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May / June 2016 | Issue 11.3

The Physcian Practice Educational Solution

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Modernizing Patient Payment Collection

ICD-10-CM is Changing Again

A Billing and Coding Conundrum?

Face of YourTaking Practice – Great Customer Service HIPAAThe Security Breaches: a Proactive Approach

Why are

Evaluation and Management Services Being Scrutinized?

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ICD-10-PCS: The Seven Approaches in the Medical and Surgical Section This interactive webinar presentation provides case-based scenarios that allows attendees to code along with the presenter as they are led through complex procedures.

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Documentation Tips for ICD-10 Success Webinar attendees will be provided with documentation tips from an AHIMA-formed multi-disciplined workgroup that went through each chapter of ICD-10-CM and ICD-10-PCS. Gloryanne Bryant, RHIA, RHIT, CDIP, CCS, CCDS Product #: AUDA020216

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EXPERT CONTRIBUTORS

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WE’RE PROUD TO INTRODUCE OUR EDITORIAL BOARD FOR THIS ISSUE Nancy Clements, Director of Marketing Communications of Practice Management Institute based in San Antonio, TX.

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advertising manager Melissa Gilchrist melissa.gilchrist@billingcoding.com

CONTACT US Billing-Coding, Inc. P.O. Box 80669 Simpsonville, SC 29680 Phone: 864 228 7310 Fax: 888 573 7210 info@billing-coding.com www.billing-coding.com approving CEU associations www.billing-coding.com/ceu

Dr. Evan M. Gwilliam, DC, MBA, BS, CPC, NCICS, CCPC, CCCPC, CPC-I, MCS-P, CPMA, is a licensed physician with a master’s in business administration. He is also a certified professional coding instructor, compliance specialist, and medical auditor. He is the Executive Vice President at FindACode.

Priscilla Holland, Senior Director of Healthcare Payments, NACHA – The Electronic Payments Association.

Dave Jakielo, CHBME, is an International Speaker, Consultant, Executive Coach, and Author, and is president of Seminars & Consulting.

William McDonald, Esq., chairs the Healthcare department at Campolo, Middleton & McCormick, LLP, the premier full-service law firm in Suffolk County, Long Island, New York.

Contact Bill at wmcdonald@cmmllp.com or (631) 738-9100, ext. 320.

PQRS Gets More Complicated

BC

How to Identify Who Sent

Lyn Triffletti, CCSP, CPCO, CPC, PCS, is a vice president of compliance at Stericycle, Inc. Steve Verno, CMMC, CMMB, NREMT-P, CEMCS, CMSCS, is a Professor of Medical Coding and Billing Instruction at Florida Metropolitan University.

Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, has worked in medical offices and clinics for over 30 years in California and Utah and is currently the Director of Content for Find-ACode and InstaCode in Spanish Fork, UT. She has authored and co-authored multiple books and articles related to medical coding, billing, and provider documentation training. She is married with four children.

Now More Than Ever

Your Healthcare EFT Payment

– Great Customer Service Bills Practice More Your

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Ranadene Tapio, MBA, CMRS, CMC, is the president of Business Office Consultants, LLC, which provides Revenue Cycle Management, Credentialing & Consulting services to a number of healthcare providers in a variety of specialties.

as 48 Measures are Retired

Relative Value Units: Important

ADVANTAGE

of Pay Who Face Patients HappyThe

for Medical Office Professionals

subscriptions manager Ashley Knight ashley@billing-coding.com

The Essential Resource

coo Nichole Anderson, CPC nichole@billing-coding.com

Alice Scott and Michele Redmond, mother and daughter, are coauthors of 15 books on medical billing at www.medicalbillinglive.com and co-owners of Solutions Medical Billing Inc. in Rome, N Y. They have also developed an online medical billing course at www.medicalbillingstudycourse.com

CONC ERNS IMPORTANT NEW PROVIDERS, AND SUPPLIERS S, FOR BILLING COMPANIE

GET PUBLISHED We are always interested in hearing from any industry experts who would like to get published in our national magazine.

Email us at editorial@billing-coding.com to request a copy of our editorial guidelines and benefits.

10.3

ceo - publisher Storm Kulhan storm@billing-coding.com

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FAHIMA, served as AHIMA’s Interim CEO in 2011 and held president positions in Eastern Missouri HIMA, Missouri HIMA, and Greater St. Louis HFMA. She is Chief Operating Officer of St. Louis-based First Class Solutions, Inc. and is recognized nationally for her texts, presentations, and articles on a variety of healthcare related topics.

May / June 2015 | Issue

editor Amber Joffrion, M.A. editorial@billing-coding.com

Maxine Collins, MBA, CPA, CMC, CMIS, CMOM, Director of Compliance, Audit and Education at CoreMDPartners, LLC.

Marge McQuade, CMSCS, CHCI, CPOM, CMCS is a certified practice office manager, a certified multi-specialty coding specialist, and a certified healthcare coding instructor who has over 35 years of experience in the medical field.

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PAGE 26

Why are

Evaluation and Management Services Being Scrutinized?

CONTENTS FEATURES

MAY/ JUNE 2016 - 11.3

REGULARS 26. Why are Evaluation and Management Services Being Scrutinized?

10. Modernizing Patient Payment Collection

8. NEWS 42. Datebook

12. How Taxonomy Codes Can Affect Insurance Payments

32. Questions from the Internet: Secondary Payer

14. ICD-10-CM is Changing Again

36. Post ICD-10: What Physician Offices Need to Consider

16. Maintaining Information Privacy in a Big Data Environment

40. HIPAA Security Breaches: Taking a Proactive Approach

18. Revenue Cycle 101: Insurance Basics 20. Medicare Providers: Don’t Let Identity Theft Cost You Money!

44. Why Doctors Should Outsource Their Billing

22. A Billing and Coding Conundrum?

4

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46. Talking to Patients about Financial Responsibilities 48. 5 Minutes with…Julie Pisacane, CCA, CPMA, CPPM, CEMC, ICD-10-CM Proficient 50. Reviews AMA: CPT® Coding Essentials

LETTER FROM

OUR CEO

Summer is coming!

Summer is coming!

Subscribe to

I don’t know about you, but summer is my most favorite season! I

BC Advantage Magazine today!

hours through my garden, enjoying all the lightnin’ bugs (and other

BC ADVANTAGE

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As I write this, we are preparing to attend the AAPC conference in

All of My Codes are Unspecified

Revenue Cycle 101: Determining

Insurance Order

Orlando, FL., which is always fun and it’s great to catch up with

Scribes and Coding Professional

s – A Natural Partnership

What Can TheYou Face Do When of Your Patients Practice Are No-Shows?

– Great Customer

for Medical Office Professionals The Essential Resource

2015

Service

& The Road Ahead

PQRS Gets More Complicated as 48

Measures are Retired

Relative Value Units: Important Now

those of you who attend. We have made some really great friends

EFT Payment Repeal

through these conferences and always have a good time during and after the sessions. This year, I’m bringing the crew as we really cannot pass up the fun of a trip to Orlando! Who wants to see the big guy with the big ears? Me, that’s who!

More Than Ever

How to Identify Who Sent Your Healthcare

ADVANTAGE

of SGR

0RGLÀHU

– Great Customer Service Practice Bills Your More of Pay Who Face Patients HappyThe

ICD-10 Implementatio on

www.billing-coding.com | Issue 10.6

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November / December

Office Professionals

flying critters) we have here in the south.

Healthcare Highlights of

BC The Essential Resource for Medical

love being outside and can be found wandering during the evening

In the interim, we are working on this issue and as always, we have secured some very interesting articles for you, written by our esteemed editorial board members.

IMPORTANT NEW CONC ERNS SUPPLIERS , AND FOR BILLING COMPANIES, PROVIDERS

Our cover, written by Aimee Wilcox, looks at the wonderful world of evaluation and manage-

May / June 2015 | Issue 10.3

ment services and why they are always included on the OIG list. Aimee offers some wonderful tips on how to be prepared for an audit for not “if” it happens but for “when.” Being

USEFUL LAYOUTS Lorem ipsum dolor sit amet, congues.

12

audited is by no means fun (for those of you who enjoy it—well really, there are no words!) so being prepared and organized for the time that one gets dropped on you will make the

www.billing-coding.com FREE CEUS FREE WEBINARS FREE ICD-10 RESOURCES

whole (very stressful) experience much easier and help you become aware of any issues that may be occurring right now.

We’ve got a couple of articles covering ICD-10 (and I hope that all has settled down now and that your office is moving onward and upward) and a couple looking closer at security (data and identity). Steve Verno continues with his Question from the Internet series and we welcome back Alice Scott and Michelle Redmond with their contribution about taxonomy codes. There’s an article on financial responsibilities as well as one on modernizing patient payment collections. HIPAA is also covered from the perspective of cyber-criminals and how you can protect vital information from this frustrating threat.

You can see that we have a jam-packed issue for you and we hope that you’ll sit down with a cuppa (yes, that’s the Aussie in me coming out!) and a few cookies—and enjoy!

Until next time,

Storm Kulhan BC Advantage Magazine

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Advertising Index This index is provided as a service to our readers. Please visit their websites listed below, and let them know you saw their advertisement in BC Advantage magazine and for any discounts offered.

For more information on these advertisers, go to www.billing-coding.com/sponsors COMPANY

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2016 | Issue 11.2

The Essential Resourc e Solution for Medica l Office Profess ionals

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HEALTHCARE NEWS AND UPDATES

CMS updates ICD-10 files for download 2016 ICD-10-CM and GEMs The 2016 ICD-10-CM files below contain information on the new diagnosis coding system, ICD-10-CM, that is a replacement for ICD-9-CM, Volumes 1 and 2. These 2016 ICD-10-CM codes are to be used for services provided from October 1, 2015 through September 30, 2016.

Downloads

• • • • • • • •

2016 Code Descriptions in Tabular Order 2016 Code Tables and Index 2016 ICD-10-CM Duplicate Code Numbers 2016 Addendum 2016 General Equivalence Mappings (GEMs) – Diagnosis Codes and Guide 2016 Present On Admission (POA) Exempt List (Updated 8/20/2015) 2016 ICD-10-CM Guidelines 2016 Reimbursement Mappings – Diagnosis Codes and Guides

https://www.cms.gov/Medicare/Coding/ ICD10/2016-ICD-10-CM-and-GEMs.html CollaborateMD Surpasses 1 Million Monthly Healthcare Claims CollaborateMD (CMD), a leading provider of innovative and intelligent cloud-based revenue cycle management solutions, is proud to announce hitting two major milestones in March 2016. The company surpassed one million healthcare claims processed in the month of March and surpassed $30 billion worth in healthcare claims processed since inception.

