Coding & Reimbursement Network News

From the Founder

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

Hello CRN Associates!

We are starting to get ready for the AAPC conference in April as we will be exhibiting and speaking. We hope those that are going to conference will stop by the CRN booth to say hello!

We're still working on our new newsletter delivery system so you should get an e-mail in the next week - so be on the look out as you will need to "reply" to that e-mail to continue to receive the newsletters. Such are the pains that e-mail spammers have causes us.

A fabulous new conference is coming next month. The Spirit of Coding is being presented by the American Academy of Professional Coders on April 2-5, 2006 at St. Louis America’s Center, 701 Convention Plaza,St. Louis, Missouri. Those attending the Academy conference are interested in:

Coding literature Instruction aids Billing services Training techniques Production efficiency Coding software Auditing services

Education Training services Government regulations APCs CMS guidelines Periodicals Compliance issues

A listing of Sponsors and Exhibitors can be found on AAPC's website .

Until next time!

--Laureen = )

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by Suzan Hvizdash, CPC CRN Senior Auditor, Instructor

Before I get started I wanted to correct a type from the last issue. I said “If you rely on the AAPC quizzes, one lister explained that they are not counted for full credit”  It should have read that they are NOW counted for full credit. Sorry about that.

These last two weeks on the list really inspired some thought provoking conversations. We had quite a few questions, as always, on codes, modifiers, and denial issues. Everyone seemed quick to answer the questions posted. It just enforces the power behind this list serve!!

A few topics worth mentioning included a long string about OP note dictation time frames, the proper way to bill prolonged services, and quite an extensive string on the future of medicine. I was really clued to the list for much of these conversations.

First, a lister asked if there are any written regulations regarding the time frame in which a physician must sign the dictated operative notes. And when these are signed must they also be dated? A few responses indicated that the facilities in which they work developed policies, but no sites of regulations were found during the string. The most common answer was that the facility should require these reports to be signed within 24-48 hours after the surgery.

What about prolonged services? Who’s still paying for this? Medicare? Commercial carriers? Medicaid? How should you bill this to insure payment? The consensus on this was that if doctors of the same group see the patient in one day and the service warrants the prolonged service code, the billing should be submitted with the E/M code, the prolonged code, and the –21 modifier. Some payers don’t recognize the modifier thought, so you’ll want to check with your local payers.

Then there’s the on-going conversation about the future of medicine. It started with a lister talking about her experiences at her PCP’s office. She waited several hours to see the patient, however, had she paid for a membership, she wouldn’t need to have waited. This appears to be an office taking advantage of the new wave of medicine some are calling “concierge services”. This began a very thought provoking debate on everything from whether patients “deserve” service to the current insurance company payment trends. It is amazing when you have so many pieces of a pie participating in a debate.

So until next time, keep those questions and answers flowing, the dialogue is impressive!

Until next time,

Joining the list serve: $0
Asking questions on the list serve: $0
Reading your bi-weekly CRN newsletter: $0
Advice received on the list serve: Priceless
The value of reading your bi-weekly CRN newsletter: Priceless

--Suzan

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The Coding Sleuth

by Tara Conklin, CPC

Incision is made, abscess is drained, and sutures are applied; easy right? Not quite Quick Draw. Don’t be so quick to apply that popular I&D code 10060 for all abscesses and hematomas. There is much more below the surface that is often over looked. Grab your coding hat and let’s check out the scene.

There are many factors that must be considered when coding an incision and drainage of the skin and muscle. Oh sure there are your internal I&D procedure such as for peritoneal abscesses but these are a whole different banana all together. Most of the confusion (and miscoding) comes from those conditions that occur in the skin, subcutaneous tissue and muscle. For this reason we’ll concentrate our investigation here.

The first thing to take note of is what exactly we are dealing with; is it a cyst, an abscess, a hematoma or some other fluid collection? How did it come about; is it post-operative, traumatic, an infection or non-healing wound? Where is it located and what structures are involved; joints, muscles, localized tissue or skin?

These are all clues that will help us solve this perplexing puzzle.

An incision and drainage is far different from a puncture aspiration. An I&D involves exactly that, an incision. How far down the incision goes offers assistance in where to get our codes. A skin or subcutaneous abscess goes no further than the first, second and third layers of the skin. A simple I&D is reported with 10060. If the abscess is complicated in any way or there are multiple abscesses we code 10061. However this is only coded once regardless of the number of I&Ds performed, even if they are considered simple. Do not code 10060 multiple times for more than one simple abscess.

