight the good deeds a handful of our chapters have accomplished.

Minneapolis, Minn.In 2012, the Minneapolis local chapter par-ticipated in several charitable activities; two of these activities were organized by Lou-ise Dowling, CPC. In the spring, Lou-ise handed out dozens of little Ronald Mc-Donald 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 Ku-dos on page 10 for more information). The chapter also stepped up to donate 12 blan-kets and 65 towels for the Hennepin Coun-ty Animal Shelter.

Tulsa, Okla.Since 2005, the Tulsa, Okla. chapter (ProTulsa) has actively supported their lo-cal food bank, participating in the “Back-pack for Kids” program, volunteering their time, collecting food items at meetings, and providing financial support. They have also collected teddy bears for local police de-partments and hospitals, who give them to children in abusive or other traumat-ic situations. In 2011, the chapter collect-ed donations from members for the Soci-ety for the Prevention of Cruelty to Ani-mals, the American Cancer Society, Al-zheimer’s Association, American Red Cross, American Heart Association, and the Blood Bank of Tulsa. In 2012, ProTulsa contin-ued their charitable work and also donated money to Project AAPC, the American Red

Cross, and the AAPC Chapter Association (AAPCCA) Hardship Scholarship Fund.

Kansas City, Mo.The Kansas City chapter started a com-munity 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 sup-plies, medical supplies, and sporting goods for Camp Hope, a children’s cancer camp. Members also had the opportunity to vol-unteer at the camp. In 2012, the chapter set its sights on the local Ronald McDonald House. At each local chapter meeting mem-bers were encouraged to donate items need-ed on the “House Wish List.” Participating members’ names were placed in a drawing for a cookbook, given away at each meet-ing. Chapter members also formed a cook-ing team to prepare an Italian feast for the families staying at the house.

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 col-lect household goods, clothing, and money to help support the shelter throughout the year. The Grand Canyon Coders have been recognized as one of CAAFA’s supporters on the charity’s website (www.caafaaz.org/Sup-

porters.html).

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 chap-ter 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 Schol-arship Fund by holding raffles for an edu-cation 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 sever-al 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 partic-ipated in Komen Race for the Cure, Light the Town Pink, and the MS Walk.

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 communi-ty. At the chapter’s year-end party, members

By Angela Jordan, CPC

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are encouraged to bring school supplies, learning toys, batteries, and any office sup-plies the organization needs.

Helping Across AmericaIn 2010, AAPCCA founded Project AAPC Chapters Aiding People in Crisis (Project AAPC) to encourage chapters to help those affected around the world by natural disas-ters. Little did we know a flood of histori-cal proportions would hit Nashville, Tenn. and the surrounding area. AAPC members came together, however, and raised over $13,000, which was donated to the Amer-ican Red Cross in Nashville for flood re-lief. In 2011, Project AAPC added a sec-ond charity, Feeding America, which sup-ports 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 Ameri-ca. 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.

Chapters Unite to Support a CauseWhether it’s 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 oth-ers is contagious and it’s one bug your chap-ter 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 provid-ers and has worked as a coding and compliance manager of a large physician network and HCA. Ms. Jordan’s experience includes surgery, or-

thopaedics, ENT, emergency medicine, laboratory, radiology, inpatient, outpatient, family practice, oncology, pain manage-ment, and other specialties. She is the AAPCCA Board of Direc-tors chair, representing Region 5 – Southwest, and has served as Kansas City chapter president.

AAPCCA: Handbook Corner

Be All You Can Be: Consult Your HandbookBy Barbara Fontaine, CPC

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 chap-ters 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 AAPC’s 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 co-workers know and understand about our organization, the more credibility you’ll 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 chapter’s needs. If your chapter needs a proctor to hold an exam, volunteer. If there’s 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. It’s easy and comes right to your inbox.

Read the AAPC Local Chapter Handbook for more good advice and soon you will be on your way to becoming all you can be.

Chapter Mentoring Program LaunchesBy Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CPPM, CPC-I, CANPC, CMRS

At the 2012 AAPC Regional Conference in Chi-cago, the AAPC Chapter Association (AAPCCA) proudly launched the Chapter Mentoring Pro-gram.

Mentoring is a very rewarding endeavor that does not require you to have mentor experience to make a difference in someone’s life, and it doesn’t take a lot of time to be effective. Some-times it’s 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.

Mentoring Program Benefits Everyone InvolvedThe 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

You can be a mentee, too. Everyone has an area that needs improvement, so here’s an oppor-tunity to get help from experts in the field. Becoming a mentee provides an opportunity to:

• Expand your knowledge in a certain field or specialty

• Learn an unfamiliar area of our business

• Seek assistance in getting organized

• Resolve difficult workplace situations

Mentoring isn’t a daunting task—it’s fun! You’ll 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.

It’s Easy to Get StartedIf you are interested or wish to have your chap-ter 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 suc-cess 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 Mont-gomery; and Heidi Larsen.

AAPCCA: Mentoring

Mail donations for Project AAPC to:

Project AAPC, c/o Local Chapter Department 2480 South 3850 West Salt Lake City, UT 84120

14 AAPCCuttingEdge

CodingNews

Ambulance Inflation Factored for 2013The 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 Consum-er 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 ad-justed by changes in economy-wide productivity, which are equal to the 10-year average of private, nonfarm business MultiFactor Pro-ductivity (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.

Medicare Summary Notices in Plain English, PleaseTo keep up with the Plain Writing Act of 2010, which requires fed-eral 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 under-stand them.

Here are few examples of changes made to CMS MSN message verbiage:

Message No. 18.13Original text – “This service is not covered for beneficiaries under 50 years of age.”New text – “This service isn’t covered for people under 50 years old.”

Message No. 18.22 Original text – “This service was denied because Medicare only al-lows the one-time initial preventive physical exam with an electro-cardiogram within the first six months that you have Part B cover-age, 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. 29.22Original text – “The amount listed in the “You May Be Billed” col-umn assumes that your primary insurer paid you. If your prima-ry 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 le-gal 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.

LetterstotheEditor Pleasesendyourletterstotheeditorto:[email protected]

Calculating Credits OwedIn the December issue, “Manage Four Key Revenue Cycle Met-rics” (pages 33-34), the author advises you to, “Determine your to-tal 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 account-ing function because, technically, credits

are a “negative” number. To clarify, here is an example of what the author meant:

Receivables: $67,901Credit 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/Ror $72,422 / $1,611 = 44.95 DaysAAPC Cutting Edge

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16 AAPCCuttingEdge

Choose with Clarity Hearing Loss Supply CodesWith so many devices to choose from, knowing what’s out there is key to proper reimbursement.

You would think that someone who has a vested interest in au-

diology would be an author-ity on the subject. While at-tending a four-day Nation-al Hearing Loss Association of America (HLAA) Con-vention 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. I’d 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 ChoicesMost familiar hearing aid HCPCS Level II codes are classified to V5030–V5267, but many prosthetic implant/hearing assist supply codes also fall into categories L8613–L8629 and L8690–L8693.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 com-ponents and L8690 Auditory osseointegrated device, includes all inter-nal and external components, respectively. Replacement implants are reported with L8619 Cochlear implant, external speech processor and controller, integrated system, replacement and L8691 Auditory osseoin-tegrated device, external sound processor, replacement.Bonus tip: Report surgical implantation of cochlear implants with CPT® 69930 Cochlear device implantation, with or without mastoid-ectomy. For BAHA, 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech pro-cessor/cochlear stimulator; without mastoidectomy or 69715 Implanta-tion, osseointegrated implant, temporal bone, with percutaneous attach-ment to external speech processor/cochlear stimulator; with mastoidecto-my. When implants are placed in both ears, you may append modi-fier 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 im-plantable with no external components. This implant is also cod-ed 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 peo-ple have the same kind of hearing loss (type, severity, and configu-ration). With so many hearing aids—classified as monaural, binau-ral, and bilateral—it is easier to keep track of them using a chart, like the one shown in Table A. If a patient is diagnosed as having uni-lateral hearing loss and one deaf ear, a choice of bilateral contra-lat-eral routing of signals (BICROS) may be appropriate. Contra-later-al 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’ vari-ables. Some hearing aids may be adjusted for high and/or low fre-quency hearing losses.

V5298 Describes Aids NOCSeveral increasingly popular hearing aids are not yet specifically de-scribed by HCPCS Level II codes, such as receiver-in-the-canal or re-ceiver-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 Hear-ing aid, not otherwise classified.

Alternate Hearing Assistance TechnologiesNot all assistive listening devices are specifically coded because of multi-functionality. Captioned telephones such as CapTel® and Cap-tionCall® may be included in the HCPCS Level II code V5274 As-sistive listening device, not otherwise specified, or simply reported with V5268 Assistive listening device, telephone amplifier, any type. These

■ Coding/Billing

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By Marita Cable-Camilleis, CPC


Coding/Billing: Hearing Loss

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

codes may also include hearing aid compat-ible smartphones. A modern digital hearing aid may have the ability to be controlled re-motely by the patient’s cell phone.Some assisted listening devices have not yet been coded because they are geared more to-ward groups, rather than individuals. One example is the increasingly popular “loop-ing” 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 mi-crophone, so anyone nearby can turn on the telecoil (t-coil) switch of his or her cus-tom-made hearing aid (or cochlear implant) to hear the speaker more clearly. Approxi-mately 69 percent of all hearing aids have a t-coil, which can be turned on for hearing-aid compatible phones with optional neck loops plugged in. T-coils (including related batteries, feedback-suppression capability, and directional microphones) are not cur-rently 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

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, Transmit-ters, and MicrophonesFor 2013, the descriptor for V5267 Hearing aid or assistive listening device/supplies/acces-sories, not otherwise specified was revised and new codes V5281–V5290 were added to ac-commodate personal FM/DM auditory de-vices, which are most often used with hear-ing 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 sig-nal 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 listen-ing device for the transmitter only.

Another system creates a “public address-type” 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 class-room, and the DynaMic is a cordless micro-phone designed to be used with it. To com-bine all three components (receiver(s), trans-mitter, and microphone), use V5281 Assis-tive listening device, personal FM/DM sys-tem, monaural, (1 receiver, transmitter, mi-crophone), any type for one receiver or V5282 Assistive listening device, personal FM/DM sys-tem, binaural, (2 receivers, transmitter, mi-crophone), any type for two receivers (one for each ear).Personal amplifiers (V5274), such as Pocke-talkers®, are useful when FM systems, infra-red systems, and hearing loop (or induction loop) systems are not available.

Marita Cable-Camilleis, M.Ed., CPC, is trea-surer of HLAA’s Cape Cod chapter. She has se-vere hearing loss and has worn hearing aids since the age of three. She has done consider-able research in the field of audiology.

Table A

TYPE OF HEARING AID OR IMPLANT

CONDUCTIVE LOSS:

MIXED LOSS:

CONTRA-LATERAL ROUT-ING OF SIGNAL

BILAT-ERAL CROS

DIGITAL PROGRAM

DIGITAL

AIR BONE SENSORI-NEURAL

CROS BICROS ANALOG ANALOG PROGRAM DIGITAL DISPOSABLE

SITE ON BODY

In the Mouth (ITM) L9900

Inner Ear: Cochlear Implant

L8690

L8691

L8614

L8619

Middle Ear: Semi-implant (VSB)

V5095

Completely In the Canal (CIC)

V5242*

V5248**

V5244*

V5250**

V5254*

V5258**

V5262*

V5263**

In the Canal (ITC) V5243*

V5249**

V5245*

V5251**

V5255*

V5259**

V5262*

V5263**

In the Ear (ITE) V5050*

V5130**

V5170 V5210 V5246* V5252** V5256*

V5260**

V5262*

V5263**

Behind the Ear (BTE) V5060*

V5140**

V5180 V5220 V5247* V5253** V5257*

V5261**

V5262*

V5263**

Body Worn V5030* V5040* V5100***

V5120**

In Eyeglasses V5070 V5080 V5150 V5190 V5230

Hearing Aids Not Classified

V5298

Key: * = monaural ** = binaural *** = bilateral

18 AAPCCuttingEdge

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Get Busy Learning New Non-cardiac Endovascular Codes2013 CPT® changes for interventional radiology are extensive; here’s where to start.

By David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC

The 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 pro-cedures. We’ll focus on the chest drainage procedures and non-car-diac endovascular codes changes, which include retrieval of intravas-cular foreign body and thrombolysis.

