HEALTHCARE BUSINESS MONTHLY - AWS
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
HEALTHCARE BUSINESS MONTHLY July 2016 www.aapc.com Coding | Billing | Auditing | Compliance | Practice Management Get Paid for Smoking Cessation: 22 Don’t give up on reimbursement: Verify coverage Exude Confidence as an Auditor: 52 Ditch the emotional baggage and gain respect Tips to Improve HEDIS Scores: 60 Enhance quality of care and reduce costs
Smart Design.
Intelligent Auditing.
Healthicity - 1
Customize, manage, train and simplify your audit process. We streamlined your
audit process by merging audit workflow, management, and reporting
capabilities into one easy-to-use, web-based solution.
HEALTHICITY.COM/AUDITMANAGER
Healthcare Business Monthly | July 2016
COVER | Coding/Billing | 38
Secrets of Successful Coders
Apply 14 strategies to help you climb your way to coding success.
By Stephanie Cecchini, CPC, CEMC, CHISP
[contents]
■ Coding/Billing ■ Added Edge ■ Practice Management
22 Get Paid for Smoking Cessation 52 Ditch the Emotional Baggage to 56 Manage Hospital
Kasandra Bolzenius, CPC Become a Respected Auditor Staff Cellphone Distractions
Holly Pettigrew, COC, CPC, CHC Michelle A. Dick
[continued on next page]
www.aapc.com July 2016 3
Healthcare Business Monthly | July 2016 | contents
16 ■ Member Feature
14 Emory Physician Group Practice Celebrates and Prepares Its Coders
Donna Beaulieu, CRC, C-CDIS, CPC-I, CPMA, CPC, CEMC, CEDC, CFPC, CCP-P, CRP
Hasan Zaidi, MPH, CPC, CEDC, CSPPM
■ Coding/Billing
16 MACRA FAQs
Renee Dustman
20 Think Twice Before Sticking It in Your Ear
Maryann C. Palmeter, CPC, CENTC, CPCO, CHC
24 Providers vs. Payers: Collaboration is the Best Medicine
24 Susanne Myler, COC
28 Cut Costs with Quality Transitional Care Management
Stephen Canon, MD
32 Combat Common Denials in Orthopedic Coding
Michael Strong, MSHCA, MBA, CPC, CEMC
42 Soothe the Sting of 2016 Paravertebral Block Changes
Amy C. Pritchett, BSHA, CPC, CPMA, CPC-I, CANPC, CASCC, CEDC, CRC,
ICDCT-CM/PCS
44 ICD-10 Restricts Same-day Sick and Well Visits
Debra Mitchell, MSPH, COC
48 WHO Winds Its Gears for ICD-11
50 Brad Ericson, MPC, CPC, COSC
50 The Latest on Multianalyte Assays with Algorithmic Analyses
John Verhovshek, MA, CPC
■ Auditing/Compliance
54 Guard PHI with Sensitivity
Andy Rusch, CPC
■ Practice Management
60 HEDIS: Manage Your Healthcare Outcomes
Lynn Stuckert, LPN, CPC, CPMA
COMING UP: DEPARTMENTS 66 Minute with a Member
•• Cardiac Cath Reports 7 Letter from Member Leadership
•• Officer Nominations EDUCATION
8 Letters to the Editor
62 Newly Credentialed Members
•• Audit Defense 9 I Am AAPC
•• Medical Device Credits 10 AAPC Chapter Association
•• ICD-10 Best Practices
11 AAPC National Advisory Board
On the Cover: Stephanie Cecchini, CPC, CEMC, CHISP, reveals 14 Online Test Yourself – Earn 1 CEU
secret strategies that will help you climb your way to coding success. 12 Chapter News
www.aapc.com/resources/publications/
Cover photo by Rachel Momeni.
47 Dear John healthcare-business-monthly/archive.aspx
4 Healthcare Business Monthly
You’ve studied for the CPC exam,
but is it enough?
Increase your chances of success with a
focused online exam review.
AAPC Membership - Virtual
Course students will: It's no secret that the CPC exam can be
● Learn testing strategies. challenging. This review was designed to focus
● Review frequently missed questions. on both the common and most challenging
● Participate in a focused review of testing sections. coding concepts of the CPC exam.
● Have Access to on-demand recorded classes for
six months. The CPC Online Exam Review is an on-demand
learning system, where students can study and
learn at their own pace.
Visit aapc.com/CPCOnlineReview or call on of our
academic advisors at 877-524-5027
Serving 156,000 Members – Including You!
Go Green! HEALTHCARE
Why should you sign up to receive Healthcare Business Monthly in
digital format? BUSINESS MONTHLY
Coding | Billing | Auditing | Compliance | Practice Management
Here are some great reasons:
July 2016
• You will save a few trees.
• You won’t have to wait for issues to come in the mail.
Publisher
Brad Ericson, MPC, CPC, COSC
• You can read Healthcare Business Monthly on your computer, tablet, or brad.ericson@aapc.com
other mobile device—anywhere, anytime.
• You will always know where your issues are. Managing Editor
John Verhovshek, MA, CPC
• Digital issues take up a lot less room in your home or office than paper
g.john.verhovshek@aapc.com
issues.
Go into your Profile on www.aapc.com and make the change! Editorial
Michelle A. Dick, BS
Renee Dustman, BS
HealthcareBusinessOffice, LLC.............................................31
vendor index
Graphic Design
www.HealthcareBusinessOffice.com
Mahfooz Alam
ionHealthcare..................................................................... 58
www.ionHealthcare.com Advertising
Ohana Healthcare, LLC........................................................ 65 Jon Valderama
www.ohanahc.com jon.valderama@aapc.com
Optum360............................................................................ 8 Address all inquires, contributions, and change of address notices to:
www.optum360coding.com/transition
Healthcare Business Monthly
Superbill Consulting Services, LLC...................................... 65
www.superbillconsulting.com PO Box 704004
Salt Lake City, UT 84170
The Coding Institute, LLC.....................................................47
www.codinginstitute.com/books (800) 626-2633
©2016 Healthcare Business Monthly. All rights reserved. Reproduction in whole or in part, in
The HIPAA Institute............................................................ 65
any form, without written permission from AAPC® is prohibited. Contributions are welcome.
www.hipaainstitute.com
Healthcare Business Monthly is a publication for members of AAPC. Statements of fact or
ZHealth Publishing, LLC.......................................................27 opinion are the responsibility of the authors alone and do not represent an opinion of AAPC,
www.zhealthpublishing.com or sponsoring organizations.
