MBJThe Medical Business Journal

OCTOBER 2013, ISSUE 9, VOLUME 4

Highlights

Exclusive Course Discounts

Student of the Month

MMI Checkup for ICD-10

McDonough Live Event

Spotlight on Modifier 24

Customer Appreciation Day

PPACA: Choosing the Right Qualified Health Plan

Why Get Certified?

October Crossword

Brought to you by The Medical Management Institute

mmiclasses.com • 866.892.2765

Monthly Newsletter for the Informed Healthcare Professional

mmi•updates

MMI News Updates

CMS News Updates

12 CEUs: Anatomy & Terminology

Registered Medical Biller Certification

Spotlight on Modifier 24

Fall Quarter CEU Bundle

Live McDonough Event

Student of the Month

Online Certification Training

PPACA: Choosing the Right Qualified Health Plan

Why Get Certified?

MMI Check-up for ICD-10

p.6 Customer Appreciation Day

October Crossword Puzzle

Customer Appreciation DayMMI would like to show their appreciation for

their loyal members & new customers by celebrating Customer Appreciation Day! MMI will celebrate this day on Wednesday, October 16th...and you’re going to want to save this date. On Customer Appreciation Date, the online ICD-10 certification programs will be 40% off...that’s a savings of up to $700! This promotion will be available for the coder, manager, or biller path, and will also include all

of the necessary study materials (ICD-10-CM Draft Set & AHIMA student

workbooks). Don’t miss out on this one day sale- SAVE THE DATE!

For more details on the training and enrollment

p r o c e s s v i s i t h t t p : / /www.mmi-classes.com/b l o g s / m m i / 9 4 7 3 4 0 1 -customer-appreciation-day-october-16-2013.

New Monthly FeaturesThe MBJ has introduced a f e w n e w m o n t h l y

features in the last few issue. We have introduced

“Modifier of the Month”, where we have reviewed

Modifier 25 & 26 (24 this month) and we have introduced

MMI Check-up for ICD-10, where we provide coding exercises and

scenarios so that you can verify your progress in understanding and coding ICD-10. This month we would like to introduce Student of the Month! Would you like to be considered for this new feature? Let us know! Email info@mmiclasses.com.

Fall Quarter CEU Bundle: Pre-Order for 50% off!This quarter bundle will be worth 12 CEUs and will cover topics including RAC audits, base-line audits, compliant i n c i d e n t - t o b i l l i n g , c h a n g e s i n healthcare, and more. This bundle is expected to be available mid-month, however pre-order online for a 50% discount! Visit mmi-classes.com/products/fall-2013. Be sure to enter the Facebook drawing for a chance to win the bundle! Visit mmiclasses.com/mmifan.

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

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

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cms•updates

September 30, 2013 - On January 31, 2013, the Centers for Medicare & Medicaid Services (CMS) announced the health care organizations selected to participate in the Bundled Payments for Care Improvement initiative, an innovative new payment model. Under the Bundled Payments for Care Improvement initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality, more coordinated care at a lower cost to Medicare.

September 25, 2013 - In recognition of Hispanic Heritage Month, Health and H u m a n S e r v i c e s ( H H S ) Secretary Kathleen Sebelius today acknowledged more than 20 Hispanic organizations and businesses that have volunteered to help uninsured Americans get coverage through the Heal th I n s u r a n c e M a r k e t p l a c e . T h e s e Champions for Coverage will help Latinos, as well as other racial and ethnic minorities, increase access to quality, affordable health coverage, invest in prevention and wellness, and give individuals and families more control over their care.

September 19, 2013 - More beneficiaries are choosing higher quality Medicare Advantage (MA) plans, and for the fourth straight year enrollment is projected to increase, Health and Human Services (HHS) Secretary Kathleen Sebelius announced.  The average MA premium in 2014 is projected to increase by only $1.64 from last year, coming to $32.60. Access to the Medicare Advantage program will remain strong, with 99.1 percent of beneficiaries having access to a plan.  The average number of plan choices will remain about the same in 2014 and access to supplemental benefits remains stable. Since passage of the Affordable Care Act, average MA premiums are down by 9.8 percent.

