Professional Association of Healthcare Coding Specialists (PAHCS)
also known as
Professional Association of HealthCare Specialists (PAHCS)
Network News
Volume 15 Number 4
In this edition
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PAHCS Happenings
Transitional Care
Management (TCM)
Coding Corner
Maximize revenue
Coding Correctly?
Coding for CEUs
Oct – Nov - Dec 2016
One association with two names, servicing practice administrators, managers and coders in the medical arena.
PAHCS Happenings
PAHCS Conference 2016 – The PAHCS Annual Conference held in Tampa, FL September 21, 22, 23rd was a
great success. PAHCS thanks our speakers and attendees who shared so much excellent information and helped
create interactive and educational sessions. The roundtable sessions were a popular part of the conference. These
sessions allowed attendees and speakers to share office issues and, together, they worked to alleviate, or solve,
many common office/coding and billing issues. We’re planning our 2017 conference; give us your input!
PAHCS NEW Specialties – We are announcing a new specialty certification. In January 2017 the CCHCS
(Certified Chiropractic Coding Specialist) will be offered. The Chiropractic Study Guide is completed and can be
ordered from PAHCS. The exam will be ready in January 2017. Contact the PAHCS office to order the study
guide. Another specialty coming in early 2017 is Oncology/Hematology. We will have several other exciting
things coming in 2017; stay tuned for information on all PAHCS happenings.
RECERTIFICATION & CEU’s – Please make sure you hold your CEU certificates until you are submitting
your recertification. The “Submit CEU” form on the website it does not keep track of CEUs, we use it as a tool to
approve or deny CEUs; not to keep track of them. We ask the individual members to keep track of their CEU’s
and submit a list of them with your recertification package. Please use your “CEU tracking form” (received with
your recertification packet) to keep a running record of your CEU’s during the 2 year period.
CEUniversity & Coding for CEUs – It can take up to 2 weeks to get your results and all PAHCS CEUs can
only be taken one time. We do not give out answers; it’s our way of keeping the integrity of the CEU program
intact. PLEASE DO NOT WAIT UNTIL THE MONTH OF YOUR RECERTIFICATION to turn in your
CEUniversity & Coding for CEU’s for grading. Please note, CEU’s are not automatically granted just because
they were submitted. CEU’s are continuing education units and, by grading them, we verify learning took place
and your education was continued. Please, take time to answer the questions correctly, you only get one try.
PAHCS EDITORIAL BOARD – All members are eligible to be part of the Editorial Board for the PAHCS
Network News. To be added to the Editorial Board contact the PAHCS Director of Education, Marge McQuade,
CPOM, CMCS, CMSCS, CHCI via email at [email protected]. Articles will be used as needed and all will be
saved for future issues. To remain on the Editorial Board you must submit at least one article per year. Writers
who submit material to PAHCS will be asked to acknowledge our rights to edit the document (due to size and/or
content). We will strive to have the writer approve the edits, before we go to print, if possible. Articles used by
PAHCS will remain the intellectual property of the writer.
PAHCS, “Like us on FACEBOOK”
TRANSITIONAL CARE MANAGEMENT
By Marie Demastus, COCS, CMCS, CHCI
Transitional care management (TCM) services were developed for health care professionals to take responsibility
for Medicare beneficiary’s care in the transition from the inpatient (acute hospital, psychiatric hospital, long term
care hospital, skilled nursing facility, inpatient rehabilitation facility, observation or partial hospitalization) care
setting back in to the community setting (patient’s home, domiciliary, rest home or assisted living). By addressing
both medical and psychosocial issues, the purpose is to avoid re-hospitalization. The 30 day TCM period begins on
the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.
Physicians of any specialty and non-physician practitioners - certified nurse midwives (CNM), clinical nurse
specialists (CNS), nurse practitioners (NP) and physician assistants (PA) - may furnish TCM services. Incident to
provisions apply when services are provided by non-physician practitioners.
The components of TCM are:
1. An interactive contact must be made within two business days following the beneficiary’s discharge to the
community setting. This contact may be made via telephone, email or face to face. If the attempts to communicate
within the first two days are unsuccessful, you must document them in the medical record as unsuccessful.
Continued attempts to contact the beneficiary are expected until they are successful. NOTE: If all other TCM
criteria are met (including a face to face visit within the allotted time frame), the TCM service may still be reported.