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These milestones come as no surprise for anyone who knows CollaborateMD. The company celebrated its 16 year anniversary this year and continues to improve the financial workflow of medical practice and revenue cycle management companies across America. www.collaborateMD.com ICD-10 at Six Months AHIMA pleased with smooth transition to the modern, more granular code set Six months have passed since ICD-10 was implemented on Oct. 1, 2015, and the American Health Information Management Association (AHIMA) is pleased to see the way the healthcare community has transitioned to the new code set.

“As a long-time leader and advocate for ICD-10, it is exciting and rewarding that all stakeholders now have the opportunity to fully benefit from a modern and robust coding system that is able to meet 21st century health challenges,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. “While there have been the expected small pockets of problems that are inevitable with a change of this magnitude, it’s clear that the overall transition has been extremely smooth and devoid of major issues.”

AHIMA attributes this success to a number of factors including provider preparation, training, collaboration and extensive dual coding leading up to the implementation deadline. This success is borne out by a Feb. 24 blog post from the Centers for Medicare & Medicaid Service (CMS) that detailed how the claims denial rates for the

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fourth quarter of 2015 were actually slightly lower than historical rates.

“The greater detail in ICD-10 will more effectively measure quality, safety and efficacy of care and reduce fraud,” Thomas Gordon said. “It will help reverse the trend of deteriorating health data and tell a patient story that is more accurate and complete. This will ultimately help lead to what everyone wants – improved patient care and better health outcomes at reduced cost.” www.ahima.org HIPAA Violations Net $5.45 Million in a Single Week The U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) continued its run of resolution agreements for HIPAA violations, pulling in $5.45 million from just two entities, North Memorial Health Care of Minnesota (NMHCM) and the Feinstein Institute for Medical Research (Feinstein), in a single week.

The resolution agreements emphasize that business associate agreements and security risk analyses are “major cornerstones” of the HIPAA rules, and research institutions working with patient information are held to the same standards as covered entities for protecting patient data.

Judging from these resolution agreements and our work with the OCR in its investigations, the OCR considers business associate agreements and security risk analyses as “low-hanging fruit” for covered entities’ HIPAA compliance.

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Medical Billing

Modernizing Patient Payment Collection Collections of patients’ outstanding bills, those charges not covered by health insurance plans, are set to challenge medical practices across the country, if they haven’t already. Consequently, physicians will need to migrate toward other methods to collect patient payments, including offering online payment portals and accessibility for patients to make a single or series of electronic funds transfer (EFT) payments via ACH. than $6,200 per year (and to more than $17,500 in annual premiums for family coverage). Notably, wages have only increased an average of 10% over that same period (2010 to 2015).

Doctors Feeling the Strain While high deductible plans can make business sense for insurance companies seeking to rein in costs, these can pose challenges for well-intentioned medical doctors running their own businesses.

T

he Affordable Care Act has compelled many companies to change the healthcare plans they offer to employees in order to reduce their rising costs associated with plan implementation.

Consequently, many employers have shifted to high deductible healthcare plans being offered by health insurance companies. But these plans require employees to satisfy a significantly higher level of medical costs up front, before any insurance will kick in. Today, many healthcare plans sport annual individual employee deductibles of $5,000 or even more—a high hurdle for many insured individuals.

Patient Pain by the Numbers According to the 2015 healthcare report from the Kaiser Family Foundation, the average plan deductible is now $1,318—up from $917 in 2010. Adding to that financial burden for employees, premiums for single healthcare coverage have risen 27% during the past five years to more

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2010 data from the Medical Group Management Association (MGMA), a trade association of medical practice administrators and executives representing 385,000 physicians, shows that 30% of patients walk out of their doctor’s office without paying. Medical practices were responsible for collecting $1 out of every $4 directly from patients. In July 2015, an MGMA survey found that collecting patient due balances is among the top 10 pain points for nearly 96% of doctors. Those numbers are expected to jump in tandem with patients having to pay for medical services against higher deductibles and higher out-of-pocket premiums.

It’s no longer just a matter of doctors’ offices collecting traditional co-payments from patients. Although not specific to collections of medical payments from patients, data from the Commercial Collection Agency Section Commercial Law League of America shows that the probability of collecting a debt generally drops to 73% after three months, and to 50% after six months. Debt that is one year past due only has a 25% chance of ever being collected.

Finding Solutions: Developing an Online Payment Portal Providers should look to expand payment option capabilities to provide more solutions for their patients. While

collecting payments at the time of service is the ideal, offering broader payment options can increase payment collection. Data from MGMA in 2010 indicates doctors collect a fractional $15.77 for every $100 in unpaid patient bills once a patient’s outstanding debt is turned over for collection. Physicians will not only need to retrain staff as to what to do in light of the changing landscape, but doctors will also need to consider other solutions.

Best practices for doctors can include having candid and detailed up front discussions with patients as to what any service or procedure will cost and what the out-of-pocket expenses will be for the patient. The faster a patient can get an estimated bill, the more likely he/she will be inclined to pay. Physicians who are already, or are open to, accepting the healthcare EFT standard can speed up the collections of funds from health plan providers, thereby enabling doctors to deliver an accurate bill to patients faster.

Doctors must also look at the problem more holistically and consider giving patients expanded options for paying their bills beyond using paper checks, whose usage has waned in the electronic age. This can include developing online payment portals.

For example, are credit cards currently accepted by the practice, and can patients log onto the practice’s website and pay by credit card right then and there, 24/7/365? Does the online payment portal allow for a single electronic funds transfer (via an easy and quick ACH payment)

from a patient’s bank account?

Patients have become quite accustomed to receiving ACH payments because that’s how many receive their pay—through Direct Deposit via ACH. In fact, more than 80% of U.S. workers receive their pay using Direct Deposit. Can patients who cannot pay the entire bill now set up to have a series of EFT via ACH payments periodically made to the doctor until the entire cost is paid?

This option could be appealing and much less expensive to patients who may favor a direct payment series over credit card finance charges.

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Moreover, ACH payments are much more cost-effective for doctors, costing an average of 31 cents per transaction as charged by financial institutions versus 3% fee for each credit card transaction. Credit card processing costs can quickly add up for medical practices, as can fees that must be paid to collection agencies to recoup unpaid money from patients. In addition, ACH payments can be just as easily executed for a one-person rural medical practice as for large multiple-doctor, multiple-office practices, making it practical for all.

Physicians who want to ensure collection of their patient revenue will want to consider alternative payment options that make sense for most patients and can cure their own collection headaches.

Priscilla Holland, Senior Director of Healthcare Payments, NACHA – The Electronic Payments Association.

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Medical Coding

How Taxonomy Codes Can Affect Insurance Payments In the past, taxonomy codes may not have played a great part in payment of medical billing claims, but that is changing. Taxonomy codes are now not only affecting the amount of payment on medical claims, but also whether or not they are paid.

W

hat is a taxonomy code?

Taxonomy Codes are an administrative code set for identifying the provider type and area of specialization for healthcare providers. They are alphanumeric and are ten characters in length. Taxonomy codes allow providers to identify their specialty. A provider can have more than one taxonomy code.

When a provider applies for an NPI number, he or she must select at least one taxonomy code indicating their specialty.

Taxonomy Codes have 3 distinct levels. Level I is the provider type, which is a major grouping of healthcare providers. For example: Dentists, Osteopathic Physicians, and Chiropractors.

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Level II is classification or a more specific service or occupation related to the provider type.

Level III is the area of specialization. This is a more specialized area of the classification in which a provider chooses to practice or make services available. This is usually based upon the sub-specialty certificate.

The taxonomy code set is maintained by the NUCC or National Uniform Claim Committee.

The code set is updated twice a year on April 1 and October 1.

How is the taxonomy code directly affecting payments?

Last year, our local Blue Cross started requiring the use of taxonomy codes on all claims. If a taxonomy code was not listed, the claim was denied. This was a two-sided sword as when we started submitting taxonomy codes on our claims, Fidelis, a Medicaid Advantage plan, started denying all of our claims.

When contacted to find out why claims were denied, we were told it was because the claim was submitted with a taxonomy code in box 24j and box 33b. Our practice management program had to be set up to print the taxonomy codes on Blue Cross claims, but not on Fidelis claims. These different requirements by different insurance carriers can present quite a challenge in the office. It almost requires a computer programming degree to get the practice management system set up properly to meet the requirements.

Taxonomy Codes allow the provider to identify their specialty at the claim level so this can directly affect your reimbursement from insurance companies. If you have an inaccurate taxonomy code linked to your NPI number, then your services may be paid at a lower reimbursement rate, or outright denied by an insurance company.

my codes on a claim depending on the services being billed.

This presents another programming issue in setting up the practice management system to include the appropriate taxonomy code for the services.

Even though taxonomy codes have been around since 2008, they really haven’t affected the billing process a whole lot. You can expect that to be changing. More and more insurance carriers will begin using taxonomy codes in processing claims. It is important to keep up to date with each insurance carrier’s requirements and how it may affect payment of your claims.

Alice Scott and Michele Redmond, mother and daughter, are coauthors of 15 books on medical billing at www.medicalbillinglive.com and co-owners of Solutions Medical Billing Inc. in Rome, N Y. They have also developed an online medical billing course at www.medicalbillingstudycourse.com and offer a free monthly newsletter, an active medical billing forum, and maintain two websites on medical billing.

When providers apply for NPI numbers, a taxonomy code must be selected. A provider can select more than one taxonomy code, but they must identify one as their primary taxonomy code. They can enter as many taxonomy codes as needed.

Example of picking a specific taxonomy: If you are a Pediatric Surgeon and you pick a taxonomy code for just straight Pediatrics, your services may be denied. You would need to pick the more specific code of Pediatric Surgeon (at Level III) in order to ensure proper reimbursement for your services.

Example of picking multiple taxonomy codes: If a provider has multiple specialties, they may need to have multiple taxonomy codes. For example, an MD or Medical Doctor may be a general practice physician seeing patients as a PCP or primary care physician and also see patients for Addiction Medicine. He would have a taxonomy code of 208D00000X for General Practice and a taxonomy code of 207QA0401X for the addiction medicine.

In addition to requiring that a taxonomy code be on a claim, the insurance carrier may also require that the taxonomy code match the services being billed. For example, if a provider is billing for services such as addiction medicine, but they have a taxonomy code of 208D00000X for General Practice, the services may be denied because the taxonomy does not represent the services being billed. The provider may need to include different taxono-

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ICD-10

ICD-10-CM is Changing Again October 1, 2015 was seen as doomsday by many in the healthcare industry.