You may think these are the only two codes for skin or tissue drainage, but guess what, you’d be wrong. What!? You say you don’t believe me? Well then I say, have faith my friend it’s true. Come, turn your pages and look at the first two codes in the musculoskeletal section of your CPT and tell me, what do you see? Go ahead, I’ll wait…………….…..OH look at that... See there are not one but two codes for soft tissue abscesses. 20000 and 20005 both report soft tissue abscess incisions. 20000 reports superficial or only involving layers of the skin and 20005 for deep or complicated. 20005 may involve the underlying muscle, fascia (that’s the protective layer of fibers covering the muscles) or even to the bone. Okay, so you say you see the difference between 20005 and 10060 for complicated, but how do you know when to use 10060 and 20000? HEY that’s a good question! Now you’re thinking.

20000 & 20005 are much more involved than a direct incision and drainage. Look for exploration of the abscess cavity, debridement of the necrotic tissue and skin in your report and these both involve drainage. In 20005 the physician may go all the way down to the bone and may actually remove dead bone often found in osteomyelitis. This condition is included as an example in the code descriptors but don’t mistake it for the only underlying condition, it’s a guideline. Abscess codes from the 682 ICD category are also applicable here.

Code 10180 reports I&D of a postoperative wound infection because these are usually more complex than a simple drainage and can involve removal of necrotic skin, sterile packing and even be left open to drain. Closure can be done at the time of drainage or later after adequate drainage. If these additional procedures are not done or simple drainage is performed use 10060.

For a hematoma or better known as a bruise on the skin, use code 10140.

The rest of the codes we are going to look at are also found in the musculoskeletal section of the CPT. Oh yes there are many more found here and they come with a much fatter purse. See you like to hear things like that right? Yeah I see you grinning don’t try to hide it.

Finding these codes is actually pretty simple even without the use of your Index. All you have to know is how the section is structured. The codes in this section being with the first two I&D codes which we have already discovered, 20000 & 20005. After all the extra “stuff” found in the beginning of this section we start with procedures in the head and work our way down to the toes. The first subsection in each anatomical category is …what else… Incision. What a great place to find incision and drainage codes. But hey... wait a minute there are no I&D codes in the head. Well silly how thick is the skin up there on your noggin anyway. We’ve all heard the saying “thick headed” well I think it’s safe to say we’re not talking about the depth of the skin. Then there’s the whole issue of “deep”. You go any deeper than the skin and you’ve gone from “thick headed” to “hard headed”. To go any deeper you would need a drill and to be pretty good in lobotomies. Safe to say no I&D’s here.

So let’s move down to the spine. Oh voila our first two codes are 22010 I&D, open, of deep abscess posterior (back) spine, cervical, thoracic or cervicothoracic and 22015 lumbar, sacral or lumbosacral .Looking at these codes we’ll use them as a guide. First, all the I&Ds in this section are for “deep” abscesses OR hematomas. These also include deep postoperative seromas and infections.

These procedures may involve deep subcutaneous conditions that are open on the skin, or they may lie below the skin and the physician must open the skin up in order to gain access to the abscess deep in the structure. This brings us to another major aspect of these procedures. They normally involve a deeper incision or tissue dissection and more than a local anesthetic. These often require a regional and not uncommonly general anesthesia, especially if going down to bone. Hello, put me out!

They can also be used for bursa of the joints.

The incision may be extended if the mass is larger than initially expected. The contents are drained, the area is irrigated and the incision is either repaired, closed with drains in place or simply left open until closure at a later time.

Let’s look at the difference in reimbursement on these. Now you know the codes and what to look for in your report we can get a better look at what the possible reimbursement might look like. First off, if you are one of those coders that didn’t know any better and has used 10060, 10061 and 10140 for all of your I&D procedures, please sit down and you may want to have someone on standby to drive you home.

Let’s say your physicians (or you for the physicians who read our newsletter) he performs all his procedures at the hospital or surgery center It’s safe to say the majority of the mistakes are made with 10160 since you may look at the report and see the physician had to go all the way down to the fascia to drain a rather large abscess of the thigh.

This looks pretty complicated so you have been reporting 10160. This has a current (2006) reimbursement of $149.47, respectable for an hour’s work right? Well armed with the new information we realize for our example, this particular report falls more appropriately under code 27301 I&D of deep abscess, this or knee region. This carries a current (2006) reimbursement of… are you breathing…. $456.30. That’s three and a half times the amount of 10160. It’s okay, take a deep breath, slow in and slow out. Do you need the smelling salts?

I won’t tell you how much the hip and pelvis code pays.

Bill out four of these reports, and that’s the difference between staying four nights at the Ramada Inn and four nights at the Ritz-Carlton.

