Coding & Reimbursement Network News

From the Founder

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

From the Founder

The CRN has been busy getting ready for the big AAPC conference in St. Louis next week. Our bags are packed (well almost) and we're ready to go. It is my last year on the advisory board so it will be bittersweet for me. Unfortunately, I may not be able to go to conference as I am currently staying with my mother in upstate NY as she recovers from pancreatic surgery (Whipple procedure) and faces cancer treatment. I will be with all my conference buddies and CRN friends in spirit. And I'm sure I'll get a few calls from some strategic networking location (like the hotel bar <g>) to keep me aprised of all the fun.

Suzan is her usual comical self in this issues "Listserv Lately" and Tara keeps us entertained and educated with her "Coding Sleuth" article. And we are very excited about all the CEU mini-courses that have been created for your viewing and listening pleasure - see Barbara's update below.

Until next time!

--Laureen = )

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by Suzan Hvizdash, CPC CRN Senior Auditor, Instructor

As we get ready for the AAPC National Conference in St. Louis, it appears the list was a bit quiet.

As usual, and always helpful, there were a lot of coding questions. Together, we solved problems about:

-Using the -25 modifier with a visit and a wound debridement
-Diagnosis code for Adult ADD (314.00)
-Billing for mastectomy
-Tissue removal during sinus surgery
-Diabetic Education (98960-26)
-Diagnosis code for abnormal calcium score (793.2)
-Manipulations done when an injection is also performed
-Taking records out of the office
-Muscle flap and tissue reconstruction coding

We talked about how long records should be kept. Forever seems to be the safest time frame, but in reality it’s something that may vary from state-to-state.

Discussion took place regarding the recent events reported about Terrill Curtis, AAPC owner and president. The AAPC issued a statement on this. If you didn’t receive it through the AAPC directly, you can read it at http://health.groups.yahoo.com/group/CRN-L/message/52127.

Can an audiologist be an appropriate consulting source? There were several different approaches to this one as well. Some say it depends on the intensions of the audiologist. Others said no, as he/she wasn’t a medical source. Still others said yes as the definition of an appropriate referral source is very broad. You can follow this thread at http://health.groups.yahoo.com/group/CRN-L/message/52109.

Looking forward to meeting many of you at the AAPC National Conference in St. Louis.

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

The Case of the Confused Consultant

It seems the more I work this case, the more it keeps coming back around. Doctors are constantly getting confused when to code a consult, when is a consult a consult and not a referral, how to properly document a consult, what is required for a consult???

So many infernal questions that can baffle the even the most genius of medical minds. But fear not, The Coding Sleuth is here to crack the case (again) and shed some light on the subject.

When you think of a consult what comes to mind? A question and answers session perhaps? Well, Webster’s Dictionary defines a consult as “to have regards to, consider” and “to ask the advice or opinion of”. This second definition is probably the best description of what service a physician is performing during a consult. He is “rendering an opinion and/or his advice on the situation with a particular patient”. This is an important piece of information to understand because on many occasions a patient is sent to a physician for evaluation and treatment of a problem. However, in this situation the service is a “referral” and not a consultation. These two services can get confusing since a consulting physician can also initiate treatment of a patient. So, in order to clear up this issue we need to be clear on what constitutes a “true consult” as far as CPT Guidelines go.

Let's go sleuth out the clues.

The first place to look is, of course, in your CPT. Guidelines for coding and documenting consults have been provided just before the first set of consult codes 99241-99245.

The first paragraph states “a consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”

This paragraph tells us a few things. First it tells us the consulting physician is asked to provided an opinion or to manage a specific problem, such as an Oncologist being asked to manage a patient’s cancer. The Oncologist is usually asked to confirm a diagnosis of cancer first and then relay his findings and his opinion on the best course of action for treating the patient. The second thing it tells us is the request can be by either another physician OR an appropriate source. An appropriate source would include nurse practitioners, physician’s assistants, and psychiatrists. These appropriate sources may also provide consults when requested.