2. Certain non face to face services including review discharge information, follow up on pending diagnostic tests
or treatments, interaction with other healthcare professionals who will assume care of system-specific problems,
providing education to the beneficiary or family, making referrals or arranging for needed community resources,
assisting in scheduling follow up with community providers, services and medication reconciliation/management.
3. A face to face visit within the prescribed timeframes.
99495 - TCM services with moderate medical decision complexity within 14 days of discharge
99496 – TCM services with high medical decision complexity within 7 days of discharge
Medical decision making refers to the complexity of establishing a diagnosis or selecting a management
option, determined by the number of possible diagnoses, the amount and complexity of medical records,
diagnostic tests or other information that must be obtained, reviewed and analyzed, and the risk of
significant complications, morbidity or mortality as well as comorbidities associated with the patient’s
problems, and the management options. Either the 1995 or 1997 documentation guidelines may be used.
Only one health care professional may report TCM services. Services may only be reported once per
beneficiary during the 30 day TCM period. The same health care professional may discharge the patient
from the hospital or observation and also bill TCM services. However, the TCM face to face visit may not
take place on the same day as discharge management. E/M services may also be billed during the TCM
period other than on the day of the face to face visit. TCM may not be billed within a post op global period,
in conjunction with care plan oversight services (G0181 or G0182), end stage renal disease services (9095190970) or chronic care management services (99490). Medication reconciliation and management must be
furnished no later than the date of the face to face visit.
At a minimum, the required documentation must include the date the beneficiary was discharged, the date
interactive contact was made with the beneficiary, the date you furnished the face to face visit, and the
complexity of medical decision making.
For further information, refer to MLN document 908628.
Page 2
PAHCS Network News
Oct-Nov-Dec 2016
Quarterly CODING TIPS
Dawn Cloud, CPC, CMSCS, CMCS, CHCI, CPOM
ICD-10, The Honeymoon is Over!
10/1/2016 begins the new era of ICD-10 codes. They have added 1,900 new
codes, deleted over 300, and have revised more than 400 codes. Last year in
order to get providers to comply Medicare relaxed their rules of allowing
unspecified codes. This gave us 1 year to get on board, learn the system, and
comply. That meant that as long as we were in the right family of codes they
would pay the claim.
CODING
Network News
Volume 15, Number 4
ISSN 1545-4843
Coding Network News is a
quarterly publication of the
Professional Association of
Healthcare Coding Specialists
(PAHCS).
Entire contents copyrighted
All rights reserved;
reproduction in whole or in
part is prohibited.
Subscriptions are provided as
one of the many benefits of
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For information on
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article submission or reprint
permission, FAX the PAHCS
National Office 888-852-8468.
Here we are 1 year later, and now the fun begins. Medicare mandates by law
that the most specific code be used on your claims. What this may mean is
more denials of our claims for more specific diagnosis codes. In turn that
means a slowdown of our revenue.
They are looking to see if there is a bilateral, right or left in the code if needed.
Some require status of the condition, acute, chronic, or recurrent. Some require
the manifestation or even the cause. Be sure to understand the coding rules.
Here are a few tips to help:
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Check claims against documentation before submitting to the insurance
carrier. This may slow down your claims time for a while, but it is better
than having it denied and waiting to have it reprocessed.
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If the claim has an unspecified code, and you check your new version of
ICD-10 and find a more specific code; check against documentation. If you
cannot assign the more specific code then take it back to your provider to
add an addendum the medical record to assign a more specific code, if
appropriate.
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Check cheat sheets in the providers’ areas and make sure that they have the
most accurate codes
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Check the providers’ favorite list or templates within your EHR to make
sure they have the most accurate codes available. We get auto updated
from our vendor, but that will not change their templates or favorites.
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As you identify problem codes educate your provider on what they need to
do in order to get paid timely.
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You may need to pull new guidelines, LCD’s or NCD’s to make sure
nothing has been updated
STAY IN TOUCH
Local: 813-333-1160
Toll Free: 888-708-4707
Fax: 888-852-8468
Mail: 218 E. Bearss Ave., #354
Tampa, FL 33613
Web Site: www.pahcs.org
E-mail: [email protected]
Oct-Nov-Dec 2016
Remember coding is always a work in progress. Communicate with all parties
involved to keep your denials to a minimum. Good luck!!
