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September 2013, Issue 8, Vol 4

Brought to you by the Medical Management Institute


mmi•updates TH E D I INS




MMI News Updates CMS News Updates Medicare’s Annual Wellness Visit 12 CEUs: Anatomy & Terminology Registered Medical Biller Certification Spotlight on Modifier 26 Patients Responsible for Nearly 25% of Medical Bill Online Certification Training Focus on Medical Loss Ratio: PPACA MMI Check-up for ICD-10 ICD-10 Exclusive Discount Physician Participation in Medicare Increases September Crossword Puzzle

Fall Quarter Bundle: Worth 12 CEUs School has started, the temperature is falling, and the leaves are changing...Fall is in the air and MMI is prepared! Based off of the survey sent out to everyone (alumni and active students), the MMI team has been putting together a winning CEU Fall Quarter. This quarter bundle will be worth 12 CEUs and will cover topics including RAC audits, base-line audits, compliant incident-to billing, changes in healthcare, and more. This bundle is expected to be available this month, however we will keep you posted through email, social media, and the MMI blog. ICD-10: Exclusive Discount As you know, the Medical Management Institute has put together an online, comprehensive training program to certify you in ICD-10. This training is on the new learning system, LearnerNation, complete with reading material, practice quizzes, interactive learning tools, and prerecorded videos. MMI offers different training paths based on your field. Visit the MMI website by clicking here to learn more about the ICD-10 training, and use promo code ICDMBJ for an exclusive $200 discount! [expires 10/1/13] New Monthly Features The MBJ has introduced a few new monthly features. Last month, we introduced “Modifier of the Month”, which we have continued in this month’s issue spotlighting modifier 26. This month, we have introduced the “MMI Check-up for ICD-10”, where we will provide coding exercises and scenarios so that you can verify your progress in understanding and coding ICD-10. Have any comments or suggestions? Please send them our way! Email, or call 866-892-2765. Get Connected If you aren’t on our email list, click here to receive the updates. Haven’t Liked our Facebook page yet? Click here to get social with us. Haven’t checked out the MMI blog? Click here to take advantage of this member perk (bookmark for future reference).



cms•updates ANTIPSYCHOTIC DRUG USE DOWN IN NURSING HOMES WORLDWIDE August 27, 2013 - Nursing homes are using antipsychotics less and instead pursuing more patientcentered treatment for dementia and other behavioral health care, according to new data released on Nursing Home Compare in July by the Centers for Medicare & Medicaid Services (CMS). Unnecessary antipsychotic drug use is a significant challenge in dementia care. CMS data show that in 2010 more than 17 percent of nursing home patients had daily doses exceeding recommended levels. In response to these trends, CMS launched the National Partnership to Improve Dementia Care in 2012. “This important partnership to improve dementia care in nursing homes is yielding results,” said Dr. Patrick Conway, CMS chief medical officer and director of the Center for Clinical Standards and Quality. “We will continue to work with clinicians, caregivers, and communities to improve care and eliminate harm for people living with dementia.”

North Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee and Vermont. C M S I S S U E S F Y 2 0 1 4 I N PAT I E N T PAY M E N T R U L E August 2, 2013 - the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating fiscal year (FY) 2014 Medicare payment policies and rates for inpatient stays at general acute care and long-term care hospitals (LTCHs). The rule improves value and quality in hospital care and provides clarification about when a patient should be admitted to the hospital and responds to recent concerns about extended Medicare beneficiary stays in the hospital outpatient department. The final FY 2014 Hospital Inpatient Prospective Payment System (IPPS) rule increases overall hospital payments (capital and operating) by $1.2 billion. The rule also moves forward with health care delivery system reforms made possible by the Affordable Care Act.  These include a new program aimed at improving safety in hospitals and refining the Hospital Readmissions Reduction program.