September 18, 2013 - Beginning October 1, 2013, consumers can begin applying for health insurance coverage in the Health Insurance Marketplaces.  When consumers fill out their Marketplace application, they can trust that the information they’re providing is protected by stringent security standards and that the

technology underlying the application process has been tested and is secure.

The Department of Health and Human Services’ (HHS) and the

C e n t e r s f o r M e d i c a r e & Medicaid Services’ (CMS)

program integrity efforts to prevent, protect against, and prosecute fraud in the health insurance Market-place, using tried and tested methods used in o t h e r p r o g r a m s , i n -cluding Medicare, gov-ernment grants, mort-gages, Medicaid, and

CHIP. These efforts are focused on designing the

front end to protect con-sumers’ personally identifiable

information (PII) and prevent bad actors from taking advantage of

consumers seeking to enroll in the Marketplaces, as well as ensuring on the

back end that CMS and other parts of the Federal government and states are ready to take action against any entity that engages in fraudulent activities.

September 18, 2013 - On September 18, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would establish methodology and payment rates for a prospective payment system (PPS) for Federally Qualified Health Center (FQHC) services under Medicare Part B. The Affordable Care Act directed CMS to develop a PPS for Medicare payments to FQHCs beginning on October 1, 2014.

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

B U N D L E D P A Y M E N T S F O R C A R E I M P R O V E M E N T I N I T I A T I V E

S E C U R I N G T H E H E A L T H I N S U R A N C E M A R K E T P L A C E

Resource: www.cms.gov

N E W P P S F O R F E D E R A L L Y -Q U A L I F I E D H E A L T H C E N T E R S

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H I S P A N I C H E R I T A G E M O N T H

M O R E , H I G H E R Q U A L I T Y O P T I O N S F O R S E N I O R S I N M E D I C A R E

Coding Exercises

Code the following conditions according to ICD-10 coding conventions and guidelines:1. Scabies2. Fatty liver, non alcoholic3. Intestinal infection due to C-diff 4. Inflammatory polyps of colon5. Thrombosis of Hemorrhoids6. Strep throat, streptococcal pharyngitis7. Legionnaires’ disease8. Patient with Chronic viral hepatitis needing

antiviral treatment( Hepatitis B)

Coding Scenario

Code the following scenario according to ICD-10 coding conventions and guidelines:

9. Robert, a 45-year-old established patient, is seen in the office after he experienced shortness of breath while burning fall leaves. The symptoms occurred after raking and burning leaves for several hours. Robert experienced no problems during raking only when he started burning the leaves. The heart examination reveals no abnormal findings. Sounds of wheezing in both lungs are found on examination. Robert reports no history of heart or lung issues. The visit included an Expanded Problem-focused history and exam, with straightforward medical decision making. The shortness of breath was the only issue discussed. A prescription is issued as treatment. The visit lasted 20 minutes. A diagnosis of upper respiratory inflammation due to inhalation of smoke fumes is made. 

October’s MMI 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 signed up for our ICD-10 curriculum and received a manual, do so today. You can also order just the manual through our web site.

ICD-10 Exercises & Scenarios | Monthly Feature

Answers:

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 E4

1. B86 Scabies, Sarcoptic itch2. K74.69 Other cirrhosis of liver3. A04.7 Enterocolitis due to Clostridium difficile4. K51.4 Inflammatory polyps of colon5. I84.0 Thrombosed hemorrhoids6. J02.0 Streptococcal pharyngitis, Septic pharyngitis,

Streptococcal sore throat7. Legionnaires’ disease8. Hepatitis, viral, virus, chronic, type B9. This evaluation and management (E/M) service may

be reported with an established patient office or other outpatient E/M code based on the key components of history, physical examination, and medical decision-making, The typical face-to-face encounter time assigned to code 99213 is 15 minutes, and the Severity of the Presenting Problem is self-limited or minor. The Medical Decision Making is straightforward. Therefore, a level 99213 is the correct code to report. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes reported should be 506.2, upper respiratory inflammation due to fumes or vapors; E016.0, Digging, shoveling and raking; and  E000.8,other external cause status (Leisure activity). When reporting in International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), use codes T59.811A, initial encounter for Toxic effect of smokeSmoke inhalation; J68.2 - Upper respiratory inflammation due to chemicals, gases, fumes and vapors, not elsewhere classified; X03.1XXA- Exposure to smoke in controlled fire, not in building or structure, initial encounter; Y92.007 Garden or yard of unspecified non-institutional (private) residence as the place of occurrence of the external cause ; Y99.8 Other external cause status(leisure activity) and Y93.H1 Activity, digging, shoveling and raking.

