November 2011 - AAPCstatic.aapc.com/5548A1AF-4C9F-49A2-BFE0-BFA7D2344700/27b... · 2011-10-27 ·...

Plus: E/M Outliers • Exemption • Nashville Conference • Hot Buttons • FESS

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Melissa Brown, RHIA, CPC, CPC-I, CFPC

Hernia Repair in Five Easy Steps

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Coding Edge AD_RVGCrosswalk 09_2011_print.pdf 1 8/1/11 3:25 PM

www.aapc.com November 2011 3

[contents] 7 Letter from the Chairman and CEO

9 Kudos

11 Letter from Member Leadership

12 Coding News

In Every Issue

20 Demystify the Physician Fee Schedule G.J.Verhovshek,MA,CPC

24 Why Your Practice Should Care About E/M Outliers MaryLeGrand,RN,MA,CPC,CCS-P

26 FESS Up! You Need a Sinus Surgery Refresher LaurettePitman,RN,CPC-H,CGIC,CCS

30 Code Fat Albert’s Hernia Repair in Five Easy Steps MelissaBrown,RHIA,CPC,CPC-I,CFPC

34 ICD-10 Testing, Testing ... One, Two, Three JuliaCroly,CPC,CPC-P,CPC-I

36 Deal with Difficult People by Managing Hot Buttons DanaLightman,Ph.D.

42 I Take Exception with That! MaryannC.Palmeter,CPC,CENTC

46 For CPC-As, Mentors Are a Must SuziMorrow,CPC

48 Since When Is “Give Less Weight” an Audit Protocol Standard? RobertA.Pelaia,Esq.,CPC,CPCO

On the Cover: If you’d like to push your hernia coding to a higher level, Melissa Brown, RHIA, CPC, CPC-I, CFPC, of Jacksonville, Fla. can walk you through the process, one step at a time. Cover photo by Jon M. Fletcher (www.jonmfletcher.com).

Special Features

Education

Coming Up

Contents

November 201130

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

16 Nashville Regional Conference

36 Added Edge

42 Featured Coder

46 Coder’s Voice

48 Legal Edge

14 AAPCCA: Have YOU Attended a Chapter Meeting Lately?

38 Newly Credentialed Members

34 ICD-10 Road Map

26

• 2012 CPT®

• AAPC’s ICD-10 Plan

• OB Ultrasound

• Pediatric Neurosurgery

• Tubal Sterilization

Features

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4 AAPCCodingEdge

Volume 22 Number 11 November 1, 2011

CodingEdge(ISSN:1941-5036)ispublishedmonthlybyAAPC,2480South3850West,SuiteB.SaltLakeCity,Utah,84120,foritspaidmembers.PeriodicalpostagepaidattheSaltLakeCitymailingofficeandothers.POSTMASTER:Sendaddresschangesto:CodingEdgec/oAAPC,2480South3850West,SuiteB,SaltLakeCity,UT,84120.

Serving 107,000 Members – Including You!

November 2011

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Serving AAPC MembersThe membership of AAPC, and subsequently the readership of Coding Edge, is quite varied. To ensure we are providing education to each segment of our audience, in every issue we will publish at least one article on each of three levels: apprentice, professional and expert. The articles will be identified with a small bar denoting knowledge level:

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

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

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

APPRENTICE

PROFESSIONAL

EXPERT

Chairman and CEOReedE.Pew

[email protected]

Vice President of Finance and Strategic PlanningKorbMatosich

[email protected]

Vice President of MarketingBevanErickson

[email protected]

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

[email protected]

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

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

[email protected]

Director of Member ServicesDanielleMontgomery

[email protected]

Director of PublishingBradEricson,MPC,CPC,COSC

[email protected]

Managing EditorJohnVerhovshek,MA,CPC

[email protected]

Executive Editors MichelleA.Dick,BS ReneeDustman,BS [email protected] [email protected]

Production Artists TinaM.Smith,AAS ReneeDustman,BS [email protected] [email protected]

Advertising/Exhibiting Sales ManagerJamieZayach,BS

[email protected]

Addressallinquires,contributions,andchangeofaddressnoticesto:

Coding EdgePO Box 704004

Salt Lake City, UT 84170(800) 626-CODE (2633)

©2011AAPC,CodingEdge.Allrightsreserved.Reproductioninwholeorinpart,inanyform,withoutwrittenpermissionfromAAPCisprohibited.Contributionsarewelcome.CodingEdgeisapublicationformembersofAAPC.StatementsoffactoropinionaretheresponsibilityoftheauthorsaloneanddonotrepresentanopinionofAAPC,orsponsoringorganizations.Cur-rentProceduralTerminology(CPT®)iscopyright2010AmericanMedicalAssociation.AllRightsReserved.Nofeeschedules,basicunits,relativevaluesorrelatedlistingsareincludedinCPT®.TheAMAassumesnoliabilityforthedatacontainedherein.

CPC®,CPC-H®,CPC-P®,CPCOTM,CPMA®,andCIRCC®areregisteredtrademarksofAAPC.

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MLN Coding Edge NOV2011 FINAL PRINT.pdf 1 9/13/11 11:47 AM


This is an inspirational story written by Bob Perks© www.bobperks.com, which has been paraphrased.It had been some time since Jack had seen Mr. Belser next door. College, girls, career, and life itself got in the way. In fact, Jack moved clear across the country in pursuit of his dreams. There, in the rush of his busy life, Jack had little time to think about the past and of-ten no time to spend with his wife and son. He was working on his future and nothing would stop him. Over the phone, his mother told him, “Mr. Belser died last night. The funeral is Wednesday.” Memories flashed through his mind like an old newsreel as he sat quietly remembering his childhood days.“Jack, did you hear me?”“Oh sorry, Mom. Yes, I heard you,” he re-plied. “It’s been so long since I thought of him. I’m sorry, but I honestly thought he died years ago,” Jack said. “Well, he didn’t forget you. Every time I saw him, he’d ask how you were doing. He’d reminisce about the many days you spent over ‘his side of the fence’ as he put it,” Mom told him.“I loved that old house he lived in,” Jack said.“You know, Jack, after your Father died, Mr. Belser stepped in to make sure you had a man’s influence in your life,” she said.“He’s the one who taught me carpentry. I wouldn’t be in this business if it weren’t for him. He spent a lot of time teaching me things he thought were important. Mom, I’ll be there for the funeral,” Jack said.As busy as he was, he kept his word. Jack caught a flight home. Mr. Belser’s funeral was small and uneventful, as he had no chil-dren of his own and most of his relatives had passed away.The night before he had to return home, Jack and his mom stopped by to see Mr.

Belser’s old house next door. Standing in the doorway, Jack paused for a moment. It was like crossing over into another dimension, a leap through space and time. The house was exactly as he remembered, and each step held memories … Jack stopped suddenly.“What’s wrong, Jack?” his mom asked. “The box is gone,” He said. “There was a small gold box he kept locked on top of his desk. I must’ve asked him a thousand times what was inside. All he’d tell me was, ‘The thing I value most.’”Everything about the house was exactly how Jack remembered it, except for the box. Someone from the Belser family must’ve taken it. Two weeks after Mr. Belser died, Jack re-turned home from work to discover a note from the Post Office in his mailbox alerting him to a package. He retrieved it the next day. It looked like it had been mailed de-cades ago. The handwriting was difficult to read but the return address, “Mr. Harold Belser,” caught his eye.In the car, Jack ripped open the package to find the gold box and an envelope. In the envelope was a note that read, “Upon my death, please forward this box and its con-tents to Jack Bennett. It’s the thing I valued most in my life,” and a small key. Heart racing, Jack carefully unlocked the box. Inside he found a beautiful gold pock-et watch. Running his fingers over the fine-ly etched casing, he unlatched the cover. In-side was engraved, “Jack, thanks for your time! - Harold Belser”The thing Mr. Belser valued, Jack realized, was Jack’s time. He held the watch for a few minutes, and then called his office and cleared appointments for the next two days. “Why?” his assistant, Janet, asked.“I need some time to spend with my son,” he said. “Oh, by the way, Janet, thanks for your time!”

Your friend,

Reed E. Pew Chairman and CEO

The Importance of Time

LetterfromtheChairmanandCEO

8 AAPCCodingEdge

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Kudos

PleasesendyourKudosto:[email protected]

Rhonda Buckholtz in The Wall Street JournalYou know you’re in the big league when you make it into The Wall Street Journal. On Sept. 13, WSJ published, “Walked Into a Lamp-

post? Hurt While Crocheting? Help Is on the Way,” a light-hearted article about the detail that ICD-10-CM will bring to diagnosis codes. In the article, our vice president of ICD-10 training, Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, mentions one of the more obscure codes, V91.07XA Burn due to water-skis on fire, initial encoun-ter, and contemplates how an accident like this is possi-ble: “Is it work-related?” she asks. “Is it a trick skier jumping through hoops of fire? How does it happen?”

Before the day was over, national and local print and broad-cast media picked up the story, which included background information Rhonda had provided and interviews with feder-al officials.

Brinson Named HumanitarianFreda Brinson, CPC, CPC-H, CEMC, compliance auditor for St. Joseph’s/Candler in Savannah, Ga., received this year’s St.

Joseph’s/Candler Lientz Award. Brinson, who volunteers at a number of St. Joseph’s/Candler’s Angels of Mercy events and serves on the AAPCCA board of directors, exemplifies the health system’s mission of “Rooted in God’s love, we treat illness and promote wellness for all people.” She received the award because of her work ethic, compassion, volunteerism, and leadership. Congratulations, Freda!

Chapters Popping Up All OverCongratulations and thanks to the new chapters that dedicate their time to helping coders and their profession. We welcome the following new chapters:

Aberdeen, S.D. Laramie/Cheyenne, Wyo.

Arcata, Calif. Manhattan, Kan.

Athens, Ga. Marion, Ohio

Aurora, Ill. Mitchell, S.D.

Beaumont, Texas Norfolk, Neb.

Brainerd, Minn. Santa Barbara, Calif.

Cumming, Ga. Savannah, Tenn.

Hamilton, N.J. Sharon, Pa.

Idaho Falls, Idaho Staten Island, N.Y.

Kingman/Havasu City, Ariz. Tawas City, Mich.

London, Ky. Warrenton, Va.

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When asked, “What are you thank-ful for?” most reply in the usual manner: family, friends, and good

health. This month, however, let’s explore this topic and look at what our AAPC fami-ly has brought to each of us, its members, for which we are thankful.

A Heartfelt Story of ThanksI’d like to share a story about one of our members, Casey Henry, CPC. Like many professional medical coders, Casey didn’t grow up wanting to be a coder. “I didn’t know what coding was,” she admits. Casey’s journey to medical coding began while studying fine arts in college. To make ends meet as a student, Casey accepted a position filing and retrieving medical records at Car-le Foundation Hospital, located in Urbana, Ill. While working in this position, Casey was introduced to medical coding through “coders who loved their job,” she said. Casey completed her bachelor’s degree in fine arts at the University of Illinois, mar-ried, and moved to southern Illinois. But she had difficulty finding employment in her field during trying economic times. This led to getting a dead-end job in manufactur-ing; needing state assistance to support her family; returning to the Urbana area; and, changing her career.

Finding a Home with AAPCHoping to return to Carle, Casey contacted her former manager and was informed that the requirements for working in the medical records department had changed during her absence. She would need to be credentialed as an outpatient coder to work in the de-partment. With the desire to move toward her dream of a stable and rewarding career, Casey began researching credentialing or-ganizations and decided that AAPC was the best fit for her. When asked what drew her to AAPC, Casey said, “They were more accessible, and easier to work and commu-nicate with. I really felt like they wanted me to succeed, it was like a family.” As a sin-

gle mom, the availability of taking medical coding classes online allowed her the flexi-bility to continue education and obtain cer-tification. Her local chapter network has also been very supportive. “They made me feel at home right away,” she said.While preparing for her Certified Profes-sional Coder (CPC®) exam, Casey again ap-plied for a position with Carle Foundation Hospital, this time in the clinical coding department. She was hired after complet-ing her studies, but before taking the CPC® exam. She passed the exam, and remains there happily working for the physician side of Carle, Carle Physician Group. When asked where she sees her future as a medical coding professional, Casey said, “I’m glad I became certified before ICD-10-CM went into effect, I plan to continue learning and eventually become a ‘go to’ person.”

Casey Gives ThanksIn the spirit of this article, I asked Casey who and what she is thankful for regarding her career. Her response: “It’s not a single person that I am thankful for—my parents David and Cathy Owens, for their support and persistence to keep going when I was frustrated and discouraged. I also personal-ly thank AAPC for changing my life.” She added, “I now have a rewarding career and continue to learn more everyday. AAPC has opened up doors for me that I never would have expected. Thank you very much!”

Thankful Realization at Conference While attending the regional conference this past September in Nashville, Tenn., I reconnected with long-time friends and made a few new ones. As usual, we spent most of our time discussing how we began in this industry, the many changes we’ve seen, where we believe health care is head-ed, and our role as coders, billers, manag-ers, teachers, and consultants in the future. During these discussions, one point consis-tently came to the forefront of every conver-sation: None of us would be where we are

in our careers and life without AAPC, its members, and their support.Thanks for another great conference.

Express Your ThanksDuring this Thanksgiving season, while you are considering what you are thank-ful for, remember to share with your fami-ly, friends, fellow AAPC members, and col-leagues the many blessings they bring into your life.

Best Wishes,

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

Thankful for AAPC

LetterfromMemberLeadership

12 AAPCCodingEdge

CodingNewsUse Revised ABN by Nov. 1Providers (including independent laboratories, physicians, and practitioners) and suppliers now have until Nov. 1 to begin us-ing the revised Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131.The original implementation date was Sept. 1, but the Centers for Medicare & Medicaid Services (CMS) extended the man-datory use date to Jan. 1, 2012 to give providers and suppliers more time to transition to using the new form, and to use up stockpiles of old forms.The revised form replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007). The latest version of the ABN has a release date of March 2011 printed in the lower-left corner. All ABNs with a release date of March 2008 that are used on or after Jan. 1 will be invalid.The ABN should be used in situations where Medicare pay-ment is expected to be denied. Skilled nursing facilities (SNFs) should use the revised ABN form when services are expected to be denied under Medicare Part B only.Download the revised ABN at www.cms.gov/BNI/02_ABN.asp, available now for immediate use.

AMA Releases CPT® 2012 Category II CodesThe American Medical Association (AMA) has released new and revised CPT® Category II codes, effective Jan. 1, 2012. Category II codes are supplemental tracking codes used for performance measurement (e.g., the Physician Quality Re-porting System, www.cms.gov/PQRS/).Category II codes are not required for correct coding and should not be used in place of Category I codes. They describe clinical components that may: typically be included in evalu-ation and management (E/M) or clinical services; result from clinical laboratory or radiology tests and other procedures; or identify processes intended to address patient safety practic-es or services reflecting compliance with state or federal law.For 2012, four Category II codes are deleted and replaced by newer codes:

• 4002F Statin therapy, prescribed (CAD) is deleted and replaced by 4013F Statin therapy prescribed or currently being taken (CAD).

• 4006F Beta-blocker therapy prescribed (CAD, HF) is replaced by 4008F Beta-blocker therapy prescribed or currently being taken (CAD, HF).

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CodingNews• 4009F Angiotensin converting enzyme (ACE) inhibitor

or angiotensin receptor blocker (ARB) therapy prescribed (HF, CAD, CKD), (DM) is replaced by 4010F Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed or currently being taken (CAD, HF).

• 4275F Hepatitis B vaccine injection administered or previously received (HIV) is replaced by 4149F Hepatitis B vaccine injection administered or previously received (HEP C, HIV) (IBD).

Several dozen new codes have been added in clinical areas such as angina, tobacco use, neuropsychiatric symptoms, and more.For a full list of revisions to Category II codes (as well as a sneak peak at some 2013 codes), see “Update to List of Category II Codes” dated Sept. 14, 2011.

Don’t Jump the Gun When Delivering DMEPOS RefillsEffective Oct. 31, 2011, suppliers of durable medical equip-ment, prosthetics, orthotics, and supplies (DMEPOS) submit-ting claims for items or services provided to Medicare benefi-ciaries shouldn’t be too hasty to dispense refills. CMS Change Request (CR) 7410 modifies the number of days a supplier

can contact the beneficiary prior to dispensing a refill and the number of days it can deliver a DMEPOS product prior to the end of the product’s usage.For DMEPOS refills, suppliers must contact the beneficia-ry prior to dispensing the refill. Do this to ensure the refilled item is necessary and to confirm any changes or modifications to the order. CR 7410 mandates,“contact with the beneficiary or designee regarding refills should take place no sooner than 14 calendar days prior to the delivery/shipping date. For subse-quent deliveries of refills, the supplier should deliver the DME-POS product no sooner than approximately 10 calendar days prior to the end of usage for the current product.”See CR 7410 (www.cms.gov/transmittals/downloads/R389PI.pdf) for more information.