2013 Breathes New Life into Chest Drainage CodesNon-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 de-scribe 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 drain-age, percutaneous, with insertion of indwelling catheter; without imag-ing guidance and 32557 Pleural drainage, percutaneous, with inser-tion of indwelling catheter; with imaging guidance. Imaging guidance includes any combination of fluoroscopy ultrasound, computed to-mography (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 re-vised, and now represents an open placement of a chest tube (usual-ly 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 al-lows separate reporting of 75989 Radiological guidance (ie, fluoros-copy, 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 for-eign body (eg, fractured venous or arterial catheter), includes radiolog-ical 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 (36010–36012 for venous; 36013–36015 for the right atrium and pulmonary artery; 36200 for the aorta; 36245–36248 for selective vessels below the diaphragm; and 36215–36218 for selective vessels above the diaphragm) for the retrieval.Example 1: Patient is a 40-year-old with fractured central venous ac-cess 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 ar-

tery for catheter placement

37197 for retrieval of the foreign body

Note: Usually, a diagnostic angiogram is not necessary because bro-ken catheters, lost coils, stents, and other intravascular foreign bod-ies are easily visible with fluoroscopy. Contrast injections are mostly used for guidance, as needed.

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.

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Coding/Billing: Endovascular

Thrombolysis Now a “Per Date” ServicePercutaneous non-coronary cathe-ter directed thrombolysis is now a “per date of therapy” procedure, for coding purposes. Thrombol-ysis infusion, follow-up angiog-raphy, and catheter exchang-es performed on a single date of therapy (12 a.m. to 11:59 p.m.) are described by a single code.Code 37211 Trans-catheter therapy, ar-terial infusion for thrombolysis oth-er than coronary, any method, including ra-diological supervision and interpretation, ini-tial treatment day describes the initial date of treatment for arterial thrombolysis, while 37212 Transcatheter therapy, venous infusion for thrombol-ysis, 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 in-terpretation, continued treatment on subsequent day during course of thrombolytic therapy, including fol-low-up catheter contrast injection, position change, or exchange, when performed is used for arterial or ve-nous thrombolysis on the subsequent day(s) of ther-apy. Use 37214 Transcatheter therapy, arterial or ve-nous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on sub-sequent day during course of thrombolytic thera-

py, including follow-up catheter contrast in-jection, position change, or exchange, when performed; cessation of thrombolysis in-

cluding removal of catheter and vessel closure by any method for the final day of therapy, when the infusion is con-cluded. If an infusion is three days or lon-ger, 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 thera-

py, 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 contra-

lateral sheath is placed into the right external iliac ar-tery. Diagnostic angiography reveals acutely throm-bosed right femoral-popliteal bypass graft with chron-ically occluded native superficial femoral artery (SFA) (75710 Angiography, extremity, unilateral, radiolog-ical 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 catheter-directed thrombolytic infusion is initiated (37211).

The patient is sent to ICU for monitoring.The patient is brought back later the same day. Follow-up 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 im-


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Coding/Billing: Endovascular


A&P Quiz AnswerThe correct answer to the quiz on page 10 is D. Many physicians docu-ment 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 cm–From the anal verge

• Sigmoid 17-57 cm–Loop extending distally from border of left posterior major psoas muscle

• Descending 57-82 cm–Approximately 10-15 cm long and located behind the peritoneum

• Transverse 82-132 cm–Lies anterior in the abdomen and is attached to the gastrocolic ligament

• Ascending 132-147 cm–Approximately 20-25 cm long and is located behind the peritoneum

• Cecum 150 cm–Approximately 6 x 9 cm pouch covered with peritoneum

aging performed, showing resolution of thrombus and an underly-ing 90 percent distal anastomotic stenosis. This is treated with a stent (37226 Revascularization, endovascular, open or percutaneous, femo-ral, 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 ServicesRoutinely, at the start of thrombolysis care, an angiographic cathe-ter is placed near the site of thrombus and a diagnostic angiograph-ic study is performed. Both the catheter placement and the imaging supervision and interpretation are reported; however, when intra-cranial thrombolysis is performed, the new cervico-cerebral codes (36222–36228) 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 re-turns 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 trans-catheter therapy, embolization or infusion, other than for thrombolysis during thrombolytic infusion therapy because it is bundled. Cath-eter exchange codes 37209 and 75900 are deleted in 2013 because

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 place-ment). Mechanical arterial or venous thrombectomy may be re-ported in addition to prolonged thrombolysis infusion procedures. Codes 37184-37188 are used to describe these associated percutane-ous 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, sub-mitted earlier in the day) at 11:30 pm, and has nothing to code.Stay tuned: Next month, we’ll review CPT® 2013 changes to cervi-co-cerebral imaging.

David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiol-ogist and president of ZHealth Consulting and ZHealth Publishing in Brentwood, Tenn.

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.

AnatomicalIllustrations©2012,Optuminsight,Inc.

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2013 Picks for HCPCS Level IIEffective 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 ap-proximately 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).

New ModifiersAmong 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., G8981-G8983 Changing and maintaining body position functional limitation …). The modifiers describe the extent of the functional limitation.

CH 0 percent impaired, limited or restricted

CI At least 1 percent but less than 20 percent impaired, lim-ited or restricted

CJ At least 20 percent but less than 40 percent impaired, limited or restricted

CK At least 40 percent but less than 60 percent impaired, limited or restricted

CL At least 60 percent but less than 80 percent impaired, limited or restricted

CM At least 80 percent but less than 100 percent impaired, limited or restricted

CN 100 percent impaired, limited or restricted

The G codes with modifiers must be reported at regular intervals for Medicare patients who receive outpatient therapy services, in-cluding:

• 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 beneficiary’s 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. Modi-fiers LM Left main coronary artery and RI Ramus intermedius coro-nary 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 he-modialysis claims, were deactivated April 1, 2012.

New Supply CodesAs always, there has been plenty of action when it comes to drug sup-ply 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® ChangesThe 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 place-ment procedures to separate ambulatory payment classifications based on the use of nondrug-eluting or drug-eluting stents. To en-act this policy, CMS created G0290 and G0291, which correspond-ed to CPT® codes 92980 and 92981. For 2013, CPT® deleted 92980 and 92981, replacing them with new, more granular codes describ-ing coronary therapeutic services and procedures. To maintain the existing policy of differentiating payment for intra-coronary stent placement procedures involving nondrug-eluting and

By G.J. Verhovshek, MA, CPC

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Coding/Billing: HCPCS II

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

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 new-ly established to report Tc-99m from non-highly enriched uranium (HEU) sources. TC-99m is the most widely used radioisotope for di-agnosing 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 lis-tening device/supplies/accessories, not otherwise specified, and 10 new codes have been added to describe personal FM/DM auditory devic-es, which are used with hearing aids to improve the signal-to-noise ratio, allowing the listener to hear better in the presence of back-ground noise.

New Code Old Code Drug Trade NameA9586 Florbetapir f18 AMYVID™

C9290 Bupivacaine liposome Exparel™

C9292 Pertuzumab Perjeta™

C9293 Glucarpidase Voraxaze®

C9294 Taliglucerase alfa Eleyso™

C9295 Carfilzomib

C9296 Ziv-aflibercept Zaltrap®

J0178 C9291 Aflibercept EYLEA®

J0485 C9286 Belatacept Nulojix®

J0716 C9288 Centruroides (scorpion) immune F(AB)2

Anascorp®

J0890 Q2047 Peginesatide

J1050

J1055

J1056

J1051 Medroxyprogesterone acetate

J1741 C9279 Ibuprofen Caldolor™

J1744 Icatibant IRAZYR®

J2212 Methylnaltrexone Relistor®

J7178

Q2045

J1680 Human fibrinogen concentrate

Q2046 Aflibercept

J7315 Mitomycin, ophthalmic Mitosol™

J7527 Everolimus Zortress®

J9002

Q2048

J9001 Doxorubicin hydrochloride

J9019 C9289 Asparaginase (erwinze) Erwinaze™

J9020 J9020 Asparaginase, not otherwise specified

J9042 C9287 Brentuximab vedotin Adcetris™

Q2034 Influenza virus vaccine, split virus

Agriflu

Q2049 Doxorubicin hydrochlo-ride, liposomal

Imported lipodox

S1090* Mometasone furoate sinus implant

Propel™

New Code Old Code ProductQ4119 MatriStem PSMX, RS, and PSM

Q4126 Memoderm, dermaspan, tranzgraft, or integuply

Q4128 Flex HD, Allopatch HD, or Matrix HD

Q4131 C9366 Epifix

Q4132 C9368 Grafix®CORE

Q4133 C9369 Grafix®PRIME

Q4134 hMatrix

Q4135 Mediskin

Q4136 Ez-Derm

*Medicare does not accept S codes.

Table 1

Table 2

24 AAPCCuttingEdge

Coding/Billing: HCPCS II

Physician Quality Reporting and Medicare Demonstration ProjectsG codes in the range G8000–G8999 are designated PQRS codes. Since April 1, 2012 there have been 114 code additions, 48 code de-letions, and 122 code revisions to the G codes used to report quali-ty performance measurements. Eligible professionals (EPs) who successfully report on quality measures in the PQRS are eligible for a 0.5 percent Medicare pay-ment incentive for years 2012-2014. In 2015, EPs and groups that do not report quality data successfully will face a 1.5 percent pay-ment 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 G9000–G9999 are applied for Medicare Dem-onstration Project reporting. Since April 1, 2012, there have been 21 new codes and two code deletions in this section. For more infor-mation on Medicare Demonstration Projects, visit the CMS web-site (www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/

Medicare-Demonstrations.html).

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.


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 CPT® ServiceC9733 N/A SPY® and other non-ophthalmic fluorescent

vascular angiography

G0452 N/A Molecular pathology procedure; physician interpretation and report

G0453 95941 Continuous intraoperative neurophysiology monitoring outside the operating room

G0454 N/A Physician documentation of face-to-face visit for durable medical equipment determina-tion performed by nurse practitioner, physi-cian assistant, or clinical nurse specialist

G0455 44705 Preparation with instillation of fecal micro-biota by any method

S0596* N/A Phakic intraocular lens for correction of refractive error

S0353* N/A Treatment planning and care coordination management for cancer, initial

S0354* N/A Treatment planning and care coordination management for cancer, established patient with a change of regimen

* Medicare does not accept S codes

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Boost Your Knowledge of Lesser-used ModifiersOverlooking these modifiers can result in improper reimbursement.

By Terri Brame, MBA, CHC, CPC, CGSC, CPC-H, CPC-I

Any coder worth his or her wage knows about modifiers 25 Significant, sep-arately 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 mod-ifier when DME is to be rented) and LS FDA-monitored intraocular lens implant? In fact, there are dozens of lesser-known modifi-ers that can help you report certain services more accurately.

Modifiers Come in Two FlavorsThere are two levels of HCPCS modifi-ers. What coders usually call CPT® modifi-ers are actually HCPCS Level I modifiers. These modifiers are always two digits, are published in the CPT® codebook as Appen-dix A, and are maintained by the American Medical Association (AMA). HCPCS Level II modifiers are used less of-ten, and tend to be less well known (two ex-ceptions are modifiers LT Left side and RT Right side). These modifiers may be any combination of two alphanumeric char-acters—except for two numbers. Level II modifiers are published by the Centers for Medicare & Medicaid Services (CMS) as part of the annual HCPCS Level II up-date, and may be applied to either Level

I (CPT®) or Level II service and proce-dure codes.

HCPCS Level I ModifiersAlthough so-called “CPT® modifiers” are generally familiar and often ap-

plied, there are a few exceptions. Among the most important are modifiers 63 Proce-dure performed on infants less than 4 kgs and 66 Surgical team.

Modifier 63When 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 patient’s small size. At best, this could garner increased reimburse-ment. Be aware, however, that most CPT® procedure codes performed on small infants include the notation, “Do not report mod-ifier 63 in conjunction with ...” because the CPT® code has already been valued to in-clude this increased complexity. For exam-ple, see the parenthetical notation follow-ing 33502 Repair of anomalous coronary ar-tery from pulmonary artery origin; by ligation and 33503 Repair of anomalous coronary ar-tery from pulmonary artery origin; by graft, without cardiopulmonary bypass.

Modifier 66Modifier 66 is applied when three or more

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.

