Dial-In Instructions
Conference Name:
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
Scheduled Conference Date:
Thursday, February 2, 2006
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1:00 p.m.–2:30 p.m. (Eastern), 12:00 p.m.–1:30 p.m. (Central), 11:00 a.m.–
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Scheduled Conference Duration:
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Program Evaluation
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h t t p : / / w w w. z o o m e r a n g . c o m / s u r v e y. z g i ? p = W E B 2 2 4 X H N M T F Q 4
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HCPro, Inc.
presents . . .
Modifiers -52, -73, and -74:
Ensure proper coding at the
point of care
A 90-minute interactive audioconference
Thursday, February 2, 2006
1:00 p.m.–2:30 p.m. (Eastern)
12:00 p.m.–1:30 p.m. (Central)
11:00 a.m.–12:30 p.m. (Mountain)
10:00 a.m.–11:30 a.m. (Pacific)
In our materials we strive to provide our audience with useful, timely information. The live audioconference
will follow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We have
noticed that other non-HCPro audioconference materials follow the speaker’s presentation bullet-by-bullet,
page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do not
include each speaker’s entire presentation. The materials contain helpful forms, crosswalks, policies, charts,
and graphs. We hope that you find this information useful in the future.
HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations,
which owns the JCAHO trademark.
ii
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
The “Modifiers -52, -73, and -74: Ensure proper coding at the point of care” audioconference materials
package is published by HCPro, 200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945.
Copyright 2006, HCPro, Inc.
Attendance at the audioconference is restricted to employees, consultants, and members of the medical staff
of the Licensee.
The audioconference materials are intended solely for use in conjunction with the associated HCPro audioconference. Licensee may make copies of these materials for your internal use by attendees of the audioconference only. All such copies must bear this legend. Dissemination of any information in these materials or the
audioconference to any party other than the Licensee or its employees is strictly prohibited.
Advice given is general, and attendees and readers of the materials should consult professional counsel for
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Accreditation of Healthcare Organizations, which owns the JCAHO trademark.
For more information, contact
HCPro, Inc.
200 Hoods Lane
P.O. Box 1168
Marblehead, MA 01945
Phone: 800/650-6787
Fax: 781/639-0179
E-mail: [email protected]
Web site: www.hcpro.com
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
iii
200 Hoods Lane
P.O. Box 1168
Marblehead, MA 01945
Tel: 800/650-6787
Fax: 800/639-8511
Dear colleague,
Thank you for participating in our “Modifiers -52, -73, and -74: Ensure
proper coding at the point of care” audioconference with Lolita M.
Jones, RHIA, CCS, and Susan Garrison, CPC, CHC, CPC-H, CCS-P,
CPAR, moderated by Lisa Eramo. We are excited about the opportunity
to interact with you directly and encourage you to take advantage of the
opportunity to ask our experts your questions during the audioconference.
If you would like to submit a question before the audioconference, please
send it to [email protected] and provide the program date in the subject
line. We cannot guarantee your question will be answered during the program, but we will do our best to take a good cross-section of questions.
If at any time you have comments, suggestions, or ideas about how we
might improve our audioconferences, or if you have any questions about
the audioconference itself, please do not hesitate to contact me. And if you
would like any additional information about other products and services,
please contact our Customer Service Department at 800/650-6787.
Along with these audioconference materials, we have enclosed a fax evaluation. We value your opinion. After the audioconference, please take a
minute to complete the evaluation to let us know what you think.
Thanks again for working with us.
Best regards,
Wendy Walsh
Audioconference associate
Fax: 781/639-7857
E-mail: [email protected]
iv
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
Contents
Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Presentation by Lolita M. Jones, RHIA, CCS, and Susan Garrison, CPC, CHC, CPC-H,
CCS-P, CPAR
Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Collection of Articles from Briefings on APCs
Source: Brian Murphy, HCPro.
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
v
Agenda
I.
Previous/former guidelines for reporting the modifiers
II. Current official guidelines—the changes and what they mean
III. OPPS 2006 issues—what to expect
IV. Review of GI endoscopy
A. Guidelines
B. Operational issues
C. Case studies
V. Interventional radiology
A. Guidelines
B. Operational issues
C. Case studies
VI. Summary
A. Data mining
B. Reporting
Live Q&A
vi
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
Speaker profiles
Lolita M. Jones, RHIA, CCS
Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services and vice president of
educational programs for Medical Marketing Resources, Inc., in Fort Washington, MD. She is the author of
two editions of HCPro’s The Modifier Clinic: A Guide to Hospital Outpatient Challenges and has authored a
column about appropriate modifier use for the monthly newsletter Briefings on APCs for the past five years.
She has over 15 years of experience in publishing, training, and auditing for the hospital outpatient and freestanding ambulatory surgery center markets.
Susan Garrison, CPC, CHC, CPC-H, CCS-P, CPAR
Susan Garrison, CPC, CHC, CPC-H, CCS-P, CPAR, is vice president of healthcare consulting services at
Magnus Confidential. She has more than 25 years of experience in healthcare management, including in the
areas of documentation, coding, billing, and reimbursement for both outpatient hospital and physician services. She was previously responsible for 3M Consulting’s Outpatient Coding Validation and Education
Services. She has conducted hundreds of engagements at hospitals across the country to improve hospital
and physician compliance and reimbursement.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
vii
Exhibit A
Presentation by Lolita M. Jones, RHIA, CCS, and Susan Garrison, CPC, CHC, CPC-H, CCS-P, CPAR
EXHIBIT A
Modifiers -52, -73, and -74:
Ensure proper coding at
the point of care
Audioconference
February 2, 2006
Lolita M. Jones, RHIA, CCS
Lolita M. Jones Consulting Service
Susan Garrison, CPC, CHC, CPC-H, CCS-P, CPAR
Vice President of Healthcare Consulting Services
Magnus Confidential, Inc.
2
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
Previous Guidelines for Reporting
the Discontinued Modifiers
Prior to February 22, 2005: Modifier -52 is used in those situations in which modifier -73 or
modifier -74 would have been appropriate, but since the use of anesthesia was not an inherent
part of performing the procedure, modifier -52 is used to show that the procedure was
discontinued. Per the April 7, 2000, Federal Register: use Modifier -52 (reduced services) to
indicate that a procedure did not require anesthesia, but the procedure was terminated after the
patient had been prepared for the procedure, received sedation and was taken to the room where
the procedure was to be performed.
Use the code that explains the extent of the procedure. If no code exists for what was performed,
report the intended code with modifier -52.
Examples: if a barium swallow is not complete because the patient can’t handle the barium,
assign CPT code 74270-52. If only one view of a chest x-ray is performed, do not report 7102052 (for x-ray, two views—reduced service), report 71010 (x-ray chest, single view)
Source: Medicare Program Memorandum Intermediaries, Transmittal No. A-99-41, September
1999, www.hcfa.gov/pubforms/transmit/A994160.htm.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
3
EXHIBIT A
Current Official Guidelines:
The changes and what they mean
Even though all modifiers are tricky, modifiers 52, 73, and 74 are particularly onerous simply
because the rules have been unclear and changing.
52 = Reduced/discontinued procedure w/o anesthesia
73 = Terminated procedure before necessary anesthesia
74 = Terminated procedure after necessary anesthesia
Fortunately, last year with Transmittal 442, Medicare clarified pieces of the puzzle for us. Let’s
begin there. You may download this transmittal from:
http://www.cms.hhs.gov/Transmittals/downloads/R442CP.pdf
The following outlines the major instructions from this transmittal.
•
•
•
•
•
“These modifiers (52, 73, 74) are used to report procedures that are discontinued by
the physician due to unforeseen circumstances.
Modifier -52 is used to indicate partial reduction or discontinuation of radiology
procedures and other services that do not require anesthesia.”
“For surgeries and certain diagnostic procedures requiring anesthesia (including
colonoscopies), the hospital may receive 50 percent of the OPPS payment amount for
cases in which the procedure is discontinued after the beneficiary was prepared for the
procedure and taken to the room where the procedure was to be performed.”
“If the procedure is discontinued after the beneficiary has received anesthesia or after
the procedure was started (e.g., scope inserted,
intubation started, incision made) the hospital may receive the full OPPS payment
amount for the discontinued procedure.”
“For purposes of billing for services furnished in the hospital outpatient department,
anesthesia is defined to include:
o local,
o regional block(s),
o moderate sedation/analgesia (“conscious sedation”),
o deep sedation/analgesia, and
o general anesthesia.
Modifier -73 is used by the facility to indicate that a surgical or diagnostic procedure requiring
anesthesia was terminated due to extenuating circumstances or to circumstances that threatened
the well being of the patient after the patient had been prepared for the procedure (including
procedural pre-medication when provided), and been taken to the room where the procedure was
to be performed, but prior to administration of anesthesia.
For purposes of billing for services furnished in the hospital outpatient department, anesthesia is
defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”),
4
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs
incurred by the hospital to prepare the patient for the procedure and the resources expended in
the procedure room and recovery room (if needed) could be recognized for payment even though
the procedure was discontinued.
Modifier -74 is used by the facility to indicate that a surgical or diagnostic procedure requiring
anesthesia was terminated after the induction of anesthesia or after the procedure was started
(e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or
circumstances that threatened the well being of the patient.
