Coding & Reimbursement Network News

From the Founder

by Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS CRN Founder & CEO

Hello CRN Associates!

Did you miss us? We took a bit of a break with the holidays. I hope your 2006 is going well so far. I can remember back to when we were worried about y2k issues - where does the time go?!

We're moving our newsletter list to a different server so you will be getting an e-mail confirming your desire to remain on this newsletter list. All you need to do is reply to that e-mail and you will continue to receive these newsletters. If you don't reply to the e-mail you will no longer received them. Sorry for the inconvenience but you can blame the spammers out there making it miserable for the rest of us.

I need to repeat myself from last issue regarding our announcement about a new vendor to the CRN Shoppe - Bill Flash. I stated they mail out claims when I meant to say they mail out patient statements - very professional statements at that. We have a 6 minute demo that you can view at the site. If you have any questions feel free to e-mail us.

Speaking of the CRN Shoppe - the sales in the Shoppe help support the costs of running our network so if you are in the market for a coding or billing product, book, CEU training, software, etc. please visit the CRN Shoppe first to see if we carry it. We have over 900 items in the Shoppe and most are offered at a significant discount. If there are any products you think we should have listed in the Shoppe please drop us a line.

--Laureen = )

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by Suzan Hvizdash, CPC CRN Senior Auditor, Instructor

It’s been awhile since I’ve been on the list serve. I am going through withdrawal. I was selected for jury duty last week. The case went from Friday to Friday. I am now back in the saddle.

The list had over 100 posts while I was gone. So, I’m confident that the earth is still rotating, coders are still coding, and winter will one day be over.

There was an interesting question posted that makes me proud of the people watching and using the list. A lister was asking about an employee policy manual. When you go from small numbers of employees to larger, you are bound to encounter scenarios that you might not have previously. For obvious reason, you have more people, more life situations, etc. The problem involved an employee wanting to not use her time off days when she had to take two days off because of a car accident. She was paid by the insurance company for those days and wanted to keep those days for something else. In the absence of a policy, what do you do? You make a policy. You don’t want to set a precedent that you can’t live with going forward. Then there’s the legal side of this situation. What can the employee do? What can the employer do? A policy manual is a great tool to consider.

Then onto the subjects of coding…fluorescein stain. Can any MD perform this type of testing? Why was it being done? What’s in the note? If the note indicates that this was part of an E/M service, it might be better to bill for the E/M service. If it was the service substantiated by the documentation billing for the test might be the better way to go.

What about coding for a repeat pap smear? What diagnosis code is best? 795.08? Should you bill an E/M service for this? The list provided some insight on this.

And there was a question about one physician taking over the care of a fracture on a patient operated on in a different city. Can he do this? Is this the most appropriate code for such a service? When is this appropriate to charge? Which modifier should be used? These and other important questions were answered on the list serve this week (but you knew that)!

Remember, as always,

Joining the list serve: $0
Asking questions on the list serve: $0
Finding answers and colleagues on the list serve: Priceless

Until next time,

Juror #3, Suzan

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The Coding Sleuth

by Tara Conklin, CPC

Snow was falling softly outside my window laying a fresh layer upon on the week old dirty one which lay beneath. A lone light sat on my desk; its soft glow reflecting on the papers that lay scattered about. As I looked over my notes the disorganized clutter of my desk contrasted sharply with the immaculate order of Dr. Osis. My last meeting with him was in 20 minutes. I looked up from my papers and gazed out the window. Day had come and gone as it does so quickly this time of year. The snow shone under the glow of the street lamps which were joined by various holiday lights that had appeared in shop windows over the past few days. The night was calm and I was getting tired.

I got up and put on my coat and scarf, grabbed my hat and headed out the door.

The warm air of Dr. Osis’s office greeted me from the cold winter air. His staff most courteously took my coat and scarf. My blood was just beginning to warm from the coffee they offered me when Dr. Osis appeared. He wore a green tie covered in red hearts which were adorned with Christmas lights. I grinned.

Several of the claims he corrected since our first visit had been paid recently which he thanked me again for my assistance. The stack of claims on his desk had decreased immensely. Looking at them I noticed these were reports that included interventions he had performed outside the heart and it’s vessels during a cardiac catheterization. Understandably this was the subject we were going to cover today.

Often times a patient requires diagnostic or therapeutic procedures in other vessels and since the catheter is already in place during the heart cath the physician will perform these at the same time. Before I explained how to code these to Dr. Osis there was some basic information he needed to understand first.

