JOURNALThe Medical BusinessThe Monthly Newsletter for the Informed Health Care Professional

Brought to you by the Medical Management Institute | Dec 2013/ Jan 2014 | Issue 1 Volume 5

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Highlights

MMI News Updates

CMS News Updates

Free ICD-10 Lunch & Learn Every Month

Spotlight on Modifier 76

2014 Book Deals

MMI Check-Up for ICD-10

Making Changes at Your Medical Practice

HIPAA Compliance Courses

December/January Crossword Puzzle

mmi•updates

MMI News Updates

CMS News Updates

Free ICD-10 Lunch & Learn Every Month

Spotlight on Modifier 76

2014 Book Deals

MMI Check-Up for ICD-10

Making Changes at Your Medical Practice

HIPAA Compliance Courses

Dec/January Crossword Puzzle

Free Anatomy & Terminology Next WeekAll next week, January 20-24th, the Anatomy &

Terminology course will be free when purchased with any certification training program!

The Anatomy & Terminology course is completely online & self-paced and is worth 12 AAPC & ARHCP approved CEUs (normally priced at $449). This course is a pre-requisite to the RMC, CPC, RMA, & RMB certification training programs. For details on the

time-sensitive promotion visit mmi-classes.com/free-anatomy.

2014 Books Are AvailableStock up on the 2014 coding

books in advance for great savings. The ICD-10-CM Draft Set is $99.95, 3 pack bundle deals (CPT®, ICD-9, HCPCS II) are $279, and 2 pack bundle deals are only $199.

Click here for details on pricing and how to order or call 866-892-2765.

Free ICD-10 Lunch & Learn Every Month!

MMI is very proud to be hosting a free ICD-10 Lunch &

Learn every month for our valued members & a lumna, worth 2

ARHCP/MMI CEUs (pending approval from other organizations). The events will be

presented by Kathy Dyson, the Learning Director for MMI, and she will speak on “ICD-10: Practices in Peril”, give a brief history of ICD-10, the structure of ICD-10 codes, as well as changes you need to know about, the documentation you will need, and how to transition your practice.

For details on locations, dates, and how to RSVP you can visit mmi-classes.com/live-ICD10.

2014 RMC Update Exam is AvailableAttention RMC Members! The 2014 RMC Update Exam is now available. If you have a renewal date coming up THIS year, you will need to take this exam. For the exam, you will need to reference your 2014 coding books (mainly the CPT®) along with the November 2013 MBJ. To sign up visit mmi-classes.com/products/rmc-renewal.

I N S I D E T H I S I S S U E

2 M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E

cms•updates

January 10, 2014 - The final rule addresses several sections of Medicaid law under which states may use federal Medicaid funds to pay for home and community-based services (HCBS). The rule supports enhanced quality in HCBS programs, adds protections for individuals receiving services.  In addition, this rule reflects CMS’ intent to ensure that individuals receiving services and supports through Medicaid’s HCBS programs have full access to the benefits of community living and are able to receive services in the most integrated setting.

January 10, 2014 - The Centers for Medicare & Medicaid Services (CMS) and the state of Maryland jointly announced a new i n i t i a t i v e t o m o d e r n i z e Maryland’s unique all-payer rate-setting system for hospital services aimed at improving patient health and reducing costs. This initiative will replace Maryland’s 36-year-old Medicare waiver to allow the state to adopt new policies that reduce per capita hospital expenditures and improve health outcomes as encouraged by the Affordable Care Act.  Under this model, Medicare is estimated to save at least $330 million over the next five years.

January 6, 2014 -   Prescription drug abuse is a serious and growing problem nationwide. Unfortunately, the Medicare Part D prescription drug program (Part D) is not immune from the abuses associated with this nationwide epidemic.  The Centers for Medicare & Medicaid Services (CMS) takes this problem seriously and is taking steps to protect Medicare beneficiaries and the

Medicare Trust fund from the harm and damaging effects associated with prescription drug abuse. 

December 31, 2013- The Department of Health and Human Services (HHS) announced a

proposed rule, entitled “Administrative Simplification: Certification of

Compliance for Health Plans.” This ru le proposes that

controlling health plans ( C H P s ) m u s t s u b m i t

certain information and documentat ion that d e m o n s t r a t e s compliance with the adopted standards and operating rules for t h r e e e l e c t r o n i c transactions: eligibility for a health plan, health

care claim status, and health care electronic

funds transfers (EFT) and remittance advice. This

proposed rule would also establish penalty fees for a CHP

that fails to comply with the certification of compliance requirements.

December 30, 2013 -The Centers for Medicare & Medicaid Services (CMS) has awarded over $307 million in performance bonuses to 23 states for improving access to children’s health coverage and successfully enrolling eligible children in Medicaid.