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Coding/Billing: Modifiers

surgeons complete parts of a procedure de-scribed by a single CPT® code. Before sol-id organ transplantation codes were sepa-rated into codes for donor organ removal, backbench work, and recipient transplan-tation (e.g., the CPT® section guidelines for Liver Transplantation), modifier 66 was ap-pended 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, you’ll 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-for-

Service-Payment/PhysicianFeeSched/PFS-Relative-

Val ue-Files.html).

HCPCS Level II Modifiers Level II includes quite a few modifiers be-yond 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 dupli-cate 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,

extensor tendon, finger, primary or second-ary; without free graft, each tendon), the cod-er would report 26418-F7, 26418-F8, and 26418-F9.

Preventing or Overriding EditsSome modifiers may be familiar to insur-ance specialists in the practice’s billing of-fice, 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 incor-rect 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

Eyelids Fingers Toes Coronary Arteries

E1 Upper left FA Left hand, thumb TA Left foot, great toe LC Left circumflex

E2 Lower left F1 Left hand, second digit T1 Left foot, second digit LD Left anterior descending

E3 Upper right F2 Left hand, third digit T2 Left foot, third digit RC Right coronary artery

E4 Lower right F3 Left hand, forth digit T3 Left foot, forth digit

F4 Left hand, fifth digit T4 Left foot, fifth digit

F5 Right hand, thumb T5 Right foot, great toe

F6 Right hand, second digit T6 Right foot, second digit

F7 Right hand, third digit T7 Right foot, third digit

F8 Right hand, forth digit T8 Right foot, forth digit

F9 Right hand, fifth digit T9 Right foot, fifth digit

Table A:AnatomicLevelIIModifiers

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.

28 AAPCCuttingEdge

Coding/Billing: Modifiers

number, and the charge is resubmitted with the correct provider number, you should ap-pend the appropriate CPT® code with CC appended.GD Units of service exceeds medically unlikely edit value and represents reasonable and nec-essary services is used to override medical-ly unlikely edits (MUEs), when appropri-ate. 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 Thy-roidectomy, total or subtotal for malignan-cy; 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 re-maining tissue, and should report the ser-vice 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 to-tal thyroidectomy because the “total” thy-roid can be removed only once. In the case described, the second surgeon has a legiti-mate 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 pa-tient’s 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 ill-ness to the hospice provider. If the patient receives care for a non-related illness, ap-pend modifier GW to allow payment di-

rectly from the payer. For example, if a pa-tient who is receiving hospice care at home for metastatic cancer is seen in a primary care office for an upper respiratory infec-tion, the primary care office should report an evaluation and management (E/M) ser-vice with modifier GW.

Clinical TrialsPayers, particularly Medicare, often expect clinical research services to be identified on the claim with Q0 Investigational clini-cal 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 iden-tify whether the services are part of routine care for the patient’s condition (care that would have been provided regardless of the research) or care that is not routine, and is part of the research.

Surgical MisadventuresWhen it is appropriate to report (or internal-ly track) a surgical misadventure, the coder should append the CPT® code with one of the following: PA Surgical or other invasive proce-

dure on wrong body part

PB Surgical or other invasive proce-dure on wrong patient

PC Wrong surgery or other invasive procedure on patient

Trauma, Disaster, and CatastropheServices 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 pay-er contracts may include a reimbursement carve-out for trauma-related services in-creasing the payment rate. When consider-

ing the modifiers below, always verify with the billing office whether they are appro-priate. CR Catastrophe/disaster related [may cur-rently 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 subse-quent clean up activitiesST Related to trauma or injury

Teaching PhysiciansCoders in academic practices are very fa-miliar with the GC, GE, and GR modifi-ers, and so should coders looking to make a career move to academic medicine. These modifiers describe services provided follow-ing Medicare or U.S. Department of Veter-ans Affairs’ (VA) rules for resident and at-tending physicians working together:GC This service has been performed in

part by a resident under the direc-tion of a teaching physician

GE This service has been performed by a resident without the presence of a teaching physician under the pri-mary care exception

GR This service was performed in whole or in part by a resident in a department of veterans affairs medical center or clinic, super-vised in accordance with VA policy

MiscellaneousThe true value of a Level II modifier (in my humble opinion) lies with the modifiers de-scribing unusual payment situations. The following are just a few examples: CA Procedure payable only in the inpatient setting when performed emergently on an out-patient who expires prior to admission. This modifier may be used when the hospital where the procedure was performed admits

The true value of a Level II modifier (in my humble opinion) lies with the modifiers that describe unusual payment situations.


To discuss this article or topic, go to www.aapc.com Coding/Billing: Modifiers

a patient after a surgery is completed rath-er than before. FP Service provided as part of the annual fam-ily planning program is especially valuable when the patient only has Medicaid cover-age for family planning. A coder may need to append GT Via inter-active audio and video telecommunication sys-tems for telehealth services.H9 Court-ordered notes services rendered due to a court order. HJ Employee assistance program is append-

ed for servic-es provided as part of an em-ployee assistance program. Large sections of Level II modifi-ers also apply to mental health servic-es, 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 ap-propriate reimbursement for your practice.

As with any code, pol-icies for using modifi-

ers may differ from pay-er to payer. Before ap-

plying any modifier, en-sure the payer accepts the

modifier and adhere to any published rules for its use.

Terri Brame, MBA, CHC, CPC, CGSC, CPC-H, CPC-I, is the compliance education officer for the University of Arkansas for Medical Sci-ences. She is a past AAPC local chapter presi-dent, and has presented at two AAPC national conferences.

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■ Coding/Billing

TimelyTidbits:CPT® 2013 Clarifies Time-based Services


When time is a key factor, follow these five basic rules.

For 2013, the American Medical Associ-ation (AMA) updated their CPT® code-book to better explain the rules for time-based 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 that—in 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.

1. Time Means Face-to-face Time with the PatientTime 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 ex-

ample, CPT® provides time-based codes to report prolonged services with-

out direct patient contact (99358-99359). 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-to-face” services may allow you to count some non face-to-face time, as long as it bears

directly on patient care. For example, time-based critical

care codes 99291–99292 include “time spent on the unit or at the

nursing station on the floor reviewing test results or imaging studies, discuss-

ing the critically ill patient’s care with oth-er medical staff or documenting critical care services in the medical record.”To be sure you are reporting all appropri-ate time, read all code descriptors and cod-ing guidelines for the code category you are reporting.

2. A Unit of Time is Attained when the Midpoint is PassedFor example, if a code describes the “first hour” of service, you don’t need to docu-ment a full 60 minutes to report the code. But at least 31 minutes of service (or “past the midpoint” of 60 minutes) must be pro-vided 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 time-based services appropriately. For an exam-ple, see the “Total Duration of Critical Care Codes” chart within the Critical Care Ser-vices subsection of the Evaluation and Man-agement chapter.If the minimum time to report is not met, ei-ther the service is not billable, or you should instead bill an (other) appropriate evalua-tion and management (E/M) service code (e.g., office visit 99212–99215). For exam-ple, 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-

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.


To discuss this article or topic, go to www.aapc.com 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) re-cording and interpretation, each 24 hours. For these codes, at least 12 hours of service must be documented to report the code. For ser-vices lasting fewer than 12 hours, you may need to append a modifier, such as modifier 52 Reduced services.

3. When There Are Two Time-based Choices, Pick the ClosestCPT® 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 ac-tual time is used.”The rule applies when reporting E/M ser-vices using time (rather than the key com-ponents of history, exam, and medical de-cision-making) as the controlling factor to qualify for a given level of service—that is, when counseling and/or coordination of care comprises more than half the en-counter. 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 out-patient visit for the evaluation and manage-ment of an established patient, which requires at least 2 of these 3 key components: An ex-panded problem focused history; An expanded problem focused examination; Medical deci-sion 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 ex-amination; Medical decision making of mod-erate complexity) has a reference time of 25 minutes. If counseling equaled 18 minutes, the closest reference time is that of 99213, at

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. Don’t Combine the Time of Unrelated Services“When another service is performed con-currently 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, don’t count the time of an unrelated service when reporting a time-based service. For example, time spent providing separate-ly 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 criti-cal care time.Be aware that what counts as “time” var-ies by the kind of service provided. For in-stance, critical care services include floor/unit time in addition to time spent at a pa-tient’s bedside, while other time-based ser-vices do not. The requirements for critical care are different than those of standby ser-vices, prolonged services, or any other time-based service. You’ll have to read section guidelines and code descriptors to know ex-actly what you can count as “time” for any given service.

5. For Continuous Services, the Date of Service Doesn’t ChangeSuppose 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 continu-ous services that last beyond midnight, use the date in which the service began and re-

port the total units of time provided con-tinuously.” For instance, if intravenous hy-dration is given in the time described above, you would report 96360 Intravenous infu-sion, hydration; initial, 31 minutes to 1 hour once and +96361 Intravenous infusion, hy-dration; each additional hour (List separate-ly in addition to code for primary procedure) twice.

Best Practices Bonus TipWhenever 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 cod-ing choices.


5 Basic Rules to Follow when Time Is a Key Factor1. 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. Don’t combine the time of unre-lated services.

5. For continuous services, the date of service doesn’t change.

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■ Cover: Coding/Billing

Infuse Yourself with Coding Knowledge

By Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA

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 Medi-care every year is any indication, it’s safe to say that drug admin-istration coding can get sticky. Proper drug administration cod-ing 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 BasicsFirst, remember that there are three categories of drug adminis-tration:1. Hydration: CPT® codes 96360-96361 are for pre-packaged

fluids and electrolytes. These codes are not used to report in-fusion of drugs or other substances and are not reported by the physician in a facility setting.


Coding/Billing: Drug Administration

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2. Therapeutic/Prophylactic/Diagnostic: See Table 1 for CPT® codes to report for the administration of drugs and oth-er 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 admin-istration is incidental hydration and is not separately report-able. These codes are not reported by the physician in a facili-ty 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

Use of these codes typically requires advanced practice training and competency; special considerations for preparation, dosage, or dis-posal; and usually entails significant patient risk and frequent mon-itoring 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 che-motherapy is administered by different techniques. Medications ad-ministered independently as supportive management of chemother-apy 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® Code CPT® Description Notes

96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour

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)

Report for intervals of greater than 30 minutes beyond one-hour increments; also report for secondary or subsequent service after a different initial ser-vice through same IV access.

96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

Report for IV infusions of 16-90 minutes.

+96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each addi-tional hour (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 ser-vice through same IV access.

+96367 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)

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).

+96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for pri-mary procedure)

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 access—must be hung in separate bags.

Table 1:Diagnostic/Therapeutic/ProphylacticInfusionCodes

Physicians in the facility setting may not use chemotherapy codes.

36 AAPCCuttingEdge

Cover: Coding/Billing

cian is not present, physician offices may not. You may use in-jection codes to report non-antineoplastic hormonal therapy.

2. IV Push: CPT® 96374 Therapeutic, prophylactic, or diagnos-tic 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 Therapeu-tic, 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 identi-fy an IV push of a new drug when provided as a secondary ser-vice after a different initial service is administered through the same IV access.

Add-on code +96376 Therapeutic, prophylactic, or diagnostic injec-tion (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility drug (List sepa-rately 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 fa-cilities 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 cod-ed differently.

Determine the “Initial” ServiceThe 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 admin-istration 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 chemother-apy 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

CPT® Code CPT® Description Notes

96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic

96402 Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic

96409 Chemotherapy administration; intravenous, push technique, single or initial substance/drug

+96411 Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure)

Report with 96409 or 96413.

96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug

Report for infusions of 16–90 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)

Report in conjunction with 96413.

Report for infusion intervals of greater than 30 minutes beyond one-hour increments.

+96417 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 only once per sequential infusion.

Report 96415 for additional hour(s) of sequential infusion.

Table 2:CPT®codesforchemotherapyadministration


Cover: Coding/Billing


The highest-ranking service provided is considered the initial ser-vice. For example, a patient comes into a hospital outpatient depart-ment for an antibiotic injection, but also receives a hydration infu-sion. The initial service is the antibiotic injection because the ther-apeutic injection ranks higher in the hierarchy than the hydration infusion.

Coding for Multiple AdministrationsIf 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 adminis-trations account for additional services provided. Use subsequent or concurrent codes where appropriate, regardless of the administra-tion 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, it’s important to know time requirements and documentation rules.