In the next paragraph, the CPT guidelines state “the consulting physicians may initiate diagnostic and/or therapeutic services at the time of the same or subsequent visit.” This is where the difference between our consult and our referral need clarification. Let’s take the example of two patients, Elvis Hipster and Letty Zepplin. Both patients see Dr. Makemwell as their primary care physician. On a particularly beautiful day in spring both patients come in to see Dr. Makemwell for a red swollen lump on the arm. Upon examination of Mr. Hipster, Dr. Makemwell feels the lump on Mr. Hipster's arm could be either an abscess or an infected inclusion cyst. Due to the size of the lump and the unsure diagnosis of the problem, Dr. Makemwell tells the patient he would like him to visit a general surgeon, Dr. Kutenso, for his opinion on the problem.

On his second patient, Ms. Letty Zepplin, Dr. Makemwell quickly determines she has an infected abscess that would benefit from a surgical drainage. Dr. Makewell tells her he will make an appointment with Dr. Kutenso to perform an incision and drainage on the abscess.

Both patients happen to get appointments with Dr. Kutenso on the same day (how coincidental is that?). First, Dr. Kutenso sees Mr. Hipster. He examines the lump on his arm and decides to take a needle biopsy of the site in order to better conclude the exact diagnosis. He makes a final determination and relays his findings or opinion back to Dr. Makemwell along with his opinion on the best way to proceed with proper care. Next Dr. Kutenso sees Ms. Zepplin. He takes a history and physical and schedules her for an incision and drainage the next afternoon at Happy Hospital.

The difference between these two patients' visits to Dr. Kutenso is that Dr. Makewell felt he needed another point of view or opinion for the problem with Elvis Hipster. With Ms. Zepplin, however, Dr. Makemwell was able to come to a definitive conclusion and sent her over to Dr. Kutenso to actually care and treat the problem. Even though in both visits Dr. Kutenso performed procedures and initiated treatment on both patients, the reason for their visits was completely different. One was a request for an opinion and best course of action and the other was simply a referral to treat.

Capeesh?

Let’s move on to our CPT Guidelines again. The third paragraph provides the most important information for billing consultations. The information stated gives specific requirements that must be present in the documentation in order to substantiate a consult code. We call them the three R’s.

There are three (yes I mentioned that) requirements.

First a written or a verbal Request for a consult (opinion) may be made by a physician or other appropriate source (nurse practitioner) and documented in the patient's chart. If Dr. Makemwell called Dr. Kutenso on the phone and said “Hey, Frank. This is Ted. How was your golf game on Sunday? Really? That’s great. We’ll have to get together and play a few holes soon… sure sounds good. Say, the reason I’m calling is I have a nice patient of mine here, his name is Elvis Hipster, and he has what appears to be an abscess on his left arm. But it also looks like he may have an infected inclusion cyst. Would you mind looking at it? Great, thanks. I’ll send him over tomorrow and look forward to hearing from you.”

In this situation, Dr. Makenwell called Dr. Kutenso to ask for his opinion. Therefore, both physicians need to document in their perspective charts for this patient that this verbal request was done. If the request had been in written form, such as a nice letter or a script, a copy of the document should also be kept in both charts.

This establishes the first R – the Request.

The second requirement is the consulting physician’s opinion. Hold on Slick - I know there isn’t an R in this step but you’re getting ahead of yourself. or at least me. Slow down. The consulting physician Renders his opinion. See our second R - if you would have given me a chance, Quickdraw. His opinion can be in the form of his history, exam and medical decision making, his office note. The most effective way to show a request was made is to start the documentation with a simple phrase such as “Mr. Hipster has been sent to me by request of Dr. Makemwell for consultation of / my opinion (either will work) of a.....”

A simple sentence such as this is quick to the point and establishes the purpose of the visit.

The third R can get a little tricky and is often the step that gets missed. Once the opinion has been made the consultants findings must be communicated by a written Report back to the requesting physicians. Now there are two ways this can be accomplished in a clear and concise manner in order to ensure this third step has been made. The first is for the consultant to dictate a letter of his findings and any treatment or diagnosis option back to the requesting doctor. This is a surefire way to meet this step… not too mention very professional. However, unless you have a doctor that likes to write or talk or is meticulous about dictating absolutely everything down, most physicians don’t take the time to do this. It’s time consuming.

The second way is to include a closing sentence at the end of the H&P showing the effort was put forth to send a copy of the documentation back to the requesting physician. For example, at the end of Dr. Kutenso’s office visit he could make the following statement, “Thank you, Dr. Makenwell, for consulting me on this very nice gentleman. A copy of this documentation will be sent to your office. I look forward to working with you on the care of this patient.” At the end of the document a cc. line to all necessary parties should also be added.