Student of the MonthMaya Kline, RMC, RMM & Member Since 2005

MMI will be interviewing a member each month for a new feature in the MBJ called ‘Student of the Month’! To introduce this monthly segment we would like to put the spotlight on Maya Kline, RMC, RMM and MMI member since 2005!

MMI: Something we hear a lot as student service representatives is, “I have the education and certification, but I can’t seem to land a coding job.” How did you first begin your career in the medical field; specifically medical coding?

MK: I was working as a clinical nurse in a small medical office, and as the practice grew I was just assimilated into the coding world. It was a natural transition from clinic to coding, and my medical background is helpful to me everyday.

MMI: Where do you currently work, and what is your position?

MK: Idaho Urologic Institute/Surgery Center of Idaho as the Director of Business Services.

MMI: What credentials do you currently hold?

MK: LPN, RMC, RMM

MMI: What made you choose the Registered Medical Coder (RMC) certification through the Medical Management Institute and how has it played a part in your career/education?

MK: I chose RMC because it was important to both myself and my employers that I have the highest credentialing possible, including Medicare knowledge.

MMI: In your opinion, what makes the RMC stand out among other coding credentials?

MK: Retesting every year validates that my education is keeping up with the current coding guidelines.

MMI: As you know, the ICD-10 implementation date is slowly creeping up...how do you feel about this major transition, and do you feel prepared?

MK: I am still skeptical that it will happen on the current timeline, but we are on EHR and I am working closely with our software vendor and clearinghouse to start testing as soon as possible.

MMI:: When you aren’t working, what do you like to do in your free time?

MK: I enjoy gardening and spending time with my family.

Would you like to be considered for a Student of the Month feature? Let us know! Email Carleigh

Benscoter at c.benscoter@mmiclasses.com, or call 866-892-2765 x 240.

Maya at work at the Idaho Urologic Institute/Surgery Center of Idaho Maya enjoying her free time

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Still waiting to begin training for ICD-10? Don’t wait any longer- MMI is offering the ICD-10 full certification training paths for coders, billers, and/or managers at a 40% discount!

Customer Appreciation Day is a one day only sale on October 16, 2013. Can not be combined with any other offers/promotions/discounts. Email info@mmiclasses.com with any questions, or call 866-892-2765.

40% OFF ICD-10Purchase the coder, manager,

or biller online ICD-10 training at a 40% discount (savings of up to $700)!

Books IncludedThe required study

materials (ICD-10-CM Draft Set & AHIMA student

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One Day Only! Customer Appreciation Day

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Live Event ICD-10: Survive & Thrive in 2014 RSVP BY 10/19

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The Affordable Care Act (ACA) requires many changes in the health insurance plans offered to consumers. The ACA established four qualified plans that can be sold on the public marketplace (formerly called exchange) and off the public marketplace beginning with effective dates of January 1, 2014 and beyond. The plans are called “metal levels” and are based on the actuarial value of the plan. The ACA creates regions or zones within each state, and those zones will affect the plans on and off the public marketplace and will affect the provider networks for each plan offered. The ACA creates an initial open enrollment period for individual/family plans. Consumers need to check more than just the cost when making this decision.

What are the qualified health plans (QHPs)? First, the plans must include all ten Essential Health Benefits (EHB’s), cover wellness benefits appropriate for age at no cost to the consumer, have out of pocket maximums for the individual and family no greater than the H.S.A out of pocket maximums, have no annual or lifetime maximums on the ten EHB’s, and they must meet an “actuarial” value. These ACA Qualified Health Plans (QHP’s) will offer much more coverage for patients, but still may have more out of pocket costs to the average consumer than plans that are sold now.