Time RequirementsOne 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-

ing between 16 and 90 minutes. Only when an infusion lasts longer than 90 minutes can you code the “additional hour” code. “Each ad-ditional hour” means increments greater than 30 minutes over the initial hour. Do not include time spent keeping veins open (see Ta-ble 3 for examples).

Know What’s IncludedThe 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.

Other ConsiderationsIf 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 out-patient visit for the evaluation and management of an established pa-tient, that may not require the presence of a physician. Usually, the pre-senting problem(s) are minimal. Typically, 5 minutes are spent perform-ing 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 bachelor’s and a master’s 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 Man-agement Assurance.

… the actual chronological order of administration is not important for coding. The initial code is not

necessarily the first service provided.

Single infusion lasting: Can be coded (assuming documentation is complete):

15 minutes or less IV push

16 - 90 minutes Initial hour

91 - 150 minutes Initial hour + 1 additional hour

151 - 210 minutes Initial hour + 2 additional hours

211 - 270 minutes Initial hour + 3 additional hours

… and so on

Table 3:Reportinginfusiontime

38 AAPCCuttingEdge

■ Coding/Billing

Tips Plus More Tips for Cardiology in 2013Part 2: Catch up on reporting of ablations and newer technology procedures.

By David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC

As we learned in Part 1 of this two-part series (see “Changes Plus More Chang-es for Cardiology in 2013,”

page 40-43, January’s Cut-ting Edge), the new year brings significant changes to cardiology coding. This month, we cover CPT® coding in 2013 for trans-catheter aortic valve replace-ment (TAVR), ventricular assist devices, electrophysiology ablations, subcutaneous defibrillators, intracardiac isch-emia monitoring systems, and left atrial (LA) hemody-namic 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, here’s 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 peripher-al cannulations

+33369 Cardiopulmonary bypass support for TAVR, central (eg, aor-ta, right atrium, pulmonary artery) cannulations

Here are some tips for applying these new codes correctly:• The only currently approved device is the Sapien valve. It’s

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 catheter-delivered prosthetic aortic heart valve, open thoracic approach,


Coding/Billing: Cardiology

(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 per-formed 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, femo-ral, iliac, axillary vessels) (List separately in addition to code for primary procedure)

Note: Do not report the temporary pacemaker.

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 de-scriptors: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

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.

TAVR requires two physicians to complete the procedure. Codes 33361–33365 and 0318T …

require modifier 62 … for physician billing.


40 AAPCCuttingEdge

Coding/Billing: Cardiology

• 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 AblationsElectrophysiology ablation codes 93651 and 93652 are deleted. New abbreviated versions of the codes are:93653 Comprehensive electrophysiologic (EP) evaluation with ab-

lation 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 fibrilla-tion 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.

Repositioning of a percutaneous VAD without imaging guidance is not a reportable procedure.


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42 AAPCCuttingEdge

■ Coding/Billing: Cardiology

• 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 intra-cardiac echocardiography (ICE) into the LA. A 3-D map is created, followed by ablations performed to achieve pulmonary vein isola-tion. 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/diagnos-tic intervention, including imaging supervision and interpre-tation (List separately in addition to code for primary proce-dure)

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

0325T Repositioning of electrode and/or generator

0326T EP evaluation (defibrillation threshold testing)

0327T Interrogation of device

0328T Programming of device with iterative adjustments

This is a newer type of defibrillator for treatment of arrhythmias that is totally implanted in the subcutaneous tissues, including the de-fibrillating 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 de-scriptions) for IMD:0302T Insertion of complete system, or removal and replacement

of both device and electrode

Defibrillation threshold testing (DFT testing) involves induction of arrhythmia and evaluation of sensing and pacing for arrhythmia termination, as well as reprogramming as necessary.


Coding/Billing: CardiologyTo discuss this article or topic, go to www.aapc.com


0303T Insertion of electrode only, or removal and replacement of electrode

0304T Insertion of device only, or removal and replacement of de-vice

0305T Programming of device with iterative adjustment

0306T Interrogation of device

0307T Removal of IMD system

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 vi-bratory 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.

Left Atrial Hemodynamic MonitorFinally, you’ll find new Category III codes for left atrial hemody-namic monitor. Easier-to-follow abbreviated descriptions are:0293T Insertion of LA hemodynamic monitor, complete with mod-

ule and pressure sensor lead

0294T Insertion of pressure sensitive lead at time of insertion of pacing cardioverter-defibrillator

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 cardioverter-defibrillator 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 cardioverter-defibrillator 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 pro-grams, and contributes to Dr. Z’s 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 South-ern Association for Vascular Surgery. He is president-elect of the AAPC National Advisory Board.

The removal of an existing IMD system and replacement with a new system is re-

ported by the single code …

Pacingelectrode

lead

Pulsegenerator(pacemaker) in subcutaneouspocket

Intravascular electrode leads in

subclavian vein

Defibrillation electrode

lead

44 AAPCCuttingEdge

Know Double Dipping Etiquette


In the coding world, the term “double dip” has two meanings (neither of which has anything to do with dining etiquette). You might think it’s never OK to double dip, but in some circumstances, you definite-ly should—or risk leaving legitimate reim-bursement on the table.

Double Dip “Don’t”The first use of double dip means to bill twice for the same item; for instance, by separately reporting a service that is includ-ed in another (already claimed) procedure. Such unbundling is prohibited, and—even if done unintentionally—can quickly land you in hot water with payers. This type of double dipping is never OK. As an example, the Medicare surgical pack-age includes routine post-operative care, in-cluding related evaluation and management (E/M) services, within the 90-day glob-al period of a major procedure. If you sepa-rately report an E/M visit for when the oper-ating surgeon checks on the patient’s recov-ery (clearly a service related to the surgery), you would be double dipping on the E/M. That’s a “don’t.”As a second example, you wouldn’t 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 jejunosto-my (44186 Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding)) with lyses of adhesions, you cannot report 44180 Lap-aroscopy, surgical, enterolysis (freeing of intes-tinal adhesion) (separate procedure). That’s another “don’t” because the separate pro-

cedure designation means 44180 is bun-dled to the related, more extensive proce-dure (44186).

Double Dip “Do”The second meaning of double dip is to use a single statement in the docu-mentation of an E/M service more than once when determining the level of ser-vice 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 De-cember 1997, Barton C. McCann, MD, publicly remarked that when selecting an E/M service level, you “cannot use one state-ment 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, pay-ers, and health care regulators. McCann’s intended meaning is that you cannot use a single documented item twice within the same component of the E/M ser-vice. For instance, if the physician docu-ments “pain since last Tuesday,” you cannot count that statement in the history of pres-ent illness (HPI) as timing and duration. It’s one or the other, but not both. Similar-ly, if the physician records “no back pain,” you can’t count that statement in the review of systems (ROS) as relevant to both mus-culoskeletal and neurological body systems. In other words, you shouldn’t use the same statement twice within the history or with-in the ROS. That’s your third legitimate “don’t.”Taken in context, McCann’s pronounce-ment about the inappropriateness of this type of double dipping was neither sensa-tional nor controversial. Unfortunately, his words were immediately taken out of con-text and applied much more broadly to re-

■ Auditing/Compliance

Although it’s usually coding taboo, at times, it’s proper for legitimate recoupment.

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Auditing/Compliance: Double Dipping

flect a meaning he never intended. Specifi-cally, McCann’s 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 mistak-en interpretation of McCann’s statement, you would not be able to count the docu-mentation as location and associated signs and symptoms in the history and as relevant to the respiratory system in the ROS.

Setting the Record Straight (Sort of)McCann later disavowed the twisted inter-pretation of his words, writing, “You ask if a single statement may be used in the histo-ry of present illness and still be counted in the review of systems without actually be-ing 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 McCann’s clarification, the “you can’t 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)un-derstanding has become one of the greatest coding “urban legends.” And because pay-ers 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 require-ments for documented patient information to be stated or written in any specific for-mat. Neither the 1995 or 1997 Documen-tation Guidelines for Evaluation and Man-

agement Services state that you cannot count a single item in both the history and ROS. Nothing in the American Medical Associ-ation (AMA) or national Medicare guide-lines says so, either. And the man who is mistakenly credited with having said it was so has publicly stated that it isn’t. Any payer or auditor who continues to in-sist 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 appropri-ately referred to. Returning to our earlier example of the pa-tient with documented chest pain with dys-pnea, you may count dyspnea as both an as-sociated 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 shouldn’t use that single complaint for both the history and ROS. Rather, you should look for documented evidence that the phy-sician 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 ab-

dominal pain, and that’s all the physician documents, you shouldn’t report that sin-gle item in the history and ROS. But doc-umentation of “abdominal pain, no nau-sea” means the physician asked additional questions beyond the presenting problem, which makes using the item in both the his-tory and ROS acceptable. Similarly, documentation of “cough” alone isn’t sufficient to count for both history and ROS; however, “cough one week, no expec-toration, moderate shortness of breath” pro-vides plenty of detail to support both the history and ROS elements. The bottom line: If the physician looks be-yond 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 ele-ment in both the history and ROS. Doing so is not only legitimate, it may mean the dif-ference between, for example, a level III and a level IV E/M code assignment.


Despite McCann’s clarification, the “you can’t 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.

46 AAPCCuttingEdge


Facility

Control Hospital Risk Using OIG’s 2013 Work PlanLet government reviews help you identify and correct potential compliance risks at your hospital.

By Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P

Each October, the Office of Inspector Gen-eral (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 com-pliance audit plan for the year ahead. In re-viewing the OIG’s areas of concern for hos-pitals, you might catch potential noncom-pliance in your workplace, allowing you to take corrective action to reduce risk of Medicare and Medicaid fraud.

Look Out for First-time ReviewsSeveral items in the 2013 Work Plan, aimed specifically at the hospital industry, are ap-pearing for the first time. Consider each of the following items carefully.

Inpatient Billing for Medicare BeneficiariesIn 2008, the Medicare Inpatient Prospec-tive Payment System (IPPS) transitioned from the traditional Centers for Medicare & Medicaid Services-Diagnosis Relat-

ed Group (CMS-DRG) system to Medicare Severity-Diagnosis Relat-ed Groups (MS-DRGs). This clas-sification 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 particu-lar, varied among different provid-ers. They also plan to examine com-pliance with inpatient billing stan-dards 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 ac-tive 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.

DRG WindowThe Medicare program currently bundles all outpatient services delivered three days prior to an inpatient hospital admission. The Medicare program does not pay sepa-rately for these preadmission services when they are delivered in a setting owned or op-erated by the admitting hospital. This pol-icy is commonly known as the “DRG win-dow,” and prior OIG work identified im-proper 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 deliv-ered up to 14 days prior to an inpatient hos-pital admission into the MS-DRG payment. To evaluate these DRG window payments,

however, CMS will examine all services pro-vided in that time frame. This will uncover potential issues with the three-day window, as well, which is an area that has been prob-lematic 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 oc-curs. For example:

• Is your facility including all diagnostic and clinically related non-diagnostic 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.

Non-hospital-owned Physician Practices Using Provider-based StatusThis 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 pro-vider-based physician practices. The Medi-care program makes additional payment to facilities for services provided in the provid-er-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 Medi-care using provider-based status meet bill-ing requirements. Hospitals should exam-

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Auditing/Compliance: Work PlanTo discuss this article or topic, go to www.aapc.com

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, it’s critical these services are not billed as pro-vider-based.

Compliance with Medicare’s Transfer PolicyTransfers 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 effec-tiveness of the claims processing edits used by the Medicare administrative contrac-tors (MACs) to identify claims subject to the transfer policies in place in the Medi-care program.Under Medicare IPPS guidelines, a hospi-tal 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 MS-DRG payment that would have been made if the patient was discharged from the origi-nal without being transferred. There are of-ten issues where patients are improperly not-ed as being “discharged” instead of “trans-ferred” from the original facility, and the en-tire MS-DRG payment is made for both fa-cilities. 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 Discharges to Swing Beds in Other HospitalsSwing beds are inpatient beds in hospitals that can be used for skilled nursing servic-es or acute care services. This review con-cerns instances when an acute care facility discharges patients from the acute care set-ting to a swing bed.A move from one clinical setting to another to receive additional care typically is consid-ered a transfer. Currently, however, Medi-care does not pay a reduced, graduated per

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.