Make NOTE: A CC. LINE ALONE IS NOT SUFFICIENT DOCUMENTATION TO MEET THE THIRD CONSULT REQUIREMENT.

Documentation should clearly show the consulting physician acknowledges his findings are required to be sent back to the requesting physician and an effort to do so was made.

You can bet your boots an auditor is going to look for crystal-clear proof that a consulting physician understands the three R requirements and is putting forth the effort to ensure all requirements are met.

Now that we understand the requirements of a consult, what happens afterwards? Well, my friend, this all depends on the purpose of future visits. A consult is only billed on the initial visit of a particular problem. In the outpatient setting the consult is billed on the first visit. All subsequent visits related to the same problem should be billed with established patient office visit codes 99211-99215. A patient may be known to a consulting physician, perhaps for a condition in the past. But if the same patient is sent for consultation back to the physician for a new problem, then the consulting physician should bill a consult code and follow the requirements for a consult.

Inpatient things are a little different. Since only the admitting physician can bill from the 99221-99223 code set (initial inpatient care) all other physicians must use either an inpatient consult code 99251-99255 or follow-up hospital codes 99231-99233. If a physician is asked to see an inpatient by the admitting physician in consult for either a new or established problem, the consulting physician should bill a code from 99251-99255 on the first day he sees the patient during a particular admission stay. If the same patient is discharged and admitted at a later date and the same consulting physician is asked to consult on that patient for the same problem he followed in the last admit, the consulting physician would again bill a consult code from 99251-99255 on the first day he sees the patient during the new admit. A new consult is billed for each separate admission by a physician following a condition unrelated to the reason for admit. For example, a patient is admitted with gallstones by Dr. Howyaben, but this patient has also been followed by Dr. Hapihart for congestive heart failure for the past two years. Dr. Howyaben asks Dr. Hapihart to follow the patient’s CHF during this admission and consult with him on how the CHF may effect treatment of the gallstones. Even though the CHF is known to Dr. Hapihart and he is the treating physician for this condition, he is not the admitting physician during this admission; he is only “consulting” with the admitting physician. Therefore, on his first visit with the patient at the hospital Dr. Hapihart will bill 99251-99255 appropriately. All subsequent visits will be billed using inpatient follow-up codes 99231-99233 respectively.

Lastly, consult codes can only be reported if the consult has been requested by a physician. Consults requested by patients should be billed using the appropriate new or established outpatient codes (note this rule is effective Jan 1, 2006 with the deletion of codes 99271-99275).

Consultations are common practice. Follow up with your physicians, educate them and help them establish healthy habits when accepting and performing consults in their practice. Be persistent and this case will finally stay cracked.

Until next time Gumshoes! Keep coding.

--Tara

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TeleWebinar Update

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

As I am getting ready to leave for the American Academy of Professional Coders National Conference in St. Louis, I reflect on the terrific things we have done in the past year. We have started a new “arm” of the CRN organization, CRN Continuing Education to bring quality telewebinars to the coding, compliance, reimbursement and billing market at a very reasonable cost. We have been growing since our start in September and have been attracting some of the best speakers and educators in the country to the CRN CE family. I am very excited as we grow our portfolio of offerings. I have been busy getting new classes planned and recorded. There will be a little gap in the recording activities as I leave for the great city of St. Louis and get to network, learn and socialize with my colleagues at the Academy’s annual conference. After that, I am off to a wel- earned vacation and then some work involving travel. So, I will restart recording new classes in May, and we will continue adding new courses for your development, training and education.

We recorded Patricia (Pati) Trites of Healthcare Compliance Resources when she did three courses the week of March 13th for CRN CE.