It was compared to Y2K and the Mayan calendar.

But, like those other situations, most clinics and payers sailed right through, leaving many of us wondering why it seemed like such a big deal.

I

CD-11 is expected to be released by the World Health Organization in 2018, but it will take the National Center for Health Statistics several more years before they are ready to release the Clinical Modification for use in the United States. In the meantime, however, ICD-10CM will be updated annually in order to keep up with the changing needs of our healthcare system.

Who is in charge of these updates?

March 9-10, 2016, the ICD-9-CM Coordination and Maintenance Committee met to discuss changes to ICD-10-CM, which begins October 1, 2016 at the earliest. A representative from the National Center for Health Statistics (NCHS - part of the CDC) and one from the Centers for Medicare and Medicaid

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Services (CMS) co-chair the meetings. NCHS is responsible for classification of diagnoses while CMS is responsible for ICD-10-PCS (which are used only in an inpatient/facility setting at this time).

The ICD-9-CM Coordination and Maintenance Committee’s role is advisory. All final decisions are made by the Director of NCHS and the Administrator of CMS at the end of the year and become effective October 1 of the following year.

Where can I find the official changes?

Official code revision packages, which are referred to as addenda, are available from the CDC. The agenda for the March 2016 meeting included 1,928 proposed new codes for ICD-10-CM, and around

5,500 for ICD-10-PCS, but the official addendum is not released until June 2016. Deadline for public comments on proposed new codes from the March meeting was April 8, 2016.

A few of the new codes (such as codes for the Zika virus) may be fast-tracked for addition on October 1, 2016, but most will likely go into effect in 2017.

How can I suggest code changes?

The ICD-9-CM Coordination and Maintenance Committee meets twice a year. At these meetings, the public is asked to comment on whether or not requests for new diagnosis or procedure codes should be created based on the criteria of the need to capture a new technology or disease. Although it is a Federal Committee, suggestions for modifications come from both the public and private sectors. Interested parties must submit proposals for modification prior to a scheduled meeting via http:// www.cdc.gov/nchs/icd/icd9cm_maintenance.htm.

Proposals for a new code should include the following: • •

•

Description of the code(s)/change(s) being requested Rationale for why the new code/ change is needed (including clinical relevancy) Supporting clinical references and literature should also be submitted.

Proposals should be consistent with the structure and conventions of the classification. In other words, submitters need to know how ICD-10-CM works and figure out how their idea fits into the existing format.

FREE

The next meeting is Sept. 13-14, 2016, with proposals due July 15, 2016. If accepted, these proposals would not go into effect until 2017, at the earliest.

ICD-10 Webinar

ICD-10-CM Diabetes:

What I really want to know is, will I need to buy a new ICD-10 code book?

Combine Coding and Documentation for Greater Specificity

It depends on your specialty. There are some significant changes proposed for myocardial infarction, lump in the breast, and type 2 diabetes, among others. If you use an online encoder library, such as Find-A-Code, you can rest easy because codes are always current since they are updated as soon as changes are made official. Many publishers, such as the InstaCode Institute, are hard at work on specialty specific 2017 ICD-10 books, which may be pre-ordered, but won’t ship until this fall once the code updates are made official. Note that after a year of using ICD-10, many things have been learned and publications should contain specific tips and tricks to make your job a little easier. Even though the codes may not have changed much, the tools and advice available gets better every year.

Dr. Evan M. Gwilliam, DC, MBA, BS, CPC, NCICS, CCPC, CCCPC, CPC-I, MCS-P, CPMA, is a licensed physician with a master’s in business administration. He is also a certified professional coding instructor, compliance specialist, and medical auditor. Dr. Gwilliam has published articles in multiple trade journals and travels the country to deliver training to physicians and staff on coding, documentation, and compliance.

He is the Executive Vice President at FindACode.

Presented by:

Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP Objective: Each participant can expect to have an excellent understanding of Diabetes coding and documentation requirements under ICD-10-CM. Topics covered: • Diabetes – ICD-9 versus ICD-10 • The ICD-10-CM codeset and diabetes • Coding Clinic and diabetes • Changes in CC/MCC

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Please visit www.hcpro.com who provides specialized information in a variety of products, including magazines, newsletters, books, videos, audio conferences, training handbooks, e-mail newsletters, and online courses.

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HIPAA / SECURITY

Maintaining Information Privacy in a Big Data Environment It’s becoming increasingly important for healthcare organizations to share, analyze, interpret and respond to patient health information. To make the shift from fee-for-service to value-based care, for example, organizations are starting to exchange clinical, demographic, and sometimes financial information between providers and across settings. Similarly, they are leveraging data analytics to drive population health initiatives, which proactively identify individuals at risk for negative health events and transition them into care. Looking ahead as precision medicine becomes more of a reality, the industry will need to work closely with sensitive patient information, studying it to gain new insights into how to treat certain diseases.

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A

s organizations move ahead with these and other data-driven initiatives, they cannot forget their responsibility to keep patient information private and secure. More specifically, they have to remain focused on the requirements outlined in the Health Insurance Portability and Accountability Act (HIPAA)—the federal regulation that requires healthcare entities to safeguard patient health information and prevent it from getting into the wrong hands.

Although HIPAA has been around for twenty years, organizations still wrestle with how to effectively meet the numerous regulations due to the size and scope of the legislation. That said, there are some concrete strategies that organizations can take to make sure their compliance efforts are up to speed, even amidst new and emerging data initiatives.

Assess the current state Not every healthcare organization will have the same requirements when it comes to HIPAA. There are more than 50 policies a facility may need to have in place, but all of those may not be necessary. As such, it is critical that an organization take the time to understand what is required based on its specific characteristics and see how that compares with what is currently in place.

Wrapping your head around HIPAA may be challenging, so it can be helpful to turn to third-party resources—professional societies or compliance partners, for instance—for guidance on how to perform this kind of gap analysis.

Develop comprehensive policies Crafting the appropriate policies may involve starting from scratch or retooling existing documents. Regardless, organizations should use the information they learned from their initial investigations to generate all-inclusive policies. Some things to cover include what constitutes protected health information, who can and should have access to it, and how the organization will keep data safe. The plans should delineate both preventive measures, such as encryption strategies and communication policies, as well as how the entity will respond if there is a data breach.

To ease the process, facilities can consult the internet, software vendors, or other outside resources to find policies that can serve as a starting point. Note that organizations should customize any documents to address their specific characteristics, risks, and needs. Auditors do not take kindly to an organization that

has a HIPAA policy that was clearly designed for someone else.

Specialty practices in particular cannot just wholesale adopt policies meant for primary care providers or hospitals.

Provide extensive staff training Staff plays an essential role in preserving the privacy and security of patient information, and they must fully appreciate what that role entails. Organizations should include an orientation to HIPAA as part of any new staff orientation and also offer annual refresher training that helps staff appreciate how compliance fits into their day-to-day responsibilities. For example, employees must understand that they can’t leave patient information lying around or discuss a patient’s condition with colleagues in a public space. To further supplement annual refresher training, an organization should consider offering quarterly education activities that foster greater information retention and help staff apply their knowledge. These exercises can take many forms, including surveys, quizzes, role-playing exercises, and so on.

One particular area to focus on during refresher training involves passwords. When a facility electronically stores patient health information, staff must use a password to access that information. Although it may seem obvious, employees must realize that they cannot leave their passwords lying around where anyone could find them and access the system. Moreover, they cannot share their passwords with others. For instance, if a physician is short on time and wishes to have a nurse or other staff person address something in a patient’s record, he or she cannot merely give the staff person his or her password. This would violate HIPAA regulations and could result in significant fines if discovered.

A Necessary Function Ensuring your organization remains in compliance with HIPAA may not seem like a top priority given all the other things on your plate. However, the need to maintain data privacy and security has never been more important—especially as organizations exponentially expand their use of patient information. By taking a systematic approach to compliance that relies on comprehensive policies and strong education, an organization can ensure it keeps data safe both now and in the ever-evolving future.

Lyn Triffletti, CCSP, CPCO, CPC, PCS, is a vice president of compliance at Stericycle, Inc.

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17

Practice Management

Revenue Cycle 101: Insurance Basics Navigating the world of healthcare insurance policies is, at best, confusing. There are so many options! Yet, most people do not take the time to thoroughly review their options and pick the best policy for themselves and/or their family.

W

hat are some things you should consider?

ing event in your family, such as marriage, divorce, death, birth, or adoption.

The following questions will help you think about your options:

October is known as the start of “open-enrollment” for most employer group policies. Meaning, if you want/ need to make a change to your current coverage, without a life-changing event in your family, October is the time to ask your HR department about your options.

Group policies vs Individual policies—What’s the difference?

Group policies are those that you’re typically offered through an employer. You have the option of covering just yourself, yourself + spouse, or yourself + family.

Then, there are usually a few different plan options available. Normally, there is a waiting period when you’re a new hire, and then you can only change plans during open enrollment time, or if there’s a life-chang-

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Individual policies are those that you research and take out on your own. These are most often taken out when someone is self-employed, between jobs, or as an alternative to COBRA. These are normally shortterm policies, defined as coverage between one to six months in length.

COBRA is the continuation of coverage that an employer must offer you when you leave a job. If you follow all the necessary steps outlined by your previous employer, you are eligible to continue your current coverage for up to 18 months. However, COBRA polices in general tend to be very expensive. The alternative is to research and find your own policy.

How do you decide which type of plan is better for you and/or your family?

In general, the higher the annual deductible is, the lower the monthly premium will be. On the other hand, the lower the annual deductible is, usually the higher the monthly premium will be.

In general, those who frequently utilize the healthcare system may find it more budget-friendly to choose the higher monthly premium with the lower annual deductible. This option gives you the “knowns” of a set monthly premium and often a set co-pay per visit. With the annual deductible being a lower amount, it’s

less likely to shock your monthly budget.

On the other hand, for those who seldom utilize healthcare services, it may be more cost-effective for them to go with the higher deductible plan that has the lower monthly premium. You still have insurance coverage, but you’re opting to take the higher risk of “if something major happens,” you’ll deal with the high deductible due when the time comes.

The most important thing to do is to research and arm yourself with knowledge of all your options!

Ranadene Tapio, MBA, CMRS, CMC, is the president of Business Office Consultants, LLC, which provides Revenue Cycle Management, Credentialing & Consulting services to a number of healthcare providers in a variety of specialties. She holds an MBA in Healthcare Administration & Management and is a CMRS (certified medical reimbursement specialist) through AMBA. To find out more about the services of BOC, please email Randi@ BizOfficeConsults.com or call 320-290-6448.