New Online Application Fee Collection Process through PECOSMedicare Learning Network (MLN) Matters® Special Edition (SE) article 1130 changes Medicare’s online application pay-ments process and affects providers and suppliers. See MLN Matters® SE1130 (www.cms.gov/MLNMattersArticles/Downloads/

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14 AAPCCodingEdge

I have been a member of AAPC for 15 years, but I have not always been a local chapter meeting attendee. In fact, I came up with many excuses not to attend: • It’s not a convenient time for me.• I have too much work to do.• I need to get home and feed the kids.• I have a paper due in a few days.• My favorite program comes on TV at that time.• I don’t know anyone there.• It’s boring.• It takes too long to get there.• There is never a speaker talking about my specialty.

The excuses are endless. I’m sure you could probably add a few of your own to the list. What if you put aside those excuses and pre-conceived notions (factual or illusory), and attended a local chapter meeting? What do you suppose would happen?

Walking in, Here’s What You’d FindSpeaking from experience, here’s a typical scenario: Prior to the meeting start time, the secretary, treasurer, and president-elect are preparing a table with the sign-in sheets and pens. The member de-velopment officer is poised at the door, ready to greet members with a smile and a kind word as they arrive. Chapter volunteers are set-ting up the meal table (Yes, my chapter has a meal at every meeting.); and, the president and education officer are at the front of the room, making last-minute preparations for the call-to-order and the speak-er presentation. There is excitement in the air as members enter the room and take their seats. Members exchange greetings and join in conversations about another unbelievable denial or an operative note unlike any-thing ever seen. It’s apparent that these folks are not just individuals attending a meeting, but friends and colleagues enjoying each oth-er’s company.

As the Meeting Begins …You hear the local chapter president call the meeting to order. It’s ex-actly the time specified on the agenda because officers are consci-entious of your time, and conduct chapter meetings professional-ly. Members are welcomed and local chapter officers are introduced. New members and guests are acknowledged and newly certified

members congratulated. Announcements of upcoming educational opportunities are shared as well as other chapter business.

Onto EducationWhen the presentation starts, there is something valuable to be learned from every speaker. It may not apply to your current posi-tion, but tomorrow is a new day with new challenges. Years ago, I came so close to skipping a local chapter meeting because I didn’t see why I would ever need to know how to code a liver trans-plant. I talked myself into going (it was during my lunch, so at least I would have food), and it turned out to be one of the most interesting lectures I’ve ever attended. The lecture had nothing to do with me, my job, or anything I might code, but it was so new to me I was like a sponge, wanting to absorb all the information I could. You never know what topics will excite you at a local chapter meeting.

Time to NetworkI love organizing and encouraging networking at local chapter meet-ings. Believe it or not, I used to sit in the back of the room, trying not to make eye contact with others. I’d pretend to read whatever I had in front of me (over and over), rather than actually talk to those around me. That was me four years ago. I’m still not a Chatty Cathy with the gift for gab, but I’m now able to talk with attendees at my lo-cal chapter meeting because I have found something we have in com-mon: We all want to share and learn from each other. Four years ago, I knew the names of maybe five fellow chapter members. Since get-ting involved with my chapter and stepping out of my comfort zone to become a chapter officer, I’m proud that I can name every single person at our meetings. I can now spot a new member or guest at 20 yards away—that’s exciting!

Become Part of the ExcitementIf you have attended a chapter meeting that wasn’t exciting, I chal-lenge you to get involved and make your chapter exciting. If you think the topics at your chapter meetings aren’t interesting or don’t apply to you, step out of your comfort zone and recruit a speaker or present a topic that interests you. Become committed and willing to share with your fellow members.

Social Media Ain’t Got Nothing on a Chapter MeetingIn this age of immediate, fast-paced information, it’s a pleasure to walk into a local chapter meeting, shake hands with real-live mem-bers, look each other in the eyes, and talk face-to-face.

Have YOU Attended a Chapter Meeting Lately?It’s not your grandma’s local chapter meeting.

AAPCCA

By Freda Brinson, CPC, CPC-H, CEMC


AAPCCA

You may have 1,000 friends on Facebook, and you may follow 1,000 people more on Twitter, but this doesn’t compare to the feeling you get when you attend a local chapter meeting. Some things just cannot be replaced, and networking and learning with fellow members of your lo-cal chapter are two of those things. Attend a local chapter meeting; and when you do, let me know about it. I’d love to hear from you.

Freda Brinson, CPC, CPC-H, CEMC, serves on the AAPCCA Board of Directors and is compliance auditor for St. Joseph’s/Candler Health System in Savannah, Ga. She has 30 years of health care experience. Ms. Brinson was 2008 AAPC Networker of the Year and chapter president when Savannah was named 2008 AAPC Chapter of the Year.

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everneedtoknowhowtocodealivertransplant.

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We Want You!TheAAPCCAisacceptingapplicationsforfivenewboardmembers,andoneofthosespotscouldbefilledbyyou.

Wewantyou,if:

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✓ Youhaveagreatmeetingideatoshare

✓ Youfindyourselfseekingoutnewmemberstowelcomeatmeetings

✓ Youdrivehomethinkingofwaystoimprovechapterattendance

✓ YoumentorCPC-As

Ifthissoundslikeyou,takethetimetofilloutanapplicationandcontacttheAAPCCABoardofDirectors(BOD)memberinyourregionformoreinformation.

—AAPCCA Vice-chair Angela Jordan, CPC

AAPCCA Handbook Corner CorrectionIntheOctoberissue,“HandbookQuickTip:KnowOfficerAttendanceRequirements”waswrittenbySusan Edwards, CPC.

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16 AAPCCodingEdge

“For a regional conference, it was AWESOME!” exclaimed Judy A. Wilson, CPC, CPC-H, CPC-P, CPC-I, CANPC, CMBSI, CMRS, as she compared the 2011 AAPC Regional Conference in Nashville, Tenn. to the national conferences she has attended. “The attendees who I met had nothing but good remarks about the conference.” The atmosphere compared to a national conference and its caliber of speakers was top-notch, according to AAPC National Advisory Board (NAB) President-elect David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCS, RCC. Although he has never been to a re-gional conference prior to Nashville’s, Dunn said, “As far as the pro-gram, the keynote, and the speakers, it felt like any national confer-ence I’ve been to.”Here’s what the conference offered:

An Attentive, Friendly SmileDavid Zielske, MD, CIRCC, CPC-H, CCC, CCS, RCC, can’t “say enough about the professional, warm, and friendly AAPC staff and volunteering members.” As a speaker and attendee, Zielske said he has “always been greeted with a smile and genuine interest, which makes a speaker comfortable and welcome at conference.” And the hospitality and professionalism didn’t end there. Zielske said, “The attendees were knowledgeable about the subject matter, attentive, and interactive during the talks. I didn’t catch anyone snoozing, even after the lunch break!”As an AAPC Chapter Association (AAPCCA) Board of Direc-tors member, Brenda Edwards, CPC, CPMA, CPC-I, CEMC, knows the goal at conference “is to make everybody feel welcome.” Throughout the conference, whenever she saw someone who AAPC-CA helped check in at registration, she would say “Hi!” and have a nice conversation.

By Michelle A. Dick

Nashville Conference a Smashing SuccessAAPC regional gathering provides sweet music for coders.


A Grand Location in NashvilleNashvillians Dunn and Zielske were thrilled when they heard the regional conference would be in Nashville. Dunn said, “When the 2010 national conference was cancelled due to the flood disaster and moved to Jacksonville, I was disappointed that we couldn’t have it here.” He added, “So, when I found out the regional conference was here, I was excited and worked very hard to help Melanie Mestas, conference director, and AAPC CEO and Chairman Reed Pew in any way I could to get the best speakers.”Zielske may be a little biased about the location since he lives there, he said, “but still, the topics were timely and pertinent, and the pre-senters were outstanding. After a few days of rain at the start of the week, even the weather cooperated.”For those who traveled to attend, such as Wilson, who is from Vir-ginia, there was a lot to do outside of conference, too. “What is there not to like about the Gaylord Opryland Resort? It was beautiful and you could shop, eat, rest, workout, etc.,” Wilson said. The Nashville location lent itself “for some fun time—like getting Grand Ole Opry tickets on sale,” said Wilson; and, the resort was “close enough to see some of the sites of Nashville—you just needed good walking shoes.”

Hot Spot for Physician Speakers“The conference had a strong contingent of Nashville physician speakers, including Melanie Dunn, MD, who delivered an out-standing Ob/Gyn presentation, and John David Rosdeutscher, MD, a plastic surgeon who did an excellent job explaining lesion ex-cision and wound care,” said Zielske. Other physician presentations included “the Nashville standbys” Dunn and Zielske, who “elabo-rated on the intricacies of vascular families and neurovascular inter-ventional coding, respectively,” according to Zielske.

Dunn’s highlight of the conference was the speakers. “I asked a good friend of mine and neighbor in Nashville, Bill Gracey, the presi-dent and COO, Blue Cross Blue Shield of Tennessee to speak,” he said. Gracey was in the hospital side of health care for 20 years, and then went over to the insurance side. “That was probably the high-light for me, introducing Bill Gracey as the keynote speaker,” Dunn admitted. “Because he’s seen both sides of the fence, he talked about health care reform from all angles of the industry.” During his pre-sentation, Gracey shared his perspective on health care as it stands today. “He was insightful and humorous, and his was a timely pre-sentation,” Zielske said.Dunn asked his wife, Dr. Dunn, to speak, as well. He said, “My wife speaking, that was really funny because it was her first time speak-ing for AAPC and the room was really hot; she got there late from the hospital; and her computer failed five minutes before it was sup-posed to start. After everything got worked out, her session was suc-cessful. She enjoyed it.”

So Much to Do, So Little TimeAlthough Edwards, an active AAPCCA board member, was busy helping attendees; gearing up for “Get 2 Know Your Local Chap-ter;” and presenting “The Good, Bad, and Ugly of E/M Auditing;” she found the time to see Melissa Brown’s, CPC, CPC-I, CFPC, “3D - Exploring the Human Body.” Edwards said this was her favor-ite presentation because, “I loved the anatomy (autopsy) since we were viewing actual bodies and not models or pictures. I benefitted from seeing the body’s organs and loved when they put dye in the GI system to ‘bring it to life.’” Wilson, an AAPCCA board member and pre-senter, had a hard time picking out one ses-sion as her favorite because “there were so

Themostimportantbenefityoucangetoutofattending

conferenceisnetworking,andthisconferencewasfullofit.

18 AAPCCodingEdge

many to pick from.” She said, “I am not sure I could pick just one thing. But I will tell you, I enjoyed all the different sessions that were available.” Wilson said she was “so glad to see some of the special-ty sessions like anesthesia;” and, enjoys going to sessions that she doesn’t know much or anything about, or use in her daily job. “It is a way to keep learning new things,” Wilson said.

Get to Know Your Local Chapter (G2KYLC)G2KYLC was a big hit. According to Edwards, “The biggest com-pliment was given to our board by Vice-president of Live Events Bill Davies when he told us the line of people at the event was for our table. Our members were that eager to know more about the local chapter board.” There was a “tremendous number of first-time at-tendees at conference—that was awesome!” said Edwards.The best thing about G2KYLC is the networking opportunities. Wilson said she was able to meet new networking buddies, and she “took away so much information.” She said, “I had such a great time at the Get to Know Your Local Chapter event. I got lots of informa-tion that I took back to help our chapter.”

It’s All About NetworkingThe most important benefit you can get out of attending confer-ence is networking, and this conference was full of it. Wilson said, “I think if I had to choose one thing as my favorite part, it would be all the networking opportunities that were available during the confer-ence.” The great part about regional conferences is that everything is on a slightly smaller scale than national conferences. This means it’s easier to network with coders in your area. Wilson agreed, “I real-ly enjoy regional conferences as it is usually a smaller group and you get more time to meet and network.”

Simply, SmashingZielske wrapped up the conference best, saying, “The Nashville con-ference was a smashing success. AAPC espouses well the concepts of networking, education, and professionalism, and I think most at-tendees had an outstanding conference experience. I know I did. See y’all in Vegas!”

Michelle A. Dick is executive editor at AAPC.

Lefttoright:JudyWilson,MelissaBrown,SusanEdwards,andMelodyIrvine

TheAAPCCAtablewasdecked-outwithsuggestioncards,give-awayraffletick-ets,doorprizes,andaboardmemberbanner.

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20 AAPCCodingEdge

Feature Apprentice

By G.J. Verhovshek, MA, CPC

Demystify the Physician Fee ScheduleYou probably already know that Medicare payments are based on relative value units (RVUs) assigned to each CPT®/HCPCS Level II code. But the 2011 National Physician Fee Schedule Relative Value File contains no fewer than 10 columns listing various RVUs, as shown on next page. This may leave you wondering exactly which of those RVU columns you should use, and how the Centers for Medi-care & Medicaid Services (CMS) determines total payments.

RVU Totals Are the Sum of Three PartsPayment rates for individual services are based on the sum of three separate RVU categories.1. Work RVUs “reflect the relative levels of time and intensity associated with furnishing a …

service and account for approximately 50 percent of the total payment associated with a ser-vice,” according to CMS’ Medicare Physician Fee Schedule Payment System Fact Sheet (www.

cms.gov/MLNProducts/downloads/MedcrephysFeeSchedfctsht.pdf). These RVUs are specifically to pay for physician effort. All work RVUs must be reviewed (and may be changed) at least once ev-ery five years.

2. Practice expense (PE) RVUs reflect the cost of non-physician labor, and expenses for building space, equipment, and office supplies.

3. Malpractice (MP) RVUs are meant to cover the cost of malpractice insurance for each pro-cedure and service. These typically account for the smallest overall contribution to the total RVU value of a given procedure or service. MP RVUs must be reviewed (and may be changed) at least once every five years.

PE RVUs Depend on Place of ServiceWork RVUs and MP RVUs for a particular code are consistent across all places of service. For exam-ple, the work RVUs for 10021 Fine needle aspiration; without imaging guidance are 1.27, regardless of whether the service is provided in the physician office, an inpatient hospital, or any other health care setting. Similarly, the MP RVUs are 0.22 regardless of the place of service.

Note: All RVUs in this article are based on the most recent 2011 National Physician Fee Schedule Relative Value File at press time. This file can be found on the CMS website (www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage).

Because the expense of providing a service may differ depending on where the service is provided (fa-cility vs. non-facility), PE RVUs also may change depending on where the service is provided. To ac-count for this, the fee schedule lists separate columns to describe “Facility” and “Non-facility” PE RVUs. The fee schedule also provides separate columns listing “Transitional” PE RVUs and “Fully Imple-mented” RVUs. As the CMS Fact Sheet explains, “For CY 2011, indirect cost data that are used in the calculation of PE RVUs for most specialties were updated using the American Medical Associ-ation’s Physician Practice Information Survey (PPIS) data. The PPIS is a multispecialty, nationally representative indirect PE survey of both physicians and non-physician practitioners. Its use is being transitioned over a four-year period beginning in CY 2010.”In other words, the “Transitional” RVUs reflect the current PE payment; while the “Fully Implement-ed” RVUs reflect what the PE RVUs will be at the end of the transition period (2014). The PE RVUs will be adjusted over each of the next three years until they reach the fully implemented amounts.

Understand how Medicare payments are made by learning how to calculate them.


Feature

Returning to 11021, for instance, the fee schedule lists the following PE values:

Code Transitioned Fully

Non-facility

PE RVUs

Implemented

Non-facility

PE RVUs

Transitioned

Facility

PE RVUs

Fully Implemented

Facility

PE RVUs

10021 2.7 2.77 0.58 0.64

From this example, we see that the current (transitioned) RVUs in the facility setting are 0.64; and in the non-facility setting (e.g., physician office), the current RVUs are 2.7. In 2014, these values will increase to 0.64 RVUs and 2.77 RVUs, respectively.

Sum the Parts for RVU TotalsTo find the total RVUs for a particular code, add together the work RVUs, MP RVUs, and the tran-sitioned PE RVUs appropriate to your site of service (facility or non-facility). The fee schedule lists these values for you (as well as the 2014 projected totals, including the fully implemented PE RVUs).

Code Transitioned

Non-facility

Total

Fully Implemented

Non-facility

Total

Transitioned

Facility

Total

Fully Implemented

Facility

Total

10021 4.19 4.26 2.07 2.13

The difference in the total RVUs for the facility and non-facility settings is a function of the differ-ent PE RVUs assigned for each setting. If you’re billing 10021 in the physician’s office in 2011, the total RVUs on which you will be reimbursed are 4.19 (1.27 work RVUs + 0.22 MP RVUs + 2.7 tran-sitioned non-facility PE RVUs). In the facility setting, the total RVUs are 2.07 (1.27 work RVUs + 0.22 MP RVUs + 0.58 transitioned facility PE RVUs).