PAHCS Network News
Page 3
Tips to Maximize Revenue
Healthcare is one of few industries where services are not paid for when they are received. Typically, one party (such
as a doctor or hospital) provides services to a second party (a patient), but a third party (a health insurance carrier) is
often involved in facilitating financial reimbursement for the services provided. Money keeps the practice in business.
Each phase of the revenue cycle is important, from payer contracts to charge capture and collections. Knowing how to
manage the revenue cycle not only ensures the financial viability of the practice, but also minimizes the time and effort
spent collecting payment for services rendered. The purpose of this article is to gain a better understanding of what you
can do to efficiently manage the revenue cycle and how to maximize potential revenue.
Review payer contracts
Payer contracts often contain complex reimbursement language and formulas that can be difficult to monitor and
manage. It is important to know what you are agreeing to when you sign any contract, but especially when it comes to
payer contracts. Be sure you know and understand the expected reimbursement and contractual allowances before you
sign. Contract negotiations can be difficult, especially if you are a solo practitioner. You have limited power to
negotiate unless your specialty is in high demand and there are limited providers available in your geographic area.
When negotiating, be sure to optimize trade-offs and to understand the total value of the agreement prior to contract
execution. It could be beneficial to take less reimbursement on office visits if you can get more money on high dollar
surgical procedures, but make sure you evaluate this against your current or expected volumes.
Know the Law - Under the "Prompt Pay" law, payers must pay or deny a clean claim within 30 days of receipt if filed
electronically and within 45 days of receipt if filed on paper. Check the laws in your state to see if there are payer
deadlines. While the definition of a clean claim could be disputed, no response from a payer within the 30 to 45 day
window should result in immediate follow up. Medicare reimbursements are dispersed within 14 days of electronic
claim submission, so inquiry on those unpaid claims should occur within 15 to 20 days. Most practice management
systems will allow batching of unpaid claims by insurance type so that inquiry can be made on multiple claims with
one phone call or internet inquiry. Pending claims should be worked on a daily basis, beginning with accounts with the
highest balance and oldest age first, such that every unpaid account is reviewed at least once every 30 days.
Clean claims = fewer denials - A serious concern in healthcare reimbursement today is decreased or delayed
reimbursement due to claim denials. The challenge is how to quickly identify the source of the denials and fix the
problems. Education is the key to clean claims. Providers, front desk, billers and clinical staff contribute to the
information that is submitted on a claim. Each needs to understand how their role impacts claim payment. When
denials are received, they should be identified with a reason code and posted in the practice management system so a
denial report can be generated at month end. This gives managers a clear picture of where further education is needed.
Respond promptly to claim denials - After receiving a claim denial it is important to correct the claim and rebill it to
the insurance carrier promptly. Claims often go unpaid and bump up against timely filing limits when the biller keeps a
"zero pay folder" to work in the future. Denied claims should be addressed daily as they are received. Each insurance
carrier handles resubmitted claims differently so it is important to know what each carrier expects. With some carriers,
if the claim is simply rebilled electronically with no notation, the claim will be denied as a duplicate. Some carriers will
allow the provider's office to fax a corrected claim directly to their claims processing department. Others require that
the claim be resubmitted either electronically or on paper.
Appeal claims paid in error - Any services paid incorrectly should be appealed. Sometimes errors can be addressed
over the phone, but often they require a formal appeal letter. It is important when appealing claims that a cover letter be
submitted explaining why the claim is being appealed. The cover letter also notifies the carrier of any attached
documentation accompanying the claim. Further documentation may include progress notes, lab or other test results,
operative notes, fee schedules, copies of CPT guidelines or Medicare policies to support the appeal. Keep copies of all
appeals and the results for reference with future appeals.
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PAHCS Network News
Oct-Nov-Dec 2016
Review payments carefully - Payers will often make mistakes when processing claims that need to be appealed for
proper reimbursement. The person posting payments must pay attention and question anything that does not look
right. Some things to watch for include:
• dropped or missed procedures
• one procedure bundled into another and paid based on one code instead of two
• modifiers dropped that justify bundled procedures
• multiple units ignored
• payment based on the wrong fee schedule
The best practice management systems have the ability to load payer fee schedules so you know when payments are
posted whether they were paid correctly or not.
Don't get frustrated, get help! - Practices should not hesitate to contact their State Insurance Commissioner's
office if they feel they are getting the run-around from a particular payer after reasonable attempts to collect. Find
your state insurance commissioner at the National Association of Insurance Commissioners website.