Whether you are a brand new practice or need to advance your practice skills, CoreMD Partners can help. Are you aware of the “Incident To” standards for: • Aetna • BCBS • CIGNA • United Healthcare • Medicare • Medicaid If you answered no to any or all of the above visit www.CoreMDPartners.com for your complimentary Reference Guide for "Incident To" Billing. This guide is loaded with all the facts: Type of Supervision required, Requirements, Reimbursement rates, credentialing requirements and policy guidelines. This guide will only be available until June 15th, 2016.

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19

Practice Management

Medicare Providers: Don’t Let Identity Theft Cost You Money!

Medicare providers face an alphabet soup of entities seeking to recover “overpayments” on behalf of Medicare.

Commonly referred to as Recovery Audit Contractors (RACs), these entities include Zone Program Integrity Contractors (ZPICs), and they have an aggressive mandate to recover Medicare “overpayments” to providers.

O

ur team recently represented a physician from whom a RAC sought $850,000 in overpayments for services billed to Medicare. The liability arose because our client did not have any documentation to support the $850,000 in billed services.

However, our client did not have the supporting documentation because she never performed or billed the services! It turns out that the client’s prior employer stole her Medicare provider “identity” and billed the services for himself.

Fortunately, CMS started a Victimized Provider Project a couple of years ago to address these situations. We performed our own investigation and confirmed that our client’s former employer pled guilty to conspiracy to commit healthcare fraud in federal court, and we obtained sufficient information from the court records to document this theft.

After we submitted a formal request for assistance from the Victimized Provider Project, CMS investigated and agreed with our assertion that our client’s identity was stolen. Happily, CMS formally announced that it would not hold our client liable for the $850,000 in overpayments and would cease all collection efforts.

CMS recommends that providers take the following steps to prevent or spot identity theft: •

20

Actively manage enrollment information with payors. Always keep reimbursement banking information current, and update pay-

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ors when opening, closing, or moving practice locations.

•

Monitor Billing and Compliance Processes. Review OIG’s guidance at oig.hhs. gov/compliance/compliance-guidance/index. asp. Always be aware of billings in your name.

Review entities to which you have reassigned billing privileges. Compare remittances with medical records.

•

Control Unique Medical Identifiers. Avoid giving your identifiers to prospective employers before performing due diligence. Train staff on appropriate use and distribution of your medical identifiers, including when not to distribute them. Control prescription pads.

•

Engage Patients. Encourage patients to request and review their medical bills and have patients report any irregularities they see.

William McDonald, Esq., chairs the Healthcare department at Campolo, Middleton & McCormick, LLP, the premier full-service law firm in Suffolk County, Long Island, New York. Bill’s healthcare practice spans transactional and litigation work. He advises clients on myriad issues in the healthcare space including compliance with Stark, anti-kickback, and corporate practice of medicine statutes, consolidation of medical practices, investigations and proceedings before state and federal agencies, HIPAA and privacy compliance, and FDA enforcement actions. Contact Bill at wmcdonald@cmmllp. com or (631) 738-9100, ext. 320.

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Practice Management

A Billing and Coding Conundrum?

I referred to the Merriam-Webster Dictionary for the meaning of the word “conundrum” and found that is defined as a “confusing, intricate, and difficult problem.” Voila! I had found my word for what is to be addressed in this article!

O

ver the years, I have worked with a number of medical specialties, including Neurology, Neurophysiology, and Pain Management. One of the lead physicians in one of the practices was always researching treatment options to keep up to date and be on the “cutting edge” of providing quality care and safety for the patients. As a result, I had the privilege of becoming introduced to Intraoperative Neurophysiology Monitoring, which is utilized during surgical procedures to protect the patient from any possible nerve damage and to provide important information to the Surgeon and

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Anesthesiologist for certain complex procedures. I had always been intrigued by the operations of our in-office Neurophysiology Lab and the highly skilled Neurophysiology Technicians who worked within the Lab. The lab performed the following types of tests: •

•

EEG (electroencephalogram) - a test that measures and records the electrical activity of the brain.

EMG (electromyogram) - a test that measures the electrical impulses of muscles at rest and

•

• •

during contraction.

Evoked Response Testing - tests that measure the time it takes for nerves to respond to stimulation as well as the size of the response. Nerves from different areas of the body may be tested.

Nerve Conduction Study - a test that measures how well and how fast the nerves can send electrical signals.

BAER – a test that measures auditory nerve signals.

According to the Encyclopaedia Britannica, the “Human nervous system is a system that conducts stimuli from sensory receptors to the brain and spinal cord and that conducts impulses back to other parts of the body. As with other higher vertebrates, the human nervous system has two main parts: the central nervous system (the brain and spinal cord) and the peripheral nervous system (the nerves that carry impulses to and from the central nervous system). In humans the brain is especially large and well developed.”

As previously mentioned, our physicians/surgeons used Intraoperative Neurophysiological Monitoring for our complex Spinal surgeries to reduce the risk to the patient of iatrogenic (caused by medical care) damage to the nervous system, and/ or to provide functional guidance to the surgical team. That is a good thing, right?

Well, unfortunately, receiving reimbursement for this very worthwhile service to monitor the patient during surgery is not always an easy task—especially receiving such for the total costs of providing the service from the Centers for Medicare and Medicaid.

You would think that, in light of recent initiatives to improve the quality of care, the benefits received from the monitoring would be a valued addition during such procedures. So, what is the problem?

(For the purpose of this article, I contacted a highly respected Intraoperative Neurophysiology Company in the Dallas, Texas area that I have been associated with on some projects. I was able to enlist the help of Lee Traweek, President of Axis Neuromonitoring, and Doreen Shinn, Healthcare Administrator at the company. They were very informative—with Lee being educated and knowledgeable of the monitoring process and the benefits of such, and Doreen being able to share some of the

reimbursement issues that her staff deals with on a daily basis.

The following is a summary of what I was able to discover about these unique services and possibly “live-saving” services.)

Most hospitals do not have the resources to invest in the logistics, technology, and highly specialized staff required for these services. Provision of IONM services has many challenges, from staffing/availability of technologists and interpreting physicians to maintenance of the equipment and software required for data collection and effective telemedicine. The best monitoring teams are continually educated, work together regularly, and are solely dedicated to providing real time feedback of neurophysiological function in the surgical environment.

Mobile Intraoperative monitoring companies are an advantageous solution. Having dedicated specialists on demand allows for more cost efficient delivery of coordinated care and an independent assessment of neurophysiological function for low volume/high risk procedures. This protects patients, hospitals, and surgeons, and lowers the overall cost of having this service available.

Although CMS has Local Coverage determinations that approve the use of IONM services for Medicare patients, CMS has a Place of Service rule that, since these services are performed in the inpatient setting, the Technical Component of the service is covered in the relevant Hospital’s DRGs (Diagnosis Related Groups) and, as a result, will not pay the Mobile service directly for all of the many expenses of investing in the equipment, securing and training the Certified Neurophysiology Technicians and Interpreting physicians, and the logistics involved in seamless delivery to the hospital. CMS indicates the hospital would have to pay for these services out of a DRG that they (hospitals) feel are already inadequate to cover their costs for these procedures.

Therefore, either the Medicare patient is subjected to the dangers of complex procedures without monitoring or the Mobile Intraoperative Monitoring Company provides the service with little or no reimbursement.

Even for the professional component of these services, information has been passed along to us that suggests that payments have actually declined. In 2011, CMS paid $27.5M for 125,000 beneficiaries to be monitored ($200/case); in 2014, CMS paid

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23

$6m for 155,000 beneficiaries to be monitored (but only 75,000 actually got charged; the other 75,000 had no charges), which is either $38.50 per case or $80.00 per charged case. This is incredible low reimbursement for a specialized physician working on average 3 to 4 hours per surgery.

According to CMS, the hospital can add the technical component costs as a purchased service to their Cost Report for assessing appropriate reimbursement under the Prospective Payment System (DRGs); however, this adds no additional reimbursement to a DRG already under financial cost pressure. It is the opinion of many that the PPS never fully contemplated telemedicine or the availability of these types of advances in healthcare. CMS language states that clinical diagnostic testing is covered by the DRG. However, IONM services are “intraoperative” testing services complicated by the surgical environment, sophisticated concurrent multi-modality tests with a real time telemedicine component. This places the hospital in a “double jeopardy” situation. The hospital is already responsible for the clinical neurodiagnostic testing and now is being asked to be responsible for additional intraoperative testing.

These services are most advantageous when provided by highly trained teams and as an independent assessment of neurophysiological function. IONM services appear to have all the criteria to be a separate service, but under current coding rules are not

treated as such. The primary billing obstacle here is that the CPT codes used do not differentiate between clinical and surgical tests. This methodology has forced IONM companies out of network in order to remain solvent. When IONM establishes its own set of CPT codes and is recognized as surgical neuromonitoring instead of clinical neurodiagnostic testing, hopefully a more equitable reimbursement will become available in support of Medicare patients.

It is just one of many “conundrums” that we each face when dealing with health care coverage and reimbursement from insurance carriers, and it is important to dig a little deeper into this issue since it could affect each one of us personally at some time in the future.

Knowledge is the key to success in the Healthcare Industry.

Maxine I. Collins, MBA, CPA, CMC, CMIS, CMOM, Director of Compliance, Audit and Education at CoreMD Partners LLC www.coremdpartners.com Contributors to Article: Lee Traweek, CMC, President Axis Neuromonitoring; Doreen Shinn, CMC, Healthcare Administrator, Axis Neuromonitoring

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That’s a clear sign you should join us.

Reimbursement Connect is an exclusive online community where healthcare reimbursement professionals come together to solve today’s toughest medical billing and coding challenges.

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25

Medical Coding

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Why are

Evaluation and Management Services Being Scrutinized?

In 2014, the Office of Inspector General (OIG) shared a report titled, “Improper Payments for Evaluation and Management (EM) Services Cost Medicare Billions in 2010,� which reported that 55% of EM service claims were incorrectly coded or lacking documentation, resulting in $6.7 billion in improper Medicare payments.[1]

T

he OIG Work Plan is released annually, delineating areas of risk for fraud and abuse and how they intend to investigate them. Evaluation and Management services are constantly listed on the OIG Work Plan.

With the possibility of recovering a large portion of that $6.7 billion, plus significant penalties, the OIG announced they intend to scrutinize providers who consistently bill outside the norm for EM services to determine if they are billing correctly.[2]

In the same report, the identified 55% error rate among EM services was further broken down to reveal where mistakes are commonly made. Of the 55% incorrectly coded, 26% were a result of upcoding (79% of those by one level and 17% by two levels). Downcoding also occurred at a rate of 15% (4% of which were downcoded by two levels). A total of 7% were both incorrectly and insufficiently documented.