GPCI Account for Regional Cost DifferencesThe Physician Fee Schedule is a national fee schedule, but the cost of living—as well as practicing medicine and providing medical services—varies from one location to another. To account for these differences, CMS applies separate Geographic Practice Cost Indices (GPCI) to each of the three rel-ative values (work, MP, and PE) used to calculate payment. CMS is required to update the GPCIs ev-ery three years, and to phase in changes over two years.The easiest way to find the GPCI for your location is by using the “Physician Fee Schedule Search” tool found on the CMS website (www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx). This tool allows you to search by code, locality (e.g., Baltimore, Los Angeles, Topeka, etc.), and type of in-formation (e.g., RVUs, pricing information, or GPCI).

TheMedicarePhysicianFeeSchedulelistsrelativevalueunitsforfacilityandnonfacilityservices.

22 AAPCCodingEdge

Feature

For example, if you’re in Atlanta and want to find the GPCI for your area, you can:1. Select “Geographic Practice Cost Index” from the “Type of

Information” choices.2. Choose “Specific Locality” from the choices under “Select

Carrier/Medicare Administrative Contractor (MAC) Option.”3. Choose “1020201: Atlanta, GA” from the “Carrier/MAC

Locality” pull-down menu.4. Click the “Submit” button.

The results will show you the “GPCI WORK” for Atlanta is 1.006, the “GPCI PE” is also 1.006, and the “GPCI MP” is 0.890. The av-erage GPCI value is 1, so we know that work RVUs and PE RVUs are paid slightly higher than average in Atlanta, while MP RVUs are paid at a lower than average rate.

Apply the Formula to Determine Final RVUsTo determine the true, total RVUs for a procedure or service in your area, apply the following formula:

(workRVUsxworkGPCI)+(PERVUsxPEGPCI)+(MPRVUsxMPGPCI)

Remember: To ensure accuracy, select the transitioned PE RVUs for your place of service (facility or non-facility).For example, if you want to determine the final RVUs for 10021 when provided in a physician office in Atlanta, apply the formula as follows:

(1.27workRVUsx1.006workGPCI)+(2.7transitionednon-facilityPERVUsx1.006PE

GPCI)+(0.22MPRVUsx0.890MPGPCI)=4.18962RVUs

In the facility setting, the total is found by applying the same formu-la, but using the facility PE RVUs:



To demonstrate how locality affects the GPCI amounts (and the overall RVU total), let’s consider one more example, using a Seattle physician’s office as our location. Note how the GPCI (found on the CMS lookup tool) differ:



RVUs Times CF Gives You a Dollar AmountTo calculate payment, you must multiply the place-of-service and lo-cality-specific RVU total by a dollar conversion factor (CF). The CF is updated annually according to a formula specified by statute. The Physician Fee Schedule Payment System Fact Sheet ex-

plains, “The formula specifies that the update for a year is equal to the Medicare Economic Index (MEI) adjusted up or down depend-ing on how actual expenditures compare to a target rate called the Sustainable Growth Rate (SGR).” On several occasions (includ-ing for 2011), Congress has acted to revise the CF when application of the formula would have resulted in drastic reductions to the CF.The CF for 2011 is $33.9764. Although the CF may change an-nually, it is the same for all places of service and localities across the nation.From our examples above, we already know the specific RVU totals for 10021 in the facility and non-facility settings in Atlanta, as well as a non-facility setting in Seattle. To arrive at a current payment amount, simply multiply these totals by the CF:Atlanta,facility:2.0569RVUsx33.9764CF=$69.89

Atlanta,non-facility:4.18962RVUsx33.9764CF=$142.35

Seattle,non-facility:4.4327RVUsx33.9764CF=$150.61

For those of you who love math, here’s the entire formula we used to arrive at these figures:

[(workRVUxworkGPCI)+(PERVUxPEGPCI)+(MPRVUxMPGPCI)]xCF=finalpayment

Those of us who are less enamored with numbers can skip all the computation and simply use the Physician Fee Schedule Search tool to find payment information. If we select “Pricing Information” from the “Type of Information” pull down menu, select “1020201: Atlanta, GA” as our locality, and specify code 10021, the lookup tool will tell us the non-facility and facility price for the code—and they are, as we calculated, $69.89 and $142.35, respectively. We can also confirm that $150.61 is the correct payment for 10021 provided in the physician’s office in Seattle, and learn that the facility price in Seattle is $71.52.With a few clicks, we can just as easily determine that an endoscop-ic retrograde cholangiopancreatography (ERCP) (43260 Endoscop-ic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen(s) by brushing or washing (separate pro-cedure)) in a Miami facility will pay $421.49, or that radiological supervision and interpretation (S&I) of abdominal aortography (75625 Aortography, abdominal, by serialography, radiological super-vision and interpretation) in Houston pays $215.66.Now, the next time you wonder about Medicare payments, you’ll know where to find them, how those payments are calculated, and exactly what all those RVU columns in the Physician Fee Schedule mean.

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

ThePhysicianFeeScheduleisanationalfee

schedule,butthecostofliving—aswellas

practicingmedicineandprovidingmedical

services—variesfromonelocationtoanother.

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

24 AAPCCodingEdge

Feature

By Mary LeGrand, RN, MA, CPC, CCS-P

Professional

Why Your Practice Should Care About E/M OutliersBenchmarking provider services shows variations in practice patterns, and helps to define a practice as an outlier.

Imagine an auditor looking at the distribution of evalua-tion and management (E/M) services for your physicians and non-physician practitioners (NPPs). What would he or she find when comparing your office’s usage pattern to oth-er practices of the same specialty in your state? If you don’t know, you need to read on.

Benchmarking Shows How Your Practice Stacks UpTo paraphrase Wikipedia, “benchmarking is comparing one’s performance metrics to industry bests, and involves management comparing the results and processes in the targets to one’s own results.” Operating under the theo-ry of “no surprises,” sharpening your benchmarking skills should be at the top of your priority list. When benchmarking performance (whether it be for col-lection metrics or coding), you may discover that you are an “outlier” in some categories. Wikipedia defines an out-lier as “an observation that is numerically distant from the rest of the data.” If a physician is an outlier on an E/M benchmark compar-ison—for instance, because he or she uses more consulta-tion codes or more upper level codes—it’s not necessarily a bad thing. In many cases, the variation can be explained be-cause a specialist, such as a neuro-otologist, is compared to general ear, nose, and throat (ENT) specialists due to Medi-care’s specialty classifications; or, a spine surgeon who only sees patients on referral is compared to general orthopae-dic surgeons. Nevertheless, being an outlier will prompt inquiring minds to ask questions. Hopefully, you will have good answers to explain the de-viation, supported by excellent docu-mentation.

Keep an Eye on Your CurvesFrom any payer’s perspective, graph-ing code usage produces a distribu-tion curve to use as a basis for compar-

ison. This is especially true for Medicare, which paid $25 billion for E/M services (totaling 19 percent of all Medicare Part B payments) in 2009, according to the 2011 Office of Inspector General (OIG) Work Plan. Comprehensive Er-ror Rate Testing (CERT) audits also revealed a national Medicare fee-for-service error rate for the November 2009 reporting period of 8 percent (up from 6 percent in 2008), which equates to $24.1 billion in erroneous payments (see www.cms.gov/CERT/Downloads/CERT_Report.pdf). Medicare’s re-covery audit contractors (RACs), CERT contractors, and zone program integrity contractors (ZPICs) are out to re-coup money paid to those outliers, and they have been suc-cessful in collecting.Knowing how you compare to other practices on a physi-cian-to-physician basis is critical. Ignore those who tell you that your coding pattern should look like the proverbial “bell shaped curve.” Your coding should instead represent the level of care and documentation in your records. Your subspecialty or other unique aspects of your practice, your patient population, and your level of automation will influ-ence your coding, E/M distribution, and variations from the “norm.”

Implement Benchmarking in Your PracticeYou can use various tools to benchmark your code use. For example, Karen Zupko & Associates’ (KZA) E&M Pro-file Analyzer™ (www.karenzupko.com/products/product_em.html)

New Patient Office or Other Outpatient Visit100%

80%

60%

40%

20%

0%

99201 99202 99203 99204 99205

National SomeState Group Physician


Feature

uses Medicare paid claims data to compare doctors in the same specialty and state with one another using a graph-ic format. The chart on the preceding page is an example of a bench-marking graph (with specialty and state concealed). What you see here is a physician’s distribution pattern for new pa-tient visits that is significantly different than other mem-bers of his group. His volume and intensity of services dif-fers from his colleagues in the state and nationally, as well. To find out why the physician’s distribution pattern devi-ates from others, you would:

• Audit a sample of 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; medical decision making of low complexity. Verify that the medical necessity and documentation support the volume of level-III visits. If you identify any issues, address them through internal education.

• Look at the other levels of service. Both the physician and practice are outliers in undercoding. Undercoding equals lost revenue to the practice, and might even raise concern that Medicare beneficiaries aren’t receiving appropriate care.

The next steps include: 1. Running a frequency report for new, established,

consultation, and inpatient codes by the physician. 2. Reviewing reports from the E&M Profile Analyzer,

or a comparable product. The E&M Profile Analyzer, for example, allows you to access monthly or quarterly reports.

3. Using the above results to audit E/M records that represent outlier status (over- or under-utilization).

4. Making sure someone with solid qualifications performs the audit, such as a certified coder with relevant experience in your specialty. The auditor must be able to command the physicians’ attention and respect.

5. Developing an internal compliance plan (if you don’t have one), identifying both coding and billing pro-cess risks.

Tip: Use the E&M Profile Analyzer, or a similar tool, as part of your internal compliance plan to pinpoint documen-tation reviews. Rather than pulling random numbers or types of charts, you can focus on outliers who are likely to attract an auditor’s interest.

Double Check E/M in EHRsUsing an electronic health record (EHR) doesn’t mean that everything is OK with your E/M utilization. In fact, the OIG 2011 Work Plan has a special callout for EHR gener-ated notes. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. It’s advisable to review multiple E/M servic-es for the same providers and beneficiaries to identify EHR documentation practices associated with potentially im-proper payments.Never assume EHR logic is perfect—few, if any, systems can accurately calculate medical necessity; and cloning is often a significant problem. For instance, it’s a good idea to review all EHR generated 99214 Office or other outpa-tient visit for the evaluation and management of an estab-lished patient, which requires at least 2 of these 3 key compo-nents: A detailed history; A detailed examination; Medical de-cision making of moderate complexity visits after about six weeks of use.

Mary LeGrand, RN, MA, CPC, CCS-P, is a senior practice man-agement consultant with Chicago-based KarenZupko & Associates. Ms. LeGrand specializes in E/M and surgical coding education, reim-bursement analysis, and compliance/auditing. She is a coding and reimbursement expert in specialties such as orthopaedics, spine surgery, otolaryngology, and general surgery.

Ignorethosewhotellyouthatyourcodingpatternshouldlooklike

theproverbial“bellshapedcurve.”Yourcodingshouldinstead

representthelevelofcareanddocumentationinyourrecords.


26 AAPCCodingEdge

ExpertFeature

By Laurette Pitman, RN, CPC-H, CGIC, CCS

FESS Up! You Need a Sinus Surgery RefresherGood documentation and a thorough understanding of anatomy and procedures will help you accurately code this service.

Anyone who has had chronic sinus infections knows how mis-erable the constant headache and facial pressure can be. For-tunately for chronic sufferers, there is a minimally invasive

surgical technique to help alleviate this problem. Today, function-al endoscopic sinus surgery (FESS) is the primary approach used for the surgical treatment of chronic sinusitis. Familiarity with the pro-cedure and sinus anatomy aids in the accurate selection of CPT® codes for this service.

Start with the Procedural BasicsFESS is performed under direct visualization to restore sinus venti-lation and normal function. Indications and ICD-9-CM codes for FESS include:

• Chronic sinusitis refractory to medical treatment (473.9 Unspecified sinusitis (chronic))

• Recurrent sinusitis (473.9)

• Nasal/sinus polyps (471.9 Unspecified nasal polyp and 471.8 Other polyp of sinus)

• Sinus mucoceles (478.19 Other disease of nasal cavity and sinuses)

• Foreign body removal (932 Foreign body in nose)• Epistaxis control (784.7 Epistaxis)

Prior to the procedure, the physician performs a thorough history and examination, a trial of medical treatment, and a computed to-mography (CT) scan (70486 Computed tomography, maxillofacial area; without contrast material). The CT scan is mandatory to identi-fy the patient’s ethmoid anatomy and its relationship to the skull base and the orbits, along with the extent of the sinus disease.In a typical FESS procedure, the physician first identifies the middle turbinate and removes the uncinate process to expose the ethmoid bulla. The anterior ethmoid air cells are opened, leaving the bone covered with mucosa. This allows for better ventilation of the ante-rior ethmoid sinuses. The maxillary ostium is examined and, if it is obstructed, a middle meatal antrostomy is performed. This minimal surgery is often sufficient to improve the function of the osteome-atal complex, which improves the ventilation of the maxillary, eth-moid, and frontal sinuses.If the CT scan shows disease in the additional sinuses, the endoscope is advanced further into these areas. Additional endoscopic proce-dures may include sphenoidotomy, frontal sinus exploration, and re-moval of localized irreversible disease in the maxillary sinuses. If in-dicated, septoplasty and inferior turbinectomy may also be done dur-ing the surgical encounter.

Select CPT® Codes by the Treated LocationThorough and accurate physician documentation is the key to cor-rect FESS code selection. CPT® provides multiple codes in the Sinus Endoscopy subsection to report these procedures, dependent on the sinuses surgically treated. CPT® also includes extensive instructions in this subsection, so become very familiar with these notes.CPT® codes 31231-31297 describe diagnostic and surgical endo-scopic sinus procedures. All of the codes report unilateral proce-dures, with the exception of 31231 Nasal endoscopy, diagnostic, uni-lateral or bilateral (separate procedure), which specifies unilateral or bilateral in the descriptor. If any other procedure in this code range


CPT®includesextensiveinstructionsinthe

SinusEndoscopysubsection,sobecome

veryfamiliarwiththesenotes.

Feature

is provided bilaterally, append modifier 50 Bilateral procedure. For unilateral procedures, anatomic modifiers RT Right side and LT Left side are used to identify the site of surgery.The surgical codes for endoscopic sinus procedures describe inter-ventions where the sinuses are manipulated, opened, and patholog-ic tissues are removed. These codes always include any diagnostic inspection performed prior to or concurrently with the surgical in-tervention. Surgical treatment of the ethmoid sinus cells is a more common com-ponent of endoscopic sinus surgery. Because ethmoid sinuses are di-vided into anterior and posterior regions, CPT® has defined two sep-arate codes for reporting these procedures. For drainage of infect-ed mucous and removal of inflamed tissue confined to the anterior ethmoid cells, report 31254 Nasal/sinus endoscopy, surgical; with eth-moidectomy, partial (anterior). When both the anterior and posterior regions are treated, assign 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior). Both 31254 and 31255 include removal of any polyps encountered and a middle turbinec-tomy. A medically necessary inferior turbinectomy may be report-ed separately with either 30130 Excision inferior turbinate, partial or complete, any method or 30140 Submucous resection inferior turbinate, partial or complete, any method, depending on the technique.Antrostomy generally is defined as making an opening into the max-illary sinus for drainage. This procedure commonly is performed with an endoscopic ethmoidectomy and assigned 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy for the maxillary an-trostomy. A more extensive procedure, which involves removal of tis-sue from the maxillary sinus(es), is used to treat polyps, redundant mucous membrane, fungal debris, or bony partitions, and is report-ed with 31267 Nasal/sinus endoscopy; with removal of tissue from max-illary sinus. This procedure includes antrostomy, and may be per-formed alone or with other endoscopic sinus interventions.During frontal sinus exploration (31276 Nasal/sinus endoscopy, sur-gical with frontal sinus exploration, with or without removal of tissue from frontal sinus), the physician creates a permanent opening from the frontal sinus to the nose. The complexity of this procedure is de-termined by the site of obstruction to the outflow tract, disease with-in the sinus, or variations in frontal and ethmoid sinus anatomy, but the same code will always apply. The surgery focuses on removing the obstructing disease and restoring drainage.

Disorders of the sphenoid sinus are likely underreported, both be-cause they are unusual and due to lack of recognition. Headache is the most common symptom, and may be caused by inflammation or expansile lesions of the sphenoid sinus. During sphenoidotomy, an opening is created into the anterior or front wall of the sinus to allow for improved drainage. Select 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy for this procedure. For a more extensive proce-dure, which would involve removal of tissue from the sphenoid sinus, assign instead 31288 Nasal/sinus endoscopy, surgical, with sphenoidot-omy; with removal of tissue from the sphenoid sinus.