First, Pati Pati taught Employee Overtime-Is Your Practice At Compliance Risk? Many physician practices underestimate the risk involved in making a mistake in administering the wage/hour laws. One of the most common mistakes made is improperly classifying certain employees as exempt from the wage and hour laws and not paying overtime when it is required. What about work time while traveling and the overtime considerations. This has not only great impact on the practice’s operations, but on their compliance program. One of the key elements of a compliance program is your employee policy manual. Come listen to Pati speak on this very timely topic. She recorded this class on 3/14/06 and it is available now for download on the CRNShoppe at TW_EmpOtCompliance. I have the wonderful opportunity of listening to all of these classes when they are being recorded and I have to tell you that it was extremely informative and of a lot of use for a practice. Not only did Pati address overtime rules, but she also touched on issues such as employees versus independent contractors and how to determine if an employee qualifies for an independent contractor. As we have more and more employees telecommute, these are important issues to grapple with and address to make sure your organization is within compliance of federal and/or state guidelines. Pati provided the information and tools to evaluate the employee and the appropriate status under which they should be paid. The practice’s employee manual and handbook is an integral and key aspect of the practice’s compliance program, and thus, this is important in making sure your business is in compliance with employment laws. If you have not started your compliance program, starting here will be starting your compliance program with your compliance program.

The second class that Pati Trites recorded was; Mandatory Compliance Programs Have Arrived. The Deficit Reduction Act of 2005 has made it mandatory to have a fraud and abuse compliance program by Jan 1, 2007. This applies to all entities that pay or receive at least $5 million in Medicaid funds. Are you ready? Find out how to comply with the law. Even if you are not a large practice, there are a lot of small things you can do to start your compliance pathway. Pati provides many practical tools for you as you either are starting to plan a new compliance program or you are reviewing your existing compliance program. This continues to be a very timely topic. This is about how do you get started and stay on track with your compliance activities; how to not have them overwhelm you, and how do they fit into your daily activities. Compliance is not just for the big operations and you can do it. This course is available on the CRN Shoppe to purchase the recording at TW_Compliance.

Pati’s third class is near and dear to my heart. The class, Evaluating EMR/EHR Systems for Compliance? addresses an area of EMR/EHR evaluation that seems to be overlooked in many system reviews. This is so important as the more we travel down the HIPAA security road and as automatic encoders become more prevalent, there will be more and more pressure on practices to prove that their electronic systems comply with certain audit and compliance issues. These systems are very expensive and their implementation is often a very rocky road. A practice cannot afford to take this lightly and not consider the compliance related issues when evaluating these systems. This recording is available on the CRN Shoppe for purchase at TW_EMR-EHR.

Last, but definitely not least, Deb Grider is doing another minicourse for CRN CE on Coding Consulting 101. I have seen the slides and it is a terrific class. A lot of us are aware of the confusion that surrounds the “clarification” that CMS created when they updated section 30.6.10 of the Claims Processing Manual (Chapter 29), and a lot of concern exists on how we operate within the parameters that CMS has placed on the physicians, the practices and the coders. Deb addresses the AMA definition of Consultations as well as the CMS Guidelines as defined and clarified in Chapter 29 of the Claims Processing Manual (section 30.6.10). Deb brings clarity where there was fog and has some great suggestions for systems and procedures in the practice. She also has suggestions for you to bring back to your physicians on how they document the requests for consultations when they are truly requests for opinions. Deb has audited many charts, in and outpatient and it is through that experience that she can bring understanding to this topic, as well as practical operating advice. This class will be recorded just before the AAPC National Conference. It will, therefore, will be available just after conference, around 4/1/06. To order this minicourse, go to TW_ConsultationCoding101.

We have some other classes lined up for May as well. I received a few emails requesting classes on Neurosurgery. So, Voila, Eric Sandhusen is developing a two-part mini course series on Neurosurgery, part 1 on the spine and part II on the brain. We have also been requested to develop something on ASC’s. I have not started on that one, but I promise I will find the appropriate Subject Matter Expert (SME) for that topic. The point here is that a few people have emailed me with their needs and we have been able to be responsive with finding the right SME’s for those topics and got them scheduled. So, do not be afraid to email me at b.cobuzzi@att.net with our needs and I will look into whether we can get your needed topics scheduled.

Do not forget to look on the CRN CE web site at www.crnshoppe.com/tw and see all the classes that are already there available for purchase. There are a few on auditing, on appeals, on modifiers, on E&M, on radiology, on marketing the independent billing company, on non-physician practitioners and more. Go to the web site and see our ever-growing library of continuing education and CEU opportunities. Put a group around the phone (and if you want, a computer, but it is not necessary) and you all can listen to the class together for one fee of $139. What better, cost effective way do you have to educate your office? This is about having great teachers and timely topics that are worth the time and effort to listen and learn!

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, AMBA and 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.