Vessels outside the heart are broken down into two subcategories, “non-selective” and “selective”. Non-selective vessels are categorized to the access vessel (site of catheter insertion) regardless of where it might be and the Aorta. All vessels that branch directly off a non-selective vessel are considered ‘selective’. These vessels are like branches of a tree. They come directly off the trunk and the further the branches go up and split the higher the order they become. The point where each vessel (branch) joins with the Aorta (trunk) is considered a first order. When that branch split into two or more smaller limbs, each of these limbs is a second order. After this each additional split is considered a third order. All diagnostic work in the lower orders is included in any work done in the higher orders. Code to the highest order in EACH vessel (branch) off the Aorta. Regardless of how many time the branch splits the orders will never go higher than the third. The whole concept of interventional radiology is rather complex and requires intense study but this was the basic understanding needed to explain the coding to Dr. Osis. Each once of these codes will have a surgical code and a radiology code. The surgical code reports the catheter placement or procedure being done and the radiology code reports the diagnostic information associated with that particular code. The surgical codes for vessels above the heart were 36215-36218 and below the heart were 36245-36248.

We learned in our first meeting that injections of the Aorta during a heart cath were coded based on their diagnostic purpose. If injection of the Aorta was for visualization of the renal or iliac vessels we billed the G codes in lieu of 93544. It is possible to bill both the G codes AND 93544 but there were requirements. 93544 was billed if one injection was done at the aortic root near the heart for visualization of the aorta and great vessels. The G codes were also billable if the catheter was then moved further down the Aorta and a separate injection for visualization of the renals or iliacs was done.

Here’s where the interventional coding rules come into play. If during a cardiac procedure the catheter is moved into the renal vessels themselves these are now “selective catheter placements”. Each separate vessel (branch) off the Aorta is coded separately. For catheter into the 1st order Rt renal we would have 36245 & 75722. If both the RT & LT renal are catheterized we would have 36245-RT, 36245-LT & 75724. We would drop the G0275 and the 93544. Only if we had the two separate injections at the aortic arch and in the renals would we code 93544 additionally. This is bundled and would need modifier -59. 75722 & 72724 include aortic run-off so separate injections for separate purposes would need to be clearly indicated. Any other vessels stemming directly off the abdominal Aorta are considered “visceral” arteries and are also coded separately when selectively catheterized.

If the catheter is pulled down the bottom of the Aorta and another injection is done after renals and/or initial Aortic injection, the coding rules change here a bit also. We could just pick up our ‘drive-by iliac’ code G0278 if the documentation only reflects to the iliacs or common femorals. However if documentation reflects interpretation from the popliteals and/or further down the leg then instead of only G0278 the physician can pick up 75716 for interpretation of bilateral lower extremities. We can’t code 75630 (aortic run-off) as this is included in the renals; so we break it into its two parts 75625 & 75716 and drop the 75625.

In the head and neck vessels these were pretty cut and dry. Code each one appropriately according to the work done. The only place this gets confusing is during Subclavian injections. During a cardiac cath, sometimes the physician needs to examine the internal mammaries whether native or used for bypass. In order to access these vessels he has to pull the catheter out of the heart and place it up into the Subclavian which stems off the aortic arch. This is one of the Great Vessels. These included the Left Subclavian, Left Common Carotid and Right Innominate vessels. When dictation reflects interpretation of these, 75650 can be coded. Anyway, back to the Subclavian.

When injection of the Subclavian is done, knowing what to code will depend on what is reflected in the operative report. If it’s done for the purpose of examining the internal mammaries the only thing we would code is 93539. However, if the same injection is done for interpretation of the Subclavian or upper extremity then we would code 36215 (1st order vessel off the Aorta) and 75710 (unilateral extremity S&I). If the same injection reflects both the mammaries and extremity vessels you can code all three codes from this one injection.

These were the most common procedures usually seen during a cardiac catheterization. Whenever performed “interventional” procedures knowing what to code is all about “what was the purpose of the catheter movements and what diagnostic injections were done”. Remember the 75000 codes are only coded when “diagnostic” interpretations are done. Follow-up up to therapeutic procedures is included, so is injection done for clarification of catheter positioning.

I looked at Dr.Osis and the look on his face reminded me of a Christmas light that had not been screwed in all the way, it was plugged in just not lit up. He seemed lost in thought, like a sponge absorbing everything around it. He didn’t speak so I just watched and waited. Then I saw it… the twist of the bulb….. He looked up and sure enough the light came on. His understanding glowed like the star at the top of the tree. I couldn’t help but laugh in spite of myself.

Weeks of notes and claims and education and all the pieces came together in a moment of clarity. We stood and he shook my hand, thanked me earnestly and actually laughed himself a bit…, but just a bit. Was he afraid to wrinkle his face.., I wondered. With this our meetings ended.. at least for now. He walked me to the door and offered me Season Greetings. As I wrapped my scarf around my neck once again, I returned the gesture and left.