Stereotactic Navigation Calls for Additional CodingAn important component of FESS is the use of the stereotactic com-puter assisted navigation (61782 Stereotactic computer-assisted (nav-igational) procedure; cranial, extradural). This image guidance pro-vides for the navigation and localization of high-risk anatomical ar-eas adjacent to the sinuses, such as the optic nerve. In its guidelines for “Intraoperative Use of Computer Aided Surgery,” the American Academy of Otolaryngology gives the following examples as indica-tions for use of the navigational system:

• Revision sinus surgery• Distorted sinus anatomy• Extensive sino-nasal polyposis• Pathology involving the frontal, posterior ethmoid and

sphenoid sinuses• Disease abutting the skull base, orbit, optic nerve or carotid

artery• Cerebrospinal fluid (CSF) rhinorrhea or conditions where

there is a skull base defect• Benign and malignant sino-nasal neoplasms

Clinical coding example: A 56-year-old male with a history of chronic sphenoid sinusitis presents with chronic headaches. A CT scan shows opacification in the sphenoid sinus and bilateral eth-moid sinus disease. Findings: Polyps and pus in the sphenoid sinuses were seen, along with green thickened debris in the lateral aspect of the right sphenoid sinus. Mucosal swelling in the ethmoid air cells and osteitic bone was noted. Maxillary sinuses were free of disease.Procedure: The patient is taken to the operating room (OR) and

28 AAPCCodingEdge

Feature

general anesthesia is induced. The LandmarX image guided head frame is placed on the patient’s forehead and her anatomy is calibrat-ed to within 2 mm accuracy. The right side of the nose is addressed first. Via transethmoid approach, a sphenoidotomy is created. Pol-yps and pus are found within the sinus. The microdebrider is used to remove polyps and diseased mucosa. Pus is irrigated. Total right ethmoidectomy was then performed under image guid-ed assistance. Air cells were seen along the skull base and some os-teophytic bone. This was all removed. The left side was addressed and identical procedures were carried out. The sinus cavity was then irrigated with dilute hydrogen peroxide and suctioned clear. Afrin pledgets were placed into the nasal cavity and tied in front of the col-umella. Sponge and needle count was accurate. The patient was then awak-ened from general anesthesia, extubated, and transferred to the re-covery room in stable condition.

CPT® code assignment for this example includes:• 31255-50 for the documentation of the bilateral total

ethmoidectomies• 31288-50 for the sphenoidotomy with removal of polyps and

tissue from the sphenoid sinuses• 61782 for the LandmarX navigational procedure

Use Dedicated Codes for Balloon SinuplastyCPT® 2011 established three codes to report endoscopic dilation of the sinus ostia. Code 31295 Nasal/sinus endoscopy, surgical; with di-lation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa describes endoscopic dilation of the maxillary sinus os-tium, either transnasally or via the canine fossa. Both CPT® and the National Correct Coding Initiative (NCCI) consider 31295 to be an inclusive component of 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy and 31267 Nasal/sinus endoscopy, surgical, with

Learn Your Way Around the SinusesThe paranasal sinuses are air-filled pockets located within the bones of the face and around the nasal cavity. There are four pairs, each named for the bone in which it is located:

{ Maxillary sinuses - located in the cheekbones under the eyes

{ Ethmoid sinuses - 6-12 small sinuses per side, located between the eyes

{ Frontal sinuses - located in the forehead

{ Sphenoid sinuses - behind the ethmoid sinuses, near the middle of the skull

Each of these sinuses has an opening, called an ostium, connecting it to the nose

In the lateral wall of the nose are the superior, middle, and inferior tur-binates. Each turbinate is a rounded projection that extends the length of the nasal cavity.

The inferior turbinate (the largest of the three) runs parallel to the floor of the nose.

The middle turbinate is part of the ethmoidal bone and projects from the lateral wall of the nasal cavity. It is just above the middle meatus into which the anterior ethmoid cells open. The middle turbinate and the middle meatus together represent the key area of the nose, known as the osteomeatal complex (OMC).

The superior turbinate, located above the middle turbinate, is the small-est of the turbinates and is not commonly associated with significant sinus disease.

The nose also contains the nasal septum, which divides it into two nasal cavities. The most common diagnosis involving this anatomic area is a deviated septum (ICD-9-CM 470 Deviated nasal septum), in which the top of the cartilaginous ridge leans either to the left or the right, causing an obstruction of the affected nasal passage. The condition can result in poor drainage of the sinuses.

EthmoidAirCells(Sinus)

FrontalSinus

SphenoidSinus

Nasal Cavity andMiddleTurbinate

MaxillarySinus

SuperiorTurbinate

MiddleTurbinate

InferiorTurbinate

Illustrations © Ingenix OptumInsight


Feature

Disordersofthesphenoidsinusarelikelyunder-reported

becausetheyareunusualandduetolackofrecognition.

maxillary antrostomy; with removal of tissue from maxillary sinus. Do not report 31295 separately when performed on the same si-nus as either 31256 or 31267.To report balloon dilation of the frontal si-nus ostium, turn to 31296 Nasal/sinus en-doscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation). Instructional notes indicate this code is not reported with 31276 when performed on the same sinus. Finally, for balloon sinuplasty of the sphe-noid sinus ostium, report 31297 Nasal/si-nus endoscopy, surgical; with dilation of sphe-noid sinus ostium (eg, balloon dilation). Per CPT® instructions, do not report 31297 with 31235 Nasal/sinus endoscopy, diagnos-tic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium),

31287, or 31288 when performed on the same sinus.CPT® guidelines that accompany 31295-31297 indicate that fluoroscopy, if used, is an inclusive component of these codes and should not be separately reported. Also, as with the other endoscopic sinus procedure codes, these codes report unilateral proce-dures unless otherwise specified. Clinical coding example: A 66-year-old patient with chronic maxillary sinusitis who has failed medical management presents for bilateral balloon dilation of the max-illary ostium. The patient is taken to the OR, where general anesthesia is admin-istered and an intranasal vasoconstrictive agent is injected. Using the endoscope, a guidewire is introduced transnasally into

the right maxillary ostia. A balloon is then passed over the guidewire and introduced into the maxillary ostia. The position of the guidewire and balloon are confirmed via en-doscope. The balloon is inflated, which dis-places bone and mucosa and results in dila-tion of the right maxillary ostia. The bal-loon is then deflated and removed. The pro-cedure is repeated in the left maxillary os-tia. The documented procedure is reported as 31295-50.

Laurette Pitman, RN, CPC-H, CGIC, CCS, is an outpatient consultant for Laguna Medical Systems, the coding and compliance service area of Springfield Service Corporation. She has over 30 years’ experience in the health care field, including ED and OR nursing, cod-ing, and DRG and APC auditing. For more infor-

mation, go to www.lagunamedsys.com or contact Ms. Pitman at [email protected].

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30 AAPCCodingEdge

By Melissa Brown, RHIA, CPC, CPC-I, CFPC

Cover Story

Code Fat Albert’s HERNIA REPAIRin 5 Easy StepsPush your hernia coding to where it belongs, with the experts.

Comedian Bill Cosby tells an entertaining story about being the cen-ter of attention after he gave himself a hernia lifting a heavy sewer lid. The punch line involves what happens when Fat Albert—the car-toon character voiced by Cosby—gets a hernia of his own. As I lis-tened to the story with my kids recently, my coder brain kicked into gear. What kind of hernia did he have? How would you code the re-pair? In the process of satisfying my curiosity, I found some great in-formation to share about hernias.A hernia occurs wherever an internal body part pushes beyond a confining wall into an area where it doesn’t belong. There are many types of possible hernias; however, let’s focus on the hernia types ad-dressed in CPT® codes 49491-49659. These codes are classified by hernia type, with additional classifications for episode, clinical pre-sentation, and patient age. Although there are many approaches to surgically repairing a hernia, they share a common theme. Generally, an incision is made over the

hernia, and the hernia sac is dissected from any surrounding structures. The contents are ex-amined for viability and returned to their orig-inal site, if appropriate. Depending on the size of the hernia sac, the sac may be ligated and re-sected. The muscle tissue is repaired and the in-cision is closed. A mesh or other prosthetic may be used for reinforcement of the muscle wall.

1. Identify the Type of HerniaTo select an appropriate repair code, first iden-tify the types of hernias described in 49491-49659.Inguinal Hernia (49491-49525, 49650-49651): An inguinal hernia is a very common hernia that occurs when abdominal contents (such as the intestines) protrude through the inguinal canal due to a weak point in the low-er abdominal wall. These are commonly re-ferred to as groin hernias because they appear just above the leg crease, close to the pubic area. CPT® code selection does not differentiate be-tween direct (superficial inguinal ring) and in-direct (deep inguinal ring) inguinal hernias.

Hiatal Hernia

Diaphragm

Epigastric Hernia

Incisional Hernia

Umbilical Hernia

Inguinal Hernia

Apprentice

Illustrations © Ingenix OptumInsight


Cover Story

Lumbar Hernia (49540 Repair lumbar hernia): Not to be confused with the lumbar disk hernia, lumbar hernias are rare hernias occur-ring through defects in the parietal abdominal wall in any area of the lumbar region (between the last rib and the iliac crest where the transverse muscle is covered by the latissimus dorsi). Femoral Hernia (49550-49557): Femoral hernias are visible in the upper part of the thigh near the groin. They are often hard to distin-guish from inguinal hernias on examination alone, although they typically occur lower in the groin (near the inner thigh).Incisional (49560-49568, 49654-49657): When the hernia occurs at the site of a previous abdominal surgery (incision), it is called an in-cisional hernia. The incision for surgery creates an area of weakness, making it prone for herniation. These hernias may appear weeks, months, or even years after the surgery. Ventral (49560-49568): Ventral means front (from Latin, mean-ing belly), so a ventral hernia is one that occurs anywhere on the ab-domen. Ventral hernias commonly occur along the midline of the abdominal wall. Epigastric (49570-49572): These are similar to the umbilical her-nia, but are situated higher between the breastbone and the belly but-ton (picture the six pack abdominal muscles area). Epigastric herni-as are typically made up of fat rather than internal organs. Epigastric hernias are not synonymous with hiatal hernias. Hiatal hernias oc-cur when part of the stomach protrudes up into the chest through a weakness in the diaphragm at the hiatus. Umbilical (49580-49587): Umbilical hernias are most often seen in infants, at or near the bellybutton. This area has a natural weak-ness from the blood vessels of the umbilical cord, presenting a prime location for a hernia. It is possible for the area of weakness to persist through adulthood; these types of hernias are not limited to pedi-atric patients.Spigelian (49590 Repair spigelian hernia): The spigelian hernia is sometimes referred to as a lateral ventral hernia. These hernias oc-cur laterally along the outer edge of the six-pack abdominal muscles in the spigelian fascia. These hernias occur between the muscles of the abdominal wall and are difficult to detect due to little outward evidence of swelling. Omphalocele (49600-49611): This birth defect occurs when the infant’s abdominal wall does not develop properly. The intestine or

other abdominal organs remain outside the abdomen, through the umbilicus, and is covered only by a thin layer of tissue.

2. Define the Episode of CareTo report hernia repair appropriately, you must often know the epi-sode of care. An initial hernia is one that has not been previously re-paired. A recurrent hernia is one that appears at the site of a previ-ous hernia repair. This can happen if the incision site weakens, or if there is infection or improper healing of the wound. The condi-tions that caused the original hernia (for example, obesity or nutri-tional disorders) may persist and encourage the development of a re-current hernia.

3. Verify the Clinical PresentationAnother factor that determines correct coding is clinical presenta-tion of the hernia. When the contents of the hernia sac return to their normal location spontaneously or by gentle manipulation, the hernia is considered reducible. While moving the contents may make the hernia appear smaller or disappear, the weakened tissue still needs to be repaired to avoid recurrence of the hernia. When the herniated tissue becomes trapped and cannot be pushed back (reduced), the result is an incarcerated hernia, also called a strangulated hernia. Incarcerated hernias are more worrisome be-cause they run greater likelihood of becoming strangulated, which happens when the blood supply to an incarcerated hernia is cut off. These types of hernias are dangerous due to the risk of gangrene when tissues die.

4. Determine Patient AgeAccording to instruction in the CPT® manual, when the patient’s age is necessary for code selection of hernia repairs, use the patient’s age at the time of the surgery. CPT® notes also help with the calcula-tion of post-conception age, as needed, for codes 49491-49496. The notes instruct us to use gestational age at birth plus age in weeks at the time of the hernia repair.

5. Put It All TogetherNow that you know what to look for, apply the steps to an actual note:PROCEDURE IN DETAIL: The 12-year-old (step 4: identify pa-tient age) male patient was prepped and draped in the sterile fash-

Whenthecontentsoftheherniasacreturnto

theirnormallocationspontaneouslyorbygentle

manipulation,theherniaisconsideredreducible.

32 AAPCCodingEdge

Cover Story

AccordingtoinstructionintheCPT®manual,whenthe

patient’sageisnecessaryforcodeselectionofhernia

repairs,usethepatient’sageatthetimeofthesurgery.

ion. An infraumbilical incision was formed and taken down to the fascia. The umbil-ical hernia (step 1: identify type) carefully reduced (step 3: clinical presentation) back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Mar-caine. The skin was reattached to the fas-cia with 2-0 Vicryl. The skin was approxi-mated with 2-0 Vicryl subcutaneous, and

then 4-0 Monocryl subcuticular stitches, and dressed with Steri-Strips and 4 x 4’s. Patient was extubated and taken to the re-covery area in stable condition.Note, for Step 2: Define the Episode of Care, there is no reference to a prior repair, so this would be treated as an initial hernia. Armed with this information, we can look at codes 49580-49587. Because the pa-tient is over 5-years-old, we narrow the se-lection to 49585-49587. And, because we

know the hernia was reducible, we can se-lect 49586 Repair umbilical hernia, age 5 years or older; reducible.

Melissa Brown, RHIA, CPC, CPC-I, CFPC, is manager of reimbursement and quality im-provement, University of Florida Jacksonville Physicians, Inc. She has 19 years of experi-ence in the health care industry. Ms. Brown’s areas of expertise also include fee analysis, budgeting and Physician Quality Reporting System (PQRS). Toastmasters International

awarded her its highest honor, Distinguished Toastmaster (DTM). She served as co-director of the annual “Coding on the River” convention in Jacksonville, Fla. for several years.

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34 AAPCCodingEdge

ICD-10 Road Map

By Julia Croly, CPC, CPC-P, CPC-I

ICD-10 Testing, Testing ... 1-2-3Lessen testing anxiety by following a timeline, creating a taskforce, and executing a plan.

ICD-10 implementation testing can be frightening. But how often have you found that when you are prepared for a test, it’s not as bad as you originally anticipated? Such is the case with ICD-10: With care-ful preparation, in just three steps, you can earn an A+.As you prepare for ICD-10 testing, keep these essential goals in mind:

• Testing needs to include ICD-10 and any projects underway.• Testing needs to be robust, due to the high number of code

changes.• Testing needs to ensure financial neutrality.• Testing may need to ensure dual processing (e.g., both ICD-9

and ICD-10 functionality).• Testing must include considerations for trading partners.• Testing must be coordinated.

1. Create a Timeline to Begin Testing in Mid-2012Your timeline should include several key events, such as when to be-gin testing. Many organizations, for example, are drafting timelines for ICD-10 implementation testing to occur from mid-2012 up to the compliance date of Oct. 1, 2013, as shown below. But there is no “one size fits all” suggested start date: The actual testing kickoff date depends on each organization. And like many organizations, you may want to segregate internal and external testing to account for vendor dependencies and the deep penetration of ICD-10 code in systems and processes.

2. Create a TaskforceEstablishing a testing taskforce helps to manage the testing effort. The taskforce oversees complete, integrated testing, and forms mul-tiple workgroups, each of which is in charge of a particular testing ef-fort. Communication among the workgroups is essential.

This effort is complex and requires a high-level test plan to address the overall requirements and the design details of subsystems and components. Test plan document formats can be as varied as the products and organizations to which they apply, but generally con-tain some common features, including:1. Test coverage in defining scope and objectives2. Identification of business areas and participants, including

roles and responsibilities 3. Testing methodologies and functions to tests 4. Identifying risk factors that may jeopardize testing5. A testing schedule

In the past, testing has focused on the transaction and whether it can be initiated, received, and understood correctly. Testing in the case of ICD-10 must involve all of the aforementioned, plus validation that business rules continue to work as designed pre-ICD-10. To help your team effort, collaborate in developing test strategies, test cases, and test scripts. Workgroups should develop specific guidelines and standard operating procedures for testing, and indi-cate desired end results for modifications made along the way. Cre-ating a test environment separate from production will greatly facil-itate this effort. The testing effort will produce a great deal of information. Use tools to log and track your findings throughout all testing. Change logs are highly recommended to maintain control over individual chang-es, and to track subsequent effects of those changes. From this infor-mation, metrics can be extracted to measure and track project mile-stones. A risk-based approach to testing helps ensure that changes, delays, and other unforeseen obstacles can be dealt with effectively. Chang-es, especially to older systems, can create unforeseen bugs unrelat-

Compliance Date

In-depth Impact Assessment

Final Rule Published

Discovery/High-level Impact Assessment

Planning and Implementation

DesignTesting Evaluate

Implementation and Integration

Gaining Value

2009 2010 2011 2012 2013 2014 2015


ICD-10 Road Map

ed to the ICD-10-CM/ICD-10-PCS conversion. The more robust your testing efforts, the better off you will be.