Payments for Canceled Surgical ProceduresFrom an analysis of data, the OIG has deter-mined large occurrences of initial IPPS pay-ment for a canceled surgical procedure, fol-lowed by a second IPPS payment for the re-scheduled surgical procedure. For the initial IPPS payment, few, if any, inpatient servic-es such as laboratory or diagnostic tests were provided by the hospitals because the surgi-cal procedure was canceled.Medicare makes two payments to hospitals, generating two bills, unless the patient is re-admitted 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. It’s clear, however, they are determin-ing how much money is spent on inpatient short stays for canceled surgical procedures without significant services being provid-ed. 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 con-cise. Have clinical documentation improve-ment staff members work with providers to clearly document reasons for surgical can-cellations, as well as all services provided for patients. Be sure coding clearly reflects all work provided for patients during their stay.

Payments for Mechanical VentilationWhen a ventilator or respirator is used to take over active breathing for a patient for 96 or more hours in the inpatient set-ting, 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

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 rel-ative weight will obviously result in a higher payment to the facility for mechanical ven-tilation 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 96-hour rule?

Use the Work Plan to Your AdvantageMost 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 im-prove compliance internally.Take the time to review the existing items in the Work Plan, such as same-day readmis-sions, outlier payments, observation pay-ments, and many of the other items contin-uously 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/reports-

and-publica tions/archives/workplan/2013/Work-

Plan-2013.pdf. For a peek into the areas of risk for physician related-items read “Get a Jump on 2013 Government Reviews” on pages 48-49 of January’s 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 expe-rience in the health care industry. She is a for-mer chief compliance officer and chief privacy official. She teaches CPT® coding as an ap-

proved AAPC instructor, and is a former member of AAPC’s ICD-10 curriculum development team. She holds a bachelor’s de-gree in health care administration from State University of New York - Empire State College and a master’s degree in health sys-tems administration from the Rochester Institute of Technology.

Hospitals should examine their provider-based clinics to determine if they are billing properly.

48 AAPCCuttingEdge

Coding Compass

New POS Rules Get Sticky for 21 and 22 E/M ServicesAlthough it may mean denials, stay compliant when reporting inpatient transports to outpatient settings.


Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC

Be sure your place-of-service (POS) code matches the setting where the patient received the service (for face-

to-face services), or the setting where the technical portion of the service was deliv-ered (for non-face-to-face services, such as diagnostic test result interpretation). Al-though this may sound easy in theory, new Medicare guidance can make POS assign-ment tricky.In recent transmittal 2563, change request (CR) 7631, the Centers for Medicare &

Medicaid Services (CMS) clarified guid-ance for assigning POS codes on Medicare claims. That guidance has posed new ques-tions 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 dis-crepancies when reporting in compliance to the new POS reporting rules:“An inpatient is transported to an outpa-

tient provider office for an evaluation and management (E/M) service and a proce-dure. The patient is still a registered inpa-tient and will return to the hospital at the conclusion of the visit. Should the outpa-tient provider report his or her E/M service using the outpatient E/M codes (99201-99215) or can they use the subsequent in-patient 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 trans-mittal 2563, effective Oct. 11, 2012:“In general, the POS code reflects the actual place where the beneficiary receives the face-to-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 beneficia-ry occurred.”And here is the specific provider instruc-tion added to the Medicare Claims Process-ing Manual:Special Considerations for Services Furnished to Registered Inpatients“When a physician/practitioner furnish-es services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/suppli-er furnishing services to a patient who is a reg-istered inpatient, shall, at a minimum, re-port the inpatient hospital POS code 21 irre-


Auditing/Compliance: Place of Service

spective of the setting where the patient actu-ally receives the face-to-face encounter. In oth-er words, reporting the inpatient hospital POS code 21 is a minimum requirement for pur-poses of triggering the facility payment under the PFS when services are provided to a regis-tered 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/practitio-ner may use POS 31, for a patient in a SNF re-ceiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpa-tient Facility, and POS 61 for patients regis-tered in a Comprehensive Inpatient Rehabili-tation Facility.”According to this provision, I see the issue where a physician performing an E/M ser-vice in an office setting for a patient who is currently a registered inpatient at a facili-ty (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 pay-ment rate for an outpatient E/M service, some carriers may not process a payment for an outpatient E/M service (e.g., 99201-99215) 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 physician’s face-to-face encounter with a patient occurs in the of-fice, the correct POS code on the claim, in gen-eral, reflects the 2-digit POS code 11 for of-fice. 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 physi-cian. 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 cor-rect POS code — regardless of where the face-to-face service occurs — is that of the appropri-ate 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 physician’s office is actually an inpatient of the hospital, POS code 21, for inpatient hos-pital, is correct. In this example, the POS code reflects a different setting than the address and ZIP code of the practice location (the physi-cian’s office).** Medicare Claims Processing Manual, Inter-net Only Manual (IOM), pub 100-4, chap-ter 26, section 10.6 (emphasis added).Although it is time consuming to appeal such denials, I have to assume that Medi-care administrative contractors will even-tually fix their payment systems to comply with this instruction, which is not yet up-dated 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 code—be-cause 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 in-structing 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 spe-cific code, where the exact facility status is known) when the outpatient E/M service or other procedure is performed on a pa-tient that is a current registered inpatient at a hospital. Note that the location of the ser-vice in block 32 would be the physician’s of-fice and ZIP code.I suspect carriers will reprogram their claims processing systems soon to deal with this payment problem, where it exists. Attempt-ing to avoid the denial by reporting an inpa-tient E/M service that was not performed, especially where that code results in the phy-sician obtaining additional reimbursement, is not recommended. Even if paid, the pro-vider 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 implement-ing regulations.

Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, has a Bachelor of Science degree from the U.S. Military Acade-my, 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 AAPC’s Na-

tional Advisory Board and a current member of the Legal Advi-sory Board. He is admitted to the Bar in California and to prac-tice 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.

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.


Effective Jan. 1, 2013Permanent J-Code for

OMONTYS® (peginesatide) InjectionJ0890

2968_takpeg_fa3_j_aapc_2pg.indd 1 11/20/12 2:19 PM

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.

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.

ContraindicationsOMONTYS is contraindicated in patients with uncontrolled hypertension and in patients who have had serious allergic reactions to OMONTYS.

Warnings and PrecautionsIncreased 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.

• In controlled clinical trials of ESAs in patients with cancer, 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 reactionsMost 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.

Please see accompanying Brief Summary.

Reducing the burden of ESA administrationConsider the first once-monthly, non-EPO ESA offering less-frequent dose administration.

Reference:SchillerB,DossS,DeCockE,DelAguilaMA,NissensonAR.Costsofmanaginganemiawitherythropoiesis-stimulatingagentsduringhemodialysis:atimeandmotionstudy.Hemodial Int.2008;12(4):441-449.

03-12-00277-A.;24102.©2012Affymax,Inc.andTakedaPharmaceuticalsAmerica,Inc.Allrightsreserved.Affymax,theAffymaxlogo,OMONTYS,andtheOMONTYSlogoaretrademarksofAffymax,Inc.and/oritssubsidiaries.TakedaandtheTakedalogoaretrademarksofTakedaPharmaceuticalCompanyLimitedregisteredwiththeU.S.PatentandTrademarkOfficeandusedunderlicensebyTakedaPharmaceuticalsAmerica,Inc.


BRIEF SUMMARY OF FULL PRESCRIBING INFORMATIONOMONTYS® (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 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 [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 USAGEAnemia Due to Chronic Kidney DiseaseOMONTYS® is indicated for the treatment of anemia due to chronic kidney disease (CKD) in adult patients on dialysis.Limitations of UseOMONTYS 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 orhealth-related quality of life.

CONTRAINDICATIONSOMONTYS is contraindicated in patients with:• Uncontrolled hypertension [see Warnings and Precautions].• Serious allergic reactions to OMONTYS [see Warnings and Precautions].WARNINGS AND PRECAUTIONSIncreased 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)).

Table 2 Adverse Cardiovascular Outcomes in Randomized Controlled Trials Comparing Higher and Lower Hemoglobin Targets in Patients With CKD

NHS(N = 1265)

CHOIR(N = 1432)

TREAT(N = 4038)

Time Period of Trial 1993 to 1996 2003 to 2006 2004 to 2009

Population

Patients with CKD on hemodialysis with coexisting CHF or CAD, hematocrit

30 ± 3% onepoetin alfa

Patients with CKD not on dialysis with

hemoglobin < 11 g/dLnot previously administeredepoetin alfa

Patients withCKD not on dialysis with type II diabetes,

hemoglobin≤ 11 g/dL

Hemoglobin Target; Higher vs. Lower (g/dL) 14.0 vs. 10.0 13.5 vs. 11.3 13.0 vs. ≥ 9.0

Median (Q1, Q3)Achieved Hemoglobin level (g/dL)

12.6 (11.6, 13.3)vs.

10.3 (10.0, 10.7)

13.0 (12.2, 13.4)vs.

11.4 (11.1, 11.6)

12.5 (12.0, 12.8) vs.10.6 (9.9, 11.3)

Primary Endpoint All-cause mortalityor non-fatal MI

All-cause mortality, MI, hospitalizationfor CHF, or stroke

All-cause mortality, MI, myocardial ischemia, heart

failure, and stroke

Hazard Ratio or Relative Risk(95% CI)

1.28 (1.06 – 1.56) 1.34 (1.03 – 1.74) 1.05 (0.94 – 1.17)

Adverse Outcome for Higher Target Group All-cause mortality All-cause mortality Stroke

Hazard Ratio or Relative Risk (95% CI)

1.27 (1.04 – 1.54) 1.48 (0.97 – 2.27) 1.92 (1.38 – 2.68)

Patients with Chronic Kidney Disease Not on DialysisOMONTYS 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 ESAsOMONTYS 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.HypertensionOMONTYS 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 ReactionsSerious 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 OMONTYSFor 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 ManagementPatients 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 MonitoringEvaluate transferrin saturation and serum ferritin prior to and during OMONTYS treatment. Administer supplemental iron therapy when serum ferritin is less than100 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 REACTIONSThe 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 ExperienceBecause 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 DiseaseAdverse 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

Adverse Reactions

Dialysis Patients Treated with OMONTYS(N = 1066)

Dialysis Patients Treated with Epoetin

(N = 542)

Gastrointestinal DisordersDiarrhea 18.4% 15.9%Nausea 17.4% 19.6%Vomiting 15.3% 13.3%

Respiratory, Thoracic and Mediastinal DisordersDyspnea 18.4% 19.4%Cough 15.9% 16.6%

Injury, Poisoning and Procedural ComplicationsArteriovenous FistulaSite Complication 16.1% 16.6%

Procedural Hypotension 10.9% 12.5%Nervous System Disorders

Headache 15.4% 15.9%Musculoskeletal and Connective Tissue Disorders

Muscle Spasms 15.3% 17.2%Pain in Extremity 10.9% 12.7%Back Pain 10.9% 11.3%Arthralgia 10.7% 9.8%

Vascular DisordersHypotension 14.2% 14.6%Hypertension 13.2% 11.4%

General Disorders and Administration Site ConditionsPyrexia 12.2% 14.0%

Metabolism and Nutrition DisordersHyperkalemia 11.4% 11.8%

Infections and InfestationsUpper Respiratory Tract Infection 11.0% 12.4%

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.

Postmarketing ExperienceBecause 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].ImmunogenicityOf the 2357 patients tested during clinical trials, 29 (1.2%) had detectable levels of peginesatide-specific binding antibodies. There was a higher incidence of peginesatide-specific binding antibodies in patients dosed subcutaneously (1.9%) as compared to those dosed intravenously (0.7%). Peginesatide neutralizing antibodies were detectedin 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 INTERACTIONSNo 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 POPULATIONSPregnancyPregnancy Category CThere 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 of3 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/kgand 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/kgin 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 MothersIt 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 UseThe safety and efficacy of OMONTYS in pediatric patients have not been established.Geriatric UseOf 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.OVERDOSAGEOMONTYS 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


54 AAPCCuttingEdge

■ Practice Management

Optimize Your Patients’ Access to CareCreate a schedule model that fulfills patient scheduling needs, reduces no-shows, improves front staff workload, and allows provider flexibility.