Marketplaces Public Exchanges, or Marketplaces as they are now called, are not new. One fact in reviewing these existing marketplaces is that marketplaces which limited the number of plans offered were more successful than those which offered many different options. The ACA called for four

different plans named for medals – bronze, silver, gold, platinum... and they added catastrophic. The qualified plans are based on the actuarial values of the benefits provided. The insurance company must pay on average 60% of the actuarial value of the claims for a bronze plan, 70% for silver, 80% for gold and 90% for platinum. The catastrophic plan is only available to those under the age of 30 and consumers over age 30 who qualify due to hardship. By limiting the qualified plans offered on the marketplaces, the ACA hopes to make comparison of plans between companies easier for the consumer. The ACA calls for no more than a 2% variance higher or lower in the actuarial value – so , for example, a Bronze plan cannot cover less than 58% or more than 62%. This makes calculating the value of the plan very tricky, and the government has established a calculator for insurance companies to use to verify their plans are in compliance with the ACA law.

Even though the plans offered will have the same actuarial values between insurance companies, the plans offered by

Essential Health Benefits

1. Ambulatory patient services (outpatient care you get without being admitted to a hospital)

2. Emergency services

3. Hospitalization (such as surgery)

4. Maternity and newborn care (care before and after your baby is born)

5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)

6. Prescription drugs

7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services including dental and vision to age 18

Choosing the Right Qualified Health PlanPatient Protection & Affordable Care Act | Janet Salyer

Essential Health Benefits: Emergency Services

different companies will still vary greatly. Plans will offer more coverage, but not necessarily coverage the majority of consumers will use. New Qualified Health Plans (QHP’s) may NOT have copays for specialists, emergency rooms, or brand name drugs as plans do today – thereby creating more out of pocket for the consumer. Instead, these costs will be paid by the consumers at network pricing until the deductible is met. Plans may have aggregate family deductibles. An aggregate deductible means that the entire family deductible must be met before any family members claims are paid by the insurance company. For example, if a plan has a $5,000 individual and $10,000 family deductible, and one family member needs surgery, the entire $10,000 deductible must be met before the insurance company pays anything towards the claim. Qualified Health Plan members will receive the network discounts until the deductible is met. Most family plans today have embedded deductibles – one where the family member meets the $5000 deductible and the insurance company starts paying on the member’s claims. The aggregate deductible can make a huge difference to consumers. New QHP’s may have multiple tiers for providers – making the costs different if you use a non-preferred doctor, or facility, or hospital, or pharmacy. Consumers need to pay attention to limitations on copays, additional deductibles, what benefits apply to the deductible first and to the provider network and prescription formulary.

Insurance CompaniesInsurance companies are creating new networks and options within their plan networks. People need to consider the network as much as the price when choosing an insurance plan. While employer groups may be able to change their coverage during the year, individual/family plan changes will not be allowed to change coverage once open enrollment ends on March 31, 2014. After that initial open enrollment period, individual/family plans (or non-group plans) will be able to make changes only during the annual open enrollment period between October 15 and December 7 each year for an effective date of January 1.

What are some of the changes within the insurance networks? You’ l l see more Health Maintenance Organizations (HMO) which do NOT have any out-of-network benefits. Some may continue to be open access plans that do not require referrals to see a specialist. Most HMO plans may require the insured to name a primary care provider and require referrals to see specialists. In the past, these primary care doctors have been called “gatekeepers” but the ACA calls these primary care providers care coordinators. The care coordinators will be responsible for the overseeing of the entire care received by the patient. The ACA intends for the use of more primary doctors as care coordinators to lower the cost of healthcare while providing better outcomes for healthcare for the consumers. These HMO organizations and many of the new networks will contract with more than just doctors. They will also contract with hospitals, free standing facilities, and pharmacies. It will be very important that patients with insurance and for doctors’ offices to know which of the new networks their practice participates in and also if they are considered a “high performance” or “preferred” doctor in the network. The copays will vary based on the network and whether or not they are preferred and/or high performance providers. This is true for the new Point of Service (POS) and Preferred Provider Organizations (PPO). Patients and practices need to know the names of the networks. It’s not enough to ask , “Do you take Insurance XYZ?” You should know if the provider is a participating provider or a contracted provider with the specific network.