3. Begin TestingInternal TestingAfter the necessary ICD-10 changes have been made, it’s time to test information technology (IT) systems and business processes. Internal testing identifies lo-calized system glitches that may occur when creating and receiving transactions that contain ICD-10 codes. Internal testing also encompasses manual and work-flow processes using diagnosis and procedure codes (in collection, reporting, or both). Every change to a system or application must be tested before it goes into production. Testing can be broken into the following categories:

• Quality Assurance: This answers the question, “Do all of the changes made provide the expected outcome?”

• User Acceptance Testing: This testing should be planned and executed by participants from the business area affected by the changes. These participants will sign off that the systems are functioning properly and workflow design is accurate and suitable for the purpose intended. With this effort, it’s critical there are no gaps in functionality.

• Integration Testing: This combines the parts to determine if they are working together.

• Regression Testing: This ensures there is no impact on previously tested results, and retests the programs to ensure there is an increase in functionality and stability. Don’t forget to test business processes not affected by ICD-10 (these may be few and far between), preferably using an automated testing tool.

• Performance Testing: This is done to ensure the system provides acceptable response times, and to identify and remove all bottlenecks that may result in less-than-optimal performance. Testing system compliance through

performance testing is usually done with a large number of users.

• End-to-end Testing: This involves testing the interfacing applications and the full life cycle of a claim from receipt to payment to data storage. It also tests business processes to ensure the desired outcome.

Remember: Internal testing must include not only time for testing, but also remediation and retesting. External testingOrganizations often depend on third-party vendors and trading partners; and with ICD-10 compliance testing, you must ensure the desired functionality is achieved and business processes are maintained.Planning and coordination are essential to external testing because such testing involves coordinating with many entities. Remediated application availabil-ity should be obtained well in advance to planning for testing activities. From the impact analysis, have a list of third-party vendor and trading partners that must be contacted to discuss testing expectations. Prioriti-zation involves identifying those who are most critical to ensuring compliance. Scheduling follows prioriti-zation. In case a vendor or trading partner is not ready on the agreed-upon date, flexibility and contingency planning may be necessary. Just as with internal testing, there needs to be adequate time for testing, remediation, and retesting to ensure desired functionality. The purpose of external testing is to identify any issues that must be resolved prior to the compliance deadline.Testing is just one component of ICD-10 implementa-tion, but it’s a critical step that is often underestimat-ed. To limit your stress and minimize operational and financial risk to your practice or facility: Understand the complexity of ICD-10 implementation; establish a timeline that includes both internal and external test-ing; and create a detailed plan.

Julia Croly, CPC, CPC-P,CPC-I, has 25 years experience in health care insurance and works as an independent health care consultant and educator in Honolulu, Hawaii. She can be reached at [email protected].

Changes,especiallytooldersystems,cancreateunforeseen

bugsunrelatedtotheICD-10-CM/ICD-10-PCSconversion.

Themorerobustyourtestingefforts,thebetteroffyouwillbe.

36 AAPCCodingEdge

Added Edge

Deal with Difficult People by Managing Hot ButtonsDon’t let a hijacked amygdala take control of your on-the-job emotions.

Coders sometimes function in emotionally charged situations. This environment can leave you feeling stressed, drained, and burned out. The key to taking care of your emotional needs

is to take charge of your reactions. By understanding how difficult behaviors trigger hot buttons, you can choose responses that neu-tralize negativity, reduce personal stress, and create a more positive work environment.

When the Amygdala Attacks … When you encounter behavior you perceive as difficult, the brain registers a threat. For example, an aggressive superior can threat-en your sense of security, resulting in anxiety or confusion; a judg-mental peer may produce feelings of doubt; a sarcastic administra-tor could leave you feeling agitated. In each of these examples, a hot button has been pushed. A hot button is a personal trigger that sends an individual’s emotions plummeting. You are not at liberty to pre-vent the detonation. But, you are at liberty to choose how to respond to that detonation. It is this choice that determines your subsequent feelings: increased stress and agitation or calmness and well-being.Of course, not all difficult behaviors are experienced as threats. For example, you may be very adept at dealing with demanding consul-tants. These situations rarely rattle you. Yet, another coder may en-counter this same circumstance as intimidating and threatening. Her hot button is pushed, and she becomes flooded with negative feelings. What accounts for this difference? The answer lies with the “amygdala,” an almond-shaped cluster of interconnected structures in the emotional center of the brain, the limbic region. The amygdala stores emotional memory; much of it based on early childhood experiences. Incoming signals from the senses let the amygdala scan every experience for trouble. Dan-iel Goleman, in his book Emotional Intelligence, explains that when the amygdala perceives a threat based on its stored emotional mem-ory, it “reacts instantaneously, like a neural tripwire, telegraphing a message of crisis to all parts of the brain … The amygdala’s extensive web of neural connections allows it, during an emotional emergen-cy, to capture and drive much of the rest of the brain—including the rational mind.” In other words, the neocortex, or rational part of the brain, has been hijacked by the amygdala. When the amygdala is activated, you will have a knee-jerk reaction. You are now emotionally flooded, with little access to reason. This process happens within nanoseconds, and produces responses char-acterized by distorted perceptions, invalidation, defensiveness, and biased judgment. It also leads to the fight-or-flight response.

Managing Your Hot ButtonsThe key to dealing with difficult people is to shift your focus from others’ behavior (over which you have no control), to your own re-sponse (over which there is total control). To understand why, let’s again examine the way the brain functions.

By Dana Lightman, Ph.D.


Added Edge

When threatened, the brain searches for a sense of control and au-tonomy. It detects that the individual is back in charge when it sens-es the ability to make a choice. What matters most to the brain is the perception of choice. In other words, if you have been hijacked by your amygdala you don’t have to involve the difficult person in your choices. You just have to let your brain know that there are choic-es to be made. One simple choice that deactivates the amygdala is to put feelings into words. Researchers have found, for example, that when people attached the word “sad” to a sad-looking face, the amygdala response decreases and response in the right ventrolateral prefrontal cortex (the part of the brain that controls impulses) increases. In practical terms, when your hot button has been pushed, you can simply acknowledge how you feel: “This is anxiety” or “This is fear.” You then can make a choice by asking yourself, “How do I choose to handle this?” In this way, you have decreased the brain activity that leads to automatic stress responses and tapped into the brain area re-sponsible for self-control and logic.David Rock, author of Your Brain at Work, describes another strat-egy for regaining a sense of control: “I decide to be responsible for my mental state instead of being a victim to circumstances. In the instant that I make this decision, I start seeing more information around me, and I can perceive opportunities for feeling happier. This experience is one of finding a choice and making that choice, and it shifts what and how I perceive in that moment. The idea of con-sciously choosing to see a situation differently is called reappraisal.”

Three Ways to Take Control of Your Hot ButtonsHow can you use reappraisal to manage hot button reactions? One technique is to find a way to interpret facts to lessen the threat. For example, by keeping in mind that overbearing superiors may be hi-jacked by their superiors, you now have an interpretation of the situ-ation that diminishes your hot button trigger. Another technique is to recognize that you are not alone in your reaction to certain diffi-cult individuals. This process of normalizing diminishes the brain’s threat arousal. Another reappraisal tactic is to look at an event from another’s per-spective. For example, consider this situation: Your work style is task-oriented. You like to get a job completed as quickly as possible. Your coding colleague likes to build relationships by chatting before fo-cusing on a task. You like to stay on task and become frustrated and

angry listening to your colleague “schmooze.” To lessen your an-ger, you can choose to see the situation through the eyes of your col-league, reappraising your initial reaction that your peer is stalling and instead interpreting your colleague’s behavior as meeting a need for comfort by talking. This type of reappraisal works well for differ-ences in work styles, values, use of time, and cultural backgrounds. A third strategy to manage hot button reactions comes from the work of Barbara Fredrickson. Her research demonstrates that nega-tive emotions tend to linger in your mind. In other words, once the amygdala is activated, the end result is not only negative feelings, but also a negative mood. To curtail the impact of negative emotions, Fredrickson suggests deliberately choosing to counteract negative emotions with positive ones. For example, when you’re hijacked, you might take a moment to think of a happy time, picture a loved one, or remember a pleasurable event. By choosing to replace negative feel-ings with positive ones, you are back in control.

Take-away LessonsOvertaxed colleagues may be in foul moods; physicians can be rude and demanding; and consultants might challenge your decisions. Although you may understand the reasons for these over-the-top be-haviors, one too many difficult encounters can push your hot button. By choosing to be “response-able”—that is, able to choose your re-sponses—you become empowered. By choosing to stop focusing on someone else’s behavior and instead shift attention to your own re-sponse, you can experience enormous relief and personal well-being.

ReferencesFredickson, B.L. (2009). Positivity: Groundbreaking Research Reveals How to Embrace the Hidden Strength of Positive Emotions, Overcome Negativity, and Thrive. New York: Crown.Goleman, D. (1995). Emotional Intelligence: Why It Can Matter More than IQ. New York: Bantam Books.Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S., Pfeifer, J. H., Way, B. M. (2007). Putting Feelings into Words: Affect Labeling Disrupts Amygdala Activity to Affective Stimuli. Psychological Science, 18, 421-428. Rock, D. (2009). Your Brain at Work: Strategies for Overcoming Distraction, Regaining Focus, and Working Smarter All Day Long. New York: HarperCollins.

Dana Lightman, Ph.D., is a national keynote speaker and trainer. An expert in posi-tive psychology, she is the creator of POWER Optimism and author of the “No More Dif-ficult People” series. For more information, visit www.danalightman.com.

… by keeping in mind that overbearing superiors may be

hijacked by their superiors, you now have an interpretation

of the situation that diminishes your hot button trigger.


38 AAPCCodingEdge

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BerthaSmith, CPC-ABethDay, CPC-ABethGoupillon, CPC-H-ABethLicter, CPC-ABethanneThomas, CPC-ABettyAnneRenshaw, CPC-ABettyHarris, CPC-ABeverleyGrunewald, CPC-ABeverlySmith, CPC-ABevinMann, CPC-ABlancaGuajardo, CPC-ABlancheBast, CPC-ABobbieNicholeHamilton, CPC-ABonnieNiec, CPC-ABrandyStevens, CPC-ABreanneTMcleod, CPC-ABrendaAtwell, CPC-ABrendaMoore, CPC-ABrennaMcCallum, CPC-ABrianneMills, CPC-ABritainBanksSingleton, CPC-ABrittanyDaphinePainter, CPC-ABrittanyPaigeArmstrong, CPC-ABrittanySizemore, CPC-ABryanEagle, CPC-ABryannaJohnson, CPC-ACarlaGrady, CPC-ACarlaJohnson, CPC-ACarlaMcGann, CPC-ACarlaRayner, CPC-ACarmenAnaMelendez, CPC-ACarolBroughton, CPC-ACarolLGoodman, CPC-ACarolUhl, CPC-ACarolineFoasberg, CPC-ACarolynSusanPomeroy, CPC-ACarriePridgen, CPC-ACaseyCross, CPC-ACaseyHeard, CPC-ACassandraLynnWiest, CPC-ACatherineAnneAult, CPC-ACatherineKinney, CPC-ACatherineMizell, CPC-ACatherineSullivan, CPC-ACatherineYoung, CPC-ACeasarTriaDatu,CPC-A, CPC-H-ACeciliaBuccieri, CPC-ACeciliaFlores, CPC-AChaletteDallas, CPC-AChantellLee, CPC-AChariceBaldon-Traynham, CPC-ACharleneArdis, CPC-ACharlesAllender, CPC-ACharlotteCaton, CPC-ACharlotteCoughenour, CPC-ACharlotteSCrump, CPC-ACharlotteVanDerLouis, CPC-AChelseaDuboise, CPC-AChelseyAnneCyr, CPC-ACheriKidder, CPC-ACherylL.Mendenhall, CPC-ACherylLouiseKriesch, CPC-AChiChenHong, CPC-AChristianDavid, CPC-AChristianLytle, CPC-AChristianMichaelElliott, CPC-AChristieValdez, CPC-AChristinaMaeGrady, CPC-AChristinaMendez, CPC-AChristineASprague, CPC-AChristineAkana, CPC-AChristineCoppola, CPC-AChristineRuther, CPC-AChristopherNaraysingh, CPC-ACiaraChatters, CPC-ACindyMurphy, CPC-ACindyPhipps, CPC-AClaireSabatino, CPC-AClaudiaLozano, CPC-AClaudineLashley, CPC-ACliffordGerhart, CPC-ACloraEHanna, CPC-ACodyJensen, CPC-AColleenMarieIsom, CPC-AConnieAddyman, CPC-A

CoriMiller, CPC-ACourtneyLynnStidham, CPC-ACristinaNikolopoulos, CPC-ACrystalHill, CPC-ACrystalLynnClark, CPC-ACrystalYates, CPC-ACrystalYvonneMata, CPC-ACynthiaFallis, CPC-ACynthiaGarrison, CPC-ACynthiaKoscinch, CPC-ACynthiaKottke, CPC-ACynthiaLamano, CPC-ACynthiaYepez, CPC-ADagmarTaff, CPC-ADanaeStephenson, CPC-ADanielKKoesterer, CPC-ADanielleBasta, CPC-ADanielleJackson, CPC-ADanielleJessieCampbell, CPC-ADanielleKristineSeeger, CPC-ADanielleMAllen, CPC-ADanielleMallozzi, CPC-ADanielleMichelleOlson, CPC-ADanielleRaeWilliams, CPC-ADarinH.Stone, CPC-ADarlaRaeZehr, CPC-ADarlaReed, CPC-ADarleneMaloney, CPC-ADarrylCurtis, CPC-ADavidDanner, CPC-ADavidDykstra, CPC-ADavidForst, CPC-ADavidHoward, CPC-ADavidRobertZeinert, CPC-ADawnBest, CPC-ADawnMariePaulini, CPC-ADawnMichelleMessier, CPC-ADawnPolidore, CPC-ADawnSTough, CPC-ADawnTaddeo, CPC-ADawnTucker, CPC-ADeannaMLisonbee, CPC-ADebbieFlemings, CPC-ADebbieFredrickson, CPC-ADebbieKWright, CPC-ADeborahAStewart, CPC-ADeborahSmith, CPC-H-ADebraAnnNeeley, CPC-ADebraEllenWhite, CPC-ADebraJSofia, CPC-H-ADebraMargaretWade, CPC-ADebraParker, CPC-ADebraReneeHalberg, CPC-ADebraSWolfCPC-A, CPC-ADeepaChandramohan, CPC-ADeliaPopovich, CPC-ADeniseEckert, CPC-H-ADeniseHawkins, CPC-ADeniseIvetteRamirez, CPC-ADeniseLynnMcCoy, CPC-ADeniseOrin, CPC-ADeniseSmith, CPC-ADennisR.Mejia, CPC-ADesireeRodriguez, CPC-ADesireeStraehla, CPC-ADianaIvetteParedes, CPC-ADianaOruciAdams, CPC-ADianeJacquez, CPC-ADianeKahre, CPC-ADianeWalsh, CPC-ADianeZiegler, CPC-ADiannaLouiseMcCarthy,CPC-A, CPC-H-ADianneMClarke, CPC-ADiatrixKinney, CPC-ADinaLeon, CPC-ADinaBuccieri, CPC-ADollieAnnWallace, CPC-ADominiqueKatieSpiller, CPC-ADonaldRCox, CPC-ADonnaBurtt, CPC-ADonnaJeanneeneRousseau, CPC-ADonnaTedone, CPC-ADori-LynnCoe, CPC-ADorotaLiczbinska, CPC-AEberFuller, CPC-H-A