The Partnership’s goal is to reduce antipsychotic drug usage by 15 percent by the end of 2013. These new data show that the Partnership’s work is making a difference:  


• The national prevalence of antipsychotic use in long stay nursing home residents has been reduced by 9.1 percent by the first quarter of 2013, compared to the last quarter of 2011. • There are approximately 30,000 fewer nursing home residents on these medications now than if the prevalence had remained at the pre-National Partnership level. • At least 11 states have hit or exceeded a 15 percent target and others are quickly approaching that goal. The states that have met or exceeded the target are: Alabama, Delaware, Georgia, Kentucky, Maine,

August 15, 2013 - Health and Human Services (HHS) Secretary Kathleen Sebelius announced $67 million in grant awards to 105 Navigator grant applicants in Federally-facilitated and State Partnership Marketplaces. These Navigator grantees and their staff will serve as an in-person resource for Americans who want additional assistance in shopping for and enrolling in plans in the Health Insurance Marketplace beginning this fall. Also today, HHS recognized more than 100 national organizations and businesses who have volunteered to help Americans learn about the health care coverage available in the Marketplace. Resource:



MEDICARE’S ANNUAL WELLNESS VISIT August 28, 2013 | Lance Carroll The Patient Protection and Affordable Care Act of 2010 added a new benefit for Medicare recipients called an Annual Wellness Visit (AWV). Contrary to patient and physician expectations, it is not a physical exam or preventive medicine service, as defined by CPT codes 99381-99397. In fact, those services remain non-covered and if billed they will be denied as routine by Medicare.

Medicare Visit (or this visit), and a list of treatment options and their associated risks and benefits; and • Furnishing of personalized health advice and referral, as appropriate, to health education or preventive counseling programs aimed at reducing identified risk and improving self-management — including weight loss, smoking cessation, fall prevention, and nutrition.

A patient is eligible for the initial wellness visit if she has been enrolled in Medicare for longer than 12 months and has not received a Welcome to Medicare visit in the past 12 months. For instance, patient enrolls in Medicare on July 1, 2011. She is eligible for a Welcome to Medicare visit from July 1, 2011 until June 30, 2012. She schedules her visit on May 5, 2012. She will then be eligible for her first wellness visit after May 6, 2013 — one year after the Welcome to Medicare visit.

What's the code for the service? G0438: Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit. The code for follow on years is G0439.


A different patient, however, enrolled in Medicare February 1, 2008. On January 1, 2011, he became eligible for the initial wellness visit. He calls immediately and is scheduled for February 5, 2011 for his initial visit.

This comprehensive visit requires: • Taking or updating his medical and family history; • Establishing a list of current providers and suppliers of medical care; • Height, weight, BMI calculation (or waist circumference), blood pressure, and "other routine measurements as deemed appropriate"; • Detection of any cognitive impairment that he may have by direct observation, with consideration of information from medical records, patient reports, concerns raised by family members; • Review for the potential for depression based on use of an appropriate screening instrument, such as P-HQ9; • Review of his functional ability and level of safety, based on direct observation, or use of a screening questionnaire; • Establishment of a written screening schedule, such as a checklist, for the next 5-10 years based on recommendations of the US Preventive Task Force and Advisory Committee on Immunization; • Practices, and the patient's health status, screening history, and age-appropriate covered Medicare services; • Development of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway — including mental health conditions or risk factors, or conditions identified through an previously performed Welcome to


There are many reasons billing services should embrace the AWV: • You are billing for additional services – approximate reimbursement $160 nationwide • You increase your billing with follow on services (tests and procedures) that can be immediately run based on the findings of the visit • Bringing an additional revenue source into your customer’s practices further presents you as a “trusted business advisor” in the eyes of your customers Improve the health of your billing company by embracing the Medicare Annual Wellness visit. Lance Carroll serves as the National Sales Manager for eC Research, located in Raleigh, NC. eC Research is a data analytics software company. Prior to eC Research, Mr. Carroll worked in various software companies, including Metagenix, the creator of IBM’s WebSphere® ProfileStage. He is a graduate of the University of Georgia with a degree in Management Information Systems. AWACS offers a unique approach to incorporating Medicare’s Annual Wellness visits into the daily routines of physician practices. By recognizing potential bottlenecks in the workflow caused by data collection and initial patient contact, AWACS manages the amount of time required before the patient is actually seen by the physician. This allows the office staff to handle the visit more efficiently while giving the physician more time per patient. The AWACS Call Center schedules wellness appointments, gathers and enters historical and lifestyle data, and provides courtesy reminder calls. This greatly reduces the overall time required by the physician office staff to complete the visit. In addition, the courtesy calls reduce the number of missed appointments, which maximizes office revenue. This approach allows physician offices to incorporate the visits with minimal change in workflow. More patients, less paperwork. Fewer no-shows, greater revenue. For more information call (919) 334-6320 or email