Commissioner's offices may be called with general questions, but in order for them to investigate a disputed claim
they must have written documentation with as many details as possible. Documentation should include a copy of
the insurance card, the claim form, and documentation reflecting all efforts to resolve the claim, as well as
responses from the payer. A separate complaint should be filed for each patient involved. Most insurance
companies respond quickly when the State Insurance Commissioner becomes involved.
Patient balances - Sometimes asking patients for payment puts the office staff in an uncomfortable position,
especially when the patient becomes disgruntled. However, most insurance companies require that the patient's
co-pay be collected at the time service is rendered. Staff members working at check-in and check-out should be
comfortable asking for payment. Often providing a script requesting payment helps staff members to be more
comfortable and consistent with requesting payments. Contracted providers are obligated to collect the co-pay at
the time of service. Failure to do so could be a breach of contract.
The most important thing an office can do is to develop an office financial policy with regard to patient payments.
Developing an office policy is important to ensure that all patients will be treated the same with regards to financial
payment. A financial policy makes the patient aware of their responsibilities with regards to payment for services.
Outline in your policy the exact process which will be followed should the patient refuse to pay on their account.
Attempts to collect outstanding balances should be made each time the patient is seen. The cost of pursuing
payment after the patient leaves only decreases the value of the dollar collected. The more time that passes the less
valuable the dollar becomes and the more difficult it is to collect. Patients know whether you are an office that
expects payment or one that will extend free credit. The most successful practices use some of these techniques:
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Notify patients when scheduling and confirming appointments that they should
• bring insurance cards and photo ID to each visit; and
• come prepared to pay copays and outstanding balances at the time of service. Let them know up front
what credit cards you accept.
Collect copays and outstanding balances at check-in rather than check-out. Staff should be direct without being
rude when asking for money. Confidently stating "Your copay is $35. Will you be paying with cash, check or
credit card?" is better than asking "You have a balance of $132. Would you like to make a payment today or
should we bill you?" Why pay today if you don't have to? Your office is not a bank and should not routinely
extend credit.
Start payment plans at a maximum of three to six months and a minimum of $25. It costs money to send
statements and process multiple payments. Offer discounts if balance is paid in full to get the account settled.
Don't spend money on statements to collect $5 and $10 balances. Collect small balances the next time the
patient is in the office.
Oct-Nov-Dec 2016
PAHCS Network News
Page 5
Is Your Practice Coding Correctly?
By Marge McQuade, CMSCS, CMCS, CHCI, CPOM
Accurate billing is essential for two reasons. First, it lets you capture all costs, and thus bill for all
services to which you are entitled payment. The second reason is accurate, justifiable coding can
keep you out of trouble with the federal government. Your bills are not only monitored for
up-coding and “unbundling” but they are also monitored to make sure that the procedure is
supported by medical necessity with the diagnosis code.
Don't let your approach to coding reflect your determination to get reimbursed. You may believe
that you are justified in billing for all services you provide, simply to receive fair payment. So it may
follow that "unbundling" is synonymous with "doing whatever has to be done to get paid for what
was done."
CMS's Office of the Inspector General (OIG) is taking an increasingly aggressive stand in their
efforts to eliminate Medicare fraud and abuse. The courts have been extremely unsympathetic
toward physicians who commit Medicare fraud and rarely see the physician's point of view with
enough clarity to accept it as justification for unbundling.
Make sure your coding is accurate and entirely justifiable. Make sure that you use three coding
books in your practice and make sure they are for the current year:
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•
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Physicians' Current Procedural Terminology, Fourth Edition (CPT-4) for procedures;
International Classification of Diseases, Tenth revision, Clinical Modification (ICD-10-CM) for
diagnoses; and HCFA's
Common Procedure Coding System (HCPCS), for materials, including injectables.
The ICD-10 codes changes are effective October 1st each year and the CPT and HCPC are
effective January 1st each year. Every year there are changes, deletions and new codes added.
Using deleted codes costs you money because your charges will be denied. If your practice uses
superbills/encounter forms be sure that they are updated annually to reflex the new codes that
have been added and that deleted codes are removed. Also make sure that all involved in the
coding for the practice are aware of any changes to existing codes as that could mean the
difference between bundling and unbundling.