EdwardEarlGlomski, CPC-AEileenBlouch, CPC-AEileenTPianka, CPC-AEkaterinaDubrovina, CPC-AElizabethAKilroy, CPC-AElizabethAnnMatty, CPC-AElizabethAppleby, CPC-AElizabethBrooks, CPC-AElizabethBurris, CPC-AElizabethCastano, CPC-AElizabethFNigels, CPC-AElizabethGrayceLoycano, CPC-H-AElizabethIshley, CPC-AElizabethMarkle, CPC-AElizabethRodriguez, CPC-AElizabethRodriguez, CPC-AElizabethRubritz, CPC-AElizabethThorley, CPC-AEllaRomano, CPC-AEllenJohnson, CPC-AElyssaDiaz, CPC-AEmilyASnyder, CPC-AEmilyBrockway, CPC-AEmilyJaneKnollenberg, CPC-AEricQuivers, CPC-AEricaHellmann, CPC-AErikaGomez-Wesby, CPC-AErikaMarieAdler, CPC-AErinDrogin, CPC-AErinFinnegan, CPC-AErinKathleenMcNulty, CPC-AErinStalnaker, CPC-AEspanolaObligacion, CPC-AEstrellaRodriguez, CPC-AEvelynGJohn,CPC-A, CPC-H-AEvelynNavarro, CPC-AFawnProvost, CPC-AFayeAnnRamey, CPC-AFayeHarker,CPC-A, CPC-H-AFeliciaGodwin, CPC-AForrestRJCampbell, CPC-AFrancesBrocato, CPC-AFrancesWEwing, CPC-AFranciscaSantiago, CPC-AFredGumbert, CPC-AGailDishman, CPC-AGaleTSibbald, CPC-AGayleErickson, CPC-AGaynelleDucharme, CPC-AGeethaLakshmiRajamohan, CPC-AGeetharaniRaja, CPC-AGenaRoseVieira, CPC-AGeneSoloway, CPC-AGenevaFonseca, CPC-AGennyLeeWegenke, CPC-AGertrudeDini, CPC-AGinaD’Annunzio, CPC-AGinaLee, CPC-AGlenaButaslacLoyola, CPC-AGlennParker, CPC-AGloriaFlowers, CPC-AGloriaHettinger, CPC-AGloriaHurtado, CPC-AGloriaMartinez, CPC-AHaleyKristinaCoffin, CPC-AHannahMarieBreese, CPC-AHarmanikaKohli, CPC-AHeatherAkridge, CPC-AHeatherBell, CPC-AHeatherCormier, CPC-AHeatherJoBenavides, CPC-AHeatherLCarlson, CPC-AHeatherReagan, CPC-AHeidiBerman, CPC-AHeidiSmith, CPC-AHenaMercibaDavamani, CPC-AHollieRoseman, CPC-AHollyFaust, CPC-AHollyRuddWaters, CPC-AIanKo, CPC-AIanMurray, CPC-AIbeLapYanChanLeung, CPC-AIkeSteitzer, CPC-AIswaryaKannaiyan, CPC-AIvaniaWiese, CPC-A

Newly Credentialed Members

40 AAPCCodingEdge


JackieLouSantos, CPC-AJackieTryon, CPC-AJacquelineAMorse, CPC-AJacquelineMartinez, CPC-AJaculinMarieAuer, CPC-AJaimeMedeiros, CPC-AJakairaRodriguez, CPC-AJalisaPearlineClark, CPC-AJaneneEyster, CPC-AJanetCHappel-Dayer, CPC-AJanetEdwards, CPC-AJanetHobgood, CPC-AJanetLunceford, CPC-AJanetMcMahon, CPC-AJaniceAbe, CPC-AJaniceAguilar, CPC-AJaniceAnnMoore, CPC-AJaniceDesrosiers, CPC-AJanineCuddy, CPC-AJannaAbney, CPC-AJannaTanelleKlinedinst, CPC-AJasminYap, CPC-AJasmineCourtney, CPC-AJasonJohnPastrana, CPC-AJayakumarRamalingam, CPC-AJayshreeShah, CPC-AJeanGoodwin, CPC-AJeanLafrenaye, CPC-AJeanMarren, CPC-AJeanetteDornRoberts, CPC-AJeanneCallahan, CPC-AJeannieMariMorgan, CPC-H-AJeffreyHewartson, CPC-AJenaCruz, CPC-AJenniferBrinkdoepke, CPC-AJenniferJuneCasco, CPC-AJenniferKindel, CPC-AJenniferLGuyton, CPC-AJenniferLynHartley, CPC-AJenniferMcBee, CPC-AJenniferMcComas, CPC-AJenniferNoelleLemongelli, CPC-AJenniferPorter, CPC-AJennyConrath, CPC-AJennyDean, CPC-AJennyTerrill, CPC-AJeriLSlaughter, CPC-AJessicaAllison, CPC-AJessicaBarrington, CPC-AJessicaPSzydlo, CPC-AJessicaPritchard, CPC-AJessicaSoncrainte, CPC-P-AJessieVescovi, CPC-AJessieWilliford, CPC-AJoHonaker, CPC-AJoannBucci, CPC-AJoannKathrynMcCabe, CPC-AJoanneSharleenBrunson, CPC-AJodieA.Brown, CPC-AJodyAnderson, CPC-AJoeGrosso, CPC-AJoelManalo, CPC-AJohnEapen, CPC-AJohnJFingal, CPC-AJoronArmandoRoss, CPC-AJoseRSantiagoTorres, CPC-AJosefinaGarsulao, CPC-AJoshLieber, CPC-AJoshMones, CPC-AJoyceFreeman, CPC-AJoyceWilson, CPC-AJudithBodson, CPC-AJudithCarnes, CPC-AJudyWiles, CPC-AJudyBibler, CPC-AJudyElliott, CPC-AJudyRiebe, CPC-AJulieAnnBellile, CPC-AJulieElizabethPhillips, CPC-AJulieFox, CPC-H-AJulieHouchen, CPC-AJulieRau, CPC-AJunStarr, CPC-AJustinCudnik, CPC-AKadambariMurugan, CPC-AKalaRGardner, CPC-AKametraHickey, CPC-AKareConradBarney, CPC-AKarenBednar, CPC-AKarenBean, CPC-AKarenChauvette, CPC-A

KarenEPorter, CPC-AKarenForster, CPC-AKarenHillman, CPC-AKarenJBrashier, CPC-AKarenJeanPhillips, CPC-AKarenLGibbs, CPC-AKarenLShelly, CPC-AKarenLongo, CPC-P-AKarenOsler, CPC-AKarenSiegler, CPC-AKarenTauxe, CPC-AKarenYvonneKirk, CPC-AKariMcCafferty, CPC-AKarinAMcknight, CPC-AKarmenIzzard, CPC-AKarthiNedunzhalian, CPC-AKarthigaSivakumar, CPC-AKaseyRoseShawgo, CPC-AKashenWood, CPC-AKatharinaHenderson, CPC-AKatharineGhaner, CPC-AKatherineKiel, CPC-AKatherineHerring, CPC-AKatherineMCoady, CPC-AKatherineWard, CPC-AKathieCawthon, CPC-AKathleenASellnow, CPC-AKathleenCasario, CPC-AKathleenGadomski, CPC-AKathleenLaurenKepler, CPC-AKathleenRipplinger, CPC-AKathleenSchroeder, CPC-AKathleenWolf, CPC-AKathryn(Kaylee)LeeJoyBlodgett, CPC-AKathrynElliott, CPC-AKathryn(Kit)MarieShotwell, CPC-AKathyBertolotti, CPC-AKathyBlankenship, CPC-AKathyKlekot, CPC-H-AKathyMarieVonArx, CPC-AKathyMokma, CPC-AKathyRound, CPC-AKatieColleenHeinz, CPC-AKatieOlson, CPC-AKatieSleger, CPC-AKatieWoodrome, CPC-AKayeBole, CPC-AKaylaGillies, CPC-AKaylaWalker, CPC-AKayleeAnnBrown,CPC-A, CPC-H-AKelliMacon, CPC-AKelliciaFreeman, CPC-AKellyHunsicker, CPC-AKellyMayo, CPC-AKellyMayo, CPC-AKeriCarter, CPC-AKerrieBliss, CPC-AKevinMacaulay, CPC-AKeyonaDowns, CPC-AKimC.Dickinson, CPC-AKimKMorgan, CPC-AKimberlyShare, CPC-AKimberlyA.Brown, CPC-AKimberlyAnnHarp,CPC-A, CPC-H-AKimberlyAnnRamirez, CPC-AKimberlyBoege, CPC-AKimberlyDGreen, CPC-AKimberlyDawnSeeger, CPC-AKimberlyGonzalez, CPC-AKimberlyJeanMoore, CPC-AKimberlyKirby, CPC-AKimberlyMoon, CPC-AKimberlyReis-Fleming, CPC-AKimberlySBartlett, CPC-AKirstenOsorio, CPC-AKissandraWalker, CPC-AKodyFarnsworth, CPC-AKrescentMosley, CPC-AKrissieJ.Carden, CPC-AKristenBensel, CPC-AKristenNewell, CPC-AKristenRich, CPC-AKristiReismann, CPC-AKristieAliciaSpillman, CPC-AKristinaEdholm, CPC-AKristineReto, CPC-AKwasiDyson, CPC-AKyvanTonnu, CPC-AL.DenaeCarter, CPC-ALaShawnSullivan, CPC-ALaCendraSheppard, CPC-A

LakshmiDeviRavichandran, CPC-ALaquittaMoran, CPC-ALarryLainey, CPC-ALaShondaReneeYocum, CPC-ALataraFord, CPC-ALatoyaFrancis, CPC-ALauraAJuanico, CPC-ALauraDicicco, CPC-ALauraMatuszak, CPC-H-ALauraRocco, CPC-ALauraSchewe, CPC-ALaurenBoggs, CPC-ALaurenVaudo-Cynova, CPC-ALaurieMcGee, CPC-ALaurieThompson, CPC-ALeandraPayne, CPC-ALeAnneFiske, CPC-ALeeAnneSSmall, CPC-ALeighA.Johnson, CPC-ALesliNeebe, CPC-ALeslieAutrey, CPC-ALeslieCaskey, CPC-ALeslieConstable, CPC-ALeslieMcCall, CPC-ALesperCurry, CPC-H-ALeTeciaInezMorton, CPC-ALethaSueStory, CPC-ALeticiaPujadas, CPC-ALindaJones, CPC-ALindaMadsen, CPC-ALindaNelson, CPC-ALindaThompson, CPC-ALindsayCaron, CPC-ALindsayTrahan, CPC-ALinleyGibson, CPC-ALionelQuartneyLee, CPC-ALisaDavis, CPC-ALisaFranco, CPC-ALisaGarcia, CPC-ALisaKirkpatrick, CPC-ALisaKottke, CPC-ALisaLMccartney, CPC-ALisaMachacek, CPC-ALisaMarieFancovic, CPC-ALisaMartinez, CPC-ALisaWhisenhunt, CPC-ALizetMeza, CPC-ALolitaAHam, CPC-ALorandaThomas-Jones, CPC-ALoreeA.Keeble, CPC-ALorellaJuneMurrow,CPC-A, CPC-H-ALoriZohner, CPC-ALoriFarner, CPC-ALoriHardison, CPC-ALoriHurst, CPC-ALoriMIsner, CPC-ALoriMcAlester, CPC-ALoriVilla, CPC-ALornaLong, CPC-ALorraeAker, CPC-ALorraineIvandittoBloss,CPC-A, CPC-H-A,CPC-P-ALorriHathaway, CPC-ALorrieMayo, CPC-ALouCarter, CPC-ALouettaBucher, CPC-ALouiseBugeau, CPC-ALouiseCravey, CPC-ALucianneBastone, CPC-ALucyDavis, CPC-ALynnBrown, CPC-ALynnGonnello, CPC-ALynnMiller, CPC-ALynnSchacht, CPC-ALynneObermeyer, CPC-ALynwoodCurrin, CPC-ALystraBrown, CPC-AM.IrmaAlonzo, CPC-AMaFimaGracielaRafa, CPC-AMabethVillaflores, CPC-AMaeLorenzo, CPC-AMagganAndreas, CPC-AMalloryKubota, CPC-AManouchkaM.Behrmann, CPC-AMarcOtomo, CPC-AMarcellaMoon, CPC-AMargaretAVirag, CPC-AMargaretClare, CPC-AMargaretEKutscher, CPC-AMargaretKNorton, CPC-AMargaretKirkham, CPC-H-A

MariaANoeldechen, CPC-AMariaBryan, CPC-AMariaCPaino, CPC-AMariaD’souza, CPC-H-AMariaLuisaMagana, CPC-AMariaMuncan, CPC-AMariahSchelhaas, CPC-AMaricelMagtalasPuyat, CPC-AMarieBernal, CPC-AMarieDexter, CPC-AMarieKathrynFoster, CPC-AMarieTSantana, CPC-AMarilynBurris, CPC-AMarinaPomida, CPC-AMariolaRapushi, CPC-AMarisaArredondo, CPC-AMarkDaveLabitigan, CPC-AMarkSGill, CPC-AMarkUmil, CPC-AMarlenaLLevengood, CPC-AMarneElizabethMeeker, CPC-AMarnieCorrineKuhn, CPC-AMarshaBurke, CPC-AMartinaMann, CPC-H-AMaryBethDorn, CPC-AMaryBrisson, CPC-AMaryDeniseRebman,CPC-A, CPC-H-AMaryERobinson, CPC-AMaryFischer, CPC-AMaryGraceQuismorio, CPC-AMaryHurley, CPC-AMaryJBridenstein, CPC-AMaryMargaretAngel, CPC-AMaryNiedermeyer, CPC-AMaryOrfanos, CPC-P-AMaryPasciuto, CPC-AMaryRutherford, CPC-AMaryStrackman, CPC-AMaureenCaldwell, CPC-AMayaSDavids, CPC-AMeganPrivett, CPC-AMelanieChaput, CPC-AMelindaFicca, CPC-AMelindaMarcelRaiford, CPC-AMelisaSchultz, CPC-AMelissaBellville, CPC-AMelissaCox, CPC-AMelissaHartman, CPC-AMelissaLBurciaga, CPC-AMelissaLMarshall, CPC-AMelissaMOlive, CPC-AMelissaMitchell, CPC-AMelissaMoore, CPC-AMelissaNicholeRandolph, CPC-AMelissaSavage, CPC-AMellissaPage, CPC-AMercedesLarkin, CPC-AMeredithAMcKenzie,CPC-A, CPC-H-AMeritaLohja, CPC-AMerrittaJStovall, CPC-AMerylABullard, CPC-AMichaelAKusman, CPC-AMichaelJamesLehrke, CPC-AMichaelRhyan, CPC-P-AMichaelSegur, CPC-AMichaelSim, CPC-AMicheleAnnEroh, CPC-AMicheleEferstein, CPC-AMicheleFinder, CPC-AMichelleAndrews, CPC-AMichelleAxelson, CPC-AMichelleGross, CPC-AMichelleJensen, CPC-AMichelleKessel, CPC-AMichelleKuntz, CPC-AMichelleLOpenbrier, CPC-AMichelleLuther, CPC-AMichelleLynnShannon,CPC-A, CPC-H-AMichelleO’Brien, CPC-AMichellePack, CPC-AMikalBailey, CPC-AMindyShaw, CPC-AMiriamBrestin, CPC-AModupeToyinOgunsakin, CPC-AMollyDeeNeubauer, CPC-AMollyO’Toole, CPC-AMonaTuccillo, CPC-AMonicaFerstadt, CPC-AMonicaJones, CPC-AMuthuselviVeluchamy, CPC-AMyrtelinaMartinez, CPC-A