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SPOTLIGHT ON MODIFIER 26 Modifier of the Month | Monthly Feature Each month in the MBJ, we will feature a modifier and discuss the appropriate use. Last month we reviewed Modifier 25, so this month we will take a look at Modifier 26. However, first let’s look at the definition and use of a modifier at a higher level. Coding provides a common language throughout health care organizations and health care payers and the use of modifiers is an important part of coding and billing for health care services. Due to changes in rules and regulations with Medicare and various commercial payers, modifier usage is increasing yearly. Correct modifier use is an important part of avoiding fraud and abuse or non-compliance issues; one of the top billing errors determined by federal, state, and private payers involves the incorrect use of modifiers. There are times when the coding and modifier information issued by the Centers for Medicare & Medicaid Services (CMS) differs from the American Medical Association's (AMA) coding advice regarding the use of modifiers. Therefore, a clear understanding of Medicare's rules and regulations is necessary in order to assign the modifier correctly. This is particularly true for modifiers 22, 25, 50, 51, 59, 76, and 78. Please take careful note of the Medicare usage guidance for these modifiers. Procedure codes may be modified under certain circumstances to more accurately represent the service or item rendered. For this purpose, modifiers are used to add information or change the description of service in order to improve accuracy or specificity. The documentation of the service provided must support the use of the modifier. There are two levels of modifiers, where there is one for each level of HCPCS codes. Please refer to your CPT® and HCPCS Coding Manuals for the complete list.

Level I (CPT) Modifiers Level I modifiers are two numeric digits. They are updated annually by the American Medical Association (AMA). A complete listing of CPT® modifiers is found in Appendix A of CPT®.

Level II (CMS) Modifiers Level II modifiers are two digits (AA through VP). They are recognized nationally and are updated annually by CMS®. A complete listing of Level II modifiers is found in Appendix 2 of the HCPCS manual.

Facts to Consider about Modifiers • Adding modifiers 24, 25, 26, 58, 59, 76, 78, or 79 to a denied service continues to be one of the top reasons for requesting a review.


• Remember that two different ICD-9-CM codes alone does not justify adding modifier 25. • Having front-end edits in your individual claim processing system can eliminate a delay in payment for you, as well as unnecessary follow-up work for your offices.

Important Documentation Facts • It may be necessary to use the phrase "additional documentation available upon request" in the narrative field of your claim in order to support the modifier used. • It is necessary to indicate you have documentation with modifier 22, critical care, and co-surgery modifiers for the same specialty. • When documentation is requested because of modifier usage, the number one reason for denial is because the documentation is not returned in a timely manner.

Important Miscellaneous Facts • It is only appropriate to report modifiers 24, 25 and 57 on evaluation and management procedure codes. • Never report modifier 76 on a surgical procedure code. • When it is necessary to report the following payment modifiers with another modifier, the payment modifier must be reported in the first modifier field: TC, 26, 52, 53, AA, AD, QK, QW, QY, and QZ. • Report modifiers 54 and 55 on the surgery code only.

Modifier 26 Modifier 26 is used for the Professional Component of certain procedures that are a combination of a physician component and a technical component. Using modifier 26 identifies the physician's component. Modifier 26 includes the provider work, associated overhead and professional liability insurance costs. This modifier corresponds to the human involvement in a given service or procedure. HCPCS Level II modifier -TC represents the technical component of a service or procedure and includes the cost of equipment and supplies to perform that service or procedure. This modifier corresponds to the equipment/ facility part of a given service or procedure. Unmodified procedure codes represent a complete service or procedure that includes both the professional and technical components. Modifier 26 must be submitted in the first modifier field. 