Bottom line… know your reports and know your codes. These procedures are similar to the game of “limbo”, just ask yourself “how low did he go?” Or in this case how deep? What kind of condition are you dealing with, where did it start and how. There are at least a 100 I&D codes in the CPT. Knowing your location and your “sonar” depth are the keys to solving this puzzle.

Until next time… happy coding!

--Tara

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TeleWebinar Update

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

This week is very exciting. Suzan Hvizdash is going to be teaching her Telewebinar, Auditor Training Workshop: Learn How to Educate Physicians, Their Staff and Your Peers this coming Wednesday, February 8th at 2:00pm. We have our largest response so far and we are very excited with the large enrollment that Suzan has received. It must be because the word got out how good her first Telewebinar was, "E&M Auditing, the Write Stuff". (which is still available in a recorded MiniCourse format).

We have some terrific Mini Courses recorded for you to purchase and use for your continuing education, CEU’s as your certification comes up for renewal and for compliance education within your facility. : First, our own Coding Sleuth, Tara Conklin, CPC taught Diagnostic Radiology. Her course called "Seeing Through Diagnostic Radiology" was 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 missed signing up for this class live, you can always get the MiniCourse recorded, via download or CD-ROM. Quin Buechner re-recorded his class, "Coding & Billing your Non Physician Practitioner Services” and it is now available as a recorded MiniCourse.

And we have an unexpected surprise. Laureen Jandroep has recorded her now very famous MiniCourse, "Modifiers – It’s All About the Money” for us. This was not scheduled, but she decided to provide this on the CRN Continuing Education site for those who have not yet seen it. Why is this class famous?. For those not there, the first time Laureen taught this class at the AAPC National Conference in Las Vegas, she had over 600 attendees in one session. And since that conference, this class has continued to be extremely popular. And along with the MiniClass comes a very useful Modifiers Tool.

January 1st is upon us and the new Medicare Appeals Process will be 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!

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:

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
• 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 April.

Classes are also held 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.

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

Student Success Stories

Congratulations to Rebecca Manderach of Mercy Health System where she is a Biller / Coder for completing the 303 Hospital Coding course.

What made you decide to take a course? The online/ ILS format made it easier to complete the work when my schedule allowed.

Why did you pick CRN Institute? I was planning to take a Hospital- based course for some time, but finding a course with reputable instructors was very important to me. It’s hard to check credentials of online course instructors. But. I was fortunate enough to read several articles written by CRN instructors in the AAPC Coding Edge magazine which gave me a good picture of their knowledge. I felt if the AAPC trusted their knowledge so could I.

What did you like best about the course? The lectures, they were lengthy, but very informative.

Is there anything you would say to someone thinking about taking a course? If you are looking for a course that will give you more than you pay for this is it.

Do you currently have any coding/medical credentials? CPC

Are you planning on sitting for a Board exam? Rebecca is planning on sitting for the CCS exam in the future. We look forward to hearing of her success.

Any other comments? I enjoyed my experience, and plan to take more courses with CRN in the future. Thank you .

Congratulations to Jean Lightcap of Southern Ocean County Hospital in Manahawkin , NJ where she is an Outpatient Medical Coder – Radiology, other testing departments and ER cases for completing the 303 Hospital Coding course.

What made you decide to take a course? I was lucky enough to move into coding, in 2000, from another position in the hospital.  I quickly realized I needed to know a lot more then basic medical terminology.

Why did you pick CRN Institute? I attended an in-depth Medical Terminology, Anatomy and Physiology class, the RN requirement, at OCC ( Ocean County Community College ) in Toms River .  I then took a couple coding courses at the college, and realized they were too basic.  When a co-worker, a medical transcriptionist, told me she had taken the Coding 301 with CRN and how intense it was, I checked it out online.  I was very impressed with the wed-site and after speaking with Laureen, was more impressed and enrolled in the 301 Course in 2004.

What did you like best about the course? The wealth of knowledge and teaching skill of Laureen and her staff is exceptional.  Also very helpful, is how the lectures follow along with the Faye Brown book and highlight the most important information.  It was a great review after my own reading.  In addition, Laureen has wonderful teaching and lecture skills. Her pronunciation of medical terms amazes me! Laureen’s ideas on notes to add to the coding manuals are so helpful.  Also Tara , from the CPC course, is exceptional!  She is energetic, very knowledgeable, and supportive.  I appreciated Pam Biffle’s follow-up on incorrect test answers, patiently giving me all the specifics and detailing the process to find the right codes.