Make sure your diagnosis, procedure, and materials codes all match at all times. In every case, the
reason established by the diagnostic code must support the action indicated by the procedure
code. If it does not, a mismatched claim could be denied for lack of medical necessity. Also be
aware that claims will be denied if the ICD-10 codes have not been carried out to its full specificity.
Be certain that every doctor in your practice is committed to accurate coding and is involved in the
coding process. Fraudulent coding even accidentally fraudulent coding can lead to criminal
prosecution of the practice's physicians and coders.
It is ultimately the responsibility of the Office Manager or Practice Administrator to make sure that
the practice is coding correctly and that your practice will not be charged with Fraud and Abuse.
To that end many times it means educating the physician on current coding problems and making
sure his documentation supports what was coded.
Page 6
PAHCS Network News
Oct-Nov-Dec 2016
Is Your Practice Coding Correctly? (continued)
Physicians often perform multiple procedures at the same operative session. Often, it is difficult to
get paid for all the work they did. Insurance companies tend to bundle codes and services together
and some practices often resort to un-bundling to get paid more. Be careful not to un-bundle. When
you are reviewing contracts, review the payor's list of un-bundled surgical procedures.
Accurate coding and good documentation is essential. No two physicians code the same way. Often,
physicians disagree on such vital starting points as degree of patient sickness or injury. Each
provider should take great pains to ensure that documentation supports all coding. Your payors
monitor your practice's records for discrepancies. Correct coding decreases the practice liability to
pay back funds received that payors subsequently contest. Correct coding also mitigates the
possibly of criminal prosecution.
Asking a non-physician to be the only person to determine a correct CPT or ICD code invites
trouble. Physicians are ultimately responsible for all coding and must take an active part in the
process, but must focus first on patient care; thus, you need a non-physician specialist, who may be
your practice administrator or chief billing clerk. The person responsible for correct coding should:
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work with your physicians to determine proper coding;
research the CPT-4, ICD-10, HCPCS, Medicare and Medicaid publications, CCI edits and your
specialty-specific publications and books, as well as your payor contracts;
obtain and use the commercially available manuals that match CPT and ICD codes and specify
which matches are acceptable; or prepare such a manual specific to your specialty/practice;
if your billing system is electronic, make sure that it includes an "edits" function that flags
mismatched codes automatically, before they are sent out;
contact specialty societies, insurance carriers, and other expert resources, as appropriate;
receive, read, use, and keep on file all coding bulletins and announcements;
attend coding conferences and seminars, as necessary;
update your practice coding books, computer software, and "superbills" annually;
consider joining a reputable coding association, attend meetings, sessions, and conferences;
question the physician every time a potential problem is spotted, to select the best possible code
and determine if there is an appropriate modifier;
confer with the physician on each "unusual" case, find out what factors made it unusual, and
determine the best way to deal with the situation, in coding;
Make sure physicians, your coding specialist, and your staff members are working together;
At random, pull a number of charge tickets and compare ICD codes against CPT, then compare
those findings against the information of the patient charts;
PAHCS recommends periodically performing a practice self-audit of your entire coding system. Your
coding specialist is usually the most appropriate person to audit the system.
PAHCS, get the word out. Tell your peers!
Oct-Nov-Dec 2016
PAHCS Network News
Page 7
4th quarter 2016
Answer all questions below correctly to receive 1 PAHCS CEU. E-mail answers to
[email protected]. Be sure to include your name in the email.
____1. These elements would be part of the ____ history: employment, education, use of drugs.
a. past
c. family
b. social
d. any of the above
____2. The level of E/M service is based on:
a. documentation
b. key components
CODING:
Two heads are
better than one
c. contributing factors
d. all of the above
____3. The HPI must be documented in the medical record by:
a. the physician
c. the patient
b. any office staff member
d. any of the above
____4. Medical decision making (MDM) is based on the ____ the physician must consider about
the management of a patient’s condition.
a. number of diagnoses
c. amount of data
b. overall complexity of the decision
d. risk of morbidity
____5. The physician must consider multiple diagnoses and management options. There is a
moderate amount of data to be reviewed and the risk of complications or death is moderate.
What is the level of MDM?
a. straightforward
c. moderate
b. low
d. high
Professional Assn of
HealthCare Specialists
218 E. Bearss Ave. #354
Tampa, FL 33613
SMARTER
PAHCS is your
association, let us
know how we can
support you.
Email your ideas to:
[email protected]
or call 888-708-4074
Together we can make
PAHCS better.