Appropriate Usage • To bill for only the professional component portion of a test • To report the physician's interpretation of a test • Procedures that have a "1" in the PC/TC field on the Medicare Physician Fee Schedule Database (MPFSDB) • Procedures falling into the following types of service; Medical Care/Injections, Surgery, Radiology, Lab, Radiation Therapy and Assistant Surgeon

Inappropriate Usage • When the same provider performs both the technical and professional components, unless the same provider reports both components and the technical portion is purchased • Reporting it for re-read results of an interpretation provided by another physician • Appending it to:

• The sleep center  reports 95811-TC, the technical component

Case Scenario: 5-year-old boy with an implanted programmable CSF valve and shunt system is referred by a pediatrician for recent onset of constant complaints of headache. His history includes implantation of the shunt 3 years prior for hydrocephalus. After reviewing the patient chart and previous films, and evaluating the patient in the office, the surgeon decides to decrease the shunt pressure. The surgeon orders a radiograph to determine the current setting of the shunt valve. After reviewing the results of the radiograph, the physician reprograms the shunt from 120 mm H2O to 80 mmH2O. This is done in the radiology department. After confirming the pressure setting, the patient is released from radiology department. The surgeon dictates a written interpretation report and a follow-up phone call to the boy's family several days later finds that a headache has not occurred since the reprogramming. The written report is sent to the referring pediatrician.

• Technical only procedure codes

• The surgeon bills 62252-26 professional component

• Global test only codes

• The radiology department bills 62252-TC for the technical component

• Professional component only codes

Additional Information • Identify technical component only codes on the MPFSDB by a "3" in PC/TC.

Claim Example The provider is billing for just the professional service of a screening mammogram, on the left side.

• Identify global test only codes on the MPFSDB by a "4" in PC/TC. • Identify professional component only codes on the MPFSDB by a "2" in PC/TC. • Modifier 26 is a payment modifier reportable in the first modifier field. • Code global services performed without modifiers. Do not report modifiers 26 and TC on the same procedure code on one line of service.

Scenarios that use Modifier 26

The provider is incorrectly billing for both the professional and technical services of a screening mammogram, on the left side on the same line.

CPT® code 95811, Polysomnography, is performed at a Certified Sleep Center. A physician not associated with the sleep center interprets the findings. • Both providers report on HCFA 1500 forms. • The physician reports the polysomnography interpretation as 95811-26, the professional component.



Patients Responsible for Nearly 25% of their Medical Bill August 20, 2013 | Kathy Dyson The AMA released their sixth annual check-up of health insurers report in June, 2013. This is the first report by AMA that looked at how much of a patient’s bill was being allocated to the patient through copays, deductibles and co-insurance. It was found that patients paid an average of 23.6% of the allowed amount for physicians. “Physicians want to provide patients with their individual out-of-pocket costs, but must work through a maze of complex insurer rules to find useful information,” said AMA Board Member Barbara L. McAneny, M.D. “The AMA is calling on insurers to provide physicians with better tools that can automatically determine a patient’s payment responsibility prior to treatment.”

What does this mean for our physician practices?

It may well be that the patient’s financial responsibility is the largest it’s been since medical insurance came onto the scene in the mid-20th Century. You cannot rely solely on your business office to take care of this change.

Your patients are your worst payers, and asking them for money long after the fact will only result in higher postage costs and ballooning accounts receivable. Engaging your front office to perform time-of-service collections is essential for financial success. You can no longer afford to let these patients walk out the door of your practice without paying. Administrative costs and low collection rates make after-the-fact collections a losing proposition for most medical practices.