Termination Where Multiple Procedures Planned
1.
2.
3.
4.
When one or more of the procedures planned is completed, the completed
procedures are reported as usual.
The other(s) that were planned, and not started, are not reported.
When none of the procedures that were planned are completed, and the patient has
been prepared and taken to the procedure room, the first procedure that was
planned, but not completed is reported with modifier -73. If the first procedure has
been started (scope inserted, intubation started, incision made, etc.) and/or the
patient has received anesthesia, modifier -74 is used. The other procedures are not
reported.
If the first procedure is terminated prior to the induction of anesthesia and before the
patient is wheeled into the procedure room, the procedure should not be reported.
The patient has to be taken to the room where the procedure is to be performed in order to
report modifier -73 or -74.”
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
5
EXHIBIT A
OPPS 2006 Issues:
What payment changes to expect
Since implementation of the OPPS in 2000, CMS has required hospitals to report modifiers -52, 73, and -74 to indicate procedures that were terminated before their completion.
Before 2006, hospitals were paid 50 percent of the APC payment for services with modifier -73
appended and 100 percent for procedures with modifier -52 or -74 reported,
The pre-2006 OPPS policy required providers to use modifier -52 to indicate that a service that
did not require anesthesia was partially reduced or discontinued at the physician's discretion. The
physician may discontinue or cancel a procedure that is not completed in its entirety due to a
number of circumstances, such as adverse patient reaction or medical judgment that completion
of the full study is unnecessary. The modifier is reported most often to identify interrupted or
reduced radiological and imaging procedures, and CMS’ pre-2006 policy was to make full
payment for procedures with a -52 modifier.
Compared to surgical procedures that require anesthesia, a number of general and procedurespecific supplies, and reserved procedure rooms that must be cleaned and prepared prior to
performance of each specific procedure, the costs to the hospital outpatient department for the
rooms and supplies typically associated with procedures not requiring anesthesia are much more
limited. For example, the scheduling maintained for radiological services not requiring anesthesia
generally exhibits greater flexibility than that for surgical procedures, and the procedure rooms
are used for many unscheduled services that are fit in, when possible, between those that are
scheduled. Consequently, CMS believes that the loss of revenue that may result from a surgical
procedure being
discontinued prior to its initiation in the procedure room is usually more substantial than that lost
as the result of a discontinued service not requiring anesthesia, such as a radiology procedure.
6
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
CMS has examined their data and given careful consideration to the public comments and the
APC Panel's discussion and recommendations regarding OPPS payment policies for interrupted
procedures. Given the nature of the procedures that were likely reported appropriately with the 52 modifier in CY 2004, CMS continues to believe that there are considerable savings associated
with their incomplete performance. CMS thinks that in the hospital outpatient setting, there are
generally many opportunities to utilize the rooms and equipment that would otherwise be left
unused as a result of discontinued procedures. CMS also believes that, although there may be
occasional instances in which a discontinued procedure appropriately reported with the -52
modifier consumes more resources than one that is completed without interruption, those are
unusual events and the vast majority of discontinued cases are significantly less costly than
completed procedures.
Therefore, CMS finalized their proposed policy to apply a 50 percent reduction to the APC
payments for interrupted procedures reported with the -52 modifier in CY 2006 (effective
January 1, 2006).
CMS will provide billing guidance for CY 2006 regarding modifiers -52, -73, and -74 to offer
hospitals additional instructions regarding the appropriate use of the three modifiers in the OPPS.
CMS’ goal is to assure that hospitals understand and report these modifiers correctly so that they
receive appropriate payments for the services they provide.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
7
EXHIBIT A
Review of GI Endoscopy
GUIDELINES
Esophagoscopy is limited to study of the esophagus. When the endoscope passes the
diaphragm, the procedure is esophagogastroscopy. When the pyloric channel is traversed, it
becomes an esophagogastroduodenoscopy.
The collection of specimens is now included in the parent code for all GI endoscopic procedures
and these are also all separate procedures.
Proctosigmoidoscopy is the examination of the rectum and sigmoid colon. Sigmoidoscopy is the
examination of the entire rectum, sigmoid colon and may include examination of a portion of the
descending colon. Colonoscopy is the examination of the entire colon, from the rectum to the
cecum, and may include the examination of the terminal ileum.
If the same therapeutic endoscopy is repeated (e.g. polyp removal) in the s
same area described by the CPT narrative, only one CPT code is reported with one unit of
service.
8
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
When endoscopic esophageal dilation is performed, the appropriate endoscopic esophageal
dilation code is to be reported.
Do not code 43450-43458 (dilation of esophagus) in addition (even if an unsuccessful
attempt prior to endoscopic dilation).
Only the most extensive endoscopic procedure is reported for a session.
For example if a sigmoidoscopy is completed and the physician performs a colonoscopy
during the same session only the colonoscopy, is coded.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
9
EXHIBIT A
OPERATIONAL ISSUES
Some considerations for Operational Issues for GI Services:
1.
Sometimes hospitals have GI codes built into the CDM and sometimes HIM codes
these cases. So, step 1 is understanding who is responsible for driving the coding.
Who makes the decision for which modifier? (charge entry, HIM, billing, built into
CDM, other?)
2.
What is that individual’s level of training around coding?
Little-to-none
10
Trained Thoroughly
3.
What is the process of entering the modifier – how clean is it? Is it reviewed prior to
dropping the bill? After dropping the bill? During random audits?
4.
What follow-up monitoring is provided to ensure the modifier is used when necessary
and not used when inappropriate?
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
CASE STUDIES
Quick exercise:
1. Patient has a planned colonoscopy with conscious sedation. When vitals are taken preprocedure, patient decides against procedure.
52___ 73___ 74___ None___
2. Patient has a planned colonoscopy with conscious sedation. Due to poor prep, the scope does
not advance beyond the sigmoid region.
52___ 73___ 74___ None___
3. CPT 82270 is for Occult Blood; feces, 1-3 determinations. If only one is performed, do I need
a modifier?
52___ 73___ 74___ None___
4. Nerve conduction studies were performed, but no measurable values were able to be
obtained?
52___ 73___ 74___ None___
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
11
EXHIBIT A
CASE 1
(paraphrased from CPT Assistant):
An upper gastrointestinal endoscopy was intended to be performed. Although attempted, the
physician could not complete the entire procedure due to obstruction at the distal esophagus.
Rationale: In this instance, for non-Medicare reporting, CPT code 43235 (EGD) with the modifier
52 appended indicates that the intended procedure was reduced.
However, CMS does not allow the use of the modifier 52 when the endoscopic procedure is
"incomplete," and there is a code to describe the actual service performed. CMS requires the
reporting of a code describing only the anatomy examined at that endoscopic procedure.
Therefore, if a code is available that fully describes the hospital outpatient procedure performed,
this code choice supersedes the reporting of a code describing the intended procedure.
Example (CMS requirement): An upper gastrointestinal endoscopy was intended to be
performed. Although attempted, the physician could not complete the entire procedure due to
obstruction at the distal esophagus.
Rationale: In this instance, for Medicare reporting, CPT code 43200, Esophagoscopy describes
the procedure performed.
12
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
CASE 2
(paraphrased from CPT Assistant):
A 70-year-old male patient is brought to the OR for repair of a recurrent inguinal hernia. Surgical
prep has occurred, but prior to the administration of general anesthesia, the patient complains of
radiating chest pain and the cardiac monitor reflecting S-T segment changes. Due to the
possibility of an evolving cardiac event, the procedure is cancelled.
Rationale: Under these circumstances, the intended service that was prepared for, but cancelled,
can be reported with its usual procedure code and modifier '73' appended (CPT 49520-73).
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
13
EXHIBIT A
CASE 3
(paraphrased from CPT Assistant):
The plan is for a laparoscopic cholecystectomy on a 66-year-old female patient. After anesthesia
is administered, the anesthesiologist detects ventricular fibrillation on the cardiac monitor.
Ventilation continues while defibrillator pads and paddles are brought into the surgical field. Upon
the second defibrillation effort, the arrhythmia abates, but ventricular irritability is present. The
procedure is cancelled pending further cardiac stabilization.
Rationale: Under these circumstances, the procedure started but was terminated. This can be
reported with its usual procedure code number with the modifier '74' appended (CPT 47562-74).
14
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
CASE 4
COLONOSCOPY REPORT
PROCEDURE: Colonoscopy with hot biopsy destruction of sessile 3 mm mid sigmoid colon polyp
and multiple cold biopsies taken randomly throughout the colon.
PREOPERATIVE DIAGNOSIS: Fecal incontinence. Diarrhea. Constipation.
BOWEL PREPARATION: The bowel preparation with GoLytely was good.
ANESTHETIC: Demerol 50 mg and Versed 3 mg both given intravenously.
PROCEDURE DESCRIPTION: The digital examination revealed no masses. The pediatric
variable flexion Olympus colonoscope was introduced into the rectum and attempted
advancement to the cecum. However, due to poor prep, we were only able to reach the
sigmoid colon. The scope was then carefully extubated. The mucosa looked normal. Random
biopsies were taken from the sigmoid colon and rectum. There was a 3 mm sessile polyp in the
mid sigmoid colon which was destroyed by hot biopsy.