The snow continued to fall gently and the crisp air felt good for a change. I looked around took a deep breath and decided to walk for a bit. Tucking my hands into the deep pockets of my coat I took off down the street. The snow crunched under my feet and the lights blinked around me. As I approached a streetlamp entwined with yellow lights I noticed one was not working. I stopped and examined it for a moment. Then reaching out I gave it a little twist.

It sparked to life and shone brightly…. I laughed and continued on my way.

--Tara

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TeleWebinar Update

by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME President, CRN Continuing Education, Inc.

Wow, did we record a terrific MiniCourse this past month, "E&M Auditing, the Write Stuff" by Suzan Hvizdash. This class was very educational, informative, teaching step by step auditing. She used a "white board" on which notes were loaded to review with the class. Suzan is a dynamic educator, with a terrific sense of humor and experience in teaching both coders and physicians. This is a MiniCourse that you do not want to miss and since it is recorded, you don't have to. Just go to the CRN Shoppe and purchase this MiniCourse. It is viewable/downloadable for the low price of $139 or for just a bit more you can have a CD-ROM sent to you. And you will receive 1.5 CEU's for this class, what more can you ask for?

Our own Coding Sleuth, Tara Conklin, CPC taught a course on Diagnostic Radiology on Tuesday, 12/13 at 2pm Eastern Time. Her course called "Seeing Through Diagnostic Radiology" is a terrific class. As you can see from her articles, Tara is a very knowledgeable coder with her own brand of wit brought to the teaching of the potential we can find in our practices. Feedback told us that there is a demand for this topic, so I hope those of you who are looking for this specialty to be covered can make it on the call. If you miss signing up for this class live, you can always get the MiniCourse recorded, via download or CD-ROM.

Next, the American Academy of Professional Coders' President Elect, Deborah Grider, CPC, CPC-H, CPC-P, CCS-P, CCP presented this wonderful course, "ABN's in the Physcian's Office" on Wednesday, December 14 at 2PM eastern time. This is such an important topic. I cannot tell you how practices loose money because they do not understand or cannot execute the utilization of ABN's in the proper way. Deb will be on the CRN TeleWebinar to explain ABN's and assist you in implementing a usable ABN program in your office.

Fianally, Robin Roach, CMRS delivered a special class for those of you on the CRN who own or work for billing companies. Robin spoke on "Marketing for the Independent Medical Biller" on Thursday, December 15 at 2pm. Robin owns a successful medical billing company and is very good at marketing her services. She is looking forward to sharing this information with you via this class. I heard Robin speak at the annual conference for The American Medical Billing Association (AMBA) and I can tell you that she knows her stuff!. AMBA is offering 1.5 CEU's for this terrific class as well.

New classes in 2006, started with Laureen's well received class, "Locate your HEM in Time! A Unique Approach to Understanding E&M Coding" on Wednesday, January 4, 2006 at 2pm Eastern Time. We have heard raves that people that did not understand E&M (in particular doctors), finally understood E&M after taking this class. So, if you were not able to attend this class live, you may want to purchase it recorded, to provide to your doctors as well :).

For those of you that could not attend the Telewebinar on “2006 CPT Changes Overview”, you missed a terrific class. Annette Grady gave a wonderful tutorial of what was changed and why. But if you missed the live class, it does not mean you missed it entirely. You can still purchase the recording for the low price of $139. You have the choice of immediate fulfillment with a downloaded recording, or if you want a CD, you can have one sent to you for an additional $60 (includes three ring binder with handouts and CD-ROM). I learned a great deal from this class and I know that you will really get a lot from it as well.

The new Medicare Appeals Process was implemented for Physicians practices as of the new year. You can still purchase the recording of the TeleWebinar, “The New Medicare Appeals Process as of 1/1/2006” (so many changes as of January 1st). You don’t want to miss this boat, because one of the changes is a modification to the time period in which you have to appeal and to whom you appeal and when you can add information to the appeals process. Not knowing this critical information can cost you reimbursement which could be due you had you known the process! Our mistake is your opportunity.

You can also purchase the new recording of Quin Buechner’s wonderful class on,"Coding & Billing Your Non Physician Practitioner Services" which went live on January 10, 2006 at 1pm Eastern Standard Time.