By David J. Moore, MD, MS

Thinking from the health care admin-istrator’s perspective, wouldn’t 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, wouldn’t 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 doctor’s 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 PracticeModified Open Access is a scheduling mod-el developed in 2001 and aimed to achieve these goals of a patient-centered, sustain-able, and viable practice model. The model strives to optimize care provider access and utilization through the creation and main-tenance of intentionally open schedule tem-plates at the start of each day. Original-ly developed by our quality improvement team, its goal is to capture—in a sustain-able way—the innovative care scheduling ideals of the “Advanced Open Access mod-

el” (as developed and described in Murray and Tantau’s 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 Tantau’s model is to make the system’s 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 im-plementation logistics, our team addressed the concern of how to prevent open sched-ules from refilling with new or transient cli-entele who may ultimately block out estab-lished patients. To address this concern and preserve an open and accessible schedule for established patients, Modified Open Access differs from the Murray and Tantau mod-el in placing limits on the interval beyond “same-day” for when appointments may be booked. It then utilizes several simple pol-icy tools to ensure that established patients can always get in when they call for either acute or follow-up care—these are tools to maintain the promise of established patient care access.

Offering Reliable, Limited Access Is KeyLike its predecessor, Modified Open Ac-cess 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 open-ing two-thirds of a provider’s schedule, we found that patient throughput volume ac-tually went up because the schedule allowed patients to see their preferred provider reli-ably. No-show rates markedly declined as a result of the time decrease between when the request was made to when the appoint-ment actually occurred. To achieve and maintain an open sched-ule, established patients are offered and en-couraged to take same-day appointments, but are limited to appointments within sev-en days. To make established patients’ ac-cess top priority, new patients are limited to same-day access only; that is, new patients (patients never before seen by the particu-lar provider) are only offered access to a pro-vider on a same-day basis, and only after time slots for established patient care needs are addressed on that day. Limiting new pa-tient access, as with traditional schedul-ing, supports and defends established pa-tients’ access.

Use Tools to Support Open SchedulingTool No. 1: EPPA TimeA behind-the-scenes tool called the estab-lished patient priority access (EPPA) time supports priority access to established pa-


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 day’s appoint-ments. After the EPPA time passes, all pa-tients, 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 flexi-ble and can be altered as needed, even on a daily basis. Before 11 a.m., only our estab-lished patients have access to the day’s two-thirds open schedule, giving them priority status. After 11 a.m., both new and estab-lished patients are offered any remaining slots for that day.New patients who call for appointments be-fore the day’s established EPPA time are po-litely informed that no appointments are available at that time, and are offered a call-back 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 day’s schedule. The EPPA time may be adjusted to accom-modate 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 prac-tice to more new patients. If established pa-tient care demand rises—for instance, due to an influenza outbreak—then you can protect more established patient slots by moving the EPPA time to a later point in the day.Central to the model’s success is that estab-lished 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 model’s openness, it satis-fies 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 actu-ally increased compared to our prior tradi-tional scheduling model experience.Tool No. 2: Receptionist ScriptsTo support this method of handling care demands, receptionist phone protocol scripts were developed to aid our recep-tionists (see Figure A and B). Although the model protocol can be integrated into the practice management scheduling software, scripts for our receptionists remain a valu-able tool for implementation and training. They are also useful for understanding the model’s f low of patient call handling.The scripts encourage filling of first avail-able slots, but our patient-centered empha-sis remains on accommodating established patient appointment needs, up to the al-lowed full week’s advanced scheduling op-tion. The scripts also introduce the next tool developed to support keeping the same-day access promise for established patients.Tool No. 3: Pressure-valve SlotsBecause patient care demand can be unpre-dictable 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.Here’s how pressure-valve slots work: They are a scheduled interval of protected ap-pointment slots built around the usual prac-

tice closing time that become available only if the day’s regular appointment slots have saturated. In our busy practice, pressure-valve slots span from one hour prior to our usual closing time to one hour after that time. These pressure-valve slots are avail-able 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 valve—closed till that point—then “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 ca-pacity beyond the usual closing time allows responsiveness to care needs and demands of established patient clientele. In our pri-mary care setting, pressure-valve care tends to be acute, urgent, and reflects the illnesses affecting the community; however, no lim-its are ever placed in the schedule on the na-ture of care requested. As the pressure-valve slots in a day progress across the interval, pa-tients with lower acuity care needs tend to accept more readily the two-thirds open ap-pointment 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 ProtocolIf 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

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.

56 AAPCCuttingEdge

Practice Management

DeclinedYes

Yes

Yes

No

“Please give us a call on or near the day you want to be seen and we will get you in.”Offer PCP

Appointment < 1 week

Offer 1st Available Pressure-Valve appointment

address concerns

YesNo

Yes

No reg appointment left?

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).

“Have you been seen at ______ Clinic before?”

Patient Name? / Designated PCP?

“We show Dr _X_ is the PCP. Would you like to see Dr _X_?

Offer: Earliest Available PCP regular Appointment

No

No

EPPA timeBefore _____ am

“Hello, may I help you schedule an appointment?”

Figure A

Figure B

Yes

Yes

Yes

Yes

Yes

address concerns

No

No“Please give us a call on or near the day

you want to be seen and we will get you in.”

Offer PCP Appointment < 1

week

Offer 1st Available Pressure-Valve appointment

No reg. appointment left?

Book PCP Appointment

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)”

“Have you been seen at ______ Clinic before?”

Patient Name? / Designated PCP?

“We show Dr _X_ is the PCP. Would you like to see Dr _X_?

Offer: Earliest Available PCP regular Appointment

No

No

Declined

“Hello, may I help you schedule an appointment?”

EPPA timeAfter ______ am


our existing practice management software capabilities. The reminder system’s foun-dation is based on the underlying principle: No matter what the scheduling model, it ul-timately is the patient’s choice and decision whether to comply with the follow-up rec-ommendations given by his or her provid-er. With this in mind, a three-tiered, fol-low-up reminder system was developed to encourage recommended return care inter-val compliance.The system starts with the provider’s recom-mended follow-up interval being delivered to the receptionist desk while the patient ex-its from an existing appointment. The first tier is a general interval follow-up card giv-en to the exiting patient (e.g., “follow up in early May”). The existing patient reminder system then triggers daily batch mailing re-minder cards at the provider’s recommend-

ed follow-up interval. After allowing a re-sponse interval, if no appointment is initi-ated by the patient, a final reminder is gen-erated and sent. Although initiation of an appointment request falls into the patient’s hands, follow-up compliance is tracked and providers are kept aware of all patient-spe-cific lapses.

Appointment Accessibility Shows Favorable ResultsThe patient-initiated access and limited ad-vanced scheduling aspects of the Modified Open Access model resulted in 50 percent or greater reductions of no-show rates ver-sus our prior appointment model, or other site traditional appointment model users in our system. Front office staff reported dra-matically improved workloads attributed to a significant reduction in appointment

rescheduling. With no locked-in appoint-ments beyond one week, provider sched-ules had a significant increase in flexibility. Most importantly, patient satisfaction with provider continuity and access has been high. Implementation challenges and cave-ats, as well as spin-off benefits of the model, continue to be noted, and opportunities for software-driven enhancements and stream-lining 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 Kentucky’s Center for Excellence in Rural Health. He has served in corporate medical di-rector and site director roles in the Universi-ty’s partner relationship with the North Fork

Valley Community Health Center in Hazard, Ky. He is a graduate of Harvard University School of Public Health’s Masters in Health Care Management and a graduate of Wright State Uni-versity School of Medicine and Family Medicine Residency in Dayton, Ohio.

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

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SridharArumugam, CPCStephanieDawnKenser, CPCStormyGrimmer, CPCSueAnnCoffin, CPCSueCarney, CPCSujithaNarayanan, CPC-HSurekoAHamilton, CPCSusanNEdge, CPCSuzanSwain, CPCSuzanneBriggs, CPCSuzanneLink, CPCSylviaSanMiguel, CPCTabathaJackson, CPCTamikoWoodfork, CPCTammyJennetteScarberry, CPC-HTammyPatterson, CPCTatyanaVasilchuk,CPC, CPC-HTenaSiebenmorgan, CPCTeresaRogalski, CPCTeresaBlake, CPCTeriMStarling, CPCTharaL, CPC-HThenmozhiSengottuvel,CPC, CPC-HTiffanyFite, CPCTiffanyShereseHurd, CPCTinaDTitsworth, CPCTinaMcGonigle, CPC-PTruptiPatel, CPCVeronicaGlasper, CPCVigneshkumarRajasekaran, CPCVinuthaR,CPC, CPC-HVishnupriyaKamaraj, CPCWendyMitchell, CPCWhitneyClarahan, CPCXinZou, CPC-HYvonneBetancourt,CPC, CPC-H

ApprenticesAHSGDasthagir, CPC-AAbbyYip, CPC-AAdelinaKobeci, CPC-AAgnieszkaPlonska, CPC-AAlginDN, CPC-AAliceACalipes, CPC-AAliceEJohnson, CPC-AAliciaMcCrudden, CPC-AAlwynDN, CPC-AAmandaBreznau, CPC-AAmandaHasser, CPC-AAmandaSoliday, CPC-AAmbarSolorzano, CPC-AAmritaRaveendran,CPC-A, CPC-H-AAmyMarieMeeks, CPC-AAmyPenman, CPC-AAmyPridemore, CPC-AAndreenaMariePulak, CPC-AAnilSingh, CPC-AAnissaBooth, CPC-AAnitaEhly, CPC-AAnnBogari, CPC-AAnnSweeney, CPC-AAnnieNguyen, CPC-AAntoinetteMunsch, CPC-AAranya(Joy)LFeagins, CPC-AArletHopkins, CPC-AArunKumarRajavel, CPC-AAshalMahoney, CPC-AAshleyTucker, CPC-AAshwiniRajan, CPC-ABarbaraMcQuade-Lantzy, CPC-ABarbaraRabatsky, CPC-ABarunKumar, CPC-ABeckyBanks, CPC-A

BeckyGoodyear, CPC-ABeckyWilliams, CPC-ABelindaStrack, CPC-ABenDominicPalomares, CPC-ABethAnnTeague, CPC-ABethTaylor, CPC-ABibinKrishnan, CPC-ABingyiMaryNi, CPC-ABlaineRush, CPC-ABonnieOakes, CPC-ABrettLRicketts, CPC-ABrigidaMariaJohnson, CPC-ABrittanyPankow, CPC-ABrittneyPoling, CPC-ACarlaJoCushman, CPC-ACarolEWildey, CPC-ACarolGaumer, CPC-H-ACarolynSueCloer, CPC-ACaseySmith, CPC-H-ACeciliaColmer, CPC-AChaithraRama, CPC-H-AChandanapalliHaranadh, CPC-ACharityARouse, CPC-ACharleneJWatkins, CPC-ACharlotteCarrow, CPC-ACheolLee, CPC-ACherylPhillips, CPC-AChrisGamet, CPC-AChristinaMott, CPC-AChristinaWebb, CPC-H-AChristineLogsdon, CPC-AChristopherBrianGlenn, CPC-ACieraNicoleBrower, CPC-ACindyChieng, CPC-AClaudiaCastaneda, CPC-AColleenPalmer, CPC-AConnieMorrison, CPC-AConnieSibley, CPC-AConradDLippens, CPC-AConstanceMcMullen, CPC-ACorinLeeDunn, CPC-ACourtneyCooper, CPC-ACourtneyJohnson, CPC-H-ACourtneyMcGinnis, CPC-ACraigRussell, CPC-H-ACrystalLGrove, CPC-ADaniaSerrano, CPC-ADanielleRuiz, CPC-ADanielleSeaman, CPC-ADannyNunez, CPC-ADanyeaKimHankins, CPC-ADaphneRachkoskie, CPC-ADavidSzeto, CPC-ADawnCThoma, CPC-ADawnCallender, CPC-ADebbieZander, CPC-ADeborahACreek, CPC-ADeborahJob, CPC-ADebraKlump, CPC-ADeepakBabu, CPC-ADellaRCanter, CPC-ADenielleCaballeroCabahug, CPC-ADeniseETorcicollo, CPC-ADeniseChase, CPC-ADeniseMBlair, CPC-ADenissaFaithGrace, CPC-ADesireeJoyceBryant, CPC-ADevonnaNireeNelson, CPC-ADevshreeNarvekar, CPC-ADiAnaOlguin, CPC-ADiannaMiller, CPC-ADiedrePCarter, CPC-ADinaCarangelo, CPC-ADivyashreeKumaraswamy, CPC-A