NancyAnnSpicer, CPC-ANancyCGreenwood, CPC-ANancyKrogman, CPC-ANancyOconnell, CPC-ANancyOsorio-Ramos, CPC-ANancyTrevizo, CPC-ANancyWalker, CPC-ANanetteBenvegnu, CPC-ANaniAlexander, CPC-ANatalieIwamoto, CPC-ANatalieValenzuela, CPC-ANatashaMilligan, CPC-ANatishaThreatt, CPC-ANavnitMangat, CPC-ANekeeshaLSlaughter, CPC-ANelaRusu, CPC-ANelsonMarkBraslow, CPC-ANicholeIwema, CPC-ANicoleBilotti, CPC-ANicoleDillon, CPC-ANicoleEnglehart, CPC-ANicoleFrett, CPC-ANicoleShantaPearson, CPC-ANicoleTelayaIngram, CPC-ANicoleWashburn, CPC-ANieveGarcia, CPC-ANikiPeterson, CPC-ANikiSchloemer, CPC-ANikiaCharles, CPC-ANikkiLeatherberry, CPC-ANikkiLynnCooley, CPC-ANinaELopez, CPC-ANishaChhetri, CPC-AOraliaAlaniz-Luras, CPC-APaceeAllred, CPC-APaigeElaineBranan, CPC-APaigeOliviaForth, CPC-APaigeVanderheyden, CPC-APamMahoney, CPC-APamelaHelms, CPC-APamelaJStanton, CPC-APamelaJeanJames, CPC-APamelaMontgomery, CPC-APatriceSchettle, CPC-APatriciaAnnVavra, CPC-APatriciaAnnWright, CPC-APatriciaBeebe, CPC-APatriciaClaybaugh, CPC-APatriciaCrump, CPC-APatriciaGarcia, CPC-APatriciaHale, CPC-APatriciaJeanKeene, CPC-APatriciaMariePeterson, CPC-APatrickEmmer, CPC-APattiJohnson, CPC-APattyObrien, CPC-APaulaHeitzenrater, CPC-APeggyBussie, CPC-APeggyMeadows, CPC-H-APeggyPowell, CPC-APhilipJenkins, CPC-APhyllisAdams, CPC-APilarUribe, CPC-APuraToste-Oliver, CPC-APuraToste-Oliver, CPC-ARachelAGrady, CPC-ARachelEdenBach, CPC-ARachelKellie, CPC-ARachelSFriedland, CPC-ARachelTomlinson, CPC-ARandyShiflett, CPC-ARaquelCanio, CPC-ARebeccaCumley, CPC-ARebeccaEwan, CPC-ARebeccaMBreckenridge, CPC-ARebeccaMoore, CPC-ARegiMathew, CPC-AReneDrouin, CPC-ARene’Perez, CPC-H-ARhondaLAdams, CPC-ARichardEvans, CPC-ARickiLeeShafferkoetter, CPC-ARitaSmith, CPC-ARobertManolakas, CPC-ARobertWilliams, CPC-ARobertaSchultz, CPC-ARobinRoberts, CPC-ARobinCathey, CPC-H-ARobinColeenWilliams, CPC-ARobinJohnson, CPC-ARogerWalterHallin, MD,CPC-A

www.aapc.com November2011 41


RondaLee, CPC-ARoseMKolvek,CPC-A, CPC-H-ARowenaCatamuraSundaram, CPC-ARoxanaGonzalez, CPC-ARoxanneLopez, CPC-ARussellScruggs, CPC-ARuthParrott, CPC-ARuthPyeatt-Herrera, CPC-ARyanArnold, CPC-ASabrinaKayBaetje, CPC-ASamanthaPatterson, CPC-ASaminaBlackmon, CPC-ASandeepKaurGill, CPC-ASandraBunke, CPC-ASandraHappel, CPC-ASandraRevueltas, CPC-ASandySzarek, CPC-ASangeethaPandarinathan, CPC-ASaraRawson, CPC-ASarahBane, CPC-ASarahBlejski, CPC-H-ASarahBowman, CPC-ASarahCollins, CPC-ASarahETowles, CPC-ASarahFLee, CPC-ASarahFWade,CPC-A, CPC-H-ASarahMoore, CPC-H-ASarithaPichandi, CPC-ASaronPye, CPC-ASathiarajKuppusamy, CPC-ASaulAmezquita-Ruelas, CPC-ASelenaSutherland, CPC-ASendilnathanSambandhamoorthy, CPC-AShadrackO.John, CPC-AShanikaMoniqueLinzy, CPC-AShaniquaAdams, CPC-AShannonJCantwell, CPC-AShannonKinnel, CPC-AShannonKonkler, CPC-AShannonLoCicero, CPC-AShannonMichelleMedlock, CPC-AShariLGilman, CPC-ASharonAharon, CPC-ASharonBHill, CPC-ASharonGrant, CPC-ASharonJanetHuff, CPC-ASharonMDoll, CPC-ASharonSchultz, CPC-ASharriAnnLarson, CPC-AShauntinaChambliss, CPC-AShawnBethay, CPC-AShawntelPeavey, CPC-ASheilaHunt, CPC-ASheilaSellars, CPC-ASheilaWarner, CPC-AShelleyAKubesh, CPC-AShelleyThomas, CPC-AShelliHopper, CPC-AShellyADessauer, CPC-ASheriHiggins, CPC-ASheri-EllenGGott, CPC-ASheronMortensen, CPC-ASherryGill, CPC-ASherryParker, CPC-AShirlSoder, CPC-AShyanneDeniseVanAllen, CPC-ASianaLynnRivera, CPC-ASimonAubreySteadman, CPC-ASivachandranSenthilArumugamVeilukandamal, CPC-ASonjaJeanetteBenton, CPC-ASpellaPal, CPC-AStaceyArndt, CPC-AStaceyRogers, CPC-AStaciNoble, CPC-AStaciStephensen, CPC-AStacyAdcox, CPC-AStacyMatula, CPC-AStacyPurkiss, CPC-AStephanieAnnErstad, CPC-AStephanieAnnRecords, CPC-AStephanieHoldaway, CPC-AStephanieJohnson, CPC-A

StephanieKayPetrie, CPC-AStephanieLovePerry, CPC-AStephanieMarieRodetis, CPC-AStephanieMcdonald, CPC-AStephanieTomsick, CPC-AStephanieWalker, CPC-AStephanieWunsch, CPC-AStephanyMena, CPC-AStephenAMason, CPC-AStevenRueter, CPC-AStevieRobinson, CPC-ASubathraMurugesan, CPC-ASueScandrett, CPC-ASujathaThangadurai, CPC-ASumanaAkther, CPC-ASumathyKumarasamy, CPC-ASummerHarris, CPC-ASummerJoyRamler, CPC-ASusanDavis, CPC-ASusanKerbo, CPC-ASusanMKolakowski, CPC-H-ASusanM.Brown, CPC-ASusanMajors, CPC-ASusanMarino, CPC-ASusanSpears, CPC-ASusanWard, CPC-ASusanWatts, CPC-ASuzannaMetteer, CPC-ASuzannePierce, CPC-ASuzetteFrederick, CPC-ASyedaSawdaBegum, CPC-ATabathaMariePace, CPC-ATamaraThompson, CPC-ATammyBoston, CPC-ATammySykes, CPC-ATammyWilson, CPC-ATaneshaJohnson, CPC-ATangerlaBurton, CPC-ATaraEstrella, CPC-ATaraLSmiddle, CPC-ATashiikaNMurdock, CPC-ATassiBrotherson, CPC-ATatumRuff, CPC-ATatyanaVasilchuk, CPC-ATaysiaHatch, CPC-ATeresaLynneMyers, CPC-ATeriReinemer, CPC-ATernekaHill, CPC-ATerriHunt, CPC-ATheresaButeraBlake, CPC-ATheresaDrew, CPC-ATheresaLittaua, CPC-ATheresaMSchuchman, CPC-ATheresaRobinson, CPC-AThomasAustin, CPC-AThonnyaSutherland, CPC-ATiaChanellRobinson, CPC-ATiffanyAmeliaGoar, CPC-ATiffanyElayneLucas, CPC-ATiffanyRamos, CPC-ATimothyPike, CPC-ATinaLouiseLowe, CPC-ATinaMarieArneson, CPC-ATinaMarieDiehl, CPC-ATizitaSGaredew, CPC-ATobieDellinger, CPC-AToddAVolden, CPC-AToddManion, CPC-ATomikaBMustafa, CPC-AToniThibodeaux, CPC-ATonyaMBryant, CPC-ATonyaTwomey, CPC-ATraceyLynnCrum, CPC-ATraciCromer, CPC-ATracyBergmann, CPC-ATracyFoster, CPC-ATracyGibson, CPC-ATracyNicoleGarner, CPC-ATracyPrice, CPC-ATracyWingard, CPC-ATriciaKoch, CPC-ATrinaTroutman, CPC-ATrishaJones, CPC-A

UshaRaniKalairaj, CPC-AValerieBlack, CPC-AValerieLeslie, CPC-AValerieNoelleDrew, CPC-AVanessaClayHarrod, CPC-AVanessaOracionaMangonon, CPC-AVanessaTurner, CPC-AVangieKBecenti,CPC-A, CPC-H-AVannarieNickieHeng, CPC-AVeronicaBrannon, CPC-AVeronicaCCrawford, CPC-AVeronicaHershey, CPC-AVictoriaLdeCharmoy,CPC-A, CPC-H-AVidhyaAnnamalai, CPC-AVijayalakshmiKrishnamoorthy, CPC-AVijayalakshmiManimozhi, CPC-AVivianEDonahoe,CPC-A, CPC-H-AWaleskaHernandez, CPC-AWandaToro, CPC-AWendyAsuega, CPC-AWendyAnnVanDerLinde, CPC-AWendyFlores, CPC-AWendyLino, CPC-AWendyMCox, CPC-AWilliamHubbard, CPC-AWilliamWong, CPC-AWilmaTeresaBaumgardner, CPC-AWrentekMacGowan, CPC-AXiomaraCampos, CPC-AXiomaraStevens, CPC-AXshantiLucky, CPC-AYanitraMichelleBoles, CPC-AYolandaMedina, CPC-AYordankaTorres, CPC-AYvonneChalko, CPC-AYvonneMarieVeilleux, CPC-AZenobiaDJean, CPC-AZinaWashington, CPC-A

SpecialtiesAmberLeaCunningham-Bookout,CPC, CPMAAmyJPowell,CPC, CEDCAmyMichelleBenton,CPC-A, CPMAAndreaJZlatkus, CRHCAngeleTWhite, CPMAAngeliMarieAbbey,CPC, CPMAAnitaHolloway,CPMAAprilReynolds,CPC, CANPCBarbaraStevens,CPC, CHONCBerardinoMPala,CPC, CPMABethAnnCrocker, CPMABeverleyAHill,CPC, CPC-I,CEMCBilliePrice, CIMCBrandyPerkins, CPCOBrittanyStanley,CPC-A, CEDCCatherineGray,CPC, CPC-H,CPC-I,CCC,CEMC,CGICCatherineMarieSerfass,CPC, CEMCChristinaMatsiga,CPC, CPCOChristineMSchaefer,CPC, COBGCChristopherBetley,CPC, CEMCCindyRoberts,CPC, CPCD,CPRCColleenGianatasio,CPC, CPC-P,CPMAColleenGilli,CPC, CPMA,CEMCCourtneyGladden, COSCCynthiaALund, CPMACynthiaMarieZent,CPC, CPMADanielleIGraf,CPC, CPCO,CIMCDarleneDean, CEMCDeannaSaxtonRivers,CPC-H, CGSCDeborahMullen,CPC, CPC-H,CPC-I,CGSCDebraKHam,CPC, CEMCDeeKelly,CPC, CPMA,CPCDDianeSanna-Galama,CPC, CPMADionneRenitaClawson,CPC, CEMCDonnaLChristian, COSCDonnaLeeOlson,CPC, CPMADonnaYHowe,CPC, CGICDorisVBranker,CPC, CIRCC,CPC-I,CEMCDythaLynnPoole,CPC, CPMA,CANPCEdideysiGomez,CPC-A, CPMAEileenRoseDowns,CPC, CPMA,CEMC

ElisaCArbeeny,CPC, CANPCEliseClark,CPC, CEMCGeannettaAdams-Alston, CGICGinnaMarieGuido,CPC, CPMA,CIMCHeatherMTynon,CPC, CEMCHeatherShaw,CPC, CIRCCHillaryWalsh, CEDCIngridRCross,CPC, COSCIsabelCGonzalez,CPC, CGSCJamesFJenkins,CPC, COSCJanMLasker,CPC, CFPCJanelleRaymond,CPC, CPMAJaniceMHall,CPC, CEMCJeanneSmith,CPC, CIMC,CPCDJenniferAKisting,CPC, CANPCJenniferDBell,CPC, CPMAJenniferGassert, CIRCCJenniferReneeParsons, CIMCJillMHarrington, CRHCJoanieMarieCochran,CPC, CPCOJodiLeslie, CIRCCJohnWilkinson, CPCOJuddiLSchneider,CPC, CPMA,CPC-IJulieDove,CPC, CEMCKadieGibson-Karanikas,CPC, CCVTCKarenHPayne,CPC, CEMCKarenWilder, CENTCKatarzynaJochim, CIRCCKatherineVonLaven, COBGCKelleyMorrell,CCS-P, CPMAKimberlyMutter,CPC, CEMCKristinLFelty,CPC, CCC,CCVTCLaniGrone,CPC, CPC-H,CCCLauraCAllen,CPC, CEMCLauraEHill,CPC, CPMA,CPC-ILaurenKrass,CPC, CEMCLawenaUPainter,CPC, CPMALeanneMarieAltman,CPC, CEMCLindsay-AnneMcDonaldJenkins,CPC, CPC-H,CIRCC,CPMA,CPC-I,CANPCLindseyRay,CPC-A, CASCCLusineDanielian,CPC, CEMCLydiaSPerry,CPC, CPC-H,CPC-P,CPMAMarcelaAlaniz,CPC, CPMA,CEMCMariaElenaDiLeo,CPC, CPMAMariaElenaMaldonado,CPC, CPC-H,CPMA,CEDC,CEMCMelanieLewis,CPC, CEMCMichelleEMcDonald,CPC, CPMAMichelleLynnBillings,CPC, CIMCMichelleMBernstein,CPC, CPMA,CPEDCMichelleTippel, CPMAMindyDPowell,CPC, CPMA,CEMCMistyShennaWalker,CPC, CPMA,CASCCNatalieHerrera, COBGCOlegKorsakov,CPC, COSCPatriciaEGrill,CPC, CPMA,CEMCPauletteWidmer,CPC, CPMAPriscillaAlfaro,MD, CPC, CPMARachaelShumate, CHONCRamonaMarieMastrangelo,CPC, CEDCRebeccaHuffman,CPC, CEMCRebekahMLoescher,CPC, CPMARobertWilson,CPC, CIRCCRoseMorales-Howland, CPMARosemarieHimick, CUCSandyFuller,CPC, CIMCSaraBarthel, CPMASharmillaGovindsami,CPC, CPC-H,CPMAShelliLynnMartin,CPC, CPC-H,CPMA,CEMCSherrySparham, CPCDShirleyMatlock, CPMASomdavoneSithibandith,CPC, CPMAStephanieWilliams,CPC, CEMCStevenKnowles, CEDCSundraSJones,CPC, CPMA,CPC-I,CHONCSusanMarieRoelant,CPC, CPMA,CEMCSusanMillerBaker,CPC, CFPCTwilaMSmith,CPC, CPMA,CEDC,CEMC,COBGCVerleneBirger,CPC, CFPCVeronicaDerosier,CPC, CGICVickiAWorkman,CPC, CPMA,CEMCVickieLPoe,CPC, CEMC,COSC

VickyCFoss,CPC, CPMAVictoriaMarieWhitby-Moll,CPC, CPMAVirginiaGBarrett,CPC, CEMCWendyHarrigan,CPC, CPMA

YvonneBRussell,CPC, CFPCMagna Cum Laude

AlisaEngel, CPC-HAndrewBetterton, CPCAnnaDokko, CPC-AAshleyStaples, CPCCarolLynnBonacum, CPC-ACatherineGray,CPC, CPC-H,CPC-I,CCC,CEMC,CGICCatrinaDenson, CPCChristineMRanvik, CPC-P-AColetteRichter, CPCCourtneyAStark,CPC-A, CPC-H-ADawnRichardson, CPC-ADonnaMPadnos, CPC-H-AElizabethAnnMcKay, CPCElizabethRZak, CPCEmilyDavidson, CPC-AEmilyDimberio, CPCEmilyMartin, CPC-AJaimeMelissaPearson, CIRCCJennaShepherd, CPCJustinEdwardBaumgardner, CPC-AKadieAllred, CPC-AKathyKoontz, CPC-AKathyStopyra, CPC-AKellySpell, CPCKimMoreno, CPCKimberlyFPruitt, CPCKimberlyPilch, CPC-AKristenLynnMcKay, CPCLaurieAnnNickolas, CPC-ALeeHilliard,CPC, CPC-HLeighMuller, CPC-ALoriKCarbonell,CPC, CPC-HMargieReynolds, CPCMariselaBustamanteLara, CPCMaryTannenbaum, CPC-AMaureenMargaretBenton, CPC-AMichelleDianeVerdon,CPC, CPC-HNinaBarlow, CPC-APamelaDillon, CPC-APaulaJKroes,CPC, CPC-HRafaelAbreu, CPC-HRebeccaStephanieEnriquez, CPC-AReedSnyder, CPCReneeBaucum, CPC-HRobbieRussaw, CPCRussDean, CPCRyanMonsonDC, CPCSandraBerger, CPCSarahEIbero,CPC-A, CPC-H-ASherrieSolt, CPCSivagamiNarayanan, CPCSkylerGebhart, CPCStaceyRubio, CPCStephanneTurner, CPCTammyJones, CPCTammyRee, CPC-ATaraJalazo, CPC-ATeenyaMagnusson, CPCTiffanyToburen, CPC-AUmaMunuswamy, CPCVijayalakshmiNammalvar, CPCVikiLBoggs,CPC-A, CPC-H-AWendySartin, CPC-A

42 AAPCCodingEdge

Featured Coder

I Take Exception with That!Understand the Medicare Primary Care Center Exception.

By Maryann C. Palmeter, CPC, CENTC

The final rule for teaching physician presence and docu-mentation requirements under Medicare Part B has been in effect since July 1, 1996. Over the years, the Centers

for Medicare & Medicaid Services (CMS) has issued chang-es and clarifications to the rule. Most recently, CMS autho-rized the addition of new annual wellness visit codes G0438 and G0439 to the list of services that can be performed under the “Primary Care Center Exception” (refer to CMS Transmit-tal 2303, Change Request (CR) 7378, dated Sept. 14, 2011). CMS also added specific manual language (Medicare Claims Processing Manual, Pub. 100-04, chapter 12, sections 100.1 and 100.1.1 (C)) to clarify how the Primary Care Center Excep-tion would apply when the teaching physician is supervising a resident with six months or less in an approved Graduate Med-ical Education (GME) residency program, as well as residents with more than six months in such a program.