For established patients, the scheduler should review the patient’s account and remind them that payment of their balance is required in addition to their copayment. Specifically, have the scheduler say, “Mr. X, I see that you have an outstanding balance due to Dr. Y of $50.00. How would you like to pay?” Teach your scheduler to STOP...and wait for the response. Be sure your scheduler is not avoiding this component of appointment scheduling. Take the patient’s money! Some practices hesitate to accept checks or certain credit cards. Instead, sign up for electronic check verification and get competitive bids on your card settlement rates. One of the most common ‘reasons’ given to your billing office for not paying a copayment is that “the front desk said they didn’t take American Express and that was all I had.” Take the excuses away. Prepare a copy of the patient’s statement with an outstanding balance to present them when they arrive, and let them know you are collecting copayments. It also eliminates the excuse patients give to your business office: “I never received a statement.” Look at many of the tools on the insurer web sites to help you in determining patient responsibility. You can collect towards the deductibles if the insurance company is telling you is not yet met. Also, know your cash price. If someone can’t afford to pay, complete a financial hardship form and offer a discount...but collect something. No one fills their car’s fuel tank or gets a hamburger without paying for it at the time of service. Follow your policy consistently.

Time-of-service collections begins with the very first contact with the patient. When making the first appointment, the scheduler should remind patients that they will collect co-pays prior to the visit with the provider. When the patient comes in the office, you should give them the financial policy. Post a sign that is up front in saying “Your insurance company requires payment of your copay.” Move the responsibility from the physician to their own insurance company, and collect the payment or offer to reschedule the visit.



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FOCUS ON MEDICAL LOSS RATIO Patient Protection & Affordable Care Act | Janet Salyer The Patient Protection and Affordable Care Act, commonly called the Affordable Care Act or ACA, establishes percentages of insurance premium dollars (adjusted for taxes) for major medical health insurance plans that must be used for the benefit of the insured, specifically payment of medical claims or improvement of the quality of health care.

The ACA identifies three major medical health insurance markets. One market is the individual/family plans (or non-group policies), the second is small group market—for identified as employers with fewer than 50 or 100depending on the state - full time employees enrolled in the group coverage, and the third market is large group plans—those with more than 50/100 full time employees enrolled in the group coverage. Insurers must spend a minimum of 80% of premium dollars received in the individual/family & small group markets for the benefit of the insured, and insurers must spend 85% of premium dollars received in the large group market for the benefit of the insureds. Measurements began calendar year January 2011 and are determined annually thereafter. This requirement is called medical loss ratio, or MLR. Insurance carriers must determine what portion of the premium dollars were used for claims and improvement of care based on guidelines provided by the ACA. The MLR calculations are by insurance company, by each state, and in each market segment in that state. If the carriers failed to use the required percentage of policy premiums on claims and improvement of care, then the percentage of premiums under the required amount are required to be refunded to the insureds in that market.

Let’s look at a simplified scenario: Insurance Company A receives $1,000,000 in premiums after tax adjustments in the small group market where the MLR is 80%. They pay $750,000 of the premiums on claims and quality care improvements. The total is 75% of the premiums received which is below the required MLR. The insurance company owes 5% of the premiums, or a total of $50,000, in MLR rebates to the policyholders in that market. The distribution of the MLR rebates will be made based on the ratio of total of all premiums received verses the total premiums each policyholder made. Let’s say Employer X paid $10,000 this year in premiums. The total premiums received were $1,000,000, so the ratio is 10,000 to 1,000,000 or .01. This policyholder will receive 1% of the total $50,000 rebate, or $500. The first MLR rebates were made in July and August, 2012 for calendar year 2011.


Insurance carriers must make any necessary MLR rebates each year in starting in July. Insurance premiums are paid with pre-tax or after-tax dollars. Most individual/family policy premiums are paid with money on which the policy holder paid taxes. Most small and large group policy premiums are paid pre-tax—before taxes were calculated for the employees’ wages. MLR rebates will be taxed according to the way the premiums were paid. If the original premiums were paid with money on which the policyholder paid taxes, then the rebate is not taxed. If the original premiums were paid with pre-tax dollars, then the rebate is taxable income. Insurance companies rebate individual/family premiums to the primary person on the policy. Group premium MLR rebates are sent to the employer. Who owns the premium dollars rebated to the employer and how can that money be used? Some answers are found in DOL 2011-04.