The performance bonuses were authorized under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), one of the first pieces of legislation signed into law by President Obama. This is the fifth and final year of performance bonus awards. 

M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E

C M S C O M B A T M E D I C A R E P A R T D

Direct Resource: www.cms.gov

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Scenario 1

Mike is a 36-year-old patient of Dr. Brice. Mike told Dr. Brice that for the past three days he has been coughing constantly. When he takes a deep breath, slight soreness is felt in his chest. He has also been coughing up some yellow-greenish colored mucus, and has experieinced two days of diarrhea. Dr. Brice checked all vital signs- there is no problem with heart, but he does hear wheezing in the right lung. From his assessment, Dr. Brice prescribes Mike with antibiotics for his acute viral bronchitis and cough. He also goes over some dietary instructions to assist with the diarrhea. The expanded visit included problem focused history, and the examination lasted 20 minutes.

What procedure and diagnoses would you use to code this encounter?

Coding Practice

Code the following diagnoses in ICD-10:

1. Iron-­‐de*iciency  anemia  due  to  poor  diet  2. Smoker’s  Cough3. Meningitis  due  to  ECHO  virus4. Acute  laryngitis  with  airway  obstruction5. Snoring6. Left  elbow  pain7. Irritable  bowel  syndrome  with  diarrhea8. Hernia  with  gangrene9. Migraine  headache10. Stomach  bloating  due  to  gaseous

December/January’sMMI Check-Up for ICD-10

MMI will provide coding exercises and scenarios each month in the MBJ so that you can verify your progress in understanding and coding ICD-10. You will need an ICD-10 manual to complete the

exercise, so if you have not already, sign up for our ICD-10 curriculum. MMI’s ICD-10 Check-Ups are posted on the MMI Blog as well!

ICD-10 Exercises & Scenarios | Monthly Feature

Answers:

Scenario 1: Procedure: 99213Diagnosis: J21.9 - Acute Bronchiolitis, R05 Cough, R19.7- Diarrhea

Since Mike is already a patient of Dr. Brice, the evaluation and management (E/M) service may be reported with an established patient or other outpatient E/M code, remembering 2 or 3 of the key components must be met: history, physical examination, and medical decision-making. Dr. Brice’s assessment of Mike is of low to moderate severity. The face-to-face encounter is at least 15 minutes. Coding E/M as 99213 would be accurate.For the diagnoses, Mike’s chief complaint was coughing, the phlegm, and diarrhea. For the diagnoses, Dr. Brice determined Mike has acute viral bronchitis along with cough and diarrhea. So all of the diagnoses can be coded as J21.9, R05, R19.7

Coding Practice1. D50.8 - Iron deficiency anemia due to poor diet2. J41.0 - Smoker’s cough3. A87.0 - Echovirus meningitis4. J05.0 - Acute obstructive laryngitis5. R06.83 - Snoring6. M25.522 - Pain in joint - left elbow7. K58.0 - Irritable bowel syndrome with diarrhea8. K46.1 - Unspecified abdominal hernia with

gangrene9. G43.909 - Migraine, unspecified, not intractable,

without status migrainosus10. R14.0 - Abdominal distensions (gaseous)

5M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E

Each month in the MBJ, we will feature a modifier and discuss the appropriate use. So far we have reviewed Modifiers 24, 25, 26 & 57, so this month we will take a look at Modifier 76. First let’s look at the definition and use.

Modifier 76Modifier 76 is use to report a “repeat procedure or service by the same physician or other qualified health care professional.”

Under certain medically necessary situation, a physician may perform a repeat procedure or service on the same patient, on the same day. The procedure or service was repeated subsequent to the original service performed and can be reported with modifier 76. This modifier indicates to the payer that this is not a duplicate bill charge, but rather, that the same procedure was performed twice. The key point to remember is that both the original and the repeat must be of the exact same CPT code.

Use of Modifier 57The first (original) service should be reported with the usual guidelines. The (repeat) subsequent service(s) should then be reported on the next line appending a 76 modifier to the procedure code. The modifier should not be

reported on Evaluation and Management services (E/M).Example A physician orders an EKG 93000 (routine EKG with at least 12 leads; with interpretation and report). It is performed at 10:00 a.m. It is repeated at 2:00 p.m. Later, the patient's condition requires a third EKG 93000, the same physician orders it and it is repeated at 8:00 p.m.

• This is billed as 93000, one unit (first line) and 93000-76, two units (next line).

It is imperative the patient’s medical records always clearly document the medical necessity of the performing repeat procedures. If a service is repeated more than once, a brief description can be provided in the narrative field of the claim form (box 19 of CMS claim form) to support the medical necessity of the repeat services. Depending on their guidelines, some payers and Medicare carriers may view modifier 76 differently and limit its use to service rendered on same day. Those payers that have restrictions on the reporting of modifier 76 often reimburse at a multiple procedure reduction rate (eg, by 30 or 50 percent) on the subsequent repeat procedure.