60 AAPCCuttingEdge

Newly Credentialed Members

DonnaDiStefano, CPC-ADonnaFord, CPC-ADonnaPlace, CPC-ADonyaCarolTucker, CPC-AEdnaGonzalez, CPC-AEdwinJohnson, CPC-AEileenCoutras, CPC-AElenaDelgado, CPC-AElisabethParker, CPC-AElizabethHewett, CPC-AElyssaAnnLuebbering, CPC-AEmilyEWalk, CPC-AEsmeraldoBatingana, CPC-AEvelynDKnott, CPC-AFarineAli, CPC-AFrancelaineSaintelus, CPC-AGailNadeau, CPC-AGailYu, CPC-AGaryEdwardAnderson, CPC-AGeorgetaMoise, CPC-AGeorgiaDodge, CPC-AGinaConoan, CPC-AGinaGrady, CPC-AGinaLFulcher,RDH, CPC-AGopalakrishnanThangavelu, CPC-AGowriManohariNatarajan, CPC-AGwendolynLawhorn, CPC-AHarrietCohen, CPC-AHeatherSoss, CPC-AHeatherWalsh, CPC-AHeidiStutz, CPC-AHilaryMulligan, CPC-AHollyHindel, CPC-AHollyChristineWideman, CPC-AHollyHenderson, CPC-AHollyJarvis, CPC-AHoraliaAcosta, CPC-AHuiyiMiao, CPC-AIndiraMahendrada, CPC-AIngeBarth, CPC-AJackieRogers, CPC-AJackieShounRingersma, CPC-AJacquelynBroten, CPC-AJaiganeshPalani, CPC-AJamesRausch, CPC-AJamesWLim, CPC-AJamieKrajewski, CPC-AJamiePylman, CPC-AJamieSchwaller, CPC-AJanetLHoldeman, CPC-AJanetYoder, CPC-AJayanthiVadivelu, CPC-AJazsmineJacobs, CPC-H-AJeanHavel, CPC-AJeanMorris, CPC-AJeanetteRobinWeiland, CPC-AJeanneUhing, CPC-AJeannetteRosas, CPC-AJenelleKeppley, CPC-AJenniferHaselby, CPC-AJenniferSwank, CPC-AJenniferAustin, CPC-AJenniferCourtney, CPC-AJenniferGabrielaDejamco, CPC-AJenniferLynMoore, CPC-AJenniferMaryBaumann, CPC-AJenniferMeade, CPC-AJenniferPorter, CPC-AJenniferRFair, CPC-AJennyEstrada, CPC-AJennySexton, CPC-AJessicaFisher, CPC-AJessicaHathaway, CPC-AJessicaJohnson, CPC-H-AJessicaJose, CPC-AJessicaSchroeder, CPC-AJillDoyle, CPC-AJillRAmmons, CPC-AJillVierck, CPC-AJillVisser, CPC-A

JingYunWu, CPC-AJoanElaineErickson, CPC-AJoanFerguson, CPC-AJoanKeller, CPC-AJohnBennett, CPC-AJohnBry, CPC-P-AJordanCBurchell, CPC-AJordanHeath, CPC-AJordanStrombeck, CPC-AJosetteFuselier, CPC-AJoyceFavier, CPC-AJudyBlock, CPC-AJudyJTaylor, CPC-AJudyLouiseAshey, CPC-AJuliaGenther, CPC-AJulianneJohnson, CPC-AJulieAMiller, CPC-AJulieKiekhoefer, CPC-AKakasahebKachole, CPC-AKandyNies, CPC-AKaraScott, CPC-H-AKarenFrancis, CPC-AKarenJMusslewhite, CPC-AKarenLuckeroth, CPC-AKatherineSeebeck, CPC-AKathleenCott, CPC-AKathleenJohnson, CPC-AKathryneLeahBarnes, CPC-AKathyHudson, CPC-AKatrinaCartwright, CPC-A,CPC-P-A

KatyNiemchick, CPC-AKaylaLeeMalone, CPC-AKeelieDalonzo, CPC-AKelliPekios, CPC-AKellyHart, CPC-AKellyMcCormick, CPC-AKellyMckay, CPC-AKellyPethtel, CPC-AKelseySorensen, CPC-AKennyM.Lee, CPC-AKeriMarieCrowley, CPC-AKimBair,CPC-A, CPC-H-AKimCioe, CPC-AKimEskew, CPC-H-AKimGreening, CPC-AKimNguyen, CPC-AKimberlyBiagioni, CPC-AKimberlyLynneMiller, CPC-AKiwannaFaulkner, CPC-AKokiladeviGopinath, CPC-AKomalaValliSelvaraj, CPC-AKomathiB, CPC-AKristenPalmer, CPC-H-AKristenTheisen, CPC-AKristiWilson, CPC-AKristineClaireLefebvre, CPC-AKristineJohnson, CPC-AKrystalLaForrest, CPC-AKrystleLister, CPC-AKunalChatterjee, CPC-ALakeniaWarren, CPC-ALalimaMehrotra, CPC-ALaRenaFitz-Gerald, CPC-ALarryPoms, CPC-ALaToshaBridgewater, CPC-ALauraAlber, CPC-ALaurenGailPoe, CPC-ALaurieRichardson, CPC-ALaurieHubbard, CPC-ALavetteDNeal, CPC-ALeahTrippanera, CPC-ALeighWillard, CPC-ALeslieBoulette, CPC-H-ALieuDoan, CPC-ALinaUngureanu, CPC-ALindaHatch, CPC-ALindaHeady, CPC-ALindaTittle, CPC-ALindsayOwens, CPC-ALinetteNavarro, CPC-A

LisaCSmith, CPC-ALisaCampbell, CPC-ALisaDavidson, CPC-ALisaFisher, CPC-ALisaHendricks, CPC-ALisaLarson, CPC-ALisaRobinson, CPC-ALoisWidener, CPC-ALokeshChaluvegowda, CPC-ALoraBolton, CPC-ALoriBrown, CPC-ALoriDenieceWise, CPC-ALoriHewitt, CPC-ALoriShinault, CPC-ALucindaJaneWaber, CPC-ALynetteValverde, CPC-ALynnArcher, CPC-ALynnKlim, CPC-ALynnKriedeman, CPC-AMMcGehee, CPC-AMachelleBeckley, CPC-AMadhusmithaGunjate, CPC-AMahendranSelvam, CPC-AMansoorThangal, CPC-AMarandaMerjudio, CPC-AMarcACox, CPC-AMarciaStewart, CPC-AMarcyMote, CPC-AMariaKathlynAcosta, CPC-AMariaLynnSchuster, CPC-AMarianneAmster, CPC-AMarianneKusbit, CPC-AMarianneMoll, CPC-AMarilynBernache, CPC-AMarinSmith, CPC-AMarleenHernandez, CPC-AMaryAnnaWilliford, CPC-AMaryHollingsead, CPC-AMaryJones, CPC-AMaryLThomas, CPC-AMaryLouWojciechowski, CPC-A,CCC

MaryMassey, CPC-AMaryTHathorne, CPC-AMaryWainio, CPC-AMaryannMcMillan, CPC-AMarybethDaley, CPC-AMassielJavier, CPC-AMauraCarty, CPC-AMeenakshiNain, CPC-AMeganKime, CPC-AMeganManning, CPC-AMeghanAllen, CPC-AMelanieDBriggs, CPC-AMelindaCSevert, CPC-AMelindaTrusty, CPC-AMelissaBouchikas,CPC-A, CPC-H-AMelissaLulling, CPC-AMelissaMancini, CPC-AMelonieGibson, CPC-AMichaelDosdos, CPC-AMichaelHarmon, CPC-AMichelleBlackshearHarper, CPC-AMichelleGrist, CPC-AMirianGonzalez, CPC-AMonicaLynnWenzell, CPC-AMorganJones, CPC-AMosesJohnLlamas, CPC-AMrinaliniSekhar, CPC-ANalagondaPriyanka, CPC-ANancyArias, CPC-ANancyQuach, CPC-ANandhiniJayakumar, CPC-ANaveenSelvaraj, CPC-ANicoleWalker, CPC-ANicoleWebb, CPC-ANinetteSantaCruz, CPC-AOndreaMaffeo, CPC-AOrsolyaSimmons, CPC-H-APaigeMcSain, CPC-APamelaBeaver, CPC-A

PamelaKlaus, CPC-APamelaSLong, CPC-APamelaTarpley, CPC-APamelaYap, CPC-APatriciaAlvis, CPC-APatriciaMcAlister, CPC-APatriciaMurrin, CPC-APaulineEllenThalmann, CPC-APavithraRamalingam, CPC-APhyllisJoanneTabanoValencia, CPC-APrabakarMuruganSekar, CPC-APrabhaChandrasekaran, CPC-APrakashShannugamAuthoor, CPC-APrathimaVaddepally, CPC-APremVinothKumar, CPC-APremilaKumarankandath, CPC-APriyaGupta, CPC-APurviShah, CPC-ARachelDOuellette, CPC-ARachelGarena, CPC-ARachellWhite, CPC-ARaghavaDanwada, CPC-ARaghuramanSundhararaju,CPC-A, CPC-H-ARajasekarRajendran, CPC-ARajithaGoli, CPC-ARajniKanth, CPC-ARameshSampath, CPC-ARamonaMerritt, CPC-ARavikiranNagabhushan, CPC-ARebeccaCox, CPC-ARebeccaPascucci, CPC-ARebeccaAnnHolderman, CPC-ARebeccaBarton, CPC-ARebeccaCooper, CPC-ARebeccaPalmer, CPC-ARebekahVoorhis, CPC-AReginaOginski, CPC-AReginaldBrock, CPC-ARegineDelus, CPC-ARenaPLening, CPC-AReneeDiaz, CPC-ARevathiE, CPC-ARhondaBlankingship, CPC-ARhondaJaneHanna, CPC-ARobertMaars, CPC-ARobertNeklesa, CPC-ARobertPezzillo, CPC-ARobertSimonds, CPC-ARobertaAJackson, CPC-ARonaPerez, CPC-ARonelleBones, CPC-ARoopaNarayanan, CPC-ARuthCase, CPC-ARuthJames, CPC-ASabineParmley, CPC-ASallyValdez, CPC-ASamanthaMesser, CPC-ASamanthaBlattner, CPC-ASandeepKumar, CPC-ASandhyaRaghavan, CPC-ASandySteele, CPC-ASarahDonaldson, CPC-ASarahHollier, CPC-ASarahMcCauley, CPC-ASarahMoody, CPC-ASarahWardCoudon, CPC-ASargunarajRaja, CPC-ASasipriyaMadhav, CPC-ASatheeshKumar, CPC-ASattieJugmohan, CPC-AScottKreutzer, CPC-AShamanthkumarMandava, CPC-AShandiAnnMcCutcheon, CPC-AShanmugavadivelVirudhagiri, CPC-AShannonKropp, CPC-AShannonToenyan, CPC-ASharaFranklin, CPC-AShareenJalaludin, CPC-ASharleneSorenson, CPC-ASharonMaureenStovall, CPC-A

ShellyFigg, CPC-ASherKosage, CPC-ASherrySawyers, CPC-H-ASherryannSinanan-Ali, CPC-AShinyAnand, CPC-AShirleeAnnKakaruk, CPC-AShrimathiRaghupathy, CPC-AShwetaTaneja, CPC-ASimoneMathers, CPC-ASintoriaJohnson, CPC-ASkyBoggs, CPC-ASoniaIthierHopkins, CPC-ASovenaHomer, CPC-ASreekanthReddy, CPC-ASriBhanuTejaswiThummoju, CPC-ASrinathDachepalli, CPC-ASrinivasanVijayan, CPC-AStaceyMorache, CPC-AStaciKuhnhenn, CPC-AStacieHylaFriedman, CPC-AStacyBurney-Jones, CPC-AStephanieAnnHoneycutt, CPC-AStephanieJoWeiner, CPC-AStephanieMcPherson, CPC-AStephenS, CPC-AStevenGraessle, CPC-ASubhaRamachandran, CPC-ASueSansoucy, CPC-ASuganthiRaju, CPC-ASujaChandrapaul, CPC-ASulochanadeviSundararajah, CPC-ASumanPatra, CPC-ASupriyaHarishchandraBhandakkar, CPC-ASureshBabu, CPC-ASusanGosselin, CPC-ASusanRedmond, CPC-H-ASuvegaSelvaraj, CPC-ASuzanneGreeneLenske, CPC-ASuzanneMMatz, CPC-H-ASwathiGoudKurra, CPC-ATabathaJKOsteen, CPC-ATabithaFoxx, CPC-ATamaraJaneSutton, CPC-ATaniaCuevas, CPC-ATashaLetreaseBryant, CPC-ATellaboinaSatyabhaskar, CPC-ATenaHillWynne, CPC-ATeresaAHawken, CPC-ATeresaLyon, CPC-ATereseMastrofrancesco, CPC-ATerriPeebles, CPC-ATiffaniDahl, CPC-ATiffanyMiklas, CPC-ATiffanyFValery, CPC-ATimVarghese, CPC-ATinaSchweitzer, CPC-ATinaMiller, CPC-ATonyVakkachan, CPC-AToraArleneKnowles, CPC-ATraceyDeniseHolzbog, CPC-ATriciaCarter, CPC-ATroilineFrezzell, CPC-AUniaPatterson, CPC-AValerieOrtiz, CPC-AValorieAnnHoffmaster, CPC-AVeneceRMartin, CPC-AVenkataRakeshChakravarthy,CPC-A, CPC-H-AVickiDoherty, CPC-AVictoriaSlavik, CPC-AVijayadeepaPandiyan, CPC-AVipinCheriyamoothore, CPC-AVishnuSharma, CPC-AWendyGonzalez, CPC-AYutianGalloway, CPC-AYvonneRosenzweig, CPC-AZakFederer, CPC-AZelenneIEsteves, CPC-A