IMPRESSION: Sigmoid colon polyp destroyed by hot biopsy.
RECOMMENDATION: I have asked the patient to call my office in a week to get the results of the
pathology. Cold biopsies taken because of history of diarrhea.
52___ 73___ 74___ Other___
None___
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
15
EXHIBIT A
CASE 5
Preoperative Diagnosis: Failed PEG tube.
Postoperative Diagnosis: Same.
Procedure: Endoscopically guided replacement of gastrostomy tube with removal of previous
failed PEG
Procedure: The patient was brought to the endoscopy suite, placed on the endoscopy table in the
left lateral decubitus position. After adequate IV sedation the flexible end viewing gastroscope
was introduced under direct visualization into the stomach which was insufflated. A polypectomy
snare was placed about the rubber bolster which was visualized at the failed gastrostomy tube
and snaring it and grasping it in this fashion. Outside the abdominal wall, the tube was cut,
residual stump of the tube with the rubber bolster was brought up next to the scope and the
scope and it removed in total. As we removed the tube, the patient’s blood pressure began
to fall and we decided to stop the procedure and stabilize the patient.
The patient, once able, will be brought back into the OR for the tube placement.
Next day, a Foley type gastrostomy tube was placed through the existing gastrostomy tract with
a 20 cc balloon of saline used to fill it and the balloon then snugged to the anterior wall of the
stomach. The patient tolerated the procedure well without difficulty and after brief period of for
reaction was taken to the floor to be evaluated and transferred to the nursing home when alert
and stable.
52___ 73___ 74___ Other___
16
None___
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
CASE 6
Postop Dx:
Gangrenous cholecystitis
Procedure:
Laparoscopic converted to open cholecystectomy
After explaining the risks and benefits of the procedure to the patient, including but not limited to
bleeding, infection, conversion to open operation, all questions were answered and informed
consent was obtained.
The patient was brought to the operating room after voiding in the holding area. He was placed
in the supine position and under general anesthesia.
A nasogastric tube, thigh high TED hose, and Thromboguards were placed. He had received IV
antibiotics preoperatively. The abdomen was prepped and draped in a sterile fashion. An
infraumbilical incision was made using a scalpel and taken down through subcutaneous tissues.
The fascia was grasped using kocher clamps and divided transversely.
A hasson cannula was inserted intraperitoneally and secured using 0 vicryl ties. The camera was
placed intraperitoneally and a pneumoperitoneum using CO2 insufflation. After sufficient
abdominal distention, a transverse subxiphoid incision was made using scalpel and taken down
through subcutaneous tissues. A 10mm disposable trocar was inserted under direct visualization
without difficulty. Two right upper quadrant 5mm incisions and nondisposable trocars were
inserted under visualization without difficulty. The gallbladder was tense with fluid and it was
unable to be grasped. It was decompressed using a needle which aspirated green foul smelling
bile. This allowed the gallbladder to be grasped and then was retracted cephalad over the liver.
There were numerous omental adhesions to the anterior surface that appeared to be fairly acute
in nature. These were taken down bluntly. The gallbladder was entered during this blunt
dissection. It was grasped at this point but all subsequent fluid was aspirated clean. Further
dissection failed to identify sufficiently the gallbladder neck.
Because of the amount of inflammation and the obvious gangrene of the gallbladder,
conversion to an open cholecystectomy was necessary. The anterior fascia was divided and
the rectus muscle was divided. The posterior fascia was divided after placing a finger
intraperitoneally through a previous port. The iron intern retractor was placed. Blood and irrigant
fluid was aspirated until the field was clear.
The gallbladder was taken down retrograde using electrocautery. After taking the anterior most
peritoneal attachments, the remainder of the gallbladder lifted easily off the liver bed. The liver
was retracted cephalad. The cystic artery was identified and encircled. It was doubly clipped then
transected. Further dissection with a Kitner and right angle was identified with cystic duct coming
the common duct. It was ligated just distal to the junction. The cystic duct was then transected
and the gallbladder removed.
The operative field was then copiously irrigated using saline then aspirated dry. Hemostasis was
checked and achieved. There was a small amount of ooze from the liver bed over which was
placed a piece of surgicel. The operative field was drained using a 19 French Blake drain brought
out through a separate stab incision and secured to the skin using 2-0 silk suture. The fascia of
the subxiphoid and infraumbilical sites was reapproximated using 0 vicryl suture in figure of eight
stitches. The posterior fascia of the right upper quadrant incision was then reapproximated using
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
17
EXHIBIT A
#1 vicryl suture in interrupted figure of eight stitches. This layer was copiously irrigated using
saline then infiltrated using .25% marcaine for postop analgesia. The anterior layer was then
reapproximated using #1 double stranded PDS suture in a running stitch started at either end and
tied in the middle. This subcutaneous tissues were copiously irrigated using saline and skin of all
incisions closed using surgical clips. The wound was then cleaned, dried, then sterile dressing
applied.
The patient tolerated the procedure well and there were no immediate complications. Sponge,
needle and instrument counts were correct x2.
Specimens:
Gallbladder
52___ 73___ 74___ Other___
18
None___
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EXHIBIT A
Interventional
Radiology—Discontinued procedures
GUIDELINES
Modifier -52 Effective 2/22/05: Use modifier -52 to indicate partial reduction or discontinuation of
radiology procedures and other services that do not require anesthesia. For purposes of billing for
services furnished in the hospital outpatient department, anesthesia is defined to include local,
regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia,
and general
anesthesia.
Although the new CMS policy states that modifier -52 should be used for the
discontinuation of radiology procedures that do not require anesthesia, there are
interventional radiology procedures that may in fact involve the use of anesthesia. When
discontinued, these interventional radiology procedures that require anesthesia, would be
reported using the modifier -73 or -74 as appropriate.
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19
EXHIBIT A
Multiple Procedures Scheduled - One or More Discontinued:
Report completed procedures as usual when one or more of the planned procedures are
completed. Do not report the other(s) that were planned, and not started. If the first procedure
has been started (scope inserted, intubation started, incision made, etc.) and/or the patient
has received anesthesia, use modifier -74. The other procedures are not reported.
Do not report the procedure if the first procedure is terminated prior to the induction of
anesthesia and before the patient is wheeled into the procedure room. The patient has to be
taken to the room where the procedure is to be performed in order to report modifier -73 or 74.
Source: Medicare Program Memorandum Intermediaries, Transmittal No. A-99September 1999, www.hcfa.gov/pubforms/transmit/A994160.htm .
20
41,
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EXHIBIT A
OPERATIONAL ISSUES
If it is your hospital’s policy to enter into the radiology information system the reason or “reason
code” for a reduced/discontinued procedure, you should do one of the following:
•
Develop a policy and procedure that requires the radiology staff to print the radiology
information system computer screen that contains the text regarding the reason or
“reason code” whenever there is a reduced/discontinued procedure.
•
Develop and carry out internal policies and procedures that specify the level of
documentation needed for reduced/discontinued procedures. This is particularly
important for departments such as radiology and interventional radiology, where the
physicians traditionally have not written or dictated a note when a procedure is
reduced/discontinued (after the patient is taken to the room where the procedure is
scheduled to be performed).
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21
EXHIBIT A
CASE STUDIES
CASE 1
CARDIAC CATH
92980-52-RC,93510,93545,93556
INDICATIONS FOR PROCEDURE:
Mr. Smith is a 75 year old gentleman with history of pulmonary hypertension, coronary artery
disease underwent catheterization in the fall of 2004. At that time he had a high grade greater
than 95% ostial right coronary artery lesion with calcification. There was a moderate 50% ostial
left main lesion. The LAD and circumflex had noncritical disease. He had prior to this, a positive
nuclear study with inferior wall reversible schema. His ejection fraction was at the low limits of
normal. He has had crescendo angina pectoris and was a very poor operative candidate.
Therefore, PTCA of the ostial right coronary artery was recommended for symptomatic therapy.
Indeed this would be a difficult case with the ostial and accentric opening of the vessel and his
history of renal insufficiency. Risks and benefits were understood, potential complications were
understood prior to the procedure and discussed with the family. He does have renal
insufficiency and dye conservation would clearly play into discussions in the cath lab.
PROCEDURE PERFORMED:
Left heart catheterization with coronary arteriography, attempted PTCA of the right coronary
artery.
SITE:
Right femoral artery.
CATHETERS USED:
8 French AR-1, 0.014 BMW wire, 0.014 choice BT wire.
ANESTHESIA:
1% Lidocaine.
DESCRIPTION OF OPERATIVE TECHNIQUE:
Please refer to cath course flow sheet on chart.
TOTAL FLUOROSCOPY TIME:
55.3 minutes. This was prolonged due to marked difficulty in crossing the lesion, the ostial lesion
and attempts at dye conservation.
TOTAL CONTRAST:
150 mL of Omnipaque.
RESULTS:
HEMODYNAMICS:
Central aortic pressure was 124/ 63.