There are some important questions to answer first. Is the group covered by ERISA? ERISA is the Employee Retirement Income Security Act of 1974, and most employer groups are subject to ERISA guidelines. The next question to answer –are the MLR rebates considered plan assets? The policyholder may be a plan (or trust) or the employer. In either case, the rebate is a not a plan asset if the plan documents identify the owner to be other than the plan. If there is no language in the plan documents, the determining factor is – who pays the premiums? According to Mark C Nielson, Esq. with the Broom Law Group in Washington, DC, who specializes in Employee Benefits law, if the premiums are 100% paid by the plan or trust, the rebate is a plan asset. If the premiums are 100% paid by the employer, then the rebate is NOT a plan asset. If the premiums are paid by employees, then the rebate is a plan asset. If the premiums split between employer and employees, then the portion paid by employees is a plan asset. So if an employer pays 60% of the premiums, and employees pay 40%, then 40% of the rebate is a plan asset. Plan assets are subject to ERISA and employers have a fiduciary responsibility to see that the portion of the rebate of health insurance premiums that is a plan asset- “generally must be held in trust, may not inure to the benefit of any employer, and must be held for the exclusive purpose of providing benefits to the participants in the plan and their beneficiaries and defraying reasonable expenses of administering the plan.” (DOL 2011-04) The employer as the fiduciary also must “deal impartially with beneficiaries”.


So, you are in a group that has received a premium rebate, and you paid 40% of the premiums for your coverage. Should you expect a check from your employer? Not necessarily. While cash distributions are the preferred DOL method of distributions, the employer may apply the assets for the benefit of the participants in one of these three ways: make a cash distribution to the plan participants, or add additional benefits to the plan for the current participants, or reduce future payments for the current participants.

There are still more questions to be answered regarding the MLR rebates. Mark C Nielson, Esq, gives this guidance: Former Participants: If not cost-effective to track down and distribute, amounts may be allocated to current participants. De minimis amounts: If not cost-effective to distribute to current participants, plan may apply toward (1) benefit enhancements or (2) reducing premium payments. Adverse Tax Consequences: If dis-tributing as cash would be taxable event, amounts may be applied toward (1) benefit enhancement or (2) reducing premium payments. Plan benefits can include adding a benefit not previously provided such as adding vision coverage, or enhancing

current benefits such as decreasing the deductible amount. Employers may also add wellness programs for the benefit of the participants. The guideline is ‘impartial and “solely in the interest of participants”’. However the employer determines to allocate the MLR rebate, it should be done within 3 months of receipt. Plan enhancements will apply to the next twelve months. (DOL 2011-04) Employers need to document the reason for their decision in MLR distributions and keep records for any future audits. For those companies that rebate premiums to the employees, the rebate is normally taxable income to the employee. For more information regarding MLR rebates including information for non-ERISA groups (mostly government and church groups), please visit from CIGNA. You can review Mr. Nielson’s entire presentation on the Medical Loss Ratio there. The distribution of MLR rebates can be complex. I urge you to seek counsel from your CPA and lawyer in determining the best legal way to handle any MLR rebates you may receive.

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

Insurance Planning Solutions Specializing in Individual & Small Group Benefits “We believe that QUALITY SERVICE to our clients is our highest priority”

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

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

Why use a broker? Licensed by the state of Georgia, the brokers must stay current in federal and state laws. They are also appointed by insurance companies, having the ability to compare policies from different companies. Ready to review your insurance coverage? For free quotes, contact Janet Salyer at 678-880-7098, or email




MMI Check-Up for ICD-10 ICD-10 Exercises & Scenarios | Monthly Feature MMI will provide coding exercises and scenarios each month in the MBJ so that you can verify your progress in understanding and coding ICD-10. You will need an ICD-10 manual to complete the exercise, so if you have not already signed up for our ICD-10 curriculum and received a manual, do so today. You can also order just the manual through our web site.

Code the following conditions according to ICD-10 coding conventions and guidelines: 1.

Premature menopause with Sleeplessness

2. Severe generalized abdominal pain with abdominal rigidity 3. Acute conjunctivitis, unspecified, of the Right Eye 4. Acute case of Salmonella food poisoning. No complications present. 5.