CPT® copyright 2015 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not as-
Ask the Legal Advisory Board signed by the AMA, are not part of CPT®, and the AMA is not recommending their use. The
AMA is not recommending their use. The AMA does not directly or indirectly practice medi-
From HIPAA’s Privacy Rule and anti-kickback statute, to compliant coding,
cine or dispense medical services. The AMA assumes no liability for data contained or not
to fraud and abuse, there are a lot of legal ramifications to working in
contained herein.
healthcare. You almost need a lawyer on call 24/7 just to help you make
sense of all the new guidelines. As luck would have it, you do! AAPC’s Legal The responsibility for the content of any “National Correct Coding Policy” included in this
Advisory Board (LAB) is ready, willing, and able to answer your legal ques- product is with the Centers for Medicare and Medicaid Services and no endorsement by the
tions. Simply send your health law questions to LAB@aapc.com and let AMA is intended or should be implied. The AMA disclaims responsibility for any consequenc-
the legal professionals hash out the answers. Select Q&As will be published es or liability attributable to or related to any use, nonuse or interpretation of information con-
in Healthcare Business Monthly. tained in this product.
CPT® is a registered trademark of the American Medical Association.
Medical Coding Legal Advisory Committee:
Timothy P. Blanchard, JD, MHA, FHFMA CPC®, COCTM, CPC-P®, CPCOTM, CPMA®, and CIRCC® are registered trademarks of AAPC.
Julie E. Chicoine, JD, RN, CPC Volume 3 Number 7 July 1, 2016
Michael D. Miscoe, JD, CPC, CPCO, CPMA, CASCC, CCPC, CUC Healthcare Business Monthly (ISSN: 23327499) is published monthly by AAPC, 2233 South Presidents
Christopher A. Parrella, JD, CPC, CHC Drive, Suites F-C, Salt Lake City UT 84120-7240, for its paid members. Periodicals Postage Paid
Robert A. Pelaia, Esq., CPC at Salt Lake City UT and at additional mailing office. POSTMASTER: Send address changes to:
Stacy Harper, JD, MHSA, CPC Healthcare Business Monthly c/o AAPC, 2233 South Presidents Drive, Suites F-C, Salt Lake
City UT 84120-7240.
6 Healthcare Business Monthly
Letter from Member Leadership
Two Unique-to-AAPC
Resources Have Unsurpassed Value
A s I glanced at the table of contents for this
month’s Healthcare Business Monthly two
things immediately came to mind. My first
thought is how fortunate we are to have a
monthly publication that provides us with
so much valuable information. The topics
are current, varied, and answer the needs of
members for each of our specialties, jobs, and
responsibilities. My second thought is how
valuable our local chapters are to members.
Local Chapters Bring
You the Best at May MAYnia
Looking at all the topics that were
presented across the country for this year’s
May MAYnia, I’m impressed at how the
local chapters went all out to provide
members with some incredible educational
opportunities. The topics were just as varied
dream jobs because of connections made at
chapter meetings.
Nothing compares
as the ones presented in this magazine.
Chapter officers worked hard to make the
The only sadness I have in regards to local to seeing members
chapters is how many of my own local
meetings successful. Some held all-day
events, others combined May MAYnia into
chapter meetings I cannot attend due to my show up at a meeting
traveling schedule.
their regular monthly meeting, adding prizes
and giveaways, and encouraging members
and watching the
Dive into Your Valuable Resources
to bring guests. The photos, posts, and
updates kept “AAPC Alex” very busy on the I hope you enjoy this month’s edition of networking that starts
Healthcare Business Monthly. Find your
AAPC Facebook page. The excitement was
contagious. favorite article and discuss it with peers at immediately.
your next chapter meeting. Better yet, think
Take the typical excitement you find at a of an article you want to write for Healthcare
normal chapter meeting and step it up a Business Monthly or a topic you’d like to
notch or two and you have the fever that present at your local chapter. Have no fear!
is May MAYnia. I was both fortunate You’ll be among friends who appreciate your
and honored to be the speaker at the expertise.
Indianapolis, Indiana, local chapter’s May
MAYnia. The spirit of the event stayed with
me for many days. Take care,
I Love Local Chapter Meetings!
Nothing compares to seeing members
show up at a meeting and watching the
networking that starts immediately. Some Jaci Johnson Kipreos, CPC, COC, CPMA,
members have made lifelong friends at their CPC-I, CEMC
chapter meetings. Others have found their President, National Advisory Board
www.aapc.com July 2016 7
Please send your letters to the editor to:
Letters to the Editor letterstotheeditor@aapc.com
Failure to Report a witnessed a murder could be charged for not Example: A patient has an existing
reporting what he or she saw to police. nephrostomy catheter. Diagnostic
Crime Is Not a Crime nephrostogram is performed (50431),
A coder’s liability under the False Claims
“Are Auditors, Billers, and Coders Liable demonstrating a mid-ureteral stenosis.
Act only arises when he or she is an active
for False Claims?” (May 2016, pages 48-49) Ureteroplasty is performed (+50706). The
participant in the misconduct (this may
contained an inaccurate statement: “Having nephrostomy tube is removed and not
have been the unstated presumption of the
knowledge and being aware of a person or replaced at the end of the procedure (50389).
statement cited from the article). In such
entity generating fraudulent claims is a crime.”
cases, a coder might face direct and/or
To clarify, no person has an affirmative duty to conspiracy liability. Additionally, a coder Biliary Coding Example
report a crime or to report fraudulent conduct could be held liable for obstruction if he or Needs Clarification
such that failure to do so is, in itself, a crime. she assisted in efforts to conceal the crime
Coders do not need to fear that they will be The article “Percutaneous Biliary
by destroying or altering records in response Interventional Coding” (April 2016, pages
liable for the misconduct of others, especially to a government investigation.
when they are instructed to code or bill in a 28-31) included an example on page 29 (top
manner they are not comfortable with. Michael D. Miscoe, Esq., CPC, CASCC, right), which should have specified:
CUC, CCPC, CPCO, CPMA Example: A patient has an existing external
Although coders have an ethical duty to
advise a provider or entity of what they biliary drainage catheter. Diagnostic
perceive to be inappropriate coding or Proper Codes for cholangiogram is performed (47531),
billing practices, they have no legal duty Nephrostomy Tube Removal demonstrating a distal common bile duct
to do so, and have no legal duty or AAPC stenosis. Cholangioplasty is performed
An example in “CPT® 2016: Urinary
Code of Ethics duty to report such conduct (+47542). No tubes are left in place at the
Interventional Coding” (March 2016,
to law enforcement. A coder could not be end of the procedure (add 47537 for tube
page 19) did not list the proper coding for
charged with a crime for failing to report removal and delete 47531 as bundled with
nephrostomy tube removal. The example
misconduct no more than a person who tube removal).
should have specified:
Thank you
TO THOSE
OF Y
VISITED U OU THAT
S AT
HEALTHCO AAPC
N 2016.
Optum360
SPECIAL SHOW OFFER EXTENDED:
Save 20% on 2017 editions and ICD-10 products.
MAKE SURE YOUR CODING RESOURCES ARE UP-TO-DATE.