SELECTIVE CORONARY ARTERIOGRAPHY REVEALED THE FOLLOWING:
22
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EXHIBIT A
The right coronary artery is a moderate size dominant vessel which has a calcified, 98% proximal
lesion. There was a posterior takeoff of this vessel. There was an AV nodal artery that arose
from the proximal portion of the right coronary artery out of the calcified ostium.
ATTEMPTED PTCA/STENT: The 98% lesion was not able to be crossed with the BMW
wire. This was stressed with the soft portion of a Choice PT wire on two occasions. Both
occasions unable to advance the transition of the wire into the proximal portion of the vessel. The
proximal portion of the vessel had an acute angle at the takeoff as well as a lateral angle out of
place. There was significant tortuosity in the proximal portion of this vessel along with the highgrade calcified lesion. There was lack of guide support due to the ostial nature of this
lesion and at this point 150 mL of contrast was used and the procedure was aborted.
There was no change in the vessel.
The patient tolerated the procedure well without complications.
COMPLICATIONS:
None.
CONCLUSION:
Unsuccessful attempted PTCA of the right coronary artery.
RECOMMENDATIONS:
1.
Continue medical therapy.
2.
Follow renal function.
3.
Possibly reconsider surgical evaluation if refractory symptoms.
Thank you for referring this interesting patient.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
23
EXHIBIT A
CASE 2
CARDIAC CATH
35471-52,93510,93545,93556,75724,G0275
INDICATIONS FOR PROCEDURE:
Mr. is a 73-year old gentleman with history of hypertensive cerebrovascular disease, risk factors
for coronary artery disease, hypertension with lability and chronic renal insufficiency, a creatinine
in the range of 2.9. He had a renal angiogram which showed right renal artery stenosis with
95% stenosis at the origin of the right renal artery. A left pelvic kidney with an arterial supply
off a branch of the inferior mesenteric artery without evidence of significant stenosis. Cardiac
catheterization is therefore recommended for diagnosis, prognosis and in consideration for
revascularization. Renal PTCA/ stent if anatomy is found compelling.
PROCEDURE PERFORMED:
1.
Left heart catheterization.
2.
Coronary arteriography.
3.
Selective renal angiogram.
4.
Inferior mesenteric angiogram.
5.
Abdominal aortogram.
SITE:
Right femoral artery.
CATHETERS USED:
8 French pigtail, JL -4, JR-4, 6 French internal mammary artery catheter.
ANESTHESIA:
1% lidocaine.
DESCRIPTION OF OPERATION TECHNIQUE:
Please refer to cathcor flow sheet on chart.
TOTAL FLUOROSCOPY TIME:
25.4 minutes. Arterial time was 48 minutes.
TOTAL CONTRAST:
117 cc of Omnipaque.
RESULTS:
HEMODYNAMICS:
Central aortic pressure was 156/77 with a mean of 107. Renal angiogram of the right renal
artery, the right kidney had a dual supple. The upper vessel had a 10% ostial irregularity. The
lower supple had a subtotal occlusion at its origin. This was in an area of aneurysmal dilatation of
the central aorta. The left renal artery arose from the interior mesenteric artery and was
visualized by MRA. Abdominal angiogram confirmed above with moderate diffusely aortic
disease. Selective coronary arteriography revealed the following. The left main coronary artery
was had a 20% distal lesion with an area of ulceration. The left anterior descending artery had a
50% mid lesion. There was diffuse disease in the distal vessel. Diagonal #1 had a 30-50%
24
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EXHIBIT A
proximal lesion. The circumflex had a 50-70% proximal lesion and gave rise to a moderate size
obtuse marginal branch. The right coronary artery had a 50-60% mid lesion with a dominant
vessel which gave rise to a posterior descending and posterolateral branch which was free of
significant disease.
COMPLICATIONS:
None.
SUMMARY:
1.
Moderate left main coronary artery disease.
2.
Three-vessel coronary artery disease.
3.
Preserved Left ventricular function by echocardiogram.
4.
Right renal artery stenosis.
5.
Chronic renal insufficiency.
6.
Attempted percutaneous transluminal coronary angioplasty of the right renal
artery was aborted due to 1. ______ contrast reaching 17 cc. At this time the
origin of the vessel was difficult to engage at this time we will hydrate and
follow renal function closely post catheterization. Would consider readmission
for attempt at percutaneous transluminal angioplasty/ stent of the right renal
artery when the renal fraction tests stabilize in approximately 4-5 weeks.
7.
Continue medical therapy risk factor reduction, aspirin and Plavix long term.
Thank you for referring this interesting patient.
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25
EXHIBIT A
CASE 3
OPERATIVE REPORT
64470-RT, 64472-RT, 64472-RT, 76005
PREOPERATIVE DIAGNOSIS: Thoracic facet artheropathy
POSTOPERATIVE DIAGNOSIS:
OPERATION:
Same.
Right T3 through T6 thoracic facet median branch nerve block with fluoroscopic
localization.
ANESTHESIA: IV sedation.
BRIEF CLINICAL HISTORY:
The patient returns for the planned diagnostic facet nerve block. He reports greater symptoms on
the right mastoid. We discussed initially performing bilateral injections for the diagnostic value.
DISPOSITION:
I explained the risks, benefits, and expectations and a written consent was obtained.
OPERATIVE PROCEDURE:
The patient was brought to the operating room and placed in the prone position. Anesthesia and
monitoring were applied. An adequate scout view of the thoracic spine was observed. The
thoracic region was prepped and draped in the usual sterile fashion., 1% preservative free
lidocaine was used for local throughout using a 22-gauge spinal needle for the procedure. The
area of pain in the thoracic region was localized with fluoroscopy from T3 through T6. On the
right side, the needle was advanced with a 3 cc syringe of lidocaine attached. It is placed in the
medial aspect of the T3, where the median branch lies. It was then advanced to T4, T5 and
T6. At each level, 1.5 cc of 0.5% bupivacaine was injected using 20 mg of Depo-Medrol in
toto. Then, the plan was to perform similar treatment on left side, however, the patient had
a degree of emesis and began coughing. He also moved in such a way that it could not hold
this position. Therefore, the procedure on the left was aborted. The patient was placed on a
stretcher and
brought to recovery room awake, alert and in good condition.
After a period of observation with stable vital signs, tolerating PO, ambulating without assistance,
and avoiding without difficulty, the patient was discharged. If this brings temporary benefits, then
we will establish the diagnosis. We will discuss results during his next visit.
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EXHIBIT A
CASE 4
INJECTION REPORT
62290-74
PROCEDURE: Attempted three-level lumbar discogram. However, the procedure was
aborted due to the patient begin vomiting once anesthesia was initiated. Therefore,
anesthesia was discontinued. Airway was protected and O2 was given, as the patient’s O2
sats went down to the 80s upon clearing of the airway and giving him oxygen, his sats came back
up to 98. At that time, his vital signs were stable, and he was transferred to the recovery room.
The patient will reschedule this lumbar discogram for a later date.
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27
EXHIBIT A
CASE 5
OPERATIVE REPORT
21660 or 61793-74
PREOPERATIVE DIAGNOSIS: Multiple brain metastases.
POST OPERATIVE DIAGNOSIS: Multiple brain metastases.
PROCEDURE: Aborted/attempted gamma knife radiosurgery for multiple brain
metastases.
INDICATIONS: This is the case of a 47-year-old lady on whom I had performed surgery
secondary to a
very large and highly symptomatic left frontal metastasis. At the time of her surgery, the patient
was found to have three other metastases. Keeping in mind that this was all she had, we decided
to present her at the gamma knife conference. At that time, she was approved for further
treatment.
For that reason, she was brought to the gamma knife suite.
DETAILS OF THE PROCEDURE: The patient came to the gamma knife suite where she
underwent the
placement of the Leksell stereotatic frame without complications. This was done via the
standard four-point fixation using local anesthetic. The patient tolerated the procedure well and
it was performed without problems.
However, upon performing her MRI we found out that the patient had blossomed into many other
metastases.
Upon discussing this with Dr. Thad, our radiation oncologist, it was decided that it would not be
in the
patient’s best interest to proceed with gamma knife radiosurgery and then implied radiating
will be the
way to go. For that reason, no gamma knife radiosurgery was given.
This was discussed with her husband. The frame was removed without complications and
the patient
discharged home. I have asked them to please come see me in a month with followup MRI
after they
complete the whole brain radiation to which the patient had preliminarily agreed.
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EXHIBIT A
CASE 6
MRI
70553
MRI OF THE BRAIN WITHOUT ANDWITH IV CONTRAST, GAMMA PROTOCOL-OPD
CLINICAL HISTORY:
Metastatical adenocarcinoma to the brain in a 47 year old woman
COMPARISON:
Outside examination from ___________ dated 9/16/05
TECHNIQUE:
The study is reviewed in multiplanar spin-echo sequences including sagittal contrast-enhanced
T1 and gradient echo axial contrast-enhanced, thin-section images
FINDINGS:
Using standard gamma protocols, there are eight lesions identified within the brain including a
large mass in the right brainstem extending from superior through inferior pons, a mass between
the lateral ventricles and their mid-body, and a mass at or adjacent to the wall of third ventricle on
the left.
All contrast-enhancing neoplastic lesions are incorporated on gradient echo contrast-enhanced
axial sequences, extending roughly from image 33 through image 163 and are separately
detailed in conference with the Gamma Radiotherapy Personnel.