Crohn’s disease of ileum with rectal bleeding and abscess

6. Female with breast cancer of lower outer quadrant of left breast 7.

Acute suppurative otitis media bilateral

8. Congenital red cell aplastic anemia 9. Male type 2 DM controlled with insulin with a diabetic cataract in right eye with retinopathy and macular edema 10. Alcohol abuse with intoxication

Coding Scenario Code the following scenario according to ICD-10 coding conventions and guidelines: 11. Jane Doe cuts her left index finger with no damage to the nail while chopping carrots with an electric knife in the kitchen at her church, preparing food for a food bank. 11.a.


How does the coding change if Jane is in her apartment in the kitchen preparing food for her family?

Answers: 1. E28.310 Symptomatic premature menopause 2. R10.0 Acute abdomen (generalized) with abdominal rigidity 3. H10.31 Unspecified acute conjunctivitis, right eye 4. A02.9 Salmonella infection, unspecified 5. K50.011 Crohn’s disease of small intestine with rectal bleeding and K50.014 Crohn’s disease of small intestine with abscess 6. C50.512 Malignant neoplasm of lowerouter quadrant of left female breast 7. H66.43 Suppurative otitis media, unspecified,bilateral 8. D61.01 Constitutional (pure) red blood cell aplasia 9. E11.321 Type 2 diabetes mellitus with mild non proliferative diabetic retinopathy with macular edema, E11.36 Type 2 diabestes mellitus with diabetic cataract Z79.4 Long term (current) use of insulin 10. F10.129 Alcohol abuse with intoxication, unspecified 11. S61.201A Unspecified open wound of left index finger without damage to nail W29.1XXA Contact with electric knife Y92.22 Religious institution as the place of occurrence of the external cause Y99.2 Volunteer activity 11.a. S61.201A Unspecified open wound of left index finger without damage to nail W29.1XXA Contact with electric knife Y93.G9 Activity, other involving cooking and grilling

Coding Exercises


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Physician Participation in Medicare Increases August 24, 2013 | Kathy Dyson

Figure 1: Percentage of Physicians Accepting New Patients with Medicare and Private Insurance, 2005-2012

Most of us have heard our physicians complain about all of the increased oversight from CMS. The disillusionment of incentives that become penalties if you fail to adopt the required practices is well known, with ePrescribing, PQRS and EHR incentives imposing the carrot then the stick approach to compliance. Most of us have had to look at what it would mean to our practice to stop taking Medicare patients. Rumors abound that more and more physicians are closing their practice to new Medicare recipients...but that may not be the case, based on the latest results from HHS. In August, Health and Human Services (HHS) published an ASPE Issue Brief on the access of physician services by Medicare recipients. The brief reports on recent trends in: 1.

Physicians that accept new Medicare patients and;

2. If the access to care for Medicare patients will be reduced with the implementation of the Affordable Care Act.

Physician’s that Accept New Medicare Patients vs. New Privately Insurance Patients The percentage of physicians who report accepting new Medicare patients has remained stable over the past seven years, with approximately 90% of physicians accepting new Medicare patients (figure 1).


In fact, preliminary results from 2012 indicate that the acceptance rates have increased slightly in 2012. The previous 7 years show that the acceptance of new Medicare patients was on par with acceptance of new private insurance patients through 2010. An interesting trend is that in 2011 and 2012, it appears that the acceptance of new Medicare patients may have increased while acceptance of new private insurance patients decreased! That is not to say that there has not been an increase in the number of providers ‘opting out’, but the number of physicians accepting Medicare has gone up in total, neutralizing the effect of the ‘opt-out’ physicians. According to the study about 1 million providers, including 650,000 physicians, were participating in Medicare in 2011.