Follow the General Teaching Physician RuleServices furnished by residents in residency programs are ex-cluded from being paid as “physician services” under Medicare Part B because the Medicare fiscal intermediary, Medicare Part A, already pays teaching hospitals for the services of interns and residents, and the costs associated with the supervisory servic-es of teaching physicians. Ordinarily, to be reimbursed under Medicare Part B, services furnished in teaching settings must meet one of the following requirements:

• The service must be personally furnished by a physician who is not a resident.

• The service must be furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.

• The service provided must be a specified service (See the Applicable Procedure Codes information box) furnished by a resident under the Primary Care Center Exception.

What Is the Primary Care Center Exception?An exception to the general teaching physician rule is some-times referred to as the “Primary Care Center Exception,” but this exception is not limited to primary care or family practice residency programs. Per CMS, the exception could apply to

any residency program with requirements that are incompati-ble with the teaching physician physical presence requirement. This is because in some residencies, the resident is the patient’s primary caregiver, and it is beneficial for the resident to see pa-tients alone to learn medical decision-making, and to recognize his or her own limitations. Direct teaching physician involve-ment in these cases may negatively affect the patient-resident relationship. Some examples of residency programs most likely to qualify for the exception are: family practice, general inter-nal medicine, geriatrics, and pediatrics. Specified services performed under the exception may be billed to Medicare Part B under the teaching physician’s provider number, without the need for the teaching physician to person-ally perform the service or to be physically present during the critical or key portions of the service.

Attest in WritingFor the exception to apply, the center must attest in writing to the Medicare Part B administrative contractor (MAC) that the following conditions have been met:1. The services are performed in a center that is located in

an outpatient department of a hospital or another am-bulatory care entity in which the time spent by the resi-dents in patient care activities is included in determining Medicare Part A payments to the hospital.

2. The residents involved have completed more than six months of a residency program.

3. The teaching physician directs the care of no more than four residents at a time and directs the care from such proximity as to constitute immediate availability.

4. The teaching physician has no other responsibilities at the time (including the supervision of other personnel) and assumes management responsibility for those pa-tients seen by the residents.

5. The patients seen are an identifiable group who consider the center to be the continuing source of their health care and are cognizant that services are furnished by residents under the medical direction of teaching physicians. The residents must generally follow the same group of pa-tients throughout the course of their residency program.

Centers exercising the exception must maintain records dem-onstrating they qualify for the exception.


Featured Coder

Teaching Physician Documentation Requirements Under the ExceptionThe teaching physician must document the extent of his or her participation in the review and direction of the services fur-nished to each patient.Teaching Physician Note ExampleI have reviewed with the resident Jane Doe’s medical history, phys-ical examination, diagnosis, and results of tests and treatments and agree with the patient’s care as documented in the resident’s note.

Services Included Under the ExceptionThe range of services furnished by residents under the excep-tion includes:

• Acute care for undifferentiated problems or chronic care for ongoing conditions, including chronic mental illness

• Coordination of care furnished by other physicians and providers

• Comprehensive care not limited by organ system or diagnosis

Know Procedure Code RestrictionsUnder the exception, MACs may make physician fee schedule payment for reasonable and necessary, low- to mid-level evalu-ation and management (E/M) services, and other specified ser-vices, when furnished by a resident without the presence of a teaching physician. Refer to the Applicable Procedure Codes information box for a list of specific procedure codes that may be billed under the exception.

Append Modifiers ProperlyModifier GE This service has been performed by a resident with-out the presence of a teaching physician under the primary care ex-ception must be appended to services billed under the excep-tion. Services furnished in a primary care exception center that do not meet the requirements for the exception would revert to the general teaching physician rule for services furnished out-side of a primary care exception center. Modifier GC This ser-vice has been performed in part by a resident under the direction of a teaching physician would be appended to these services.

Sample Scenarios with 4-to-1 Ratio

Residentwith6

monthsorlessin

residencyprogram.

NewresidentA

Residentwithmore

than6monthsin

residencyprogram.

OldresidentB

Residentwithmore

than6monthsin

residencyprogram.

OldresidentC

Residentwithmore

than6monthsin

residencyprogram.

OldresidentD

Exceptionappliesto

oldresidentsB,C,

andD,butnottonew

residentA.Follow

generalTPrulesfor

newresidentA.

ApplymodifierGCto

chargefornewresi-

dentA.Applymodifier

GEtochargesforresi-

dentsB,C,andD.

Residentwith6

monthsorlessin

residencyprogram.

NewresidentA

Residentwithmore

than6monthsin

residencyprogram.

OldresidentB

Residentwithmore

than6monthsin

residencyprogram.

OldresidentC

Residentwithmore

than6monthsin

residencyprogram.

OldresidentD

Residentwithmore

than6monthsin

residencyprogram.

OldresidentE

Exceptiondoesnot

applytoANYresidents

becausethe4-to-1

ratioisexceeded.Fol-

lowgeneralTPrules

forALLresidents.

ApplymodifierGC

tochargesforALL

residents.

Residentwith6

monthsorlessin

residencyprogram.

NewresidentA

Residentwith6

monthsorlessin

residencyprogram.

NewresidentB

Residentwithmore

than6monthsin

residencyprogram.

OldresidentC

Residentwithmore

than6monthsin

residencyprogram.

OldresidentD

Exceptionappliesto

oldresidentsCand

D,butnottonew

residentsAandB.

FollowgeneralTP

rulesfornewresidents

AandB.

ApplymodifierGC

tochargesforALL

residents.

44 AAPCCodingEdge

Featured Coder

Become Familiar with These Key Definitions

Resident Anindividualwhoparticipatesinanapprovedgraduatemedicaleducation(GME)

program,oraphysicianwhoisnotinanapprovedGMEprogrambutwhois

authorizedtopracticeonlyinahospitalsetting.Thetermincludesinternsand

fellowsinGMEprogramsrecognizedasapprovedforpurposesofdirectGME

paymentsmadebythefiscalintermediary(MedicarePartA).Receivingastaff

orfacultyappointmentorparticipatinginafellowshipdoesnotbyitselfalter

thestatusof“resident.”Thisstatusremainsunaffectedregardlessofwhethera

hospitalincludesthephysicianinitsfulltimeequivalencycountofresidents.This

termisnotapplicabletomedicalstudents.

TeachingPhysician Aphysician(otherthanaresident)whoinvolvesresidentsinthecareofhisorher

patients.

TeachingHospital AhospitalengagedinanapprovedGMEresidencyprograminmedicine,osteopa-

thy,dentistry,orpodiatry.

TeachingSetting Anyprovider,hospital-basedprovider,ornon-providersettinginwhichMedicare

paymentfortheservicesofresidentsismadebyMedicarePartAunderthedirect

GMEpaymentmethodologyorfreestandingskillednursingfacilities(SNFs)orhome

healthagencies(HHAs)inwhichsuchpaymentsaremadeonareasonablecost

basis.

PhysicallyPresent Theteachingphysicianislocatedinthesameroom(orpartitionedorcurtained

area,iftheroomissubdividedtoaccommodatemultiplepatients)asthepatient

andperformsaface-to-faceservice.

“CMSrecentlyprovided

manualguidanceclarifying

thatteachingphysicians

mayincluderesidentswith

lessthansixmonthsina

residencyprograminthe

mixoffourresidentsunder

theteachingphysician’s

supervision.”

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Follow 4-to-1 Ratio RulesAs mentioned, the teaching physician under whose name payment is sought must not supervise more than four residents at any given time. CMS recently provided manual guidance clarifying that teaching phy-sicians may include residents with less than six months in a residen-cy program in the mix of four residents under the teaching physician’s supervision. The teaching physician would have to be physically pres-ent for the critical or key portions of the services furnished by the resi-dent with less than six months in a residency program. That is, the ex-ception would not apply in the case of the resident with less than six months in a residency program. Because the exception would not ap-ply in this case, modifier GC would be appended to the service, rath-er than modifier GE. The fact that one or more of the residents has less than six months in a residency program does not affect the application of the exception to the other residents with more than six months in a residency program. The 4-to-1 ratio of residents to teaching physician must not be exceeded, in any case.

Maryann C. Palmeter, CPC, CENTC, is director of physician billing compliance for University of Florida Jacksonville Healthcare, Inc., and provides professional direc-tion and oversight to the billing compliance program at the University of Florida Col-lege of Medicine-Jacksonville. She has over 29 years of health care experience in both government contracting and physician billing. She is the education officer and two-time past president of the Jacksonville, Fla. chapter. Ms. Palmeter is AAPC’s 2010 Member of the Year, and is a member of the AAPC National Advisory Board.

Applicable Procedure CodesCPT® Codes

Newpatientofficeorotheroutpatientvisit:99201,99202,and99203

Establishedpatientofficeorotheroutpatientvisit:99211,99212,and99213

HCPCS Level II Codes

G0402 Initial preventive physical examination; face-to-face vis-it,services limitedtonewbeneficiaryduringthefirst12monthsofMedicareenrollment

G0438 Annualwellnessvisit,includesapersonalizedpreventionplanofservice(PPPS),firstvisit

G0439 Annualwellnessvisit,includesapersonalizedpreventionplanofservice(PPPS),subsequentvisit

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46 AAPCCodingEdge

To discuss this article or topic, go to www.aapc.comCoder’s Voice

By Suzi Morrow, CPC

For CPC-As, Mentors Are a MustFor you, it’s an extra set of hands to rely on.

Ifyougiveitsomethought,Ithinkyou’llrealizethatyou’dbedoingyourself

andyourfacilityabigfavorbystartingamentorprogram.

I attended a local AAPC meeting recently in Mattoon, Ill. There were a few members who had just passed their coding certification test, so New Member De-

velopment Officer Dalene Mary Brandenburg, CPC, had everyone introduce themselves and tell where they worked. Sadly, many AAPC members in attendance were either jobless or had jobs outside of their certification’s scope. I have several friends looking for their first job as a Certified Professional Coder-Apprentice (CPC-A®), so this did not surprise me. For many CPC-As® the old ad-age holds true, “You can’t find a job without experience and you can’t get experience without a job.”

Internships Give CPC-As ExperienceI have served as mentor for two new coders who now have paid coding jobs, and I am a mentor for a third. In each case, I approached my employer to get an unpaid intern-ship approved. I use a shadow system where the intern codes the same charts as me, and then the intern com-pares his or her code selection with mine. I code as I nor-

mally do and this takes very little extra time on my part. Questions are answered, instruction is given as necessary, and I watch with satisfaction as the intern learns and gains confidence, accuracy, and speed. Our interns are not paid, so only very motivated new coders are interested in this program. This is a good thing, since success is in their hands. Interns must be critical of their coding, acutely aware of any differenc-es they find, and very eager to ask questions and learn.When a coding job opens up at the intern’s facility, he or she is at the top of the list to hire. My students know the facility, the physicians, and the routine so they are able to step right into the position. These coders are excited to learn, eager to jump into their new career, and thrilled that someone gave them a chance to do the job they worked so hard to get.If one person can carve out a few hours a month to lend a hand to a talented new coder, why can’t a large

institution, physician group, outpatient clinic, or bill-ing company do the same? If you give it some thought, I think you’ll realize that you’d be doing yourself and your facility a big favor by starting a mentor program. The cost is minimal—every CPC-A® I’ve spoken to would jump at the chance for an unpaid internship—and the reward is great.

ICD-10 Will Call for an Extra Set of HandsThe transition to ICD-10 is a great time to bring enthusi-astic, new coders into our workplaces. With the expected slowdown of revenue associated with ICD-10 implemen-tation, you’ll be thankful you have the extra set of hands on which to rely.

Suzi Morrow, CPC, has more than 30 years experience working in many areas of medicine including hospital-based obstetrics, emergency care, a private physician practice and, for the last 12 years, as a remote medical coder for two emergency room physi-cian groups and a cancer treatment center. She attended Millikin University and Richland Community College.

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48 AAPCCodingEdge

Legal Edge

Since When Is

“Give Less Weight” an Audit Protocol Standard?

QuestionHere is an excerpt from the Medicare Program Integrity Manual, Pub. 100-08, chapter 3, section 3.3.2.5, which addresses Late Entries in the Medical Documentation:“This section applies MACs, CERT, Recovery Auditors, and ZPICs, as indicated.A provider may discover that certain documents were misfiled or needed to be filed in the medical documenta-tion during the process of responding to an ADR. Providers are encouraged to add to the medical record or notes file all relevant documents that were created at the time of service or within a few days of the date of service. The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal query responses, created more than 30 calendar days follow-ing the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the que-ry responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO and State Agency. A query is a communication tool used between facility coding personnel and the physician and/or other health care practitioners whereby the coder obtains additional documentation to improve the specificity and complete-ness of the data used to assign diagnosis and procedure codes in a beneficiary’s health record. The process may take place concurrently (while the beneficiary is in the facility) or retrospectively (after discharge).”I find this very interesting because I have no idea what Medicare means when it instructs the Medicare administrative contractors (MACs), comprehensive error rate testing contractors (CERTs), and zone pro-gram integrity contractors (ZPICs) to “give less weight when making review determinations” to docu-mentation created more than 30 days after the date of service.Since when did something as vague as “give less weight” become an audit protocol standard? Does any-one on the Legal Advisory Board have any insight on this?Robert A. Pelaia, Esq., CPC, CPCOSenior University Counsel for Health Affairs, University of Florida College of Medicine, Jacksonville, Fla.

AnswerHere are the responses of AAPC Legal Advisory Board members:—David M. Vaughn, JD, CPC, Vaughn & Associates, LLC“I do a lot of appeal work, so I get questions about after-the-fact documentation all the time, and frankly, this rule is in line with the general rule I tell my clients: That is, at some point creating after-the-fact doc-umentation is going to be viewed as too stale to be credible. Most of my clients can’t remember specific cases in the operating room (OR) that happened last week, much less last month, or last year. So, I’ve been telling my clients for a while that although they can add late documentation, at some point there will be a presumption that the information is too stale to be considered credible. That doesn’t mean there aren’t appeal rights to overcome the “give less weight” (whatever that means) standard.In legal speak, I view the “give less weight” standard as a presumption of non-allowability in the audit phase. I believe it will be upheld in the redetermination phase by the MAC, and the reconsideration phase

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50 AAPCCodingEdge

Legal Edge

by the qualified independent contractor (QIC), but can be overcome in the administrative law judge (ALJ) phase when the doc is on the phone with the ALJ testifying under oath that he remembers this specific case. If he can’t remember this specific case, I think the presumption will be upheld.While I don’t necessarily agree with the 30-day time frame, what I do like is that there is a specified time frame. I can tell my clients, ‘You’ve got to get it documented in 30 days or else the presumption is going to be that it is too stale for you to have remembered that.’Robert, hats off to you for bringing this to our attention.”

—Michael D. Miscoe Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, Miscoe Health Law, LLC“This is consistent with the U.S. Department of Health & Human Services (HHS) Office of Inspector Gener-al/Office of Audit Services (OIG/OAS) audit process guidance regarding assessing the credibility of the infor-mation provided. Notwithstanding this provision, most ZPICs or QICs will cite the PIM Ch. 3 §3.4.1.2 (or a portion thereof) as a basis for completely ignoring supplemental information. Regardless, most ALJs will con-sider the information, especially where the doctor’s direct testimony is credible and the supplemental info does not conflict with information recorded contemporaneously.I concur: ‘Give less weight’ is meaningless and likely improper. What it should demand is an assessment of cred-ibility. Note that 3.4.1.2 is contrary, indicating that the date a record was created is essentially irrelevant.”

—Timothy P. Blanchard, JD, MHA, FHFMA, Blanchard Manning LLP“I think the Centers for Medicare & Medicaid Services (CMS) is off base with this instruction and that provid-er comments to CMS are warranted. Any valid (important point) medical record entry is entitled to full faith and credit. After all, it is backed up on the physician’s license (which could be lost if an entry were shown to have been false or fraudulent). While legit-imate questions might be raised in connection with very late entries, either they are valid or they are not. There is no basis for either a sliding scale or a presumption of invalidity. As long as the authenticating physician has a sufficient present recollection of the events or observations he or she can properly make a late entry and it should be respected (given full credit normally afforded) if properly entered and authenticated. I hope providers do not just cave in and accept this. Determinations based on this instruction should be chal-lenged in the appeal process. From time to time late entries will be necessary for almost every provider and it should not matter what triggered the conclusion that a late entry was appropriate to assure an adequate and ac-curate medical record.”

—Julie Chicoine, Esq., RN, CPC, Senior Assistant General Counsel, Ohio State University Medical Center“I have given this some further thought and suspect that the underlying issue turns on the issue of what I think of as ‘evolving documentation’ where coders or other support staff seek supplemental (additional) documenta-tion from providers to clarify the services rendered during a particular encounter.Documentation enhancement usually takes the form of addendums to the medical record. To me, this makes sense; though, if the contractors see too much of it—especially with one or two providers several days or even weeks after the original patient encounter, and when it follows an ADR—then it becomes suspect.This might serve as a foundation for an excellent article or presentation on documentation improvement.”

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