IMPRESSION:
Gamma protocol MR of the brain for localization of metastatic lesions.
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29
EXHIBIT A
CASE 7
OPERATIVE REPORT
62268-74, 76003
Anesthesia:
Total intravenous anesthesia/local infiltration.
Procedure:
1.
Attempted facet injection with drainage of synovial cyst, right L4-L5.
2.
Fluoroscopic needle placement/guidance, right L4-L5 facet.
Diagnoses:
1.
Evidence of synovial cyst, right L4-L5, causing pressure and pain following the right
L4 and L5 distribution.
2.
Acute/chronic abdominal pain with history of severe abdominal adhesions, states
post lysis of adhesions times eight.
3.
Chronic back and lower extremity pain in association with evidence of diffusion
degenerative disc disease.
4.
Evidence of pancreatitis with secondary history of diffuse abdominal pain and scar
formation, improved sinus implantation of a drug delivery system, March 1999.
5.
Depressive disorder associated with panic attacks and an anxiety response.
6.
Status post basilar skull fracture, 2001.
7.
Status post implantation of a drug delivery system in March 1995, revised in July
2004.
INDICATIONS: The patient has been seen previously when drainage of the synovial cyst was
completed by
in the Radiology Department, under CT guidance. Recently the patient
has had a re-exacerbation of her discomfort and we planned today to drain the cyst and
replace this fluid with a steroid. We discussed the risks versus the benefits as the details of
the procedure. The patient understood and wished to proceed.
PROCEDURE: The patient was seen preoperatively where informed consent was given. She
was then taken to the fluoroscopy room and placed in the prone position. Throughout the
procedure, the patient as monitored with the use of a Dinamap and a pulse oximeter and was
given oxygen by nasal cannula.
The area over the right L4-L5 level was noted and marked as such. With the use of
fluoroscopic guidance, the widest aperture of the facet joint to the right of the midline and in an
oblique positioning of the fluoroscopic beam at approximately 30 to 45 degrees. It was noted
that there was significant evidence of sclerosis of the facet joint. This area was marked as such,
utilizing fluoroscopic guidance.
The area over the right flank was prepped and draped in the usual sterile fashion, using Betadine
solution. At this juncture, in order to make the patient as comfortable as possible in a rather
awkward, uncomfortable prone position, I felt it medically necessary to sedate the patient. The
patient was substantially sedated with incremental doses of 100 milligrams of propofol.
After appropriate sedation, a total of 3 ml of 1.5% lidocaine with epinephrine solution was
injection subcutaneously into the deep subcutaneous tissue of the target site. After appropriate
analgesia and sedation, a #22 gauge 5 inch Chiba needle utilized in an attempt to enter the
30
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EXHIBIT A
facet joint, in multiple locations, and multiple angles. We were unable to penetrate the
facet joint and the procedure was then abandoned. The needles were removed and a sterile
dressing was placed over the angle site.
The patient was awakened from her light anesthesia and returned to the Recovery Room in
satisfactory condition. She tolerated the procedure well without complications.
PLAN: We will be seeing the patient in the near future in our office. We will write the patient a
prescription for lyrica today, utilizing 75 mg one tablet every twelve hours for the first week and
two tablets every twelve hours for the second week.
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31
EXHIBIT A
CASE 8
OPERATIVE REPORT
33208-74
(Can’t use 33225-74 because this is an add-on code)
INDICATIONS FOR PROCEDURE:
Mrs.
is a middle-aged lady with an ischemic cardiomyopathy bypass grafting and a
pacemaker that I placed over on the right side a number of years ago because of sick sinus
syndrome. She now is being paced with left bundle branch block and left ventricular dysynchrony
and class III stable systolic congestive heart failure.
She had initially undergone an attempt at upgrade to biventricular device from the right
subclavian vein which is the site of her earlier lead implant but unfortunately the right subclavian
vein could not be cannulated.
She comes back for a whole new system on the left side.
PROCEDURE PERFORMD:
1. Attempted placement of a left ventricular lead
2. Attempted placement of a dual chamber pacemaker
3. Coronary sinus venogram
DESCRIPTION OF OPERATIVE TECHNIQUE:
The patient was brought to the electrophysiology laboratory in the fasting resting state. She
underwent infusion of vancomycin. The left chest was prepped and draped sterilely. 1% lidocaine
was used as local anesthetic. A 2-inch incision was made in the left pectoral region and carried
down to pectoralis fascia using electrocautery. The pocket was made over the pectoralis fascia
using blunt and shard dissection.
The left axillary vein was cannulated via two separate needle sticks using an 18 gauge thin-wall
needle and the J-wired advanced to the level of the inferior vena cava. Over one of the J-wires a
7-French sheath was placed, double wired and then advanced over one of the wires. Via this
sheath, a Medtronic model #5076 lead was advanced, prolapsed across the tricuspid valve
and advanced to the high right ventricular septum where it was affixed under fluoroscopic
guidance.
Over the separate needle stick wire, a 10.5 French sheath was introduced into the axillary vein.
Next a Medtronic Attain multipurpose catheter was then advanced over an 0.025 J-wire.
Initial attempts to cannulate the coronary sinus were unsuccessful with the multipurpose
Attain sheath and an 0.025 J-wire.
I then switched to a multipurpose inner guide catheter which was a 6= French coronary catheter
and with this I still could not cannulate the vein using a wire. I then switched to an AL-2 , AL-3
and a right Judkins #4 coronary catheters and even with these end dye I could not cannulate the
vein.
I then switched back to a multipurpose coronary catheter and with a multipurpose guide sheath
going very posteriorly I was able to inject dye imaging the interatrial septum and finally I was able
to locate the os of the coronary sinus that was quite posterior and more superior than I had
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EXHIBIT A
originally thought. With dye injection immediately after the os, there was a very acute takeoff
posterior vein and also a very acute takeoff coronary sinus proper.
I then tried for the next hour to cannulate this vein using a multitude of inner guide catheters
including the previously mentioned coronary 6-French catheters, a Medtronic navigator
electrophysiology steerable radiofrequency ablation catheter and also a Medtronic steerable inner
lumen catheter. I also switched out and tried a straight Attain coronary guide sheath with a
variety of the aforementioned inner guide catheters.
The case time was approaching three hours and we were over eighty minutes of
fluoroscopy and I decided that I was going to be unable to cannulate the coronary sinus.
At that point the case was aborted with the J-wires, sheaths and previously placed 5076
lead being removed. Hemostasis was obtained, the pocket irrigated with vancomycin irrigation
solution, and then the pocket was closed in three layers using a 2-0 interrupted, 3-0 running and
a 4-0 mattress Dexon suture. Steri-Strips and a dry sterile dressing were applied.
CONCLUSION:
I conclude abnormal coronary sinus anatomy precluding successful cannulation of the
coronary sinus for placement of lead.
RECOMMENDATIONS:
I am going to go ahead to refer the patient to Dr. Armani for an epicardial LV lead. I have fully
explained this to the family.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
33
EXHIBIT A
CASE 9
INJECTION REPORT
0062T-74
Today’s Procedure (under light MAC sedation)
1. Attempted again bilateral extrapedicular intradiscal electrothermal annuloplasty at
L4-5. From both sides again, despite introducer needle being perfectly placed in center
portion of the disc by AP and lateral views, a thermal catheter could not be threaded
around adequately to the posterior annulus or safely within the posterior annular
wall to obtain the desired positioning across the mid posterior disc annulus. We had tried
this before on 10/26/05. The decision was made to retry it today before moving onto a
surgical decision. Knowing that on 10/26/05 we had not been able to accomplish the
catheter threading with multiple attempts, I limited the number of tries from each side
today in order to assess whether we could thread the catheter again and we could not.
2. Postprocedure intradiscal corticosteroid and antibiotic injection. I did not give any
local anesthetic. On the 10/26/05 procedure, I did not give local anesthetic and
corticosteroid, and the patient actually did have at least 20 to 30% pain relief for two
weeks and actually used half of her pain medicine compared to usual baseline and was
able to go out shopping, etc.
Diagnoses and Indications:
1. Lumbar discogenic pain
2. internal disc disruption and annular tears at L4-5 with positive discogram
Allergies and Anticoagulants: The patient is allergic to penicillin; therefore, she received Cleocin
today for her discitis prophylaxis and intradiscal postprocedure injection.
Pregnancy: Negative.
Procedure Note:
The patient was again cleared medically an by anesthesia for the light MAC sedation.
Consent was obtained and the procedure was discussed. In the fluoroscopy suite again, the
patient was sterilely prepped and draped and padded in the usual fashion in the prone position.
Fluoroscopy was utilized to identify the target position counting from the last rib as T12
down to the last number segment which is considered L5. There is a partial pseudoarthrosis
of the right L5 transverse process to the sacral ala. The L4-5 disc space was identified. I initially
approached from the right using the L5 superior articular facet process as the guide towards the
L4-5 central disc space making the end plates of L4 and L5 parallel for the approach to the disc.
The same technique was done on the left when we came from that side.