Access to Care for Medicare Beneficiaries One concern about the impact of the Affordable Care Act has been that Medicare recipients would have difficulty getting timely care using their Medicare benefits. Long waits for appointments is a trademark of many countries with similar programs to the ACA. The study looked at the trend for timely appointments for Medicare patients versus private insurance patients. The report finds that the access to care for Medicare patients has been comparable to private insurance patients over the last five years. The Medicare Payment Advisory Commission (MEDPAC)


Figure 2: Access to care among Individuals with Medicare and Private Insurance, 2008 and 2012

conducts a study every year to measure the availability of timely access to medical treatment for Medicare beneficiaries. In the March 2013 report to Congress, the commission indicated that “Medicare beneficiaries report good access to care, and access to physician services remains stable”. The commission also reports that Medicare beneficiaries were less likely than privately insured patients to postpone or not have needed medical care in 2012. The Medicare beneficiaries reported that 8% did not have needed medical care in 2012 as compared to 11% of the privately insured patients that posted or did not have needed medical care (figure 2). Based on the study, Medicare beneficiaries’ satisfaction with the program remains at 77% of those surveyed in 2012. Those recipients say they have never waited longer than they wanted to for an appointment during the past year, compared with 76% in 2008. Among those with private insurance, the numbers were 72% and 69%, respectively. Among those seeking treatment for an illness or injury, 84% said they never had to wait longer than they wanted, the same percentage as in 2008.

2012, so it does not reflect the impact of the Medicare sequestration 2% cuts on physician participation. CMS reports that their preliminary data does not show a significant change in the physicians accepting Medicare payments for 2013. If the Sustainable Growth Rate formula is not fixed, it is quite possible that the reimbursement for Medicare patients would be so low that many physicians would cease to accept Medicare patients and many would be forced to close their doors. The constant threat of payment delays, penalties, and cuts make knowing exactly where your practice stands on Medicare patient volumes and dependency very important, so that you can assist your physician to make the right decisions for the practice. If you do not know how many Medicare patients you see on a monthly basis and what percentage that is of your overall practice encounters, look at the last 12 months and calculate it. Equate that to the loss in revenue so that when your physician asks, “What happens if I stop taking Medicare?” have the answer ready.

Impact on our Practices So, while there remains a perception by our physicians that everyone else is opting out of Medicare, the trend, as indicated in the study is higher among Psychiatrists and Plastic Surgeons than other physicians. The study ended in

Resource: PhysicianMedicare/ib_PhysicianMedicare.cfm#_ftn3



We hope you enjoyed this issue‌ now test your knowledge!


Across 3. The ________ is not a physical exam or preventative medicine service. 8. Having ________ edits in your individual claim processing system can eliminate a delay in payment for you and unnecessary work for your office. 12. It may well be that the patient's _________ is the largest it's been since medical insurance came into the scene in the mid 20th century. 14. ________ provides a common language throughout health care organizations and health care payers. 15. Offers a Unique approach to incorporating Medicare's Annual Wellness visits into the daily routines of physicians practices. 16. May be modified under certain circumstances to more accurately represent the service or item rendered.

Down 1. Level 1 modifiers are two numeric digits. They are updated annually by the _______________.


2. ________ procedure codes represent a complete service or procedure that includes both the technical and professional components. 4. When documentation is requested because of a modifier usage, the number one reason for denial is because the documentation is not returned in a ________ manner. 5. Each month in the MBJ we will feature a ________ and discuss it's appropriate use. 6. There are approximately 30,000 fewer ________ on [antipsychotic] medications now than if the prevalence had remained at the pre-National Partnership level. 7. Never report modifier 76 on a _________________. 9. Serves as the National Sales Manager for eC Research. 10. There are ________ levels of modifiers. One for each level of HCPCS codes. 11. The ______ establishes percentages of insurance premium dollars(adjusted for taxes) for major medical health insurance plans that must be used for the benefit of the insured, specifically payment of medical claims or improvement of quality of healthcare. 13. Unnecessary _______ drug use is a significant challenge in dementia care.



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

Issue 8, Vol 4

Editor in Chief Carleigh Benscoter

Contributors Kathy Dyson Lance Carroll Janet Salyer

Layout & Design Carleigh Benscoter


Link List [Issue 8, Vol 4] MMI News Updates:, email-subscription,, CMS News Updates:, Anatomy & Terminology: collections/ceu-options/products/anatomy-terminology-in-preparation-for-the-icd-10-transition, MMI Checkup for ICD-10:, ICD-10 Training Ad: Coder:, Manager: Start Training from Home Ad:

September 2013 Medical Business Journal (MBJ)  
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