It is easy to see from these percentages, that the biggest problem providers have is with

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27

upcoding by one level. This means that there is a disconnect between provider documentation and proper code level selection, based on the guidelines.

CMS uses extensive data analytics, like the Comprehensive Error Rate Testing Program (CERT), to identify providers with aberrant coding behavior or those considered outliers in their coding and billing habits. An outlier is a provider who bills services significantly different from other providers in his same geographical location and specialty.

According to Inspector General, Daniel R. Levinson’s report, he recommended to CMS contractors that they should “conduct additional reviews of physicians who consistently bill higher level EM codes to ensure the claims are correctly coded. If CMS determines that inappropriate claims have been paid, it should take steps to recover those overpayments.”[3] What can providers do to avoid an audit?

The question is not “How do I avoid an audit?” but rather “How can I be prepared for an audit when it’s my turn?”

1.

2.

3.

4.

Understand Evaluation and Management (EM) coding guidelines Learn proper documentation habits Conduct annual internal audits and report findings Institute provider education and training programs

1. Understand Evaluation and Management (EM) Coding Guidelines There are two Official Evaluation and Management Coding Guidelines (1995 and 1997) published by CMS.[4] Providers may determine the EM service code based on one of them, but not both. Providers can use both in their practice but a single patient note can only be coded following one set of guidelines. In other words, you cannot score the history portion of a note using the 1995 guidelines and the medical decision making portion using the 1997 guidelines. Only one set of guidelines can be used to score a single EM service. CMS announced that as of “September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness.” This means the status of three chronic conditions is now applicable to the 1995 guidelines.[5] It is important to study these guidelines to understand the dos and don’ts associated with EM coding for Medicare patients and for those insurance payers who follow Medicare guidelines.

2. Learn Proper Documentation Habits Several documentation mechanisms providers employ may seem advantageous at the time of documentation; however, they are

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also the root cause of much of the upcoding that is taking place.

Some of these include: Electronic Health Records (EHRs): With more providers employing electronic health records (EHRs), the incidence of upcoding based on improper use of EHR templates and macros has also skyrocketed. Functions like copy/ paste, cloning, pulling information forward from a prior note, and pre-populated macros and templates; which are all used to make documentation easier, are also being used to the disadvantage of the provider, in that medical necessity is being lost in the pursuit of meeting the criteria for a higher level EM code. Where the assessment and plan used to contain the provider’s thoughts on possible treatment methods, it has essentially become a list of diagnoses with codes, making it hard to see the provider’s train of thought regarding their patient’s progress or issues.

Ancillary Staff: Many providers use ancillary staff (RNs, MAs, CNAs) to prepare patients for the provider encounter collecting information about their visit, checking vital signs, and performing tests ordered by the provider. CMS guidelines state that ancillary staff may obtain the review of systems (ROS) and past medical, family, and social history (PFSH), but only the providers may document the chief complaint (CC) and history of present illness (HPI). Auditors are trained to look at the electronic signature/sign on to see who documented the CC/HPI, which if found to be inappropriate, can invalidate a claim.

Timely & Accurate Completion of Documentation: Are provider notes being completed within a 24-48 hour period?

Are the guidelines for amendments, deletions, or changes to documentation being complied with? Although CMS does not provide a specific timeframe for notes to be completed and signed, individual Medicare Administrative Contractors (MACs) have clarified that a reasonable expectation would be “no more than a couple of days away from the service itself,” meaning 2448 hours.[6] 3. Conduct Annual Internal Audits and Report Findings Does your organization have a compliance program in place?

With the implementation of the Patient Protection and Affordable Care Act, they are now mandatory.[7] If so, does it address how often internal audits should be performed and how many charts per provider are to be audited? A minimum of 10-15 charts per provider should be audited internally each year. Findings from these audits should be carefully reviewed and training and education in the areas found to be weak should ensue. Providers with identified documentation, coding, and billing issues should be re-evaluated several times a year until they are fully compliant.

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29

4. Institute Provider Education and Training Programs The majority of providers have never been formally educated on medical coding rules and regulations. Each coding data set (CPT, HCPCS, ICD-10-CM) comes with its own rules/guidelines, which should be thoroughly understood.

However, each insurance company a provider contracts with also requires providers to follow their specific rules and guidelines, which may differ from the others. It is important that providers understand the rules and regulations they are agreeing to when contracts are signed.

Many commercial payers adopt the CMS guidelines and identifying which ones do is important. Maintain a file for each insurance contract, which identifies important information needed to code and bill correct claims.

Providers create most of the medical record from which codes are assigned, but generally have not been formally trained in documentation as it relates to code selection.

All providers should undergo some additional training/ education on the official documentation requirements that determine the overall code selection. If provider documentation is correct, concise, and detailed, the selection of a correct EM code will be easier to do and confidence in passing an audit will be higher.

Consider the following example for potential CMS False Claims Act penalties that could easily be associated with a smaller organization.

Dr. Smith underwent an external audit of 45 patient records. Of the 45 records audited, 9 were found to be false claims due to upcoding (simply put, they were coded incorrectly). The following is a breakdown of audit findings as well as possible penalties, based on the CMS nonfacility fee schedule for California: Seven (7) new patient claims coded as 99205 ($214.91) had documentation that only supported 99204 ($171.70), an overpayment of $43.21 per claim and a total overpayment of $302.47.

Two (2) established patient claims coded as 99214 ($112.57) had documentation that only supported 99212 ($45.74), an overpayment of $66.83 per claim and a total overpayment of $133.66.

The total overpayment was $436.13 before penalties are applied. Penalties consist of three times the overpayment and up to $11,000 per false claim submitted.[8] The total overpayment for these nine (9) overcoded services comes to $100,308.39. Ouch.

One of the documentation issues identified was a template, a 10-organ system pre-populated review of systems (ROS) that was added to many of the patient reports.

It was not edited properly, which resulted in the ROS contradicting the chief complaint and history of present illness. It was noted that the ROS template was used in an attempt to support a higher level of EM service but with the intent that providers would edit accordingly. The editing wasn’t being adequately performed.

An audit is inevitable so take the time now to prepare to pass it. Add to your compliance program regular internal audits and training for both staff and provider. Remember to audit ICD-10-CM codes for accuracy as well. InstaCode Institute developed an ICD-10-CM training tool for providers called Provider Documentation Guides (PDGs) for ICD-10-CM. In simple 10-minute training sessions, providers can fully understand the documentation changes needed to allow for proper code selection, based on the codes they report most often.[9]

Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, has worked in medical offices and clinics for over 30 years in California and Utah and is currently the Director of Content for Find-A-Code and InstaCode in Spanish Fork, UT. She has authored and co-authored multiple books and articles related to medical coding, billing, and provider documentation training. She is married with four children.

Resources [1] http://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf [2] http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf [3] http://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf; Letter from Dr. Levinson [4] http://www.findacode.com/medicare/e-m-guidelines-manuals.html [5] https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/EM-FAQ-1995-1997.pdf [6] http://wpsmedicare.com/j8macpartb/claims/submission/documentation-timelines.shtml [7] https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf [8] https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf [9] https://instacode.com/store/pdgs

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31

Medical Billing

Questions from the Internet:

Secondary Payer Question: Patient has Medicare primary and [ABC Insurance] secondary. Medicare pays their portion leaving the 20% coins to be billed to [ABC Insurance] secondary. [ABC Insurance] processes claim and states that Medicare allowed more than they would have paid. The EOB also says the patient is not responsible. Per Medicare, this is not true. They stated that the Dr can bill for the 20%. Called [ABC Insurance] and they state that we cannot bill the patient. It is a write off.

A

nswer: I see this so many times where a commercial insurance company will tell me I cannot bill their member, when, in fact, billing the member is permissible.

We need to do some homework. As with many questions from the internet, there are unknowns. These unknowns can provide us with the capability to provide a more definitive and correct answer.

When you face a situation such as this, you need to do your homework. What we don’t know is what kind of laws are regulating this situation and what does this patient’s policy tell us? For all I know, the commercial insurance company could be completely wrong and I need to prove this.

When we, as patients, have multiple health plans, these plans must communicate with each other, to determine who is primary and who is secondary.

This is called coordination of benefits

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(COB). COB may be regulated by State insurance law. The common problem with COB is when you have a situation such as this, the secondary will not pay the claim you sent to them. They deny using the excuse that “We don’t pay any more than what the primary paid or what the primary allowed.” Now, are they correct? Let’s look at a sample of a COB law.

For those of you in Florida, I will provide you with the Florida Statute: FS 627.4235 (Coordination of Benefits) (1) A group hospital, medical, or surgical expense policy, group health care services plan, or group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses delivered or issued for delivery in this state must contain a provision for coordinating its benefits with any similar benefits provided by any other group hospital, medical, or surgical expense policy, any group health care services plan, or any group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses for the same loss.

2) A hospital, medical, or surgical expense policy, health care services plan, or self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses issued in this state or issued for delivery in this state may contain a provision whereby the insurer may reduce or refuse to pay benefits otherwise payable there under solely on account of the existence of similar benefits provided under insurance policies issued by the same or another insurer, health care services plan, or self-insurance plan which provides protection or insurance against hospital, medical, or surgical expenses only if, as a condition of coordinating benefits with another insurer, the insurers together pay 100 percent of the total reasonable expenses actually incurred of the type of expense within the benefits described in the policies and presented to the insurer for payment.

Now I have to look at the policy, but the big question is: Where do I get my hands on a copy? The simple answer is—the patient.

You cannot be afraid of speaking to the patient even if they threaten you or try to intimidate you, which might happen. I sent a patient a letter asking for their policy manual so I could help them get the balance of their claim paid. The wife called me, screaming, yelling, and badmouthing my parents. When that didn’t work, the husband came to my office with his wife. I recognized the husband as a co-worker from 20 years earlier; however, his wife was not the wife he had years before. They apologized, brought the benefit manual, and with it, some

Chinese food. After reviewing the benefit manual, the insurance company was incorrect. They were supposed to pay what the primary didn’t pay, but all they were supposed to pay was 60%.

The patient was supposed to pay the 40%. We sat down and discussed this, but his wife continued to say that they didn’t have to pay. She called their insurance company who said the same thing; the patient was not supposed to be billed.