• Note: Remember the “need to know basis”: Medical records, notes, or other supporting documentation should not be attached to the claim unless specifically required and/or requested by the Company. Only submit the requested information on the procedure that is being requested.

Appropriate Usage of Modifier 76

• Service  must  be  performed  by  the  same  physician

• May  be  used  on  procedures  or  diagnostic  tests

• On  procedures  that  is  not  quantity  billed• Repeat  procedure  MUST  be  of  same  procedure  code  

• It  is  generally  intended  in  reporting,  when  

SPOTLIGHT ON MODIFIER 76Modifier of the Month | Monthly Feature

6 M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E

appropriate  on:  

‣ Surgical  (10021-­‐69990)‣ Radiological  procedures  (70010-­‐79999)‣ Diagnostic  services  (90281-­‐99199)‣ Home  health  (99500-­‐99607)

When to Not Use Modifier 76

Do  not  use  modi*ier  76  to   report  a  planned  or  anticipated   procedure   or   if   the   procedure   is  ordered  by  a  different  physician  (modi*ier  77)  on  the  same  day.

Let’s put Modifier 76 to use:

Example 1: In the emergency room, the attending physician inserts a chest tube into an injured patient. A chest x-ray is done prior to placement of the chest tube before and after placement to verify the position of the chest tube at the same operative procedure.

• From the above case, along with the insertion of the chest tube, the x-ray can be billed twice for the before and after insertion placement. The codes to report on the claim form are:

‣ Line one: 32551

‣ Line two: 71020-26 Radiologic examination, chest, two views, frontal and lateral

‣ Line three: 71020-76-26 Radiologic examination, chest, two views, frontal and lateral, repeat procedure by same physician

Example 2: A radiation oncologist performs a twice-a-day (BID) Brachytherapy radiation treatment on a cancer patient. The High-dose radiation (HDR) was administered two fractions per day, for 5 days for a total 10 treatments. The first dose to the primary tumor was delivered on Monday- once at 8:15am and then again at 3:15pm, following the same delivering dose schedule for the rest of the next 4 days.

• From this case scenario, the biller can bill both treatments (am/pm) per day for 5 days of radiation treatment:

‣ Monday: Line one: 77785 x 1 unit, Line two: 77785-76 x 1 unit

‣ Tuesday: Line one: 77785 x 1 unit, Line two: 77785-76 x 1 unit

‣ Wednesday: Line one: 77785 x 1 unit, Line two: 77785-76 x 1 unit

‣ Thursday: Line one: 77785 x 1 unit, Line two: 77785-76 x 1 unit

‣ Friday: Line one: 77785 x 1 unit, Line two: 77785-76 x 1 unit

• From the example above, treatment was done AM and PM. A narrative can be placed in box 19 of the claim form to indicate “CPT 77785 rendered in AM and PM treatment” to let the payers know that this procedure was done twice on the same day.

By knowing your top payer guidelines and the appropriate use of modifiers, you will maximize reimbursement payments for your practice. We will cover modifier 77 (repeat procedure, different physician) in next month’s MBJ.

SPOTLIGHT ON MODIFIER 76

M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E 7

In the coming year, physicians and managers can anticipate even tighter reigns on future reimbursement, and may realize they will be expected to accomplish more with fewer resources. One of the things they can do is streamline their operational processes — however, that means change, which is not always welcomed.

There are many people who don't like dealing with change.  It encroaches on the way they do things and brings uncertainty — not knowing if the outcome will  really make things better for them. The truth is, without everyone's cooperation in your practice, change results can be compromised. Here are a few steps you can take to avoid "unwitting or calculated sabotage" as you navigate your way through operational changes at your practice.

1. Think strategicallyAnalyze the reason change is necessary. What is happening internally or externally that requires the change? What will happen if you don't make

change? Just as importantly, it is essential to determine how your practice and the people in it will be affected by the change, and how they will deal with potential barriers that might threaten results. Beyond this, agree on your ultimate objective and decide how you will measure results. These are important strategic elements for monitoring progress and ensuring that the appropriate level of accountability exists.

2. Examine the barriers to changeAnalyze everyone's needs and understand their p e r c e p t i o n s . A f t e r a l l , s t a f f w i l l b e asking  "WIIFM:  What's in it for me?"  It's management's job to paint a picture of hope and improvement. The barriers begin with and are fueled by fear — fear of the unknown and fear that the results will not be good, in fact fear that (in the end) things might actually be worse. People feel a loss of control when faced with change; worry that they will not be heard; and concern that change will make their work more difficult to accomplish.