ORDER TODAY. Visit optum360coding.com or call 1-800-464-3649, option 1, and use promo code AAPC0516.
Make life a little easier with Optum360® digital coding solutions.
To learn more and see a demo, or visit optum360coding.com/transition.
8 Healthcare Business Monthly
I Am AAPC
TIERNEY DAVIS HOGAN, RN, MBA, CPC
#IamAAPC
A fter a couple years in clinical nursing, I was drawn to the business side
of healthcare. Originally, I thought that meant I would be working
as a utilization review nurse for a health plan. After a couple of years in
medical management for health plans, including utilization review and case
management, I discovered my true interest was in medical claims review.
That gradually led to an interest in reviewing claims not only for medical
necessity but for all guidelines pertaining to coding and billing healthcare
services.
Solidifying Knowledge on the Business Side of Healthcare
I went on to earn my Certified Professional Coder (CPC®) credential in
2007. I now work for a large health plan, where I transitioned from medi-
cal claims review to coding specialist project lead on a team responsible for
health plan benefits coding configuration.
My primary work focuses on ensuring that procedure and diagnosis cod-
ing configurations of health plan benefits are aligned with state and feder-
al mandates, especially related to preventive care benefits mandated by the
Affordable Care Act.
It is interesting and challenging work. I have learned so much about
After a couple of U.S. Preventive Service Task Force guidelines, Bright Futures guidelines,
Health Resources and Services Administration Women’s Preventive Ser-
years in medical vices Guidelines, the Centers for Medicare & Medicaid Services FAQs re-
lated to preventive services, and state mandates related to preventive care.
management
Front- and Back-end Coders Working to Meet Standards
for health plans, I work on the “back end” with health plan medical directors, ensuring that
including utilization coding of insurance benefits align with current standards of practice, as well
as state and federal mandates. My work has led me to greatly respect coders
review and case who work on “the front line” with their physicians, ancillary providers, and
facilities.
management, I
discovered my
true interest was
in medical claims
review.
#IamAAPC
www.aapc.com July 2016 9
AAPC Chapter Association
By Faith C.M. McNicholas, RHIT, CPC, CPCD, PCS, CDC
Validate Your Expertise
with a Specialty Credential
Show employers that you have coding,
reimbursement, and compliance know-how
in a unique area of healthcare.
H ealth facilities of all
sizes rely on medical
coders, compliance
A complete list of specialty credentials is listed on the AAPC
specialty credentials website: www.aapc.com/certification/specialty-credentials.
aspx, as shown in Figure A. Which certifications are right for you?
officers, practice managers, Find out at www.aapc.com/certification/medical-coding-certification.aspx.
etc., to protect their livelihood by
obtaining proper reimbursement from Figure A: AAPC offers 22 specialty credentials.
payers and patients for services rendered by providers on staff.
istock.com/Casanowe
As such, these positions have a high degree of responsibility, and
employers are sometimes reluctant to hire new staff unless they can
prove competence in a specific area. Specialty certifications prove
you have what it takes to get the job done right.
Prove to Employers You Mean Business
Employers today are looking for applicants with a solid academic
foundation and relevant experience in particular areas of
healthcare. As the industry becomes more demanding, complex,
and competitive, certification gives you a distinct advantage among
other, less qualified job applicants.
Certification shows you are proficient in your specialty area Faith C.M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, specializes in dermatology coding. A
national speaker on coding and regulatory issues, she presents at American Academy of
and committed to quality healthcare. Employers understand Dermatology annual and summer meetings, AAPC regional conferences, and several other
the importance of certification, which is why it’s one of the first venues. McNicholas has a wide range of experience in various medical specialties and practice
qualifications they look for when scanning for potential candidates. settings. She is also a certified and approved ICD-10-CM/PCS expert and trainer, a former
You’ll find it’s also an asset when you’re negotiating salary. member of the AAPC Chapter Association, and has served office for the Des Plaines, Ill., local
chapter.
Choose Your Specialty
AAPC offers 22 specialty credentials you can earn to demonstrate
a superior level of expertise in your respective specialty disciplines.
That means they are standalone certifications with no requirement to
obtain the Certified Professional Coder (CPC®) credential. As the industry becomes more
Popular core credentials include:
CPMA® Certified Professional Medical Auditor demanding, complex, and
CPCO® Certified Professional Compliance Officer
CPPM® Certified Physician Practice Manager competitive, certification gives
CIRCC® Certified Interventional Radiology and
Cardiovascular Coder you a distinct advantage among
CPB® Certified Professional Biller
CRC® Certified Risk Adjustment Coder other job applicants.
10 Healthcare Business MonthlyAAPC NATIONAL ADVISORY BOARD ■
By Angela Jordan, CPC
NAB Regional Spotlight: Region 6 – Great Lakes
Two representatives team up to promote, serve, and support AAPC and its Region 6 members.
T he National Advisory Board (NAB) is
turning the spotlight this month to Region
6 – Great Lakes and its representatives. The
meetings and conferences. You have probably
read her many articles in this publication over
the years. She was featured on the cover of the
and Development, at which time she was
mentored by Rhonda Buckholtz, CPC,
CPCI, CPMA, CRC, CHPSE, CENTC,
Great Lakes region is comprised of Wisconsin, October 2010 edition of AAPC’s Coding Edge CGSC, CPEDC, COBGYN.
Minnesota, Illinois, Indiana, Michigan, and for her expertise on 5010 transaction prior When traveling became too difficult with a
Ohio. The six states of Region 6 cover 388,306 to ICD-10 adoption. Boynton is an active young son, Reid went back to work for UVM
square miles. This region is home to 21,511 member of the Worchester, Massachusetts, Medical Center. But when she confessed to
AAPC members and 77 local chapters. local chapter. Buckholtz that she missed the camaraderie
Angela (Annie) Boynton, RHIT, CPC, Outside of work, Boynton is savvy with she felt at AAPC, her mentor suggested she
COC, CPCO, CPC-P, CPC-I, CCS, genealogy. While working on her family tree, apply to be on the NAB. She did, and the rest
CCS-P, of Shrewsbury, Massachusetts, and she discovered she was related to another NAB is history.
Kimberly Reid, CPC, CPMA, CPC-I, member, Chandra Stephenson, CPC, COC, “AAPC has been an incredibly positive
CEMC, of Burlington, Vermont, are the two CPB, CPCO, CPMA, CPC-I, CIC, CCS, influence in my life. My coding credentials
NAB representatives who promote, serve, and CANPC, CEMC, CFPC, CGSC, CIMC, have given me the opportunity to grow in a
support AAPC and its Region 6 members. COSC. She traced her lineage back six or way that I never thought was possible,” Reid
seven generations to the same family in the said. “Being part of the NAB allows me to
Annie Boynton, RHIT, same little town in Tennessee. It’s impressive meet other coders and help them understand
CPC, COC, CPCO, CPC-P, for two relatives to have honored AAPC with the value of what we do every day.”