When the benefit manual was presented, this is when the insurance company changed their story. What added ammunition was the addition of the Federal law, ERISA. The insurance company was using the State no balance billing law. The insurance company employee asked, “What’s ERISA?” When she said this, my mind yelled, “STEVE, YOU WON A BRAND NEW CAR!” So the plan was under the protection of ERISA thereby superseding the no balance billing law, not to mention that the benefit manual clearly said the patient is supposed to pay the 40% of what the primary didn’t pay, including the difference between the charges and what was allowed by the insurance company. Before they left, we worked on a payment plan that was agreeable to them, which would work and not hurt them financially.

So, what do you do in this situation?

1.

(1) Check your State insurance laws to see if there is one regarding Coordination of Benefits. You want to see if your State law language is similar to Florida’s where is specifically states that both plans, combined, pay 100% of the charges. This is what you bring to the attention of the insurance company when you appeal (dispute) the denial.

2.

Check to see if the health benefit is under State law jurisdiction or Federal Law (ERISA) jurisdiction. State law may prohibit you from billing the patient. ERISA has no such prohibition. ERISA may actually allow patient billing.

3.

Read the benefit manual. This document is a wealth of information to help you overturn a denied claim. It tells you the medical care that is covered and payable, the medical care that won’t be paid, the claim submission timeframe, how much the insurance company is required to pay for the medical care, coordination of benefit rules, the appeals process, and much more.

Ok, now I can imagine that some questions have come to mind as you’ve read this. The first question that often comes to mind: “What do I do if the patient refuses to provide me with their benefit manual?”

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The answer is really simple. You bill the patient and you inform them that they are responsible to pay the bill until they provide you with the manual so you can appeal the denial.

Another question arises: “My doctor will not allow me to bill the patient, what do I do?” This is where you discuss this with the doctor. If the patient will not help you help them with the claim denial, they have no choice but to accept responsibility to pay for the medical care that they received. Once they provide you with their benefit manual, their bill will be suspended pending the answer from the insurance company or they can appeal it themselves and if there is a denial or no response from the insurance company within 45 calendar days, then they will have to pay this bill themselves.

Last question: “Why 45 days?”

ERISA, specifically the ERISA Regulation 29 CFR 2560-503-1 states the following:

Modernizing Patient Payment Collection

ICD-10-CM is Changing Again

A Billing and Coding Conundrum?

Face of YourTaking Practice – Great Customer Service HIPAAThe Security Breaches: a Proactive Approach

Why are

Evaluation and Management Services

May / June 2016 | Issue 11.3

Being Scrutinized?

A group health plan that provides for two appeals of an adverse determination, such notification shall be provided, with respect to any one of such two appeals, not later than 30 days after receipt by the plan of the claimant’s request for review of the adverse determination.

While ERISA requires an appeal response of 30 days, I prefer to be a bit more generous so that it gives the insurance company plenty of time to reverse the denial.

Now, if the doctor is adamant about

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not billing the patient or contacting the patient, then this is where a serious discussion should be made.

I’ve worked for these types of doctors before. As a patient, I don’t want to be billed, and as a medical biller, I don’t want to bill the patient if I don’t have to. However, the doctor hired me to do my job, which is medical billing, and to do my job well; I just need all the tools provided to me so that I can succeed. One of those tools is patient communication.

Recently, my personal doctor contacted me about a claim of mine that was denied. Because he knew I was a medical biller and appeals are one of my strong attributes, he asked me to help with an appeal.

He provided me with the information I asked to be sent to me. The appeal was denied for frivolous reasons. I submitted a second appeal and the denial was overturned. The doctor we work for cannot complain that his/her revenue is decreasing when the cause is due to restrictions placed upon us to do our job.

If the provider chooses to continue with his/her restrictions, we must make a decision and that decision could be to leave and find work elsewhere.

Stay tuned for more questions from the internet. Never Give Up and Never Surrender!

Steve Verno, CMMC, CMMB, NREMT-P, CEMCS, CMSCS, is a Professor of Medical Coding and Billing Instruction at Florida Metropolitan University

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| 35 OPTPRJ6526 6

ICD-10

Post ICD-10: What Physician Offices Need to Consider Yes, ICD-10 was not an apocalypse but the extra year of planning was a godsend! With the CMS-AMA compromise, do we really need to worry about anything until 10/1/16? AFFIRMATIVE! Physician practices should be taking advantage of this grace period to fine-tune their business and coding practices.

M

edical Necessity:

The “compromise” has a clearly stated caveat—medical necessity.

Understanding which conditions are in vs. out of the local coverage determinations (LCDs) is key, especially for practices that perform some testing or procedures in their offices. When ICD-10 went live, there were a number of condition codes that were not included in the LCDs. Many of these were unspecified codes. To an extent, that makes sense because we have these very specific ICD-10 codes, we should not use a generic “unspec-

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ified.” However, on the other hand, if we know what the condition really is, we would not need the test! Consequently, Medicare and other payers have made some adjustments. In the meantime, we should make sure our registrars are verifying the medical necessity for the test and, where indicated, obtaining Advance Beneficiary Notices for the testing.

Assessing Documentation: The “compromise” will end 10/1/16. If a review of documentation has not occurred, do it now!

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Identify which provider is and is not capturing the specificity of conditions. For primary care, look past the initial encounter when often there is not enough known about the patient to be specific. For surgeons and oncologists, we should expect that the key attributes of laterality, specific site, specific type, stage, and episode of care should be known and be documented. For obstetricians, the trimester should be there, too. Once you have completed the review, meet with the provider, one-on-one, and share the findings. Meet with your IT department or EHR vendor to modify screens to assist the provider in capturing required information, if indicated. Continue monitoring to avoid excessive rejections or denials this fall.

Evaluate Every Denial: Some payers may have denied for lack of medical necessity and, after the fact, have adjusted their rules to accommodate some of ICD-10’s nuances. If you do not monitor the payer’s rules, you may be missing an opportunity to appeal. On the other hand, you may be able to identify denials that can be prevented prospectively. Consider prohibiting any write-off until a manager assesses the denial and enters it into a tracking sheet. Denial trends will not be obvious initially, but over time (e.g. 6-9 months), some trends may surface. Pounce on them as soon as possible.

RACs, MACs, and the Rest of the Alphabet Soup: Recognize that the mission of recovery audit contractors (RACs) for Medicare and Medicaid is to identify and correct Medicare and Medicaid improper payments through the detection and collection of overpayments made on claims of health care services provided to Medicare and Medicaid beneficiaries and to prevent

future improper payments. CMS is also pursuing contract modifications to the current Recovery Auditor contracts to allow each of the four existing Recovery Auditors to continue recovery auditing activities through July 31, 2016. Do not assume that since their contract is “under negotiation” that the RACs will not be as active. This interim period is a “proving stage” for them.

The MACs will be monitoring the codes that providers submit versus the codes that facilities submit for the same beneficiary. Significant code variation will certainly surface a red-flag.

Do not be surprised if encounters done on an inpatient basis where the inpatient stay is later determined to not meet medical necessity will cause an adjustment to the physician’s inpatient encounter reimbursement. Similarly, the OIG’s workplan continues to assess those inpatient 3-day stays to trigger eligibility for skilled nursing (SNF) stays. If denied, there could be consequences for the physician, hospital, and SNF. Conclusion: Fine-tuning your operational workflow and documentation could set you up for smooth sailing post 10/1/16. Take advantage of the “compromise” window to do so.

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FAHIMA, is a former AHIMA President and recipient of AHIMA’s Distinguished Member and Legacy Awards. She served as AHIMA’s Interim CEO in 2011 and held president positions in Eastern Missouri HIMA, Missouri HIMA, and Greater St. Louis HFMA. She is Chief Operating Officer of St. Louis-based First Class Solutions, Inc. and is recognized nationally for her texts, presentations, and articles on a variety of healthcare related topics.

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ICD-10: A Look at Payer Processing Time As we keep an eye on what the data is revealing, this month we’ll take a look at how payers are doing since the transition to ICD-10.

Our data is showing the national average for payer processing time is 13 days. State-by-state, our data is showing: • 18 states have payers with processing times longer than the national average • 20 states that are equal to the national average •

12 states have payers with processing times shorter than the national average

As we examine denial rates, we are definitely seeing an upward tick in denials across the board between mid-January 2016 and mid-March 2016. Payers also are beginning to take longer to pay claims, as the data reveals below for each:

Evaluating Payment Velocity for Q4 2015

Be sure to check back in April, as we will look at Q1 2016 compared to Q4 2015 statistics.

Stats provided by: RemitData www.remitdata.com

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HIPAA / SECURITY

HIPAA Security Breaches:

Taking a Proactive Approach Gone are the days when paper charts could be kept in a file cabinet under lock and key. Today, health care facilities are becoming more frequent targets of massive data breaches. The losses can pile up in terms of monetary fines and penalties if data is not properly secured, not to mention to the loss of patient trust.

I

t has been 20 years since the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Every health care office is obligated to protect patient information; it’s second nature at this point, right? Consider that even the most stringent protection measures may erode over time due to employee turnover, lack of awareness, or taking shortcuts. But sidestepping compliance is like playing a game of Russian roulette, said Rose B. Moore,* faculty for Practice Management Institute.

“Now that we have electronic health records, we have heightened risk from outside attacks. Cyber-criminals are always on the hunt to access personal information creat-

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ing chaos for our patients, organizations, and associated entities,” said Moore.

“Things like password security and full disk encryption measures on laptops and portable devices such as phones are best configured by certified IT experts. There is quite a lot of technical detail involved and there are different types of encryption. For example, she said that logical (role-based) encryption is more effective when securing data that resides on a continuously-running server.”

Whether in-house or outsourced, working with an NISTcertified IT Expert is recommended for matters of data

security. HITRUST certification is a rigorous security framework that ensures that you have taken definitive steps to protect, store and exchange sensitive data.

Security and compliance go hand-in-hand, but they are not the same, Moore said. An audit of your privacy measures should be performed by a qualified compliance officer with specialized training in current standards. In small facilities, the practice manager is often the one that assumes the compliance role. Keeping up with the latest compliance obligations for privacy and security in your office is an ongoing learning process and continuing education is a must.

“Employees need to know how serious you are about security and privacy. Pay close attention to who has access to what,” she said.

“Creating and maintaining a culture around privacy and security in your office can be accomplished through compliance training of all new employees and with annual training thereafter.”

Moore said that 95 percent of breaches originate from within the office. Employees are caught with documents they should not have access to. She recommends setting consequences for employees if they are caught digging into protected health information. They may have no idea what consequences they and the office may face if a breach happens.

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Clinical Practice Compliance Conference October 23-25, 2016 Phoenix, AZ www.hcca-info.org/clinical

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“One of the biggest violations that I find when I go into a practice are employees with their personal phones out.