And finally, the last course we have scheduled at this time, Suzan Hvizdash will be speaking on “Auditor Training Workshop: Learn How to Educate Physicians, Their Staff and Your Peers”. This class will be held on 2/1/06 at 2pm ET. We are working on other terrific classes for Neurology, Fee Schedule Establishment, Compliance, Otolaryngology, Orthopaedics, Neurosurgery, and many other terrific topics. Email me at b.cobuzzi@att.net if you have any particular topics that you would like covered. Remember that you can purchase any of these classes recorded if you cannot attend them live.

Bookmark this link to our calendar of events . We have commitments from many speakers and we are excited as the calendar fills up. Get the word out to your colleagues about this great opportunity for education that can be used for compliance and CEU’s. We provide CEU’s from the AAPC and AMBA. We will be getting approval soon to provide CEU’s from HCR (Healthcare Compliance Resources). Stay tuned, this is just getting bigger and better and we are very excited to be bringing it to you.

Remember, all you need is a phone to participate. Optionally, you can be on the Internet and watch the show as the presenter advances their slides - just as if you were at a live event. This is also what the recorded version of the TeleWebinars will be like should you not be able to attend live but want the content. You will earn CEU credit either way. Click here to check it out.

Upcoming Live Events:

	2/1/06 Auditor Training Workshop: Learn How To Educate Physicians, Their Staff and Your Peers by Suzan Hvizdash, CPC, CPC-PC
	To Be Announced Orthopaedic Arthroscopic Surgical Coding Annette Grady, CPC, CPC-H

Upcoming Speakers - Dates to be set

• Marvel Hammer
• Frank Cohen
• Pam Biffle
• Nancy Reading
• Caral Edelberg
• Terry Leone
• Linda Martien
• Peggy Pugh
• Betty Johnson
• Terrance Johnson
• Brenda Chidester

Interested in becoming a speaker? E-mail me.

Join our CEU Notification List to be notified when new topics are added.

Join us on CRN CE as we experience the future of coding, compliance, billing and reimbursement education. Go to http://www.CRNShoppe.com/tw to purchase your TeleWebinars. Go to http://www.CRN-CE.com to explore the CRN Continuing Education site. Have a great 2 weeks until we chat again! 

--Barbara

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Institute News

by Pam Biffle, CPC CRN Coach

CRN Institute News

Do you have a CRN Institute Student Success Story to share? Just drop an e-mail to pam@crn-institute.com. Let us know about your promotions, new jobs and new credentials or anything else you would like to share!

If you need college credit E-mail Laureen about how to enroll at Drexel University even if you don't live anywhere near Philadelphia. New classes start in January.

New classes are being formed for January at Christina Healthcare in Delaware. E-mail Laureen if you are interested in joining this group.

For those working full time in NJ the CRN Institute is forming a consortium where employers can take advantage of a grant program that provides training funds (including books and possibly the board exam fees) to provide their employees added skills. The employer contributes the paid time for the employee to attend the training. For more information and to be put on the interested list E-mail Laureen.

Most of you are aware that we offer courses in Medical Billing, Physician Coding and Hospital Coding but were you aware that we also offer self-study courses in Pathophysiology and Pharmacology for only $199.00 each. Check back as we announce new courses now under development. Let us know what new courses you would like to see the CRN Institute offer.

At your request

Physician Based Chart Auditing by Suzan Hvizdash, CPC, CPC-EMS
This 10-Week course will be offered on Monday nights from 8:00 - 10:00 PM beginning 1/23/06. Designed for the advanced coder/manager/compliance specialist to learn how to audit the notes of a doctor's office. The information obtained in this course can apply to small office of one or two physicians through a mutlti-specialty or academic based office. The anatomy of an evaluation and management note will be a large focus; understanding the history, exam and decision-making. We will explore the different levels of the exam as well as the many facets of the medical decision-making. We will learn to take all the components of these notes and apply them to the documentation guidelines to learn how to substantiate the billed level of service. We will also learn the regulations surrounding these audits (when to refund, how wide an audit is required, teaching the physicians, etc.) Click here to register.

Don’t forget we offer payment plans $195.00 down and $100.00 a month.

Student Success Stories

Congratulations to Emma Flattery of Surgical Specialists of NJ, LLC where she is a Surgical Coordinator/ Charge Posting for completing the 301 Medical Coding for Physicians course.

What made you decide to take a course? I have always enjoyed the medical field and have procrastinated on this for a few years. My husband always says, "Knowledge with action is power," and how true! He has been a true inspiration to me. I lost my Mother in an car accident a few years ago have struggled tremendously. Believe it or not, this was a challenge I endured to make something positive come from something negative. I feel much more valuable than I ever imagined I could.

Why did you pick CRN Institute? I liked the fact I could work at my own pace and complete the assignments on line.

What did you like best about the course? The self pace.