NAB service.
CPC-I, CCS, CCS-P Reid has lived in Burlington, Vermont, for the
Boynton has served in past 15 years. Although Reid loves Vermont,
the health information
Kimberly Reid, CPC, she still has strong roots in Michigan, and
management field for 15 CPMA, CPC-I, CEMC proudly displays her Michigander spirit; she
years in provider, payer, Reid has worked in the especially loves the Red Wings.
and educational capacities. She is principal of medical field for 28 years.
Boynton Healthcare Management Solutions, She began as receptionist Making Region 6 Stronger
specializing in practice and payer consulting, for a walk-in clinic near Both Boynton and Reid have a passion for our
compliance, and education. Boynton holds Detroit, Michigan. Reid profession, and they are dedicated to acting
several certifications in coding, as well as recalls, “All I had to do was smile, pull charts as a voice to see us through the changes as
degrees in health information technology and and chat it up with the patients. I loved it! healthcare evolves. We encourage you to reach
healthcare management, and she is pursuing Everything about that job was fascinating, out to them; they would enjoy hearing from
graduate work in health, hospital, and except when they taught me how to draw you. You can reach Boynton at Annie.Boynton@
pharmaceutical law at Seton Hall University. blood. That’s when I knew the coding part of aapcnab.com and Reid at Kimberly.Reid@aapcnab.com.
The past few years, Boynton has traveled the medical field was where I belonged.” The
If you want to be part of something that can
the country teaching ICD-10 and other sight of blood made her faint.
change people’s lives and provide you with
workshops for AAPC. She has also spoken Reid worked hard to gain experience in billing exceptional personal growth, we encourage
at several national and regional AAPC and coding, and later took a position as you to submit an application to serve on the
conferences, in addition to numerous chapter coding educator at the University of Vermont NAB. It will be an experience you’ll never
(UVM) Medical Center. When the Medical forget!
Center asked her to teach the Certified
Great Lakes Region Fun Fact Professional Coder (CPC®) class, she figured Angela Jordan, CPC, is managing consultant at Med-
it was high time she became credentialed. ical Revenue Solutions, LLC, with more than 25 years of
With a name like “Great Lakes” you’d expect a lot of experience in the healthcare field, and has been a mem-
water. According to the U.S. Geological Survey Water Reid also got involved in the Burlington, ber of AAPC for 15 years. Her career path has taken her
Science School, Michigan is covered with the highest Vermont, local chapter, and worked her way from a small family practice, radiology, large physician services group to a
percentage of water at 41.50 percent. Minnesota, up the ranks to become president. AAPC managing consultant. Jordan is on the AAPC NAB and has held many offic-
known as “the land of 10,000 lakes,” is covered by later chose her to become an expert ICD- es in the Kansas City, Mo., local chapter, including president. In 2009, she
8.4 percent water. 10 trainer, and eventually offered her the served on the AAPC Chapter Association board of directors and was chair-
woman in 2012.
position of director of ICD-10 Training
www.aapc.com July 2016 11Chapter News
By Michelle A. Dick
May MAYnia: Fun and Education Overload
Chapters turn up the value for this annual event.
E very year AAPC local chapters celebrate May MAYnia, which is a
fun way to provide members with quality education, draw in new
members, and promote networking with colleagues. Four chapters
of Clearwater’s officers smoked a pork butt all day, so members could
enjoy pulled pork sandwiches. In addition to the goodies AAPC sent,
they raffled off a gardening basket and a tote bag filled with beach
share how they ramped up participation at their monthly meetings essentials. They also gave out dozens of “beachy” door prizes. As for
last May. coding education, Laureen Jandroep, COC, CPC, CPPM, CPC-I,
CEO of Certification Coaching Organization, gave a presentation
Clearwater Gulf to Bay, Florida on modifiers.
The Clearwater Gulf to Bay, Florida, local chapter chose a beach The newest member of the Clearwater chapter, Terry Paulus, CPC, a
theme for their May MAYnia celebration, complete with sand transplant from Kentucky, said, “The Clearwater Gulf to Bay AAPC
toys, flip-flops, and seashells. They named the foods to correspond local chapter May MAYnia was the best I have ever experienced in
the 10 years of attending local chapter meetings. The food, fun,
and fabulous raffle items were over the top. Good job Sandi Webb,
Christine Cornforth, and Cindy Lewis. You guys are the best!”
Webb said, “The best part was a larger-than-usual turnout and the
fellowship we all enjoyed that evening.”
Big Stone Gap, Virginia
May was filled with positive activities for the Big Stone Gap,
Virginia, local chapter. On May 1, several members participated
in the Mountain Empire Older Citizens Walkathon. The proceeds
from each walkathon benefited the Emergency Fuel Fund for the
Elderly and assisted senior citizens with home heating-related
emergencies during the winter months. The chapter raised $550. To
top off the chapter’s good deeds, on May 13, six of Big Stone Gap’s
Clearwater’s “Beach Rules” helped members come out of their shell at May MAYnia. students and AAPC members (five are Certified Professional Coders
(CPCs®)) earned their associate degree in Health Information
with the beach theme: “Spinach dip was seaweed dip, pretzel sticks
Management.
were driftwood, blue punch was gulf water, and we had a cake with
a shoreline motif on top, as well as Nutter Butter flip-flops,” said Sabrina Ward, CPC, CCA, CEHRS, CBCS, said, “We are a small
chapter Vice President Sandi Webb, BA, CPC. The husband of one chapter — but thanks to the involvement of our students, we are
Nutter Butter flip-flops and shoreline Big Stone Gap and their families join Mountain Empire
cake were a big hit at Clearwater’s beach-themed May MAYnia. Community College for a walkathon to benefit senior citizens.
12 Healthcare Business MonthlyChapter News
Cynthia Brigg’s PAC Family Trivia game was a big success in Petersburg.
codebooks as door prizes and two new coders each won an AAPC
The Big Stone Gap HIM graduates are a proud group. Coder subscription. Briggs said, “All of them wanted me to pass
along their appreciation for the prizes!”
seeing a growth in our meetings and looking forward to what’s to
come!” Toledo, Ohio
The Toledo, Ohio, local chapter knows how to pack in a crowd at
Petersburg, Virginia May MAYnia. President Robin Moore, CPC, proudly announced
May MAYnia was a success for the Petersburg, Virginia, local that, “87 members were in attendance, up from 45 last year.” Pizza,
chapter. Keisha Sutton, CPC, from The American Congress of salad, and cake were served;
Obstetricians and Gynecologists, or ACOG, spoke for two hours and Janet Cullum, CPC,
on defining the obstetrics/gynecology global package. After her gave a presentation on
presentation, members played a trivia game that Petersburg President documentation.