Consumers Taking Rx Medication Consumers who are taking prescription medication will also want to verify that their prescription is covered by the new Qualified Health Plan they choose. Since the ACA only requires the insurance plans to cover one prescription drug per therapeutic category, the consumer needs to verify the prescription coverage for their existing conditions before deciding on their plan. Many consumers may only look at the bottom line premium pricing, while the factors that can

Essential Health Benefits: Maternity & newborn care (care before and after your baby is born) 9

cause more out of pocket costs such as the formulary for the drug coverage and the in-network providers are not even considered.

Marketplace: Public or Off Insurance companies may choose whether or not to offer QHP’s both through the public marketplace and off marketplace, or to only offer plans off the marketplace. Each state has determined whether or not to set up the state’s own public on-line marketplace or to allow the federal government to establish the public on-line marketplace referred to as federally facilitated marketplace (FFM). Within a public marketplace, consumers can compare plans from all companies that are participating in the public marketplace. The same plans offered by an insurance company both on and off the public marketplace must be identical in benefits and pricing. Insurance companies will continue to have their own private websites or marketplace and to offer coverage directly to consumers—this is referred to as “off” marketplace. Insurance carriers may offer more plans off the marketplace than they offer on the marketplace. Consumers can still purchase insurance directly from an insurance carrier or through an agent or broker as they do today. In fact, many experts recommend continuing to use brokers to help explain the changes in the coverage and the networks that will be available for plans sold after January 1, 2014.

Zones The ACA allows states to set up “zones” or community areas in each state for purpose of determining the community

rating. For example, Georgia has identified 16 zones or groups of counties within the state. The community rating for these zones differs based on claims history and the provider network availability within the zones. Insurance companies may choose in 2014 to participate in the public marketplace in specific zones and not participate in all zones in the state in the public marketplace. So, some counties within a state may have fewer options on the public marketplace than other counties. Only plans purchased on the public marketplace can offer advanced premium tax credits which are available to households whose modified adjusted gross income is 400% or less than the Federal Poverty Level.

Health Insurance will Change DrasticallyHealth insurance will change drastically in 2014. Whether you purchase your coverage on the public exchange, off the exchange, or through your employer, consumers need to pay attention to the details of the plans. Understanding your coverage will help you to get the more from your benefits and have fewer out of pocket costs. A trusted agent or broker can be your best source of information and help in finding the right plan for you as we transition into the new guaranteed issue qualified health plans.

Janet Salyer is a MMI Instructor & Senior Broker at Insurance Planning

Solutions

Insurance Planning SolutionsSpecializing in Individual & Small Group Benefits

“We believe that QUALITY SERVICE to our clients is our highest priority”

We believe each individual, family, employer, and group has their own unique requirements and our job is to find the product, price, and quality plans with coverage that best fits those unique requirements. We believe that honesty, integrity, and professionalism are the foundation for our relationship with our clients.

What we offer: Coverage for small businesses and individuals/families.

Why use a broker? Licensed by the state of Georgia, the brokers must stay current in federal and state laws. They are also appointed by insurance companies, having the ability to compare policies from different companies.

Ready to review your insurance coverage? For free quotes, contact Janet Salyer at 678-880-7098, or email jsalyer@insuranceplanningsolutions.com.

10 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

Whether you are brand new to the medical coding and billing field or are a seasoned vet, having a medical coding and billing certification will set you apart. Certification puts you on path to increased salary and greater success in the field, and it shows your employer (or potential employer) that you are dedicated and relevant in the ever-changing industry. 