Making Changes at Your Medical Practice, Overcoming Resistance

By Judy Capko, pulled from PhysicianPractice.com

M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E 218

3. Find a championCreating enthusiasm for change and getting everyone on board is no small task. Your best way to accomplish this is to identify the person inside your practice who is most appropriate to "lead the charge" for change — to be your champion for this cause.

There are a few key requirements: First of all, this person must feel passionate about the changes you plan to implement and be willing to be a key player in guiding the change process. This individual will be instrumental to your success and needs to be someone that will be closely affected by the change. For example, if you are going to centralize scheduling and it requires all the physicians to agree, then seek the physician who is the mostly likely to have a vision for how he will benefit from the change — improved access for patients, fewer missed appointments, fewer complaints, and getting out of the office on time each night.

Your champion, guided by management's skill and talent, will need to sell the vision to everyone involved in the change process. When changes result in success for your champion, the other physicians will feel more confident and will come on board.

4. Introduce and manage change wellApproaching change and getting acceptance not only requires overcoming barriers, but also managing cultural and political challenges within the practice team.   Management must meet individually with staff that are most vocal about sabotaging efforts to implement operational changes. Open the doors of communication and discuss perceived resistance and issues that concern each of them. It may require some real negotiating finesse to overcome these hurdles, but without doing so, you can expect problems with introducing and managing change. It should to be a two-way dialogue, so that you have a clear understanding of how they feel and they understand what you expect of them.

When you are ready to implement change, call an orientation meeting. Prepare for the meeting with a plan that sells your vision. You want everyone to hear the message the same way, at the same time. Remember the grapevine has no mercy and can be easily misinterpreted or

distorted. Also, communicate what kind of training and support staff will receive during the process. In the end it's making everyone feeling valued and reassured that their feedback will be heard.

Change is not about personal gain, it's about gain for the entire practice. Keep everyone focused on this, celebrate steps of progress along the way and show appreciation for a job well done.

To read the original article you can visit http://bit.ly/19xBDS5.

Judy Capko is the founder of Capko & Morgan, a healthcare consulting firm. She is located in Thousand Oaks, Calif. Judy is the author of "Secrets of the Best-Run Practices," "Take Back Time," and coauthor of "The Patient-Centered Payoff." Capko is a national healthcare speaker may reached at judy@capko.com.

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For details visit mmi-classes.com/online-hipaa

24 M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E

MMI 2014 Book Bundle DealsRange from $99-$279

>>Check out 2014 Book Deals

Across

1. How many HIPAA training options does MMI offer?

2. CMS & this state announced a new initiative to modernize their unique all-payer rate-setting system for hospital services aimed at improving patient health and reducing costs.

3. Where will the free ICD-10 Lunch & Learn be held on February 21, 2014?

4. R06.83 is the ICD-10 code for what diagnoses?

Down

1. What does CHP stand for?2. Which 2013 issue of the

MBJ will you need to reference for the 2014 RMC Update Exam?

3. Who will host the free ICD-10 Lunch & Learn each month through MMI?

4. Modifier 76 is used to report a repeat procedure or service by ____ _______ or other qualified health care professional.

DECEMBER/JANUARY CROSSWORDWe hope you enjoyed this issue… now test your knowledge!

M B J B Y T H E M E D I C A L M A N A G E M E N T I N S T I T U T E 11

The Medical Business Journal is a monthly source of up-to-date information on all issues affecting the healthcare industry. Its content ranges from medical coding and billing to healthcare reform legislature and beyond. The MBJ is not affiliated in any way with the Department of Health and Human Services, Medicare, or the Centers for Medicare and Medicaid Services. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional services, and is not a substitute for individualized expert assistance. The CPT® codes, descriptors, and modifiers are copyrighted by the American Medical Association. For more information, please call MMI at 866-892-2765.

October, Issue 1, Vol 5

Editor in ChiefCarleigh Benscoter

ContributorsKathy Dyson

Loan Tran

Carleigh Benscoter

Layout & DesignCarleigh Benscoter

W W W . M M I C L A S S E S . C O M • 8 6 6 - 8 9 2 - 2 7 6 5

T H E M E D I C A L B U S I N E S S J O U R N A L B R O U G H T T O Y O U B Y

T H E M E D I C A L M A N A G E M E N T I N S T I T U T E

Link List [Issue 1, Vol 5]2014 Books: http://www.mmi-classes.com/blogs/mmi/9948897-day-of-thanks-on-november-19th-save-the-date, 2014

ICD-10 Official Draft Set: http://www.mmi-classes.com/collections/2014-medical-coding-books/products/2014-icd-10-

draft, ICD-10 Online Certification Training: http://www.mmi-classes.com/pages/icd-10-online-certification-training,

ICD-10 Blog: http://www.mmi-classes.com/blogs/mmi-check-up-for-icd-10, Physician Practice Blog: http://

www.physicianspractice.com/staff/making-changes-your-medical-practice-overcoming-resistance?

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