Cynthia Briggs, CPC, CPMA, created called PAC Family Trivia. Moore said, “Our seminar
If you are interested in incorporating the game at your next chapter was such a success last
meeting, here’s how it’s played: month, so we wanted to
• Each table has 25 cards containing coding-related questions This cake says it all. Nice job Toledo, Ohio! give back to our members.”
facing down in the middle of the table. Toledo offered two
• Members take turns reading the questions, and the remaining continuing education units to members for only $1, and they gave
members at the table try to be the first to answer each question away prizes galore: books, gift cards, shirts, and lots of other AAPC
correctly. chapter goodies, according to Moore.
• The member who answers correctly first gets the card. If no one
answers the question correctly the reader keeps the card.
• Whomever has the most cards at the end of the game wins!
Petersburg had over 30 members attend, which is up from last year.
AAPC’s giveaways were a big hit: Two members won ICD-10-CM
It’s a full house listening to Janet Cullum’s presentation at Toledo’s May MAYnia.
No doubt these chapters will see a return on their invested efforts.
Great job officers!
For more May MAYnia celebrations, check out the AAPC Group on
Facebook, www.facebook.com/groups/21496405430/.
Michelle A. Dick is executive editor at AAPC and a member of the Flower City Coders, Rochester, N.Y., local chapter.
Keisha Sutton explains the obstetrics/gynecology global package at Petersburg’s May MAYnia.
www.aapc.com July 2016 13■ MEMBER FEATURE
By Donna Beaulieu, CRC, C-CDIS, CPC-I, CPMA, CPC, CEMC, CEDC, CFPC, CCP-P, CRP, and Hasan Zaidi, MPH, CPC, CEDC, CSPPM
Emory Physician Group Practice
Celebrates and Prepares Its Coders
Georgia’s largest healthcare system embraces the new face of
healthcare and prepares its staff for change.
Emory Physician Group Practice coders
celebrate Medical Coders Day.
Establishing Georgia
Medical Coder’s Day
Emory’s Coding Education Department
worked with Governor Nathan Deal’s
office to designate May 19, 2016, as
Georgia’s Medical Coders Day. Emory
was thrilled to receive proclamation
from the governor, recognizing coders
across the state of Georgia for their
invaluable support to physicians, care
teams, insurance payers, and patients.
Bridging the Provider - Coder Gap
E mory Physician Group Practice (Emory) encompasses 2,000
providers, more than 39 specialties at more than 80 locations, six
hospitals, and at least 130 medical coders. This healthcare system
Emory’s Coding Education Department strives to create a strong
partnership among providers, coders, and clinical departments by
supports its medical coding professionals, and is leading its clinical and serving four key functions:
business staff into healthcare’s future: the value-based payment model. 1. Coding to capture true patient acuity
Let’s look at how they honor their coding professionals and help them 2. Documentation improvement
prepare for an evolving healthcare industry. 3. Strategic initiatives
4. Education engagements
14 Healthcare Business MonthlyMember Feature
... they have focused on faculty physicians from Emory School of Medicine. Coders
who attend earn free continuing education units from
design, development, and AAPC.
Emory Coding University is deployed. This is an online
integration of future healthcare
MEMBER FEATURE
platform of coding- and documentation-related webinars
created by the Coding Education Department (short videos:
reimbursement models. 10-15 minutes).
2016:
The Provider Shadowing Initiative is initiated for continued
ICD-10 support. Coding educators observe provider workflow to
ensure services rendered are documented and coded accurately.
Since its inception in 2013, the department Weekly coding lab sessions are initiated to partner front
has supported multi-specialty service lines end (operations) and back end (account receivables) coders
ranging from primary care to surgical with coding educators to resolve coding-related denials at a
services. Service lines were created patient account level.
to standardize revenue cycle processes
by allocating designated resources for The Coding Education Department is redesigned to prepare
success: Coding Educator and Revenue for the Ambulatory Clinical Documentation Improvement
Cycle Analyst. initiative while partnering with physicians and care teams.
Since the inception of the Coding
Education Department, they have focused Leading Clinicians and
on design, development, and integration of Coders into New Payment Models
future healthcare reimbursement models. With the movement towards value-based reimbursement models and
a strong emphasis towards better population health management, the
A Timeline to Help Coding Education Department has partnered with their physicians,
Revenue and Patient Care care teams, coders, and care coordination centers to assist with
patient acuity capture.
In only a few years, Emory has launched
programs and educational improvements to help employees The Ambulatory Clinical Documentation Improvement initiative
transition through healthcare changes. Here are highlights of what was launched to ensure accurate coding/documentation and
they have accomplished for coding and healthcare professionals: predictive analytics around population health management. Emory
instills the following guiding principles for patient acuity capture:
2013:
The Coding Education Department is created to assist providers, 1. Clinical Care – to capture pertinent diseases of each patient
coders, and clinical departments with coding/documentation needs. 2. Patient Stratification – to identify high-risk and high-cost
patients
2014:
3. Care Protocols – to generate care plans to match patient
Professional Medical Coding Curriculum (PMCC) is launched
healthcare needs
under guidance and leadership of Donna Beaulieu, CRC, C-CDIS,
CPC-I, CPMA, CPC, CEMC, CEDC, CFPC, CCP-P, CRP. To By capturing true patient acuity, Emory will be able to improve
date, 175 students have successfully completed the coding course, patient health outcomes while optimizing revenue streams —
which is offered at no cost to Emory healthcare employees as part of ensuring a win-win-win situation for their patients, providers, and
their professional development. payers.
2015:
Donna Beaulieu, CRC, C-CDIS, CPC-I, CPMA, CPC, CEMC, CEDC, CFPC, CCP-P, CRP, is
Specialty-specific ICD-10 readiness documents are created and assistant director at Emory Physician Group Practice. She is a member of the Atlanta. Ga., lo-
deployed to providers via faculty meetings and published on Emory’s cal chapter.
website. A successful transition to ICD-10 was realized with no loss
in physician and coder productivity.
Hasan Zaidi, MPH, CPC, CEDC, CSPPM, is senior manager at Emory Physician Group Prac-
The Coder Development Program is launched to enable tice. He is a member of the Atlanta, Ga., local chapter.
coders to become highly specialized in multiple specialties
and reduce the need for external coders. This monthly
program brings in keynote speakers who are world-renowned
www.aapc.com July 2016 15■ HOT TOPIC
By Renee Dustman
istock.com/StockFinland
Get answers to questions about the affect 2015 legislation
will have on Medicare Part B reimbursement.
T he Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) repealed the sustainable growth rate (SGR) formula
— used since 1997 to determine Medicare payment updates — and
A proposed rule published in the Federal Register (FR Vol. 81, No.
89) on May 9 outlines CMS’ intentions for establishing these two
components of the Quality Payment Program.
established an annual 0.5 percent update to the Medicare Physician Note: To determine whether clinicians met the requirements for the
Fee Schedule (MPFS) through 2018. But what happens after that? Advanced APM track, all clinicians will report through MIPS in
Inquiring minds want to know. the first year.