There needs to be a set of rules to abide by in order to remain compliant and to protect security. Even if your aunt comes to the office and your mother wants to know how her sister is doing, you need to stay away from those records. Employees need to understand how serious this is and what the consequences are.”

Compliance Officer (CMCO), created by Robert W. Liles and administered by Practice Management Institute.

“The program covers compliance in great detail including the analysis of a breach. It teaches participants how to conduct a risk analysis and is the only certification that focuses on compliance in the medical office as opposed to others which are focused primarily on compliance for hospitals and health care systems.”

Moore said medical practices should not wait for a privacy or security breach to happen.

A handbook on a shelf is not the same thing as actively exercising compliance. Taking a proactive approach will ensure that the practice’s compliance measures are up to current standards.

Moore suggested establishing and enforcing internal policies that emphasize privacy, security, and everyone’s responsibility for maintaining compliance. Stay current with security updates and patches to keep up with threats that constantly evolve.

Develop a plan that regularly identifies potential vulnerabilities in your attack surface.

Prioritize security efforts and implement effective counter-measures to alleviate the risks. Make sure business agreements are updated and appropriately documented.

Robert W. Liles, managing partner of Liles Parker, PLLC, a Washington DC-based law firm specializing in health care fraud defense and regulatory matters, said the chance of being audited in the current phase two audit stage is still relatively small, but if there is a breach, then the Office of Civil Rights (OCR) gets to come in and ask questions.

“If they find out that you haven’t taken preventive measures, then you will face the civil and monetary penalties that you are trying to avoid,” Liles said.

Moore touted one of the best resources she has found to help medical offices adapt compliance policies into their office is the Certified Medical

www.billing-coding.com

“When you know how to identify potential vulnerabilities, it becomes much easier to encourage a culture of security and compliance in your medical office,” she said.

Rose Moore teaches classes for Practice Management Institute.

She has worked in the medical field since 1976. She is a former Physician Practice Advocate for the Medical Society of Virginia. www.pmimd.com

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Practice Management

Why Doctors Should Outsource Their Billing The practice of medicine is comprised of numerous specialties. Doctors train for over a decade to obtain the skills necessary to successfully practice medicine in their chosen field. Additionally, they must continually stay abreast of technological advances and the changing protocols in their chosen specialty to ensure they are providing the best possible care to their patients. ally change a rule and give you ample notice to adjust your processes. Denials averaged less than five percent of total claims.

Today, if you don’t have sophisticated claim scrubbing software, it’s not unusual to have a 35 percent or higher claim rejection rate which requires extensive and expensive follow-up.

The challenges that your internal billing operations are faced with on a regular basis can lead to collection shortfalls and non-compliance issues. Here are some reasons why outsourcing your billing to a professional practice’s management/billing company makes sense.

Y

ou won’t find a general practitioner performing a triple bypass on their patients.

The skill and complexity of that operation requires a specialist.

Similarly, given the complexity of today’s revenue cycle processes, it takes the specialized skill of medical billing professionals to ensure your practice’s economic success and compliance with the plethora of government regulations. Billing is no longer something someone does to fill in the time between scheduling and rooming your patients.

When I first started in the medical billing field, things were much simpler. Payers would occasion-

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Regulations change constantly which means that dedicated personnel must have the time to read bulletins, interact with payers, and attend industry seminars and webinars.

Billing managers should be certified to ensure their competency. One such designation is the Healthcare Billing and Management Association, CHBME designation.

Coding personnel who have the responsibility for ensuring that your documentation and coding is compliant with the new ICD-10 requirements should also be certified by one of the accredited coding organizations.

MEDICAL BILLERS & CODERS:

Implementing and maintaining a compliance plan can be expensive for an individual practice. A professional billing company can spread the cost of their compliance professionals across many clients.

Technology is another major expense for an individual practice.

Besides the initial cost of an EMR and Practice Management system, you also need to invest in additional software, such as a claim scrubber, denial management tools, and a business intelligence reporting software—while expensive, it is necessary to proactively manage a practice.

Lack of follow-up relating to unpaid claims or under-paid claims are two of the biggest problems I usually encounter when reviewing a practice’s billing operation. Follow-up is time-consuming and burdensome and it seems to be the last thing people get around to—if ever.

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When follow up isn’t done on a regularly scheduled basis, it can lead to lost revenue due to “timely filing” requirements. I have also seen contractual allowance adjustments applied to a patient’s account even when the practice doesn’t participate with the third party payer.

Today, most physicians are working harder than ever and taking home less due to declining reimbursement and increased expense to collect on a claim. The question every doctor should ask themselves is, “Why should I have the additional burden of running an internal billing operation?”

It is also getting harder to attract and retain competent billing personnel. The Society of Human Resources states that the cost of recruiting, hiring, and training a new employee is at least $4,000. Utilizing a professional billing company eliminates this expense in its entirety.

Finally, there are two things for a practice to keep in mind. First, you should: “Do what you do best (practice medicine) and outsource the rest.” Secondly: “Never do anything that you can have someone else do more efficiently and at a lesser cost.”

Professional billing companies offer economies of scale which makes their services less costly than if a practice does their billing in-house. The goal of any billing company is to maximize collections while ensuring compliance.

Dave Jakielo, CHBME, is an International Speaker, Consultant, Executive Coach, and Author, and is president of Seminars & Consulting. Dave is past president of Healthcare Billing and Management Association and the National Speakers Association Pittsburgh Chapter. Sign up for his FREE weekly Success Tips at www.Davespeaks.com or Text Davespeaks to 22828. Dave can be reached via email Dave@Davespeaks.com; phone 412-921-0976.

Given the complexity of the revenue cycle process, practices need full time professionals to handle their billing operations.

No longer can billing be something someone will get around too.

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Office Talk

Talking to Patients about Financial Responsibilities Now more than ever, it seems the majority of outstanding revenues are patient responsibility balances.

S

ending multiple statements, reminder letters, collection letters, and then making those awkward, inquiring phone calls can often be avoided when you have proactive approaches in place.

There are several opportunities to inform clients of their financial responsibilities beginning with their very first encounter.

People tend to be more receptive and open to discuss financial matters, at this point in the relationship, so it’s much easier to collect money upfront then trying to collect it at a later date.

And it’s not as difficult as you think if you have some responses ready to use for the most common situations you will encounter with your clients.

Remember, you are providing a service like anyone else with whom they choose to do business, and you have every right to expect them to honor their financial obligation for that service.

When patients do not have insurance coverage, they need to be aware of your policies regarding self-pay patients whatever that may be. “Payment in full is due at the time of service, but we do offer a 20% cash discount to our self-pay patients.”

When patients are covered by insurance: “Please bring your current insurance card(s). We do collect all copays and/or unmet deductible amounts that may be due at the time of service.”

When a patient says they forgot to bring their insurance card: You should have previously collected their insurance information when they initially scheduled. Many times, on the insurance website, you can view the actual card and print a copy to keep on file. It makes it very easy to verify benefits quickly.

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“No problem Mr. Smith, I went ahead and already verified your benefits. It looks like you have a $20 copay per visit. I also made a copy for you so you have the same information for your personal records. How would you like to pay your copay today; cash, check, or credit card?”

And remind the patient that he still does need to bring his insurance card/driver’s license to the next visit.

When a patient with a previous balance makes an appointment: “Just a reminder, Mr. Smith, that a $20 copay will be due at the time of your upcoming visit and it seems you do also have an outstanding balance on your account in the amount of $XX.XX. So, the total now due is $ XX.XX.” It’s always a good idea to note on the client’s account that they were made aware of their balance due when they scheduled.

Then when they come in for their next visit, whoever checks them in knows they were informed of the total balance due and should be prepared to pay it.

FREE CEUs / Webinars To all BC Advantage Subscribers I wanted to take a moment and reach out to everyone about When a patient says “Bill me.”: “As we explained, Mr. Smith, when you scheduled your appointment, your copay responsibility is due at the time of your visit.

That’s a requirement of your insurance carrier. So, that will be $20 today please.”

For those patients who constantly say “Bill me,” I recommend that you collect the copay before he sees the physician or maybe suggest he/she reschedule the appointment.

When a patient says “I forgot my checkbook.”: “That’s alright, we accept all major credit cards.” If the patient still does not pay, provide him with a self-addressed envelope and restate the amount due.

When a patient says “I don’t have that much with me.”: “Well how much can you pay today? You can pay half today and I can give you an envelope to send in the rest. We also take all major credit cards if that’s more convenient.”

When a patient says “My insurance will take care of that.”: “We will be submitting your bill to your insurance for you, Mr. Smith, but your policy shows that a $20 copay is due for each visit. So, that does need to be paid today.”

When a patient says “I don’t get paid till next week.”: “That’s alright, you can just postdate your check and I’d be happy to hold it until next Friday’s deposit.”

One way to help educate your patients is to either have an insurance coordinator or have someone on your staff who can speak with new patients about what is expected of them and to go over their insurance coverage with them so they understand what their responsibility is from the start. Many times, that would be up to the office manager, but even

though it takes some time, in the end, you will have educated patients and less problems with patients not paying copays or deductibles, etc.

Another way to educate patients is with a financial policy that is written for patients to understand what is expected of them. They should receive it with their new patient packet and I always make sure they read and sign it and put a signed copy in their file.

Another way to educate patients about their financial responsibility would be to create an insurance brochure that can be given to patients explaining the terms used by insurance companies, what copay means, and how deductibles work. It also helps to explain in the brochure about allowed amounts vs the physician’s fee schedule.

your FREE CEUs and Webinars that come with your magazine subscription.

Please do not forget to take advantage of earning your CEUs online.

All of our CEU packages have an expiry date and you will find that

An educated patient is a financially responsible patient. If you educate them at the start, the cash flow for the practice will improve. It can be time-consuming at the beginning, but well worth it.

to the right side of each package when you login into your account.

I also want to remind you that you can also login to

These are just a few of the common situations that can come up when dealing with patients about their balances. It may seem awkward at first, but it does get easier with time, and once again, realize that you are not asking them to pay for anything that they are not responsible for.

www.bcadvantageaudio.com to go directly to your on demand webinars.

If you have any questions about your account, please contact me at Ashley@billing-coding.com or by calling 864-228-7310.

Marge McQuade, CMSCS, CHCI, CPOM, CMCS is a certified practice office manager, a certified multi-specialty coding specialist, and a certified healthcare coding instructor who has over 35 years of experience in the medical field. www. pahcs.org

Thank you all for being a part of BC Advantage!

Ashley Knight Subscription Manager

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5 Minutes with...