On each side separately, surface marks were made. Superficial local anesthetic was given. A
3.5 inch, 25-gauge spinal needle was advanced down to the SAP of the particular side being
approached with local anesthetic being given there and then all along the deep and intermediate
muscle needle tract. Then under fluoroscopic imaging, the introducer needle was threaded down
to the lateral margin of the SAP and then skiving just past it into the posterolateral annulus of the
L4-5 disc. It was kept close to the SAP lateral margin in order to avoid the course of the
traversing nerve root superolateral to this. With the posterior annulus engaged, the needle was
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EXHIBIT A
threaded through the introducer needle monitoring from AP and lateral views. Despite multiple
attempts on the right, the catheter could not be threaded around to the posterior annular
wall. It did make it to the left posterolateral corner, but I could not get it to turn that corner or stay
within the disc space as far as my judgement is concerned to make it to the posterior part of the
L4-L5 annulus centrally. After several attempts, this catheter was removed as was the introducer
needle. The exact same set of steps was done on the left side with the same fluoroscopic
guides and the local anesthetic infusions. A new catheter was used on the left and could
not be threaded from that side either. With some concern for kinking of the catheter
because of running into obstruction likely due to internal disc disruption, the catheter was
removed without a problem as was the introducer needle. Before removing the introducer
needle however, I used a combination of Decadron and Cleocin infused into the intradiscal
space. 1 mL of Decadron (10 mg/mL) combined with 2 mL (150 mg/mL) of Cleocin was
combined. 1.75 mL of this combination was infused in the intranuclear position. The further
1.25mL remaining was infused into the annulus and then out along the deep needle tract. The
rest of the needle tract intermediate and superficial muscles were infused with 4 mL of 0.05% PF
Marcaine without epinephrine for assistance in pain block.
The patient tolerated the procedure well and was aroused from her light sedation and transferred
herself back onto the cart. She will be brought to the recovery room. Once cleared there by
Anesthesia, she will be discharged to Same Day, and once stable there will be discharged home.
I will have the patient follow in the office. We will likely have to discuss with Dr. Stapler moving on
to a decision about surgery options, whether fusion or disc replacement given the inability despite
two bilateral attempts to avoid surgery and try to do a percutaneous decompression and annular
pain fiber cauterization.
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35
EXHIBIT A
Summary
DATA MINING AND REPORTING
How do hospitals struggle?
• Lack of automated edits in nonsurgery coding areas
• Lack of consistency in modifier application
• Documentation does not support modifier use
• Feedback not provided to generating department
• Misunderstanding of modifiers
STEP 1 – Ask yourself:
•
What is the problem?
o Modifier used—not needed
o Modifier omitted—needed
•
How do you know?
•
What/who caused the problem?
•
How to correct?
o TrainingProcess
o improvementInterface
o improvement
•
Train (documentation, charging, billing, coding)?
•
Feedback to generating department
STEP 2 – Data mining and reporting:
•
Keep it simple and easy to understand
•
Make it specific (claim, service)
•
Get a reporting tool to provide consistent data for analysis.
o Reports could be:
report on remittance data from your FI
top 10 cancelled scenarios in that department
top procedures where the modifiers were used
o Compare the same report(s) each time to avoid confusion and delay
STEP 3 - Make effective—not fast—changes:
36
•
You won’t resolve all problems immediately
•
Focus on priorities (risk/$) and drive expedient improvement here
•
Basics:
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EXHIBIT A
o
o
o
o
o
o
•
Generate reports
Determine what departments are generating cancelled procedures
Determine which codes are tied to those procedures
Errors should be taken back to generating department to be resolved correctly
and for education - Problems should be addressed at source
Departments should be held accountable to bring problems to resolution
Monitor reports to ensure that problems are fixed
Investigate:
o Inadequate chargemaster maintenance procedures
o Insufficient training and regulatory updates
o Lack of quality control audits
o Data entry issues
o Incomplete or incorrect documentation by care giver
o Revenue code/CPT mismatches
o Inappropriate use of modifiers
o Lack of coding references
o Incomplete coding policies
o Interface issues
STEP 4 – Solutions
•
Chargemaster review
•
Chargemaster update and maintenance procedures
•
Ancillary department education
•
Modifier implementation
•
Delineation of services that should be coded in the chargemaster versus in HIM
•
Charging forms/screens update
•
Coding education
•
Periodic audits
•
Process assessment
•
Chart audit/training
•
Ongoing communication
•
Staffing analysis
•
Charge protocol inadequacies
•
Good and consistent reporting is vital
•
A/R management needs strength!
•
1-stop coordination is helpful
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
37
EXHIBIT A
USA Hospital Center
Medicare OP with CPT Modifier -52, -73 or -74 and CPT Range 10000-99999
Period: 01/01/05-10/31/05
38
Acct No
5645535
5646289
5647859
5648115
5649050
5650206
5650413
5650931
CPT
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
5651154
5652967
5653116
5655207
5655215
5656540
5657144
5657354
5657942
5658118
5661633
5664784
5666352
5667987
5668379
91110
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
5669792
5671090
5673248
5674353
5676221
5676500
5677506
5678191
5682783
5684130
5686091
5686118
5686489
5690034
5691428
5693326
5695425
5695870
50590
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
CPT Desc
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
GI TRACT CAPSULE
ENDOSCOPY
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
FRAGMENTING OF KIDNEY
STONE
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
Discharge
Date
1/4/2005
1/8/2005
1/7/2005
1/11/2005
1/12/2005
1/14/2005
1/14/2005
1/13/2005
1/14/2005
5/5/2005
1/18/2005
1/24/2005
1/24/2005
1/25/2005
1/27/2005
1/28/2005
1/31/2005
1/28/2005
2/7/2005
2/11/2005
2/15/2005
2/17/2005
2/18/2005
2/22/2005
2/23/2005
3/1/2005
3/1/2005
3/7/2005
4/13/2005
3/7/2005
3/9/2005
3/17/2005
3/21/2005
3/24/2005
3/23/2005
5/10/2005
3/30/2005
5/19/2005
4/7/2005
5/23/2005
4/11/2005
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT A
5696958
5697571
5699216
5700183
5701310
5702645
5704576
5706406
5709112
5709639
5715699
5715912
5716037
5716055
5717283
5718772
5719467
5720395
5720535
5721162
5722458
5724504
5725146
5725288
5725621
5725941
5728670
5729623
5730642
5730918
5734704
5738125
5738287
5738482
5741282
5741410
5742655
5755599
5756462
5762717
5763004
5763066
5766422
5766991
5767101
5768297
45378
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
45378
7609252
7609252
7609252
7609252
45378
7609252
7609252
7609252
7609252
45378
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
7609252
45330
7609252
7609252
7609252
7609252
7609252
5780232
5802309
92961
43235
DIAGNOSTIC COLONOSCOPY
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
DIAGNOSTIC COLONOSCOPY
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
DIAGNOSTIC COLONOSCOPY
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
DIAGNOSTIC COLONOSCOPY
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
DIAGNOSTIC SIGMOIDOSCOPY
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
MAMMOGRAM, SCREENING
CARDIOVERSION, ELECTRIC,
INT
UPPR GI ENDOSCOPY,
DIAGNOSIS
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
4/15/2005
4/14/2005
4/15/2005
5/4/2005
4/25/2005
4/22/2005
4/27/2005
4/28/2005
6/24/2005
5/6/2005
5/18/2005
5/16/2005
5/17/2005
5/17/2005
5/19/2005
5/24/2005
7/21/2005
6/1/2005
5/27/2005
5/25/2005
5/27/2005
6/3/2005
6/6/2005
6/28/2005
7/27/2005
7/28/2005
8/4/2005
6/14/2005
7/29/2005
8/9/2005
6/24/2005
6/27/2005
7/1/2005
7/1/2005
7/7/2005
7/6/2005
7/6/2005
8/5/2005
8/3/2005
8/12/2005
8/16/2005
8/16/2005
8/25/2005
8/24/2005
8/25/2005
8/26/2005
9/14/2005
10/24/2005
39
EXHIBIT A
Snapshot Comparison Chart of the Modifiers
Pre-2006
As of 2006
40
Modifier -52
Modifier -73
Modifier -74
No discount
50%
No discount
50%
50%
No discount
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
Exhibit B
EXHIBIT B
Modifiers negate need for C codes with device-dependent procedures
from
Briefings on APCs
In this month’s Modifier Clinic, Lolita Jones, RHIA, CCS, of Lolita M. Jones Consulting in Fort
Washington, MD, discusses how modifiers negate the need for reporting a C code with a devicedependent procedure.
Per the OPPS 2005 final rule published in the November 15, 2004, Federal Register, for services
provided on or after January 1, 2005, CMS requires hospitals to report device category HCPCS C
codes on claims when providers use these devices in conjunction with procedures billed and paid
for under OPPS.
To ensure hospital compliance with these device coding requirements, CMS provides updated
lists of these codes on the agency’s Web site at www.cms.hhs.gov/providers/hopps/default.asp.
The current version is the October 2005 device code edits, which you can find near the bottom of
the Web page.
For example, per the October 2005 device code edits, if you report CPT code 63650
(Percutaneous implantation of neurostimulator electrode array, epidural), you must also report
device code C1778 (Lead, neurostimulator [implantable]).