Get to Know What MACRA Has in Store for You Q: What is MIPS?
Q: What else does MACRA have in store for clinicians? A: In 2019, MIPS will replace the Physician Quality Reporting
System, the Medicare Electronic Health Record (EHR) Incentive
A: MACRA also requires the Centers for Medicare & Medicaid
Program, and the Value-based Payment Modifier with a more
Services (CMS) to create a new, streamlined system for
straightforward approach to quality and value reporting.
incentivizing clinicians to provide quality care: the Quality
Payment Program. The program allows eligible clinicians to choose Eligible clinicians will be evaluated based on their performance
one of two paths for quality reporting: scores in four categories:
1. A Merit-based Incentive Payment System (MIPS); or Cost – This category replaces the cost component of the Medicare
Physician Value Modifier Program. Scores will be based on
2. Incentive payments for participation in an Alternative Medicare claims, so there are no reporting requirements for
Payment Model (APM). clinicians.
16 Healthcare Business MonthlyMACRA FAQ
MACRA doesn’t change how
existing APMs function or reward
value; it rewards participation.
Clinical Practice Improvement Activities – This category Table B: MIPS-adjusted Medicare Part B Payments
rewards activities that benefit patients, such as those focused on care Year Maximum Adjustment
coordination, patient engagement, and patient safety.
2019 +/- 4%
Advancing Care Information – This category replaces the 2020 +/- 5%
Medicare EHR Incentive Program, or Meaningful Use, for
2021 +/- 7%
physicians.
2022 +/- 9%
Quality – This category replaces the PQRS and the quality
component of the Medicare Physician Value Modifier Program. In the first year, negative adjustments can be no more than -4 percent.
According to the proposed rule, clinicians will be able to choose the The positive adjustments will be scaled to achieve budget neutrality,
activities and measures that are most relevant to their practice. so the maximum positive adjustment could be as much as 4 percent.
Each category will be weighted and worth up to a specified number In the first five payment years, MACRA allows CMS to reward
of points, as shown in Table A. exceptional performance. Exceptional performers could earn as
Table A: MIPS Performance Categories for 2017 much as an additional 10 percent without a budget neutrality
adjustment.
Category Max points Weight
CMS has not mentioned a cap on the maximum adjustment after
Quality 80-90 (based on size) 50%
2022, but it’s clear that eligible clinicians stand to lose or gain quite
Advancing Care Information 100 25% a bit of money under MIPS.
Clinical Practice Improvement Activities 60 15%
Cost (Resource Use) Average score 10% Q: Who are MIPS eligible clinicians?
A: In 2019-2020, MIPS eligible clinicians include:
The MIPS score measures clinicians’ overall care delivery; reporting
• Physicians (medical doctor/doctor of osteopathy and doctor of
is not limited to care provided to Medicare beneficiaries.
dental surgery/doctor of dental medicine)
Note: CMS proposes to make clinicians’ MIPS scores and APM
• Physician assistants
performance public on the Physician Compare website.
• Nurse practitioners
Q: How will MIPS affect Medicare reimbursement? • Clinical nurse specialists
A: A MIPS-eligible clinician’s composite performance score (CPS) • Certified registered nurses anesthetists
will result in a positive, negative, or neutral payment adjustment In subsequent years, the definition of “eligible clinician” may
beginning in 2019. A clinician’s CPS for 2019 will be based on 2017 expand to include other qualified healthcare professionals.
performance data in the aforementioned categories. Table B shows
Exempt from MIPS are clinicians in their first year of Medicare
the proposed adjustments to Medicare Part B payments for eligible
Part B participation; clinicians who bill Medicare up to $10,000
clinicians based on their CPS.
and provide care for 100 or fewer Medicare patients in one year; and
qualifying participants in Advanced APMs.
www.aapc.com July 2016 17MACRA FAQ
Q: What is an APM? Note: MACRA doesn’t change how existing APMs function or
A: As defined by MACRA, APMs include: reward value; it rewards participation.
• CMS Innovation Center models
Q: What are the advantages of participating in an Advanced APM?
• Medicare Shared Savings Program
A: Qualifying APM participants (QPs) are excluded from MIPS
• A demonstration under the Health Care Quality and receive a 5 percent lump sum bonus in 2019-2024. Beginning
Demonstration Program in 2026, QPs will get a 0.75 percent update to the fee schedule
• A demonstration required by federal law conversion factor each year, compared to 0.25 percent for non-QPs.
MACRA defines Advanced APMs as those using certified EHR The APM bonus payment will be based on the estimated aggregate
technology; basing payment on quality measures comparable to payments for professional services furnished the year prior to the
those in MIPS; and either bearing more than nominal financial payment year.
risk for monetary losses or participating in a Medical Home model According to Blue Ocean Performance Solutions CEO Chris
expanded under the authority of a CMS Innovation Center model. Sawyer, “These changes are going to drastically increase physician
According to the proposed rule, models considered Advanced ACO participation around the country.”
APMs for 2017 include: CMS thinks so, too. “We expect that the number of clinicians who
• Comprehensive End-stage Renal Disease Care Model qualify for the incentive payments from participating in Advanced
• Comprehensive Primary Care Plus APMs will grow as the program matures and as physicians take
advantage of the intermediate tracks of the Quality Payment
• Medicare Shared Savings Program (Tracks 2 and 3)
Program to experiment with participation in APMs,” writes CMS
• Next Generation Accountable Care Organization in a MACRA Quality Payment Program FAQ.
AAPC VIRTUAL WORKSHOPS NOW AVAILABLE!
Find a virtual workshop near you:
www.aapc.com/Workshops
AAPC's virtual workshops AAPC - Workshops Workshop Features:
gives you more of what
you need: • Interactive and hands-on exercises
with case studies
• Up to 6 CEUs • 4-hours includes presentation and
• 4 hours of virtual presentation skill-building practice
• Authored and presented by leading experts • Access on-demand recording
• In-depth information on critical topics
800-626-2633 | aapc.com/workshops
18 Healthcare Business MonthlyMACRA FAQ
Q: How can clinicians qualify for incentive payments Final Rule
for participation in Advanced APMs?
Although this information is based on a proposed
A: Eligible clinicians must meet certain thresholds rule, it’s safe to say these changes are in our future. It’s
to be considered QPs and qualify for incentive a very near future, so the time to act is now. Clinicians
payments. CMS will calculate a percentage threshold who submit Medicare Part B claims should be ready
score for each Advanced APM entity using two for the 2017 performance period to ensure future
methods — payment amount and patient count — revenue.
and compare it to the corresponding QP threshold.