Julie Pisacane CCA, CPMA, CPPM, CEMC, ICD-10-CM Proficient

BC Advantage (BCA): Can you tell us a little bit about yourself and how you got started in the healthcare industry?

Julie Pisacane (JP): I am from Long Island, New York, and have lived with my husband there for over 25 years. We have two grown children. We are both employed in the healthcare setting for over twenty years. I started working for an Orthopedic Surgeon while I was still in high school and I loved it. I worked many different roles within a few orthopedic offices over the years and each experience taught me something new and valuable regarding the flow of all office operations. I have also worked in my home as a remote orthopedic coder for Aviacode.

Currently, I am employed at Orthopedic Sports & Associates of Long Island located in Woodbury, New York and attend local AAPC Selden chapter meetings.

BCA: What does a typical work day entail for you?

JP: A typical work day is reviewing all commercial insurance charge tickets prior to charges being entered and comparing documentation to the billing, answering ICD-10 questions, and helping to collect on delayed or denied claims. I track carrier-specific denial patterns by creating spreadsheets where the problems and resolutions are shared with the practice management team and the physicians.

BCA: You have a lot of respected credentials. What made you choose these for yourself and how have they helped in your current role?

JP: The CCA credential is with AHIMA and this was the first credential I earned. I wanted to learn more about coding guidelines and insurance carrier decisions in connection to their actions to downcode or deny claims so this was my first step toward learning more about this subject on a deeper level. Passing my

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certification exam opened the doors for me to explore additional credentials that would help further my knowledge with other areas connected to coding, reimbursement, medical necessity and compliance. Healthcare has changed so much and the continuing education that goes along with earning the credentials helps to keep me current with all the latest topics and coding updates.

BCA: To you, which credential is the most important and why?

JP: The CPMA速 credential with the AAPC is probably the most important credential to me because it is all about proper clinical documentation of the patient record, observing coding guidelines, EMR issues, and the overall importance of the auditing process. There are all different kinds of audits performed and employers have called on me to help out with internal auditing projects. Earning my CPMA速 taught me rules, regulations, and knowing exactly what to look for when auditing a medical record.

BCA: When ICD-10 finally went into effect, was that an easy/hard transition for you? If it was easier, what did you do to make sure you were well prepared beforehand?

JP: Attending an AHIMA boot camp months before ICD-10 was implemented definitely helped a great deal with the ICD-10 transition. The boot camp consultants explained in detail all the changes we needed to be aware of with the new coding set. I also took the AAPC ICD -10-CM proficiency training which was very helpful as well and I am so very thankful for both of these professional medical coding organizations that offer an abundance of training for ICD-10. They are both trustworthy organizations.

BCA: Were there any other tools that helped you to better understand the new code set for ICD10?

in my own local office, if I have a question on documentation or a code, I can ask the physician directly and get the answer immediately.

JP: The ICD-10 codebooks have all the official guidelines regarding the new coding system. Frequent review of the guidelines is helpful to me and I also like the coding forums that are found on the AAPC and AHIMA website. Many coders visit these forums to bring questions and find answers on challenging coding scenarios. I attend my AAPC local chapter meetings which happen to have a large group of active members who are focused on professional development. The American Medical Association, CMS.Gov, and The World Health Organization websites also have a complete set of training materials for those new to coding or for those who simply want a refresher course.

BCA: With all that you have accomplished in your career, what has been the most important thing you have learned, earned, or given to someone else, and why?

BCA: With your experience, can you give us a breakdown of how remote coding differs from office coding?

JP: Remote coding was a positive experience for me because I was given the opportunity to work on different EHR systems. There are some really great EHR systems out there that are both user friendly and efficient. I was able to work the hours I wanted and I had a very supportive coding manager. I still keep in touch with her to this day. An important difference for me is turnaround time when coders have to question a client regarding a claim where more information is needed. Claims are then placed on hold and response turnaround time is not as fast. Working

JP: Support and encouragement. I will always remember those who gave me encouragement when I chose to further my education in coding and compliance and it is my pleasure to give the same encouragement and support to those who are ready to step in the same direction. I have helped others with the pre-test stress, answer questions on the professional coding forums, and have given advice to a few people who contacted me through my LinkedIn email.

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BCA: Is there anything else you would like to add for our readers?

JP: For anyone new to thinking about a coding or billing position and whether or not to be certified, you will notice that many healthcare organizations hiring these days are seeking out those with either AAPC or AHIMA credentials as a requirement for coding jobs.

Earning your certification will definitely open more doors for you and with your certification, you are investing in yourself and your career. If there is anyone with questions regarding the process of becoming certified or any coding-related issue, please feel free to contact me on LinkedIn. I would love to hear from you!

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Advertising Manager Melissa Gilchrist 864.228.7310 Melissa.gilchrist@billing-coding.com

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PRODUCT Reviews - Discounts Title: CPT® Coding Essentials for Ophthalmology 2016 Authors: AMA Price: AMA Member-$134.95, Non-member-$143.96 Where to buy: www.commerce. ama-assn.org/store The CPT® Coding Essentials for Ophthalmology 2016 is suitable for ophthalmology coders, including those who are subspecialty coding experts. It provides a foundation of information that facilitates correct code assignment, organized in a simple way that displays all pertinent information for the targeted CPT code on code detail pages.

The book is divided into chapters that cover all things ophthalmology. There is a great chapter covering terminology, abbreviations, and basic anatomy of the eye, another discussing ICD-10CM/PCS coding, and a very comprehensive chapter devoted to anatomy and physiology for ophthalmology. If you’re so inclined, you can answer the coding practice questions that are sprinkled throughout the chapter to test your knowledge. The ICD-10-CM documentation chapter compares documentation requirements for ICD-9 versus ICD-10, guidelines, exclusions, etc., providing coding examples and notes that will help you master any coding challenges you may face.

The bulk of the book is devoted to the CPT codes and is broken into an easily understood, well-laid out format. Every CPT code has the code description, AMA Coding Notes, a plain English description, ICD-9-CM and ICD-10-CM diagnostic codes, CCI edits, AMA CPT Assistant reference, Facility and non-facility RVUs and modifiers. See? Everything that you would need to know!

Title: CPT® Coding Essentials for Obstetrics and Gynecology Authors: AMA Price: AMA Member-$134.95, Non-member-$143.96 Where to buy: www.commerce. ama-assn.org/store The CPT® Coding Essentials for Obstetrics and Gynecology 2016 is another fine example of a one-stop resource for obstetrics and gynecology and an excellent resource for coders and practice management alike.

Formatted in a similar fashion to all of the AMA’s Coding Essentials resource books, there are chapters devoted to specific topics, written in easy-to-read terms and chock full of information. The chapters include: Terminology, abbreviations and basic anatomy, Introduction to ICD-10-CM/PCS, ICD-10-CM Anatomy and Physiology for Obstetrics and Gynecology, ICD-10-CM Documentation for Obstetrics and Gynecology, CPT Procedural Coding for Obstetrics and Gynecology Including AMA guidelines, CPT codes and descriptions, etc., Modifiers and Appendixes A (NCCI edits) and B (Clinical Documentation Checklist).

This book is so easy to use and provides a wealth of information for each code it contains. Each CPT code has its range, description, AMA Coding Guidelines, plain English descriptions, ICD-9-CM diagnostic codes, ICD-10-CM diagnostic codes, CCI Edits, AMA CPT Assistant, RVUs (facility and non-facility) and modifiers relating to it outlined. You cannot go wrong with this!

Go online to access all of our product reviews Since 2004, BC ADVANTAGE has been testing the latest software, publications, services, and more - all to help you, the consumer, make the smartest purchasing choices and spend your money wisely. View all reviews and discounts at www.billing-coding.com Do you have a product that you would like reviewed or want us to review a product before you purchase it?

Send us an email to nichole@billing-coding.com.

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::STEP1::

TYPE in the procedure directly from the OP report.

::STEP 2:: Hit SEARCH.

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AHCAE

AHCAE

Association of Health Care Auditors and Educators Make Defensible Decisions on Your Audits and Learn to Communicate Effectively Your Results!

“Intensive Chart Auditing Practicums!”

Gain knowledge and learn with hands-on experience from nationally recognized auditing professionals, coding and compliance educators. Dig into regulations and rules as you’ve never seen before. The (CHCA) Certified Healthcare Chart Auditor exam be available to take the last day of the training.

This original, one-of-a-kind program, is a collaborative effort developed by the (AHCAE) Association of Health Care Auditors and Educators and is designed to provide critical elements needed for accurate medical record chart auditing and effective compliance.

Intensive Chart Auditing Practicums!

Memphis, TN

June 13-17, 2016 Hosted by

St. Jude Children’s Research Hospital Professional—CHCA Exam 6/17/16

*BONUS! Attendees will receive a VIP tour of St. Jude Children’s Research Hospital Register today—and show your support!

The Intensive Chart Audit training is designed for those seeking true auditing skills and knowledge within the auditing arena. Whether you are new to auditing or are a seasoned auditor, this program will greatly benefit you!

San Diego, CA July 25-29, 2016 Professional—CHCA Exam 7/29/16

Plus, you will receive the comprehensive AHCAE Chart Auditing Tool Kit, Chart Auditing Resource Manual, and CD / USB to start auditing immediately!

Las Vegas, NV Aug. 29-Sept. 1, 2016 Surgical—CHCAS Exam 9/1/16

Meet Some of our AHCAE Intensive Audit Instructors!

www.ahcae.org Inquire for Group Discounts, On-site Host Programs, and Private Tailored Trainings - Hardship Scholarships Available! -

Susan Garrison, CHCA, Susan Thurston, CHCA CHCAS, CPC, PCS, CHC

CPC-I, CCS-P, CHCO

Need On-Site or Tailored Training?

The AHCAE conducts many private, tailored and on-site training programs that may include your facility’s documentation for examples in the training process if desired.

These training sessions are both cost effective and will limit travel expenses and staff time off. Not sure what you need? Not a problem, our staff will assist you without any obligation.

Robin Linker, CHCA, CHCAS, CPC-I, CCS-P, CHC

Sarah Goodman, CHCAF, MBA, COC

2016 AHCAE National Conference!

Denver, CO August 3—6, 2016

Who Should Attend xAuditing Professionals xCompliance Professionals

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xCoders / Billing Specialists xHIM / Practice Management

Economically friendly for vendors and members (Approved for 28 CEUs!)

xClinical / Technological

The Intensive Chart Auditing Practicum and National Conference have been approved for up to 33 CEU units for use in fulfilling the continuing education requirements of AHIMA, AHCAE, AAPC and other organizations.