Pros for the IndividualHigher salary & continued education

Earning a medical coding and billing credential sets you apart from other non-credentialed co-workers and/or job applicants, positioning you as a self-disciplined leader and educated individual. Gaining a certification is a lasting investment in not only yourself but in your long-term career. A medical coding and billing certification can help: 

• Set you apart when applying for jobs• Provide networking through the credentialing

organization• Keep you relevant and up-to-date in the ever

changing medical field• Increase your job opportunities (especially remote)• Improve your chances of career advancement

Pros for EmployerCredentials & knowledge

Having a staff certified in medical coding and billing demonstrates proficiency and knowledge. Certified professionals must go through comprehensive training to pass the medical coding and billing certification exams, and must commit to this training through continued education. Having a staff certified in medical coding and billing will help: 

• Hold them accountable to minimize errors and abuse charges

• Reduce cost• Increase efficiency• Ensure efficiency and competence level• Promote self-improvement and dedication

Gain your CertificationOnline training & certification options availableThe Medical Management Institute offers online training to prepare you to become a medical coder through the RMC (Registered Medical Coder) or the CPC® (Certified Professional Coder) training programs and a medical biller through the brand new RMB (Registered Medical Biller) training program.  

Why Should You Become Certified?Quick look at the pros for the individual and the employer | Carleigh Benscoter

Online Training

Instructor Support

Self-Paced

Become Certified Today!

Visit mmiclasses.com

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

Modifier 24Modifier 24: Unrelated Evaluation & Management service by the same physic ian during a postoperative period.

Many offices comment on why they are not paid for delivering services to patients during the post-operative period, even though the care given is unrelated to the surgery. It is important to understand when to use modifier 24 and when you should not use modifier 24. This modifier, like modifier 25, has no restriction as with the level of E&M code as long as it meets medical necessity, all its components or are time-based. It can only be used on E&M codes. If you are performing another procedure, consider modifier 79.

This modifier cannot be used on the same day as the procedure. Consider Modifier 25 for this. It must not include care that is considered part of the postoperative package. You will need this modifier if the patient is being seen by another physician in the same practice with the exact same specialty and is still in the global period for the surgeon/physician that performed the procedure.

Post-operative PackageYou have to know what the payer includes in the postoperative package. Normally, any complication from the surgery and it’s treatment is considered part of the surgical package. Treating a surgical wound for infection is part of the surgical package. If you are not in the global period, there are no post-operative package considerations. If you admit a patient to a SNF due to the surgery, it is considered part of the post-operative package.

Coding ScenariosConsider the following scenarios and see if you would use the modifiers correctly:Scenario 1: The patient is 2 weeks post mastectomy (postoperative global period is 90

days) and is in the surgeon’s office for E&M services to begin chemotherapy for the next 4 weeks. Clearly, the patient is still in the post-operative period. There must be clear documentation that shows the visit for starting chemotherapy is not related to the surgical package. The treatment is for the underlying cause of the surgery but is not part of the surgical package.

Explanation: The Society of Gynecological Oncology is very explicit when outlining this scenario. It specifically states that physicians who are managing chemotherapy during the post-operative period of a procedure may bill for the E/M service with modifier 24. Use diagnosis codes that clearly indicate the nature of the visit. ICD-9-C M V 5 8 . 1 - E n c o u n t e r f o r a n t i n e o p l a s t i c chemotherapy and immunotherapy is usually used.

SPOTLIGHT ON MODIFIER 24Modifier of the Month | Monthly Feature

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 E12

Scenario 1 Modification: But let’s change this slightly. Let’s say the patient is just counseling the patient on the best method of surgical follow-up for chemotherapy, radiation or both. They are not administering chemotherapy at this time. While this is being done by the surgeon, it is still okay to use the Modifier 24 for the E&M. However, a better ICD-9-CM code for this visit might be V65.49 – Other specified counseling.

Explanation: The level of E&M used would be determined by the standard E&M guidelines. If, in the second case, the physician spends 45 minutes face-to-face with the patient and more than 50% of that time is spent counseling the patient on treatment options, then time would be the determining factor on the E&M Level. This would be billed as a 99215-24.

Scenario 1 Continued: To continue this example, what happens if the patient is also concerned about some swelling or pain in the surgical site? This would not be included in the calculations for the E&M levels, as this would be directly related to the surgery and part of the post-operative package.

Scenario 2: Here is another example of the appropriate use of modifier 24. A patient is 2 weeks post-surgery for a surgery on his hand with a global period of 90 days. Today, he is seeing the surgeon and complaining of pain and swelling in his knee. The physician completes the history and exam and decides the best course of treatment is to drain the fluid from the knee while the patient is in the office. Appropriate medications and instruction are provided for treating the knee and the patient will return to the office in a week.