Those who reach the threshold are rewarded. Renee Dustman is executive editor for AAPC, and a member of the Flower City Coders,
In 2019 and 2020, QPs must have 25 percent of their Rochester, N.Y., local chapter.
payments or 20 percent of their patients come through
an Advanced APM. In 2021 and 2022, QPs must have
50 percent of their payments or 35 percent of their
patients come through an Advanced APM. And in Resources
2023 and beyond, the threshold goes up to 75 percent Quality Payment Program slides: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/
for the payment amount method or 50 percent for the Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MACRA-NPRM-Slides.pdf
patient count method. Quality Payment Program fact sheet: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/
?
As with MIPS, the QP performance period for the Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf
2019 incentive begins in 2017. Physician Compare website: www.medicare.gov/physiciancompare/search.html
“MACRA in 4 Minutes” (www.youtube.com/watch?v=UXLvu_eop8k)
The
The
DID
DID
CPC-H
CPC-H
is now the
is now the
YOU
YOU AAPC - Certification COC
COC
KNOW Come
Come see
is a
see why
wise
why the
the COC
COC
investment.
is a wise investment.
Learn
Learn more
more at at
www.aapc.com/certification/coc
Advancing the Business of Healthcare
800-626-2633
800-626-2633
Advancing the Business of Healthcare
www.aapc.com July 2016 19■ CODING/BILLING
By Maryann C. Palmeter, CPC, CENTC, CPCO, CHC
Think TWICE Before
Sticking It in Your EAR
Although removing
foreign bodies
from the ear is an
otolaryngological
pain, coding it
doesn’t have to be.
A s curious kids, the sage advice “Don’t put anything in your ear report 69205 Removal foreign body from external auditory canal; with
istock.com/Vicgmyr
smaller than your elbow” didn’t stop my friends or me from general anesthesia. This procedure is also unilateral.
putting many things into our ears (and mouths and noses) that weren’t Code 92502 Otolaryngologic examination under general anesthesia is
intended to go there. As a (sensible adult) coder, now when an object considered a standard of medical/surgical practice when performed
ends up in an ear, I need to determine whether it’s there by way of with the removal of a foreign body. As such, do not report it separately
nature or some other manner, as well as how the object was removed. if the examination is performed on the same ear and during the same
encounter as the foreign body removal.
Removal of Foreign Object
Removal of a broken cotton swab, an insect, or a Cocoa Puff ™ from Removal of Cerumen
an ear qualifies as the removal of a foreign body. Removal of a foreign Impacted cerumen (ear wax) is typically extremely hard and dry and
body from the external auditory canal without general anesthesia accompanied by pain and itching. Impacted cerumen obstructing
is coded 69200 Removal foreign body from external auditory canal; the external auditory canal and tympanic membrane can lead to
without general anesthesia. This code is unilateral, so if the patient hearing loss. There are two different methods for removing impacted
sticks a Cocoa Puff ™ in both ears, report 69200 on a single claim cerumen. (For cerumen removal that is not impacted, refer to
detail line and append modifier 50 Bilateral procedure. evaluation and management codes.)
Note: Individual payers may have different rules on billing unilateral
procedures performed bilaterally, and may prefer that the procedure Cerumen Removal: Instrumentation
code be billed on two separate line items, appended with modifier RT Report 69210 Removal impacted cerumen requiring instrumentation,
Right side or LT Left side. unilateral if instrumentation is used to remove impacted cerumen.
The type of removal described by 69200 is performed under direct Code 69210 captures the direct method of impacted earwax removal
visualization with an otoscope. Forceps, a cerumen spoon, or suction using curettes, hooks, forceps, and suction.
is used to remove the foreign body. In the case of a live insect, mineral CPT® considers this procedure to be unilateral, stating, “For bilateral
oil is usually dropped into the ear to immobilize the insect before it procedure, report 69210 with modifier 50.” The Centers for Medicare
is removed. & Medicaid Services (CMS) sees things differently. In the 2014
If the patient cannot tolerate the procedure while awake, general Medicare Physician Fee Schedule, CMS stated its opinion that the
anesthesia may be used. This may also be the case if the foreign body procedure will typically be done on both ears at the same encounter
is so large that an incision is made into the external meatus to enlarge because “the physiologic processes that create cerumen impaction
the opening before the foreign body can be extracted. In this instance, likely would affect both ears.” CMS also said, “Given this, we will
20 Healthcare Business Monthly ■ Coding/Billing ■ Auditing/Compliance ■ Practice ManagementTo discuss this
article or topic, go to
www.aapc.com In Your Ear
Medicare will pay the same amount for 69210 whether it is
performed on one ear or two, even though the CPT® descriptor
CODING/BILLING
stipulates it is unilateral. Other payer policies may differ from Medicare’s.
continue to allow only one unit of CPT 69210 to be billed when Cerumen Removal with Audiologist Service
furnished bilaterally.” The Medicare Physician Fee Schedule Look-
HCPCS Level II code G0268 Removal of impacted cerumen (one or
up Tool on the CMS website lists procedure code 69210 as bilateral;
both ears) by physician on same date of service as audiologic function
appending modifier 50 is unnecessary.
testing was created to allow payment to a physician who removes
Bottom line: Medicare will pay the same amount for 69210 impacted cerumen on the same date a contracted or employed
whether it is performed on one ear or two, even though the CPT® audiologist performs audiologic function testing.
descriptor stipulates it is unilateral. Other payer policies may differ
CMS does not separately reimburse audiologists for removal of
from Medicare’s.
cerumen because this is considered inherent in the audiologic function
test. If a physician removes the impacted cerumen on the same day
Cerumen Removal: Irrigation as the audiologic function testing, however, the physician (or other
New procedure code 69209 Removal impacted cerumen using qualified healthcare practitioner) may separately report G0268.
irrigation/lavage, unilateral describes an indirect and less invasive The moral of this story is: The next time you’re thinking about
method of cerumen removal. The creation of this code for CPT® sticking something in your ear to remove some bothersome earwax,
2016 was warranted to differentiate between direct and indirect think twice.
approaches of removing impacted cerumen performed or supervised
by physicians or other qualified healthcare professionals. Maryann C. Palmeter, CPC, CENTC, CPCO, CHC, is employed with the University of Flor-
Report 69209 when the removal of impacted cerumen does ida Jacksonville Healthcare, Inc. as the director of physician billing compliance where she pro-
vides professional direction and oversight to the billing compliance program of the Universi-
not require instrumentation. Irrigation/lavage involves using a
ty of Florida College of Medicine – Jacksonville and its practice plan. She has over 30 years of
continuous low pressure flow of liquid (e.g., saline solution) to experience in federal and state government billing and compliance regulations gained
gently loosen impacted cerumen and flush it out, with or without through working on both the physician billing and government contractor sides of the healthcare industry. Pal-
the use of a cerumen softening agent (e.g., cerumenolytic), which meter served on the National Advisory Board from 2011-2013 and served as the board’s secretary from 2013-
may be administered days prior to, or at the time of, the procedure. 2015. She is the education officer for the Jacksonville, Fla., local chapter. Palmeter received AAPC’s “Member of
the Year” award in 2010.