CRN will have a booth at the AAPC National Conference in St. Louis. Come see us at booth #216. We look forward to meeting a lot of you that we have only known from your email addresses. We want to meet you face to face. Come meet Pam Biffle, Suzan Hvizdash and I at booth #216. And, during the off hours, the meeting place will be the bar in the lobby of the Renaissance Grand at 800 Washington Avenue. I am totally looking forward to conference and seeing those of you that are coming. I will be checking in people registering for conference on Sunday, so that is where you can find me. And I will also be at the Local Chapter Meeting on Sunday Morning. See you in St. Louis

Upcoming Live Events:

	Employee Overtime-Is Your Practice At Compliance Risk? Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP
	Mandatory Compliance Programs Have Arrived Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP
	Evaluating EMR/EHR Systems for Compliance? Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP
	Consultation Coding 101 Deborah Grider, CPC, CPC-H, CPC-P, CCS-P, EMS

Upcoming Speakers - Dates to be set

• Marvel Hammer
• Frank Cohen
• Pam Biffle
• Nancy Reading
• Caral Edelberg
• Terry Leone
• Linda Martien
• 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 April 1, 2006.

For those of you who will be attending the AAPC meeting in St. Louis the first week of April be sure to come to the CRN booth to say hello. I’m looking forward to being able to see you in person.

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 Susan Cafaro who is the Office Manager for Dr. Tully and Dr. Napierala, Ph.D.. Susan recently completed the 301 Physician Coding Course.

What made you decide to take a course? My friend, Gina Nuske, told me about the course and I wanted to further my career by taking the course.

Why did you pick CRN Institute? I liked that you could take work at your own pace throughout the course.

Is there anything you would say to someone thinking about taking a course? I feel this course was very informative and would suggest anyone interested in coding, take this course.

Do you currently have any coding/medical credentials? No coding credentials yet. I have been in the medical field for the past 15 years and doing some coding in my jobs.

Are you planning on sitting for a Board exam? Susan is planning on sitting for the CPC exam April 22nd in Canton , Ohio at Mercy Hospital. We look forward to reporting her success.

Any other comments? I want to thank you very much for all the help when I would have to call you. If you were not available you got right back to me as soon as possible.

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

Gina M. Nuske, CPC , CMBS

Where are you from?
Canton , Ohio

What is your favorite activity?
Walking my miniature schnauzer.

Do you have any hobbies?
Water skiing, reading to advance my skills.

What credentials do you hold?
CPC, CMBS

What organizations do you belong to and how have they helped your career?
I belong to the AAPC, MGMA and the Medical Association of Billers. All of these organizations have helped me network and grow as a coder and a medical manager.

How did you get into the field of medical billing and coding?
I took a part-time job billing for a speech and language clinic while I was in college. I used to handwrite the diagnosis and the visit description. Codes were not required. I know I am showing my age.

What is your current position?
I am the Director of HIM for EMP in Canton , Ohio. I also have my own consulting business.

What is one of your accomplishments in this field that you are most proud of?
My CPC certification.

What do you find most exciting about this field?
It is always changing. You have to stay on top of your game.

What do you find most frustrating?
It is always changing. You have to stay on top of your game!

What do you feel the future holds for this field?
Lots of opportunity. I believe the need for certified coders and billers will continue to grow. Our opportunities are unlimited.

What would you tell someone just starting out in this field?
Get certified, network, and read everything you can get your hands on.

If there was one thing you could change about this field what would it be?
I would like to see more respect for the skills and contributions of the certified coder to the healthcare team. I know that we can develop the respect that we deserve. I feel that every position in the healthcare field is vitally important to the health of the patient. I worked in Oncology for 5 years, and I discovered that the patients were very concerned about the accuracy of the coding and billing process. The last thing the patient needed to be worried about was the bill. Accurate coding and billing is very important to the overall health of the patient.

Who do you consider a mentor?
Every single practitioner that I have and will work for in the future. I love the opportunity to grow, learn, and understand the work nurses and physicians do.

What is your favorite billing or coding product?
Currently my favorite product is Code Correct. It is one-stop shopping for many coding resources.

What is your affiliation with the CRN and how has that helped you?
I have been a member since taking the CPC courses from Laureen in 2001. I love the networking and all of the great advise from very qualified and trustworthy people.

How can other members reach you?:
Gina can be reached at… ginacpc@earthlink.net or 330-491-4067.

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