Is there anything you would say to someone thinking about taking a course? Having taken courses at the community college, I know there is no comparison with the intense coding courses at CRN .  People are finding out that coding is paying well and think it is easy money.  They say: “all you do is look it up in the book”.  I caution them and direct them to CRN for their own good! I recommended CRN to 3 people and will continue to do so.  I give them the website and tell them to check it out.

Do you currently have any coding/medical credentials? Jean is sitting for her CCS exam soon and we look forward to hearing from her.

Have you taken any other CRN Institute courses or are you planning on taking another course? I might look into a refresher for the CPC-H course.  I am interested in doing case studies in the classroom prior to taking the CCS in the Spring.  I have to see what is offered.

Do you have any other credentials? No.  I am embarrassed to say, I did not pass the CPC -H test in December 2004. I have to admit that I did not finish the case studies and that was my downfall.  I am glad I have this background anyway.  It is the logical way to progress to the next level of coding.  I am going for the CCS this time. My employer recognizes this credential with a substantial amount of additional money per hour.  My job position in coding does not allow me to apply my wealth of knowledge to higher levels of coding and I am eager to do this.  The prefect scenario for me would be to pare knowledge with experience. To open doors to advancement, validate my knowledge, and achieve a personal goal, I hope I pass the CCS .  I agree with the experts who say credentialed coders assure a high level of professionalism in the field.

Any other comments? Some employers are still overlooking the impact on reimbursement and other costs when hiring uneducated staff. They do not include coding education in the areas of registration, finance and billing, and service technicians who apply charges.  The doctors also need constant support and training from coders to maintain quality documentation.  So much time and dollars are wasted due lack of a coordination of education.  I do see this changing. I have provided information to my boss and those in higher authority have to make these choices.  As for me, I believe: “EDUCATION IS THE KEY!    Thanks CRN!”

If you are a CRN student and have recently gotten a new credential, job or have something exciting you want to share send it to me so you can be featured in our next issue.

Until next time...

--Pam

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CRN Member Highlight

Don Self , FMSL (former McVey Seminar Leader), CSS, BFMA

Where are you from?
Born near Olympia , WA at Ft Lewis Army base – but relocated to Dallas Texas at less than six months old (as soon as I realized what Texas was).

What is your favorite activity?
Sex with my wife is first, then flying, then work.

Do you have any hobbies?
See number 3.

What credentials do you hold?
FMSL (former McVey Seminar Leader), CSS, BFMA.

What organizations do you belong to and how have they helped your career?
AAPC (it gets CEUs for members), PAHCOM (Ditto), PAHCS (I like these folks), AMBA (I like entreprenueral spirit).

How did you get into the field of medical billing and coding?
I used to sell Control-o-fax one-write (pegboard) systems and superbills to doctors and started advising doctors what to put on the superbill to the point I was more of a consultant than a salesperson – although I was number one in the country out of more than 500 superbill salespeople.

What is your current position?
Semi-vertical – also the CEO of Don Self & Associates and a partner of PMCA (Practice Management Consultants of America – with Trish Bukauskas-Vollmer, CPC).

What is one of your accomplishments in this field that you are most proud of?
I’ve helped a lot of doctors stop drawing from their savings to make the practice profitable, while enabling the physicians to be able to offer services to their patients that are helping the patients – where other physicians have given up on the patients.

What do you find most exciting about this field?
It used to be making doctors an extra $100K a year got to me. No more. Now – I’m able to introduce different services to physicians to help their patients get out of pain for the first time in 20 years or change the patient’s lives.

What do you find most frustrating?
Physicians who think they know it all – yet through their own ignorant pride persist in treating patients with drugs to cover up symptoms – unsuccessfully instead of learning something new.

What do you feel the future holds for this field?
I believe patients will someday cause an upheaval with mangled care (what others call managed care) so that patients and physicians can once again determine what the patients need – but that will only happen when the silent majority (physicians) start educating their patients to the dangers of mangled care.

What would you tell someone just starting out in this field?
Always give more to your clients in service than you receive in compensation.

If there was one thing you could change about this field what would it be?
To awaken physicians to the fact they do not have to be slaves to the mangled care industry.

Who do you consider a mentor?
Terry McVey of McVey Seminars.

What is your favorite billing or coding product?
Unicor Easy Coder (which I always thought should be called “Coding For Dummys”.

What is your affiliation with the CRN and how has that helped you?
I have probably learned more from CRN than all of the other listservs combined.

How can other members reach you?:
xxx can be reached at… (unless your fingers are cold) whatever you can reach. 1-888-DONSELF or donself@donself.com Please visit www.donself.com – which is second only to the codingandreimbursement.net website.

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