Only one method of impacted cerumen removal (i.e., either
69209 or 69210) may be reported when both are performed on the
same day, on the same ear. Procedure code 69209 is unilateral. If
performed bilaterally, report 69209 on a single claim detail line with
modifier 50 appended.
Note: Individual payers may have different rules on billing
unilateral procedures performed bilaterally and may prefer the
procedure codes to be billed as separate line items with modifiers
RT and LT for the right and left ears, respectively. Resources
2014 Medicare Physician Fee Schedule: www.cms.gov/medicare/medicare-fee-for-service-
Tip: Don’t confuse procedure code 69020 Drainage external auditory canal, abscess with the
payment/physicianfeesched/pfs-federal-regulation-notices-items/cms-1600-fc.html
service described by procedure code 69209. Although both describe a method of irrigation/
lavage and/or drainage, 69209 is specific to impacted cerumen and 69020 is specific to Medicare Physician Fee Schedule Look-up Tool: www.cms.gov/apps/physician-fee-schedule/
abscesses. search/search-criteria.aspx
www.aapc.com July 2016 21■ CODING/BILLING
By Kasandra Bolzenius, CPC
Get Paid for Smoking Cessation
Proper documentation and verifying coverage criteria prior to
claim submission can improve your chances for reimbursement.
istock.com/Joe Belanger
M any healthcare providers perform tobacco use counseling daily,
but they may not be documenting or reporting it appropriately.
Reliable guidance is needed to ensure all performed services are
2. Who are competent and alert at the time counseling is provided;
and
3. Who receive counseling furnished by a qualified physician or
claimed and supported by complete documentation. other Medicare-recognized practitioner.
Where Opportunity Knocks Each payer may have its own restrictions for coverage, so inquire
about a patient’s benefits prior to claim submission.
The Centers for Disease Control and Prevention (CDC) has
produced evidence supporting that tobacco use remains the single
largest preventable cause of death and disease in the United States. A Documentation May Determine Payment
study in 2010 indicated that seven out of 10 adult smokers wished to As with any time-based evaluation and management (E/M) service,
quit; however, studies also indicate that only an estimated 4 percent documentation must include sufficient detail to support the claim.
to 7 percent of people are able to quit smoking on any given attempt Proper documentation for tobacco-use cessation counseling should
without medicines or other help. Counseling and other types of include the total time spent face to face with the patient, and what was
support can increase success rates better than medications alone. discussed. The patient’s desire or need to quit tobacco use, cessation
techniques and resources, estimated quit date, and planned follow
Medical Necessity up should be noted within the patient’s medical record. Without
this information, medical necessity for coverage may be questioned,
The Centers for Medicare & Medicaid Services (CMS) set a standard
which could result in denied or delayed payment.
for coverage (which commercial payers may not follow). Per MLN
Matters® article MM7133, CMS will cover tobacco cessation Without documentation of significant and separately identifiable
counseling for beneficiaries: work, the payment for smoking cessation counseling may be included
in the payment for the primary E/M service.
1. Who use tobacco (regardless of whether they have signs or
symptoms of tobacco-related disease);
22 Healthcare Business Monthly ■ Coding/Billing ■ Auditing/Compliance ■ Practice ManagementTo discuss this
article or topic, go to
www.aapc.com Smoking Cessation
As with any time-based evaluation and
management (E/M) service, documentation must
include sufficient detail to support the claim.
CODING/BILLING
Examples of incomplete documentation: pack of cigarettes per day after several failed attempts at quitting.
• “I have counseled the patient again to quit smoking. The Approximately 15 minutes were spent counseling the patient
patient verbalized understanding, but is not ready to quit in cessation techniques. He understands continuing to smoke
smoking.” could lead to stroke and death. The benefits of stopping were also
presented to him. The patient has verbalized his desire to “give it
• “>3 minutes spent counseling patient on tobacco use.”
another try.” He has set his own goal of 30 days to be completely
smoke-free. We will follow up in two weeks to check progress.
Proper Billing Means Prompt Reimbursement
CPT® coding:
Private payers may follow CMS’ direction when it comes to billing
99407
requirements for these services; however, it’s important to know
your patient’s insurance benefits. ICD-10-CM coding:
Medicare will cover two cessation attempts per year. Each F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders
attempt may include a maximum of four intermediate or intensive
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
counseling sessions.
The total annual benefit covers up to eight smoking and tobacco-
use cessation counseling sessions in a 12-month period. The
Know Your Patient Coverage
beneficiary may receive another eight counseling sessions during If your clinic is just beginning to provide these services to your
a second or subsequent year after 11 months have passed since the patient population, it’s best to verify coverage criteria prior to claim
first Medicare covered cessation counseling session was performed. submission. For instance, Preventive Medicine Services guidelines in
the CPT® codebook state, “Codes 99381-99397 include counseling/
Example: The beneficiary received the first of eight covered sessions
anticipatory guidance/risk factor reduction interventions which
in January 2011. The count starts beginning February 2011. The
are provided at the time of the initial or periodic comprehensive
beneficiary is eligible to receive a second series of eight sessions
preventive medicine examination.” Many payers group tobacco use
in January 2012. Medicare’s prescription drug benefit also covers
cessation counseling under this umbrella and will not reimburse it
smoking and tobacco-use cessation agents prescribed by a physician.
separately. Knowledge of potential reimbursement errors keeps the
CMS specifies symptomatic patient criteria as beneficiaries “who denial rate low and provider-patient relationships strong.
use tobacco and have been diagnosed with a recognized tobacco-
related disease or who exhibit symptoms consistent with tobacco Kasandra Bolzenius, CPC, is a senior compliance specialist with a large healthcare system
related disease.” in the Midwest. She regularly provides guidance to healthcare providers, administration, and
medical staff on billing and coding standards, government policy, and internal revenue op-
CPT® descriptions: portunities. Bolzenius is a member of the Saint Louis West, Mo., local chapter.
99406 Smoking and tobacco cessation counseling visit for the symptomatic patient; intermediate,
greater than 3 minutes, up to 10 minutes
99407 intensive, greater than 10 minutes
G0436 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate,
greater than 3 minutes, up to 10 minutes Resources
G0437 intensive, greater than 10 minutes www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-
These counseling services must be submitted with appropriate QuickReferenceChart-1TextOnly.pdf
diagnosis coding to support medical necessity. The claim and www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
documented encounter should include tobacco use status and MLNMattersArticles/downloads/MM7133.pdf
confirmed tobacco-related diseases, as appropriate. www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/
Example: A 67-year-old male Medicare patient presents with www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-
exacerbated COPD on oxygen. This patient continues to smoke one quitting-smoking-success-rates
www.aapc.com July 2016 23You can also read