Is there anything you would say to someone thinking about taking a course? Just do it! It's a little scary at first but once you get things moving along, it all comes together. Don't be intimidated by the medical terms and so forth.

Any other comments? It has been very rewarding and enjoyable! I'm already looking for my next challenge!

What did you like best about the course? I appreciate being able to work at my own pace.

Emma will be sitting for the CPC exam on December 10th and says she is a little nervous “ I get test anxiety.” We wish Emma well and look forward to posting her test results in this area soon.

Congratulations also go out to Diana Wilson of Med-Phy Management Services and Career Point Institute where she is a Claim adjudicator/Coding Specialist (Med-Phy..) and Instructor for completing the 301 Medical Coding for Physicians course.

What made you decide to take a course? I wanted a course that would boost my confidence and help me pass the AAPC certification test.

Why did you pick CRN Institute? Prior to taking the course, Laureen took her time on the phone, always returned my phone calls, and if a I had a coding question, she was there for me. Laureen was never too busy and that made a difference because she made me feel, that I as a student, I would be given the attention that I needed.

What did you like best about the course? EVERYTHING !! Especially the lectures and the bubbling and highlighting.

Is there anything you would say to someone thinking about taking a course? I have recommended it highly.

Are you planning on sitting for a Board exam? I did in August, and I made it!! Which exam? CPC

Do you currently have any coding/medical credentials? Yes CMC Certified Medical Coder, through Practice Management Institute and CPC through AAPC.

Any other comments? Tara gave great lectures !!

Until next time...

--Pam

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CRN Member Highlight

Denae M. Merrill, CPC

Where are you from?
Michigan

What is your favorite activity?
Sleeping :) (I have a one year old!)

Do you have any hobbies?
Scrapbooking, crafts with my daughter, reading, cuddling with my boys

What credentials do you hold?
Certified Professional Coder since November 2002

What organizations do you belong to and how have they helped your career?
American Academy of Professional Coders; I found a local chapter and appreciate the opportunity to network with others in the area. I am hoping to be elected chapter secretary. I think the biggest help is the confidence one gains by being around others who understand your situation.

How did you get into the field of medical billing and coding?
This could be a long story, but I’ll make it as short as possible. My mom retired from the doctor’s office as secretary so I applied, interviewed and was hired. Not too long afterwards I starting doing a little billing-pulmonary function test billing only, ended up with the all the physician’s hospital billing and was moved out of the secretarial position. I then started training myself through lists (like PartB and CRN) and other internet sites (like CMS) and decided to try for certification. I’ve been with the same pulmonary office for 8 years, growing with them from one to three doctors.

What is your current position?
Manager, Medical Billing Specialists

What is one of your accomplishments in this field that you are most proud of?
Well, obviously, passing my certification test. Beyond that, I’m just happy to share my knowledge and proud when I’m helpful.

What do you find most exciting about this field?
Difficult as it can be, I really like auditing, each note is different so it keeps you on your toes.

What do you find most frustrating?
Auditing is also frustrating because there are a lot of gray areas. I actually find all the gray areas in this field frustrating!

What do you feel the future holds for this field?
I see a trend towards college being a requirement as opposed to just experience or certification. I think this field is going to expand greatly and there will be more specialty-type positions.

What would you tell someone just starting out in this field?
Research, read, and learn as much as you can and be confident in your knowledge. Start out at the bottom if you have to prove yourself and work your way up.

If there was one thing you could change about this field what would it be?
The ambiguity in documentation requirements and the requirement for doctors to be just as concerned with “counting bullets” as patient care.

Who do you consider a mentor?
Vicky V. O’Neil, CPC, CCS-P. She convinced me I could pass the CPC exam and she was right. She’s been there to help me ever since. I also enjoy all of the regulars on the lists, Don, Fred, Quin, Karen, and Stanley (whose seminar I enjoyed a year or two ago).

What is your favorite billing or coding product?
I’ve only used these in trial but really like them and hope to convince those above me to purchase them for me, Intelicode and E&M Coder. Other than that I use just my CPT, ICD-9, HCPCS and a book for Pulmonary/Critical Care billing put out by ACCP.

What is your affiliation with the CRN and how has that helped you?
I’m mainly on the emailing list. This list is the best for getting quick answers to any question you have. There are no real rules or regulations about what can be asked.

How can other members reach you?:
Feel free to contact me with any Pulmonary/Critical Care or Auditing questions at dmerrill@chs-mi.com

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Humor

Thanks for your joke submissions! Keep 'em coming!
Submit your joke or cartoon here and be entered in a drawing for a free TeleWebinar of your choice!

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