Explanation: Here we have a 99214 E&M level visit, where the decision to perform the Aspiration of the knee joint is made. In addition, the patient is still in the global period from the hand surgery. Since this visit is not related to the surgery, we definitely need modifier 24 and the diagnosis of pain in the knee. But we also performed a procedure today, after a complete E&M, so we need to also include the modifier 25 to indicate that the decision to treat the pain with aspiration was determined during the E&M Service. Finally we will need to a p p e n d M o d i f i e r 7 9 – t o t h e C P T 2 0 6 1 0 -

Arthrocentesis, aspiration and/or injection, major joint or bursa to indicate that this procedure was performed during the 90-day postoperative period for the hand surgery.

Determining the Global PeriodI was recently asked how to determine the post-operative or global period for different surgeries. Without knowing what the global period is for a procedure, you can not appropriately use Modifier 24. The global period for a procedure is specified in the Medicare Physician Fee Schedule. This is available for lookup at: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

You will be able to look up the information for any CPT®, and by selecting ‘show all columns’ and ‘show all modifiers’ from the fee table you will find the GLOBAL period expressed as a number, the number of days, along with all of the other relevant information about a CPT® code such as the supervision requirements or the RVU, etc.Appropriate use of the modifier 24 can boost revenue, but be prepared to appeal denials with this modifier and provide medical records with clear documentation of the unrelated condition.

- Kathy Dyson, MMI Learning Director

SPOTLIGHT ON MODIFIER 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 13

Price: $449 CEUs: 12 (certificate issued upon completion)

Course Highlights: •Completely online•Self-study•Interactive learning tools

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Across5. The percentage we are taking off of our ICD 10 training for Customer Appreciation Day (Wednesday, October 16th)10. The ACA established four qualified plans that can be sold on ___ ___ ___, and was once called the exchange.12. The Fall bundle is worth ____ CEUs and will cover topics including RAC audits, base-line audits, compliant incident-to billing, changes in healthcare, and more.

Down1. Since the passage of the ___ ___ ___, average MA premiums are down by 9.8 percent.2. MMI will provide this for coding each month in the MBJ so that you can verify your progress in understanding and coding ICD-10.3. _____ is the fifth plan of the ACA, which is only available to those under the age of 30 (and also consumers over 30 who qualify due to hardship.)4. The ACA calls these Primary Care Providers _____, they are responsible for overseeing the entire care received by the patient.6. This organization, abbreviated HMO, does NOT have any out-of-network benefits. Some may continue to be open access plans that do not require referrals to see a specialist.7. The average _____ in 2014 is projected to increase by only $1.64 from last year, coming to $32.60.8. Modifier _____ covers Unrelated Evaluation & Management service by the same physician during a postoperative period.9. To make it to the ICD-10: Survive & Thrive in 2014 live event you will have to RSVP by this day in October.11. What are the four individual qualified plans which are based on the actuarial values of the benefits provided through the ACA, named in alphabetical order *hint: medals.

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 15

OCTOBER CROSSWORDWe hope you enjoyed this issue… now test your knowledge!

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 9, Vol 4

Editor in ChiefCarleigh Benscoter

ContributorsKathy Dyson

Janet Salyer

Carleigh Benscoter

Layout & DesignCarleigh Benscoter

W W W . M M I C L A S S E S . C O M

E : I N F O @ M M I C L A S S E S . C O M P H : 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 9, Vol 4]MMI News Updates: http://www.mmi-classes.com/blogs/mmi/9473401-customer-appreciation-day-

october-16-2013, http://www.mmi-classes.com/products/fall-2013, CMS News Updates: http://www.cms.gov, Anatomy & Terminology: http://www.mmi-classes.com/collections/ceu-options/products/anatomy-terminology-in-preparation-for-the-icd-10-transition MMI Checkup for ICD-10: http://www.mmi-

classes.com/collections/2014-medical-coding-books, Customer Appreciation Day: http://www.mmi-classes.com/blogs/mmi/9473401-customer-appreciation-day-october-16-2013Why Get Certified: Ad: http://www.mmi-classes.com/collections/programs