Modifiers negate need
However, modifiers -73 (Discontinued service/procedure prior to anesthesia) and -74
(Discontinued service/procedure after anesthesia) allow providers to bypass these new edits,
since these modifiers signify an interrupted procedure.
“CMS recognizes that in those cases, the procedure might have been interrupted before the
device was implanted,” Jones says.
Below is a case study that includes a physician’s notes about a procedure for which a coder
reports a device-related CPT code with a modifier indicating a discontinued procedure.
Case study: Discontinued device-dependent procedure
Preoperative diagnosis: 1. Lipoprotein lipase (LPL) syndrome with radiculopathy; significant
epidural fibrosis and septi
Postoperative diagnosis: 1. LPL syndrome with radiculopathy; 2. Significant epidural fibrosis
and septi
Procedure: Attempted spinal cord stimulator lead placement at T12-L1 to T9 and at L5-S1 to T9
and to T12
Anesthesia: Local with IV sedation
Complications: None
Narrative of procedure: The patient was in the operating room status post epidurogram for
neural mapping at T12-L1 and L5-S1 (epidurogram report is on file). At T12-L1 level with the
needle in place, a Pisces-Quad™ electrode was placed through the needle and guided up
42
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT B
just to the right of midline at T9. When using multiple configurations with programming, the
patient could not feel any stimulation. The electrode was then pulled back and reguided in the
midline to the superior aspect of T9 and again the patient could not feel any sensation. The
catheter was then pulled back and guided up to the T8 right of midline. The patient could not feel
any sensation. The catheter was pulled back again and guided to a more lateral position at the T9
level and duplicated the exact configuration that was seen on the trial. The patient again could
not feel any sensation. The electrode was then trolled down all the way to L2 and the patient
could not feel any sensation.
At this point I elected to remove the needle and place it in again, this time at the L5-S1 level.
Again, using numerous configurations and multiple advancements and positions, I could not
cause any sensation in the patient’s right lower extremity or hip. After spending approximately
50 minutes attempting to manipulate the catheter and electrode to various positions and
programming, I could not get the patient to feel any sensation. Therefore, I elected to abort
the remainder of the procedure. No incision was made. The needles were removed. The
patient was discharged to the recovery room where I talked to him, his wife, and family.
Coding-modifier rationale
The correct code to report for this case study is 63650-74.
The physician attempted this patient’s procedure after administering a local anesthetic with
conscious sedation to the patient, therefore, modifier -74 is appropriate. The intended procedure
was the percutaneous implantation of an electrode, therefore code 63650 is appropriate.
The device code edit for code 63650—used by the Medicare fiscal intermediary—does not
require coders to report device code C1778 if the procedure is appended with modifier -74
(Discontinued outpatient procedure after anesthesia administration).
“However, the hospital will not be penalized if [it] reports C1778, since the electrode was in fact
utilized in this unsuccessful attempt to stimulate the patient,” Jones says.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
43
EXHIBIT B
New reporting guidelines for modifiers -52, -73, and -74
CMS now considers conscious sedation part of anesthesia
from
Briefings on APCs
CMS released on January 21, 2005 a major update that both clarifies and changes the reporting
of modifiers -52, -73, and -74. Most significantly, CMS now considers conscious sedation a part of
anesthesia and requires the reporting of these modifiers to reflect this new definition. The
changes took effect February 22, 2005.
Go to www.cms.hhs.gov/manuals/pm_trans/R442CP.pdf to read CMS Transmittal 442, “Use of
modifiers -52, -73, and -74 for reduced or discontinued services.”
“This is a major change,” says Lolita Jones, RHIA, CCS, of Lolita M. Jones Consulting in Fort
Washington, MD. “For the past four and a half years, a CMS guideline has prohibited hospitals
from reporting modifiers -73 and -74 for discontinued procedures involving conscious sedation.”
The old guideline derived from a question and answer CMS posted on its OPPS claims
processing Web site in September 2000. In the guidance on reporting modifier -52 with a
colonoscopy, CMS’ answer limited the definition of anesthesia to local, regional block, or general.
Anesthesia gets new definition
Effective February 22, 2005, the definition of anesthesia changed. In Transmittal 442, CMS states
that for purposes of billing for services furnished in the hospital outpatient department, anesthesia
includes
• local
• regional block(s)
• moderate sedation/analgesia (“conscious sedation”)
• deep sedation/analgesia
• general anesthesia
This manual revision also clarifies that providers cannot use modifiers -73 and -74 in the reporting
of discontinued radiology procedures that do not require anesthesia. Modifier -52 indicates partial
reduction or discontinuation of radiology procedures and other services that do not require
anesthesia.
Instead, facilities should use modifier -73 to indicate that a surgical or diagnostic procedure
requiring anesthesia was terminated due to extenuating circumstances or those that threatened
the well-being of the patient after preparation for the procedure (including procedural premedication when provided) and transfer to the site of the procedure, but prior to administration of
anesthesia.
“This modifier was created so that the costs incurred by the hospital to prepare the patient for the
procedure and the resources expended in the procedure room and recovery room (if needed)
could be recognized for payment even though the procedure was discontinued,” Jones says.
Use modifier -74 to indicate that a surgical or diagnostic procedure requiring anesthesia was
terminated after the induction of anesthesia or after start of the procedure (e.g., incision made,
intubation started, scope inserted) due to extenuating circumstances or circumstances that
threatened the well-being of the patient.
44
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT B
“This modifier was created so that the costs incurred by the hospital to initiate the
procedure—preparation of the patient, procedure room, recovery room—could be recognized for
payment, even though the procedure was discontinued prior to completion,” she says.
Case scenarios
With the above information as guidance, read the following two case studies to understand how
the new guidance operates in real-life scenarios.
Case study 1
Discontinued outpatient hospital/ASC procedure after anesthesia. Colorectal cancer screening;
colonoscopy on high-risk individual.
Operative report
Procedure: Colonoscopy
Indications: Family history of colon cancer
Instrument: Olympus video colonoscope CF 100L
Pre-medication: Versed 4 mg, Demerol 75 mg
Description of procedure: A 75-year-old patient presents for a colonoscopy. He understands
the nature of the procedure, the risks and consequences, and alternative procedures, and
consents to the procedure. The patient receives educational materials, information on the risks of
the procedure, and answers to frequently asked questions.
The patient is placed in the left lateral decubitus position. The rectal exam reveals normal
sphincter tone and no masses. A colonoscope is introduced into the rectum and advanced
to the distal sigmoid colon. Further advancement is impossible due to the marked fixation
and severe angulation of the rectosigmoid colon.
On withdrawal, no masses or polyps are noted and the mucosa is normal throughout.
Retroflexion in the rectal vault is unremarkable. The patient tolerates the procedure without
difficulty.
Final impression: Normal colonoscopy, only to the distal sigmoid colon.
Plan: Strong recommendation for a barium enema.
Coding: G0105-74 (Colorectal screening, high risk individual). Use G0105 because this is a
colonoscopy screening exam. No signs or symptoms necessitate this exam performed on a highrisk patient due to a family history of colon cancer.
Case study 2
Discontinued outpatient hospital/ASC procedure without anesthesia. Colonoscopy through stoma;
diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).
Operative report
Preoperative diagnosis: History of colon cancer with recent constipation
Postoperative diagnosis: Inability to intubate the stoma site, questionable stricture at the
colostomy site
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
45
EXHIBIT B
Procedure performed: Attempted colonoscopy through colostomy site
Anesthesia: None
Instrument: Olympus video colonoscopy tried first, then Olympus video upper endoscope of
smaller caliber
Complications: None
Description of procedure: Patient is placed in the supine position and the colostomy bag is
removed. The colostomy site is identified and lubricated. The instrument is inserted into the
ostomy and insufflated. Physician makes several attempts to intubate the colon through the
colostomy site but is unsuccessful.
Final impression: Questionable stricture of the ostomy site.
Plan: Barium enema via colostomy to delineate the anatomy. Follow up based on the findings of
the barium enema.
Disposition: Patient is discharged without recovery because she did not receive any
conscious sedation. The physician will see her again two weeks after the barium enema for
further management.
Coding: 44388-52. Use code 44388 (Colonoscopy), and per Medicare Transmittal 442, use
modifier -52 for services that do not require anesthesia.
Additional clarifications in Transmittal 442
• Bilateral modifier -50. Per the Transmittal, you may report bilateral procedure modifier -50 with
diagnostic and radiology procedures, as well as with surgical procedures. Use it to report bilateral
procedures performed at the same operative session as a single line item.
Do not use modifiers -RT and -LT when modifier -50 applies. Report a bilateral procedure on a
single line of the claim using modifier -50. Modifier -50 applies to any bilateral procedure
performed on both sides at the same session.
• Termination of multiple planned procedures. When you complete one or more planned
procedures, report them as usual. Do not report other planned but not started procedure(s).
When you complete none of the planned procedures, but have prepared the patient and taken
him or her the procedure room, append the first procedure that was planned (but not completed)
with modifier -73.
If you begin the first procedure (e.g., scope inserted, intubation started, incision made, etc.)
and/or give the patient anesthesia, use modifier -74. Do not report the other procedures.