Newly Credentialed Members

SpecialtiesAliciaAjonFlynn,CPC, CGSCAmandaBanksNelson,CPC-A, CRHCAmyJoanneCoffee,CPC, CPMAAmyMichelleBenton,CPC-A, CPCO,CPMAAngelaMWilson,CPC, CENTCAngelaScott,CPC, CPMAAnnetteFayRawlins,CPC, CCCAshleyDMiller,CPC, CHONCBarbaraStruve,CPC, CEDCBethEveSchleeper,CPC,CPCO, CEMCBobbiJeanetteMartin,CPC-H, CPMABrendaLeaParker,CPC, CPC-P,CPMABrookeThao,CPC, CEDCCandissAGrannis,CPC-H, CIRCCCarolynAGriffiths,CPC, CHONCCassandraAllison, CPMACathyERoberge,CPC, CPPMCathySJennings,CPC, CEDC,CHONCCharlesBHarveyJr,BSN,RN, CPC,CPMAChristineMSchaefer,CPC, CEMC,COBGCClarenceMiltonStewart,CPC, CSFACColetteMink,CPC, CPMAConnieMoering,CPC, CPEDCCourtneyPolito,CPC,CPMA, COBGCCristinaMNicoara,CPC, CPMA,CEMCCrystalMayer,CPC, CPMACynthiaA.James, CRHCCynthiaAnneOwens-Muller,CPC, CPMACynthiaSTucker,CPC,CPMA, COSCDarlaJeanellMorrison,CPC-A, CRHCDavidCarr,CPC-A, CPCODeborahKubida,CPC, COBGCDeidreJandeska, CCCDenaFerranteWilcox,CPC,CCC, CEMCDeniseDula,CPC, COSCDianaMMorehead,CPC, CEMCDiannaSchrimsher,CPC, CHONC

DonnaBeaulieu,CPC, CPMA,CPC-I,CEDCDonnaKayRing,CPC,CPMA, CEMCEdwardJohnson, CPCOEleinysPupo,CPC, CPMAElizabethAnnCook,CPC, CASCCElizabethApicella,CPC, COSCElizabethFrias,CPC, CPMAErinTerrones, CFPCFionaBLange,CPC, CPPMGailActon,CPC, CPMA,CEMCGailVogt-McGeehan, CIRCCGigiGeorginaPrice, CHONCGloriaBroganPh.DACS-AN,CPC, CPMAHeatherReneeSmith,CPC, CPMAHelenMarieGerdes,CPC, CCCHollyBrown,CPC,CPC-H, CEMCJadeHarden,CPC, CEDCJamesThomasCarter,CPC, CPMAJanTurley,CPC, CPMAJenniferWestfall,CPC, CPMA,CGSCJenniferYoung,CPC, CPCOJillDConley,CPC, CEMCJoAnneMWolf,RHIT,CPC, CEMCJohnitaSmith, CRHCJonathanRobertSanford,CPC,CPC-H, CPPMJulieBrandt, CHONCKarenGuadalupi, CPRCKathleenMKampe,CPC, COSCKathleenMSherbrooke,CPC, CANPCKathrynJKasper,CPC, CPCDKellieDress,CPPM, CPRCKerryBethAtkins,CPC, CPMA,COBGCKimberlyMathews,CPC, CPPMKristaJackson,CPC, CPCO,CPC-PKristinaSLauer,CPC, CHONCLaurieJHartford,CPC, CCC,COBGCLeslieDailey, CGSCLoriAnnGelgutBBA,CPC,CPC-H, CCVTCLoriJLawson,CPC, COBGC

LydiaChitwood,CPC, CCVTCMalgorzataTyszko, CRHCMargaretCoyle,CPC,CPC-H, CHONCMarilynGlidden,CPC, CPMA,CGIC,CGSCMarilynKitchensCecil,CPC, CPMA,CPCD,CPRCMarilynLKoerner,CPC, CHONCMaryBort,CPC, CANPC,COSCMaryBuike,CPC, CEMCMaryGore,CPC, COBGCMaryRikley,CPC, CPMAMauraMacri, CPPMMelanieCooper,CPC, CEMCMelanieLewis,CPC, CPMA,CPC-I,CEMCMichaelLeeTaylor,CPC, CPMANancyFlowers,CPC, CPMANancyLHenry,CPC, CPPMNancyLoveWeith,CPC, CCVTCNaomiAHinton,CPC, CPMANicoleMarieClatterbuck, CRHCNikkiStrang, CANPCPeterWeiser, CRHCPhilipGBrown,CPC, CPMA,CASCCRachelElaineBriggs,CPC, CPMA,CEMCRobinErinnBay,CPC-A, CPMARobinSzuchman, CPCDRodolfoPBangilan,CPC,CPC-H, CASCCRuthKerekes, CIRCCRuthAnnCHansen,CPC, CPMASabrinaRLeichtman,CPC, CENTCSandraGamboa,CPC, CPMASandraEbersole, CHONCSandyColson,CPC,CPC-H, CPMASebrenaAtencio,CPC, CEDCShawnDunn,CPC, CPMAShawnMarieMuench,CPC, CANPCSheenaLunsmann,CPC, COBGCStaceyLynnWilson,CPC, COSCSunnyTriana,CPC-A, CPMATanikaJennings,CPC, CHONC

TanyaBaker,CPC, CPMATaraK.Johnson,CPC, CANPC,CGICTashaTodd,CPC, CANPCTeresaMBerry,CPC, CIRCCTerriBrown,CPC, CGSCThelmaMaeBishoff,CPC, CPMATiffanyBobbitt,CPC-A, CPEDCTiffanyNicoleTaylor,CPC, CPMATinaLouiseDaley,CPC, CCCTracyAliseSarver,CPC, CEMCTracyLeeRada,CPC, CPMA,CEMC,COSCTristaLJohnson,CPC, COSCVandnaChaudhary, CRHCWindyBaughman, CANPC

Magna Cum LaudeAleidaSPadron, CPCAllegraWheeler, CPCAmandaBriggs, CPCAniladivAcuna, CPC-AAnisiaLTorres, CPCAnnForrister, CPCAnnFullerton, CPC-AAnnaWade, CPC-AAvaniHart, CPC-ABrigetteBurton, CPCCharlottePerrone, CPC-AChitraLakshmanan, CPCChristineSchmotzer,CPC,CPC-H, CPMA,CEMCDaleSmith, CPCDarleanYankovich, CPCDeniseGLopez, CPCDianaDavid, CPC-ADianaLHutchings, CPC-ADoloresZaldivar, CPCEileenCamillone, CPCEileenO’CarrollMcCully, CPC-AEmilioSanchez, CPC-A

EvelynMedina, CPCFreddyMercado, CPCGaganTKadahalli, CPC-AGenovevaCPrieto, CPCGiselaMiller, CPCHeidiBeggan, CPCHeidyVilliers, CPCJoeJoseMoreno, CPCJohannaMarieNovoa, CPCJuliaMSerrano, CPC-AKerryLFulks, CPC,CEDCKomalMeisuria, CPCKristinJacobs, CPCMaritzaIsabelVazquezLopez, CPCMaryDeano, CPC-AMirellaPlaton, CPC-AMonicaPersaud, CPC-ANormaRRomero, CPCOdalysRodriguez, CPCRafaelaGallo, CPCRichardCampbell, CPC-ARonnaAPate, CPCRosalinaCespedes, CPCShahinaJaffer, CPCShariBrauch, CPCSylviaCram, CPC-AThomasAllenBrown, CPCTinaLPelton, CPC,CPC-HToniaHaralson, CPC-AVanmathiSivaraman, CPCWilliamFiala, CPCWilmienizaYamsonSale, CPC-AYeimaPerez, CPCYonaicrisdelasMariaPlasencia, CPC-AYuanlingBNuez, CPC

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*Entire office can attend from Jan. 1, 2013 through Dec. 31, 2013

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ADoctor’sProspective• SpecializedSurgicalChartAuditing

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andDataAnalytics• CreateSimpleandEffectiveFinancialDashboard

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62 AAPCCuttingEdge

■ Minute with a Member


Holly Brown, CPC, CPC-H, CEMCQuality Gatekeeper, Jacksonville, Fla.

Tell us a little bit about your career—how you got into coding, what you’ve done during your coding career, what you’re doing now, etc. I began working in the health care industry in 1999 as an insurance company’s custom-er service representative, speaking to mem-bers and answering health benefit questions. After a year, I was transferred to the provider line and spoke with physician offices regard-ing 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 sur-gical technician program classes at a local col-lege and, upon finishing the course, began an internship at a local hospital.During the job search as a surgical tech, I re-alized I didn’t enjoy the clinical side of health care; what I really enjoy is constantly learn-ing and keeping up with guidelines and regu-lations—the back office side of the industry. I even turned down a surgical tech position to

accept a position in a cardiology office, where I worked the front desk and did patient sched-uling for three years. I then moved to the bill-ing department, entering office charges and scrubbing billed codes. That’s 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 Certi-fied Professional Coder® (CPC®) exam on the first try. In 2010, I began working for a third-party 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.

What is your involvement with your local AAPC chapter?I am president of the Orange Park, Fla. chap-ter, 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 year—a huge ac-complishment! The wonderful people in the chapter have received so much support from other local chapters in the area.

What AAPC benefits do you like the most?I love networking through AAPC. There are so many avenues for speaking with other pro-fessionals. I enjoy the convenience of the fo-rums. If I have a coding question, I can eas-ily 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. Lo-cal chapter meetings are another great way to meet other professionals and to find jobs and externships for newly certified members. Lo-cal chapters open so many doors.

What has been your biggest challenge as a coder?The biggest challenge for me was finding con-fidence to speak to others about coding. I have always been on the quieter side and I consid-ered my past jobs as work, not a career. Since

I have been involved with AAPC and local chapters, I am more confident in my work, and it shows. I’m 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 de-velopment team that will train all coding and auditing personnel. The education will con-sist of webinars, lectures, and hands-on cod-ing exercises. As we approach the 2014 dead-line, we are ramping up education and prepar-ing everyone for implementation.

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 ed-ucator.

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 en-joy going to the movies and being with fami-ly 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 pass-es 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 span-iel who keeps us busy when we’re home.

You could be here . . .

• ICD-10 Code Set Training Begins in Orlando - Two Complete Tracks

• 26 Specialty Coding Sessions• Six Auditing Sessions• Four Billing Sessions• Three Compliance Sessions• Four Facility Sessions• Six Practice Management Sessions• CPPM Boot Camp available concurrent with this Event

2013 AAPC NATIONAL CONFERENCE Walt Disney World Resort - Florida

Learn more and register at:

www.aapc.com/orlando2013

NAMAS’ CPMA® Training will be offered as a pre-conference event at the AAPC National Conference

April 11-12, 2013

Two day Live training event for CPMA® examination prep

16 CPMA® /CPC® CEUs

Convenience of same session testing on April 13, 2013

Special Conference Pricing—$695

www.NAMAS-auditing.com 877-418-5564

Join NAMAS at the AAPC Conference April 2013 in Orlando, FL

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