If you terminate the first procedure prior to the induction of anesthesia and before the transfer of
the patient into the procedure room, do not report the procedure. The patient must be moved to
the room where the procedure is to be performed for you to report modifier -73 or -74.
Outstanding issues raised by Transmittal 442
Transmittal 442 does not clearly address some issues pertaining to reporting modifiers -52, -73,
and -74. Industry experts say CMS will likely clarify them in a future transmittal.
46
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
EXHIBIT B
In the meantime, Lolita M. Jones, RHIA, CCS, of Lolita M. Jones Consulting in Fort Washington,
MD tells providers to contact Dana Burley ([email protected]), the listed Transmittal contact
at CMS for further assistance.
Per Transmittal 442, “discontinued radiology procedures that do not require anesthesia can not
be reported using modifiers -73 and -74.” However, CMS doesn’t state whether providers can
report discontinued interventional radiology procedures with modifiers -73 and -74. “Interventional
radiology procedures have both a radiological and surgical/procedural component,” Jones says.
For example, when a patient undergoes a percutaneous transluminal angioplasty, radiological
imaging for the placement of the balloon is used to perform the procedure, which is the balloon
dilation/angioplasty of the vessel.
Also, per Transmittal 442, “modifier -52 indicates partial reduction or discontinuation of radiology
procedures and other services that do not require anesthesia.” Training manual OPPS guidelines
used by CMS contractors in 2000 said, “Do not use modifier -52 if there is a code that classifies
the extent of the procedure that was performed. “
“However, in the Transmittal 442, CMS doesn’t state whether it is still appropriate to code to the
extent of the procedure performed,” Jones says.
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
47
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Lolita M. Jones Consulting Services
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Fort Washington, MD 20744
Phone: 301/292-8027
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52
Modifiers -52, -73, and -74: Ensure proper coding at the point of care
attended
OF ATTENDANCE
Rob Stuart
Senior Vice President / Chief Operating Officer
February 2, 2006
a 90-minute audioconference
on
“Modifiers -52, -73, and -74: Ensure proper coding at the point of care”
C ER TIFICATE
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• Fron t-End So lut ion s Wor
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• Ph ys ici an Pe rf or ma nc e
Prof ile Co urse
• Public Ac co un ta bil ity fo
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• Ca se M an agemen t In st
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Se nd a Te am
• Co re Pr iv ile ging Ad va nc
To register, call 800/801-6661
or visit www.greeley.com
Spring 2006 Seminar Calendar
MARCH
March 3, 2006, MGM Grand Hotel, Las Vegas, NV
Rapid Response Team Retreat
Learn how to create Rapid Response Teams—dedicated staff that respond to an emergency before it occurs. This life-saving patient safety
innovation—featured in the Wall Street Journal and part of The Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign—has
been adopted by facilities of all sizes to decrease mortality rates by reducing adverse events and codes in critically ill patients.
Register early for team discounts!
APRIL
April 6-7, 2006, The Ritz-Carlton Hotel, Phoenix, AZ
April 20–21, 2006, The Ritz-Carlton Golf Resort, Naples, FL
NEW! Case Management Institute: Managing by influence to
maximize the effectiveness of your case management program
UPDATED! Medical Staff Quality: Practical strategies for
effective peer review, physician performance feedback, and
managing physician performance
Through the institute’s step-by-step strategies, leaders can
find solutions to problems related to excessive utilization and
clinical resource costs, the enhancement of quality (while keeping
expenditures in check), and the improvement of communication/
cooperation between case management, physician, and
hospital leaders.
Get concrete steps to make your medical staff quality program
truly effective. Learn how to encourage positive physician
performance, create effective physician performance feedback
reports, solve the challenges of peer review, improve hospital
systems, and address clinical performance problems.
Early-Bird Discount: Register by February 2 to save $100!
Early-Bird Discount: Register by February 16 to save $100!
April 6-7, 2006, The Ritz-Carlton Hotel, Phoenix, AZ
April 20–21, 2006, The Ritz-Carlton Golf Resort, Naples, FL
Effective JCAHO Survey Preparation for the Medical Staff
Advanced Medical Staff Leadership Retreat: Where today’s
leaders come to solve their toughest medical staff problems
The JCAHO is seeking to re-engage physicians in a new, more
dynamic survey process. Train your physicians and their teams
on what to do when they disagree with the surveyor’s findings,
the 2006 standards and patient safety goals, documentation
challenges, and much more.
Early-Bird Discount: Register by February 2 to save $100!
April 7, 2006, The Westin Hotel, Michigan Avenue, Chicago, IL
Get an in-depth look at the six toughest challenges faced by
medical staff leaders today: ED coverage, disruptive physician
behavior, physician/hospital collaboration and competition,
matching proven competency with clinical privileges, physician/physician and physician/hospital conflict, lack of effective
physician leaders.
Early-Bird Discount: Register by February 16 to save $100!
NEW! Discharge Planning Summit
Decrease denials, maximize length of stay, and increase
efficiency. Learn how to comply with significant federal
regulations and use your discharge planning process
to support the business side of healthcare. You’ll walk
away from this summit with strategies to boost revenue
without losing sight of the needs of the patient.
Register early for team discounts!
©2006 The Greeley Company, a Division of HCPro, Inc. HCPro is not affiliated in any way with the Joint Commission on
Accreditation of Healthcare Organizations, which owns the JCAHO trademark.
April 21–22, 2006, The Ritz-Carlton Golf Resort, Naples, FL
Surgical Team Summit: Bringing together chiefs of surgery,
chiefs of anesthesia, and surgical services leadership to tackle
the toughest OR challenges
Surgical teams can bring in some of the highest revenue for
your facility. However, stress-free, efficient operating-room
(OR) management is difficult to attain. Improve revenue and
reduce inefficiencies while getting practical strategies for OR
management, regulatory compliance, turf-battle resolution,
credentialing, and patient flow.
Early-Bird Discount: Register by February 16 to save $100!
To register, or for continuing education credit opportunities for these seminars, call 800/801-6661 or visit www.greeley.com.
Spring 2006 Seminar Calendar
MAY
May 17, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV
May 18–19, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV
NEW! Core Privileging Advanced Course: Design and
implementation
Magnet Resource Center Advanced Workshop
Are you charged with the job of reviewing and recommending a
redesign to core privileging? Where do you start, and how can you
avoid the roadblocks that can hamper smooth implementation of
core privileges? A pre-conference to the 9th Annual Credentialing
Resource Center Symposium, this full-day offering will take
participants through the key steps needed to design, modify, and
implement core privileges.
Ask about additional discounts!
May 18–19, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV
UPDATED! The 9th Annual Credentialing Resource Center
Symposium
Learn practical and innovative approaches to solving your toughest
credentialing and medical staff challenges. For the past nine years,
experts from The Greeley Company have offered medical staff and
credentialing professionals nationwide seminars on credentialing
hot topics. Past topics have included low-volume/no-volume
providers, core privileging, physician performance profiles, new
technology, and much more.
Confused and overwhelmed by how to achieve Magnet
status—the highest seal of nursing excellence? Then attend
this seminar to work one-on-one with the elite few nursing
professionals who have already achieved Magnet status.
These experts will outline clear action plans toward successful
completion of your Magnet application.
Register early for team discounts!
May 18–19, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV
NEW! Front-End Solutions Workshop
Need help in improving your front end payment collections?
Worried about the challenges of collecting high deductibles
and negotiating patient drug coverage that will change under
Medicare Part D? Learn how to collect copays, respond to
payment refusals, reduce bad debt, track results, and interact
with customers to help increase future business.
Ask about additional discounts!
May 20, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV
Early-Bird Discount: Register by March 16 to save $100!
NEW! Physician Performance Profile Course: Quality data and
current competence
May 18–19, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV
Understand the collection and use of quality data to improve
physician performance and appraise the ongoing competence
of your medical staff. Topics include the domains of physician
performance, the use and application of rule, rate and review
indicators, and gaining physician buy-in.
UPDATED! Achieving Continuous Survey Readiness Through
Patient Tracers: A practical 5-step model to compliance
On January 1, 2006, the unannounced survey process goes into
effect. Prepare now with the 5-step model to continuous survey
readiness, a look at JCAHO hot spots, what’s new for 2006.
Ask about additional discounts!
Early-Bird Discount: Register by March 16 to save $100!
JUNE
June 1–2, 2006, The Ritz-Carlton, Amelia Island, Amelia Island, FL
Coming Soon (June date and location to be announced)
Medical Executive Committee Institute: The essential training
program for all medical staff leaders
Public Accountability for Quality
Gain skills never taught in medical school. Topics include how
to solve MEC challenges (turf battles, disruptive physicians, ED
coverage, impaired physicians, conflict of interest, medical records
completion, external peer reviews, fair hearings, physician apathy)
and improve performance for medical staff leaders.
Hospital and physician data is being measured and reported
publicly with consequences for marketing, reimbursement and
accreditation. This program will teach hospital teams responsible
for improving performance on publicly reported data how to
gather data, interpret data, train management on how to use
data, and much more.
Early-Bird Discount: Register by March 30 to save $100!
Ask about additional discounts!
MT42135
200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945 • tel 800/801-6661 • fax 800/738-1533 • e-mail [email protected] • web www.greeley.com